Rural-to-Urban Migrants and the HIV Epidemic in China

Abstract

China is the next probable frontier for the global HIV epidemic. Central to this anticipated growth of the epidemic is the nation’s new and growing population of rural-to-urban migrants. Although there are an estimated 120 million migrants, little information is available about their social and cultural context of their lives in urban areas and their HIV-related perceptions and behaviors. On the basis of the in-depth individual interviews conducted among 90 rural-to-urban migrants in 2 major Chinese cities, Beijing and Nanjing, this qualitative study was designed to explore these issues with a particular focus on their relevance to sexual transmission of HIV. The findings suggest an urgent need for HIV/STI prevention programs that address the cultural, social, and economic constraints facing the migrant population in China.

INTRODUCTION

A 25 year-old male migrant, describes, through tears, the night he left his rural village and his family three years ago in search of a better economic future in the city:

At that time, my mom was working on the farm. My dad was working in the town and didn’t return home that night; he had to work overtime . . . I just carried a bag with some clothes; I didn’t even have a blanket with me. I only had a pair of shoes, a pair of shoes, a pair of pants and a shirt. I had nothing but these. So I came. My mom didn’t have any money either, so she borrowed 100 yuan [approximately US$12] from the neighbor for my bus ticket. When I was walking out of the village, about half way, I ran into my dad. My dad asked me ‘what are you doing?’ I said ‘I am going to Beijing.‘ He didn’t say anything and then asked if I had money. I said I had 100 yuan. Then my dad became very sad, ’Just go, and have your own life. If you can’t survive there, come home.’ I said ‘OK.’ My tears ran down. They are my dad and mom.

China is the next probable frontier for the global HIV/AIDS epidemic (Zhang and Ma, 2002). As a harbinger of this looming development in the epidemic, new cases of HIV infection in China increased by 140% from 2002 to 2003 (China Ministry of Health, 2003) and the incidence of STDs increased 420% among women and 390% among men from 1990 to 1998 (Zhang and Ma, 2002). About 70% of HIV infection is among rural residents, 80% of whom are males and 60% aged 16-29 years (Qi,2002). Although injection drug use and contaminated blood transfusion remain the main sources for the majority of HIV infections in China, sexual transmission appears to account for approximately 10.5% of infections (UNAIDS, 2003). Most of the sexually transmitted HIV infections have been reported among high-risk populations including the nation’s millions of commercial sex workers (Yang et al., 2005).

Since the implementation of the “open-door” policy in China in the 1970s, and especially since the economic reforms of the middle of 1980s, sexual behaviors and attitudes have been undergoing significant change in China, especially among the young population (Gao et al., 2001; Zhang et al., 1999). In traditional Chinese society, a woman is expected to remain virginal until her wedding night and to remain faithful to her husband throughout her life. Homosexual practices or multiple sexual partners have been disdained by mainstream society (Zhang et al., 1999). Following centuries of silence on the subject, only in very recent years has sex education been addressed in the school curriculum (Gao et al.,2001). Although premarital sex, extramarital sex, and prostitution are strongly denounced by traditional Chinese cultures, the population is becoming more tolerant of these activities and their prevalence is rapidly increasing (Gao et al., 2001; Zhang et al.,1999).

China’s rural-to-urban migrant population has been identified as the “tipping point” for the AIDS epidemic in China (Anderson et al., 2003). The estimated 120 million migrants comprise 9.3% of the total population of 1.3 billion people, and include 88.4 million rural villagers, with the remainder coming from townships and small cities (China National Bureau of Statistics, 2001). This massive migration was generated by rapid economic development and industrialization and surplus agricultural labor (Thomas, 1998). As the majority of migrants have not received work skills training, they frequently undertake manual labor related to goods transportation, construction work, domestic service, and restaurant services (Jia et al., 2001; Zhang, 2001). Consistent with findings in other countries that within-country migration is frequently based on kinship-ties (Hanor-Knipe et al., 1999; McMunn et al., 1998), recent ethnographic studies among several migrant settlements in Beijing and other cities have found that most rural-to-urban migrations in China are based on kinship-ties and native-place networks (social relations based on a common place of origin) (Ma and Xiang, 1998; Zhang, 2001).

