1. Perceived HIV risks, types of sexually transmitted diseases, and discordant infection status among low-tier female sex workers in China (Roundtable Presentation) Presenters: Shan Qiao, Chen Zhang, Xiaoming Li, Yuejiao Zhou, Wei Liu

2. Acknowledgement  Funding Agency  The study was in part supported by NIH Research Grant R01AA018090 by the National Institute for Alcohol Abuse and Alcoholism

3.  Discordant infection status for an individual is defined as the discrepancy between biologically confirmed and self-reported sexually transmitted diseases (STD).  The awareness of their infection status is a key to modifying their sexual risk behaviors (Porter, Wall, & Evans 1993).  A literature gap exists in the global literature to examine the discordant infection status among high- risk populations (e.g., FSWs). Background

4.  Vulnerability of Low-tier FSWs in China Personal Attributes New arrivals from rural areas The least knowledgeable on health risk of unprotected sex Most desperate for financial survivals Older age, less educated, lower SES Work-Related Risks Having little control over the sex practice with their clients The least protected and often the main target of government crackdowns Higher HIV/STD Prevalence Facing higher and more severe risks in their life context (e.g., violence)

5. Existing Studies on Low-tier FSW in China  The low-tier FSW had highest prevalence of syphilis infection (9.7%, 95%CI: 8.3-11.1%), followed by the middle-tier (4.3%, 95%CI:3.6- 5.0%), and higher-tier FSW (2.2%, 95%CI:1.6- 2.9%)  Tucker et al. (2011)’s study indicated that the prominent syphilis epidemic among low-tier FSW with the prevalence estimate as high as 12.5% (IQR 4.1-20.1)

6.  The prevalence of discordant infection status among the current sample  The current study aims to detect factors associated with discordant status among a sample of low-tier FSWs in China Research Questions

7.  A total of 907 FSWs were recruited from nine types of low-tier commercial sex venues in Guangxi, China.  FSWs who provided consented forms completed a self-administered cross-sectional survey on their demographic and behavioral information, as well as history of STD infection.  A blood sample for testing HIV, hepatitis C virus (HCV) and syphilis was also collected. Method

8. Characteristics of low-tier FSW (N=907) Low-tier FSW  The average age of FSWs in the current sample was 32.1 (14-68) years old  Majority of them cohabited with their partners and 43% of them had less than middle school education  Averagely, they have been working as sex workers for 24 months (SD=23.58)  The low-tier FSWs met 15 (SD=20.24) clients in the recent week and charged a price with 41 yuan (about 6 US dollars) (SD=21.18yuan) for each service  About 15% of them had clients more than 50 years old and 61% reported inconsistent condom use with clients last month.

9.  In the current study, 16.0% of FSWs had discordant status with 7.8% of unrecognized STD infection and 8.2% of recovered cases.  More FSWs infected with gonorrhea (aOR=10.31, 95%CI=3.19, 33.29) and Chlamydia (aOR=21.41, 95%CI=3.74, 122.59) were likely to have discordant status compared to women with other types of STD (e.g., syphilis, genital herpes).  FSWs with higher perceived HIV risks were less likely to have discordant infection status (aOR=0.50, 95%CI=0.27, 0.94). Results

10.  The pervasive discordant status among the current sample underscored urgent needs to address this problem  Several specific STDs were more likely to be ignored by infected persons  Perceived HIV risk was a protective factor for discordant infection status among FSWs Discussion

11.  Socially desirable reporting and volunteer bias  Limited ability of generalizing the findings to other areas of China  Cross-sectional study design prevents us from making a causal conclusion between discordant status and its correlates Limitation

12.  Our findings reinforce the need for a multidimensional approach to HIV/STD preventions among this high-risk population  Resources and efforts are called for making the HIV testing and counseling service accessible and available without barriers  Effective educational outreach is needed  Empowerment-based interventions are needed among women in vulnerability Implication

13. Questions