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This article examined the differences in causes and health consequences between synthetic drug and heroin abuse in urban China. Two-group comparisons were conducted to quantify differences in individual characteristics, causes of drug use, and HIV/STI risky sexual behavior between synthetic drug and heroin users; logistic regressions were employed to assess the net effect of synthetic drug use on risky sexual behavior. Results revealed that causes of synthetic drug use differed from those of heroin use; a combination of the knowledge gap concerning the harmful impact of synthetic drugs and the lesser punishment for their use appeared a main reason behind the shift from heroin to synthetic drugs; and synthetic drug use was a significant and powerful risk factor for HIV/STI risky sexual behavior. Educational and behavioral interventions are urgently needed to prevent the initiation of synthetic drug use among users to reduce their HIV/STI risky sexual behavior.

This study examined the effectiveness of a behavioral intervention that combined cognitive and social influence approaches. The intervention consisted of small group sessions targeting HIV knowledge, protection motivation, behavioral skills, and social influences of risk reduction. The control was an attention-controlled HIV/STI health education and counseling. Two-group comparisons were conducted to assess the effectiveness of the intervention; risk reduction over time was analyzed to determine the sustainability of the effectiveness. The analyses revealed that the intervention was effective in reducing/increasing HIV risk/protective behaviors and the effect was sustainable. While participants in the control reported a greater reduction/increase in risk/protective behaviors 3-month post-intervention, the initial strong effect quickly faded and completely disappeared 12-month post-intervention. By contrast, the moderate initial effect of the intervention was not only sustained but actually strengthened over time. The intervention was well received by participants and holds promise for HIV risk reduction behavior change among female entertainment workers in China.

Summary Female entertainment workers (FEWs) in China are at increased risk of HIV and other sexually transmitted infections, but correlates of their risky sexual behaviour remain poorly understood. Using data from a series of four surveys, this paper employs repeated measures analysis to identify individual and social correlates of consistent condom use among FEWs in Shanghai. Results reveal that both individual cognitive and social influence factors are statistically significant in their bivariate relationships to consistent condom use with a stable or non-stable partner; only prevention motivation and perceived self-efficacy in condom use remain significant in the multiple regressions. When individual and social correlates are examined together, only peer support for condom use remains a significant and independent correlate of consistent condom use in sex with a non-stable partner. Behavioural intervention is urgently needed and should take a multilevel approach, emphasizing individual prevention motivation and behavioural skills training and promoting peer/social support.

The link between migration and STD/HIV risky sexual behavior has been well documented. Research of risky sexual behavior that addresses the issue of gender-migration interaction or employs a multilevel perspective is still limited in China. Using data from a probability survey and applying multilevel modeling, this paper examines gender differences in (1) the link between migration and risky sexual behavior and (2) individual and community correlates of risky sexual behavior. Results suggest significant interaction between gender and migration. Being a temporary migrant is associated with significantly more risky sexual behaviors for females but significantly fewer for males. There are also significant interactions between gender and marriage and living arrangement. Being married and living with others both appear to be more powerful deterrents to risky sexual behavior for females than for males. Single migrant women who live alone have the most risky sexual behaviors while married nonmigrant women who live with others have the least. Risky sexual behavior is further influenced by family and peers and conditioned by community contexts. Prevention programs are urgently needed for female temporary migrants and must address the issue of gender and pay attention to social influences of family and peers and community contexts.

Diffusion of innovation (DOI) is widely cited in the HIV behavior change literature; however there is a dearth of research on the application of DOI in interventions for sex workers. Following a randomized-controlled trial of HIV risk reduction among female entertainment workers (FEWs) in Shanghai, China, we used qualitative approaches to delineate potential interpersonal communication networks and contributing factors that promote diffusion of information in entertainment venues. Results showed that top-down communication networks from the venue owners to the FEWs were efficient for diffusion of information. Mammies/madams, who act as intermediaries between FEWs and clients form an essential part of FEWs’ social networks but do not function as information disseminators due to a conflict of interest between safer sex and maximizing profits. Diffusion of information in large venues tended to rely more on aspects of the physical environment to create intimacy and on pressure from managers to stimulate communication. In small venues, communication and conversations occurred more spontaneously among FEWs. Information about safer sex appeared to be more easily disseminated when the message and the approach used to convey information could be tailored to people working at different levels in the venues. Results suggest that safer sex messages should be provided consistently following an intervention to further promote intervention diffusion, and health-related employer liability systems in entertainment venues should be established, in which employers are responsible for the health of their employees. Our study suggests that existing personal networks can be used to disseminate information in entertainment venues and one should be mindful about the context-specific interactions between FEWs and others in their social networks to better achieve diffusion of interventions.