Migrants have been difficult to reach with preventive health education and they have been deprived of access to health care (McCoy and Yu,1999). Among the 120 million migrants in China, 60% are males and 40% are aged 20-24 years (Huang and Yang, 2000; Thomas, 1998). About 10% of the adult migrants (15 years of age and older) are illiterate, 24% finished elementary school, 52% finished middle school, and 13% finished high school (China National Bureau of Statistics, 2001). Most of the migrants are unmarried or married but living apart from their spouses or children and with low awareness of HIV/AIDS. It has been reported that the HIV prevalence among rural-to-urban migrants was 1.8 times higher than it was among rural residents who did not migrate to cities (Xu et al., 1998). The legal system in China has significantly curtailed the entitlement of the migrant population to basic benefits available to other segments of the population. Specifically, migrants have to pay more than local residents for many of their daily essentials such as housing, utilities, education, and transportation. There are also institutional barriers for migrants from seeking legitimate employment in urban areas, including governmental restrictions on employment opportunities for migrants (Zhang, 2001). Because of the growing disparity between rural and urban incomes, the increasing surplus of rural labor, and reduced governmental control on population mobility, the rural-to-urban migrant population is expected to continue to increase (Li et al., 2004).

This large migrant population has attracted attention both domestically and internationally, with many observing that it might play a crucial role in catalyzing an explosion of the HIV epidemic in China (Anderson et al., 2003; Grusky et al., 2002; Thomas,1998). Nevertheless, current HIV prevention programs have primarily targeted drug users (Luo et al.,2002; Wu et al., 2002) and commercial sex workers (Liao et al., 2003), with few intervention efforts focusing on the rural-to-urban migrants. Moreover, the social, economic, and health implications of the migratory lifestyle in China have received little scholarly attention (Anderson et al., 2003; Liao et al., 2003). Accordingly, this qualitative study was conducted to explore these factors and their implications for HIV epidemic in China, with a goal of developing a social cognitive-theory-based behavioral intervention program preventing sexual transmission of HIV/STI among this vulnerable population.

METHODS

Research Sites: Beijing and Nanjing

This study is a qualitative study including 90 semi-structured and open-ended interviews conducted in two major Chinese cities, Beijing and Nanjing. It was designed to collect qualitative data regarding HIV/STI risk factors and potentially related social and cultural factors. Beijing, the capital city of China, with a population of 13.82 million, is located in northern China (China National Bureau of Statistics, 2001). Approximately, 3 million rural-to-urban migrants (69% males and 31% females) originating from throughout China are currently residing in Beijing (Beijing Municipal Bureau of Statistics, 2002). Nanjing, with a population of 5.6 million, is located in east China and currently hosts approximately 800,000 migrants largely from neighboring provinces (Nanjing Municipal Bureau of Statistics, 2003). Beijing and Nanjing are among the Chinese administrative regions reporting the highest incidence of STDs (Gong et al., 2000).

Participants

A convenience sample of 90 participants was recruited from their work sites, job market sites, or homes. Local community leaders (both formal and informal) in the migrant settlements served as facilitators for the recruitment process. The 90 participants ranged in age from 16 to 37, with majority of them (80 participants) being 20-29 years of age. Forty-four participants were males; 69 were single. Thirty-six had completed junior high (required by the law—although 14 additional migrants had only a primary school education or less); 9 had graduated from high school, and 30 had graduated from postsecondary schools (including vocational school, 3-year colleges, etc.). Fifty-three had first migrated when they were younger than 20 years. The duration of their stay in Beijing or Nanjing varied from 1 to more than 11 years; 41 had stayed in the cities for less than 5 years.

Procedures

A semi-structured interview guide was developed from informal discussions with young migrants, local community leaders (both formal and informal), health care providers, government officials, and project staff to elucidate information regarding young migrants’ personal and social experiences and their health perceptions, behaviors, and concerns. The resultant interview guide consisted of open-ended questions with suggested probes covering several broad topics, including (1) demographic information, (2) reasons for migration, (3) life in the city, including working and living conditions, experiences of seeking employment, and interactions with urban residents, etc., (4) sexual attitudes and behaviors, and (5) general awareness and attitudes toward HIV/STDs.

Individual interviews were conducted in places established for the convenience of the interviewees. All interviewers were psychology or education graduate students and faculty members from Beijing Normal University and Nanjing University. The interviewers received extensive training on how to conduct in-depth interviews among the migrant population in the preparation stage of this study. Each participant was assured of his/her confidentiality in the study, and provided a written informed consent before the interview started. Each interview took about 60-90 min. A total of 90 interviews were conducted (50 in Beijing and 40 in Nanjing).