Women working in China's entertainment industry are at increased risk of acquiring or transmitting HIV/sexually transmitted infections (STIs). Efforts to develop effective risk-reduction interventions for female entertainment workers (FEWs) remain limited. We conducted a randomized controlled trial of a theory-based risk-reduction intervention among FEWs in Shanghai. The intervention condition consisted of small group, peer-assisted sessions integrating information-motivation-behavioral skills training with social influences of behavior change. The control condition was an attention-matched HIV, health education, and counseling. At three-month post-intervention, participants in the intervention condition reported greater reductions in unprotected sex with a stable partner than participants in the control condition. However, participants in the control condition reported greater reductions in unprotected sex with a non-stable partner than participants in the intervention condition. Some aspects of the study design may have diluted the effects of the intervention. Future intervention studies need to pay more attention to social influences of behavior change and the particular challenges of risk-reduction with stable partner(s).

Laws and law enforcement practices influence the risk environment for commercial sex workers in China. Law is also a prime potential mode of structural intervention. In China, evidence indicates commercial sex workers as a group are an important segment of the emerging Chinese HIV epidemic. China is undergoing a dramatic economic transition characterized by growing and extreme inequality in the population. This is influencing the growth of the sex industry as a site of economic activity by poorer people, particularly rural women. Sex worker behavior is also influenced by laws and law enforcement practices. Corruption among law enforcement officials, the system for funding law enforcement, and the limited protection of human rights, all have the potential to create a more dangerous environment for sex workers in relation to HIV and STDs. Despite intensive law enforcement action and considerable expense, the state has not achieved the goal of eliminating prostitution. The commercial sex trade has not been forbidden just informally regulated. Police practices are, to some extent, independent of the written laws concerning prostitution. Ethnographic data are reviewed and recommendations are offered for further research.

Gender differences in sexual behavior as a consequence of migration have been ignored in both the migration and the HIV literature in China. This study examines differences among temporary migrants in terms of sexual behavior and factors that make female migrants more vulnerable to the risk of acquiring HIV infection. Results suggest that the interplay of migration and gender renders female temporary migrants particularly vulnerable to engaging in casual and commercial sex. Although male temporary migrants do not differ from male nonmigrants in prevalence of casual and commercial sex, the prevalence rates of casual and commercial sex for female temporary migrants are found to be 14 and 80 times those for female nonmigrants, respectively. Female temporary migrants' higher unemployment rate and concentration in the service and entertainment sectors are keys to understanding differences in the prevalence of casual and commercial sex among temporary migrants according to sex. Policy measures to promote female temporary migrants' equal access to employment are urgently needed to improve their economic well-being and to reduce their risky sexual behavior.

We proposed to integrate cognitive and social factors in the study of unprotected commercial sex. Data from 159 female entertainment workers from 15 establishments in Shanghai who reported commercial sex in the month prior to interview were used to test the approach. Two-sample t tests and multivariate logistic regression were conducted to examine if and how individual cognitive and social influence factors affect the odds of consistent condom use. About 21% of participants reported consistent condom use. Both individual cognitive and social influence factors were important correlates of condom use; models containing either alone suffered significantly in explanatory power. Perceived easiness in condom use was the most proximate determinant of condom use. It helped to translate HIV knowledge and prevention motivation into behavior and to mediate the impact of sexual relationship power. Prevention intervention is urgently needed and should focus on self-efficacy training and promoting supportive social and working environments.

Using qualitative information from in-depth interviews of 40 female entertainment workers (FEWs) in Shanghai, this article explores factors associated with unprotected sex and barriers to consistent condom use among FEWs. Results suggest that not all FEWs were at high risk, nor did they all engage in unprotected sex for the same reasons. Prevalence of unprotected sex varied by individual characteristics, across different settings where commercial sex took place, and by the FEWs' relationship to pimps or establishment owners. Factors contributing to unprotected sex included lack of HIV transmission knowledge, economic hardship, client refusal/coercion, and control by pimps/establishment owners. Incorrect beliefs also contributed to use of methods that offered no protection. Study participants endorsed the need for HIV/sexually transmitted disease prevention, but were suspicious about government programs. Prevention interventions need to target simultaneously clients of commercial sex and pimps/business owners and to promote a social environment supportive of 100% condom use in commercial sex.