Data Analysis

All 90 interviews were audiotaped and transcribed. Of the 90 transcripts, 60 were translated into English, including all 40 transcripts from the Nanjing sample, and 20 transcripts randomly selected from the Beijing sample. Data analysis followed the procedure outlined by Ryan and Bertrand (2000): identifying themes, building codebooks, marking texts, constructing models (relationships among codes), and testing these models against empirical data. Preliminary coding started with reading and rereading the English and Chinese transcripts by the American and Chinese research team members. Coding themes were developed from the theoretical framework of sexual transmission of HIV among migrant population as reflected in the domain of the interview guide and new themes emerging during the interview and coding process (LeCompte and Schensul, 1999; Rubin and Rubin, 1995; Silverman, 1993).

In the second stage of data analysis, a research team member coded all the Chinese transcripts with a word processing software, according to the coding themes developed in the first phase and following the procedures outlined in the recent qualitative literature (La Pelle, 2004; Ryan, 2004). Each transcript was coded at least twice. From all 90, 20 transcripts were selected randomly and coded independently by another researcher with qualitative research experiences, and the interrater reliability (Cronbach’s kappa coefficient) was .80. Detailed summaries with substantial retention of original quotes were prepared in English to facilitate further discussion and elaboration among both the U.S. and Chinese investigators. Quote excerpts and summaries were then categorized by participant characteristics and the coding domains; they were further compared and reviewed for interrelationships and correspondence with coding and theoretical framework (Rubin and Rubin, 1995; Ryan and Bertrand, 2000). The findings presented in this manuscript reflect the range of responses, with some indication of the more consistent responses. Because this manuscript is focused on aspects of migrant life that increased their risk of sexual transmission of HIV, we have confined this analysis to relevant life experiences, sexual perceptions and behaviors as well as the social and cultural context of their migrant life and the broader experiences they faced as migrants.

RESULTS

Life in the city—hardship, discrimination, but still “I want to stay”

Transitions are difficult; this experience was no different for rural-urban migrants in China. Despite their hopes that the city would bring fortunes and opportunities not possible in their villages, many had experienced hardship when they started their new lives in the cities:

The first time I came to Beijing was 1999; I was only 17 ... It was really hard. I only had money for taking the bus and all I could afford to buy for food was one big cookie ... I didn’t want to beg for help, and so I slept in a big tree. [Male aged 21]

Even those fortunate enough to find work often discovered that they were being taken advantage of by their employers, and with no legal recourse for complaint:

I worked for half a year and earned only 500 yuan [approximately US $60]. No more! I was tricked by the boss! [Male aged 21]

For migrants, the opportunity to find employment that included housing was highly desirable, although often the housing conditions themselves were not optimal:

We don’t worry much about personal hygiene. We have too many people. There are 50 people in our company. We live in a big room. And we plan to have more people soon. The plan is to have 80 people and we will live in two rooms. It is actually a big underground storage space. [Male aged 21]

The urban residents usually did not welcome these migrant workers from rural areas; instead, they frequently expressed disdain or rejection:

There is an old nanny in the market, very very snobbish. She never likes us and says we are dirty. When I sold fish to her, just a little touch on the fish, she said, ‘Ah, so dirty!’ [Female aged 20]

More severe harassment was encountered from law enforcement agents. At the time that this study was conducted, Chinese law required rural-to-urban migrants to register for a Temporary Residence Card in the city. Without this permit, migrants in cities were considered illegal and were subject to incarceration and/or deportation. Many participants complained the burden of obtaining the permits:

For those permits—it is really hard to get them. For a Temporary Residence Card, you need to spend 200 yuan in Beijing. But it is not just this—you still need a Work Permit, an Employment Permit—you will need four permits! The Work Permit costs 400 to 500 yuan! Who has it—We don’t have the money! If you had the money, why the hell you came to work outside [your village]?! Like us, we only have 200 or 300 yuan when we arrived here. If you spend the money for the Permit, where is the money to feed yourself? [Female aged 30]

As difficult as it was to obtain these funds, the migrants were aware of the importance of the permits, for several had the experience of being detained without them:

Last year, I was even caught up and sent home. And the same thing happened two years ago. It cost me 700 to 800 yuan to get out. It was discrimination, wasn’t it?! I didn’t commit any crime, and did nothing, and I was walking alone! We migrant workers have no way about this, we can’t fight with the local snakeheads [local villains, hooligans]; and we have no place to complain. When we were caught .... it was a real jail, a real jail ... can you believe it?! I never understood why. I will never forget this in my lifetime ... . They used the van for prisoners to send us. It was really too much! I did not break any laws, not at all! You see, I am a citizen, I have my citizenship, and I have my identity! [Male aged 20]

Despite these countless personal hardships and the initial financial disappointment experienced by many, many of the migrants grew to embrace this new lifestyle, with the economic rewards, conveniences, and faster pace:

Working in here, you get yourself fed, and you get money. Working on the farm—to be honest, you got to be so angry—and it was too tiring. And you need to pay this, pay that, this fee, that fee, all kinds of taxes. You have nothing left for living. [Female aged 30]

It is easier to earn money and life is more convenient. [Female aged 29]

Even if I return home, I won’t return to our village, I won’t return to any village. I will stay in a city, like Zhengzhou [capital city of Henan Province]. [Female aged 27]

Conflicts of Traditional Chinese Values and “Modern” Sexuality—“Looks like every body does that [premarital sex]”

Sexual norms and values are changing among some in China. The migrants’ perspectives and experiences represent the wide spectrum of views and behaviors that exist in China at this period of transition, as well as the conflicts and confusion that accompany change in basic cultural values. For many young migrants, living with a girlfriend or boyfriend is a common practice among their peers:

Nowadays, living with girlfriends before marriage is quite common, isn’t it? It is what age now? Now it is ‘Reform and Open-up Society’. Young people won’t think about this too seriously, even though old people might still condemn you. [Male aged 25]

However, some people continue being attached to traditional values, including the concern for women’s virginity, which is highly valued in Chinese traditional sexuality:

I thought about it [having sex with his girlfriend]. But I think if we cannot be together in the future, I would have hurt the girl for the rest of her life. So I controlled my thoughts. People in the city might not care about this, but people from the countryside really do. It [loss of virginity] will ruin her whole life. Villagers are conservative after all, not as open as the urban residents ... Boys are fine, but the girls will suffer big losses; girls can’t afford such loss. [Male aged 20]

Likewise, some women reflected that given the importance placed by society on virginity among brides, the potential costs for a young woman for her future would be too great:

I definitely won’t agree [to have pre-marital sex]. If we do that, and he abandons me in the future, what should I do? Nobody will marry me. [Female aged 20]

Living together without marriage is a big loss of face for the girl. If her family knows this, they would think that this girl went wild outside; and it brings a bad reputation to her family. [Female aged 24]

Speaking to the clash of values between generations, some offered a “compromise” solution:

Cohabitation is very common now, but don’t get pregnant—because parents and other family members in the hometown won’t accept such things. [Male aged 24]

However, pregnancies happen frequently. Pregnancies sometimes resulted in marriage, but many times were ended by abortions:

Some of my friends—about three or four—do cohabitate. They are in stable relationships, and they will get married ... . Most have become pregnant once or twice. They usually get married when they are pregnant. For instance, if they are two or three months pregnant, they will get married at the end of the year. Some go to the hospitals to have abortions. [Male aged 22]

Cohabitation is very common. Few get married, but most cohabitate. Like my two best friends, they live with their boyfriends. One had been pregnant, and then she had an abortion. They had to get rid of the child. My friend was too young and she is still working outside of home. It is impossible to have the child, because she could not raise a child. [Female aged 26]

Commercial Sex Workers—“Misses,” “Mommies,” and “Little White Faces”

Buying and selling sex were frequently reported, although only a small percentage of the respondents reported they had engaged in these behaviors. They referred to commercial sex workers as “misses”:

There are two kinds of ‘misses’. Some only accompany the clients, drinking, chatting, singing and dancing with clients. Some ‘go out’: I do not need to explain that ... [Male aged 21]

Several respondents identified Karaoke bars and hair salons as the work sites for misses; women were said to start working as bar maids and then become linked with clients. “Mommies” are more experienced “misses” who supervise and manage the activities of other “misses.” The “little white faces” are boyfriends of the “misses,” or men who are supported by women:

She is very beautiful. She used to be an excellent student. Her mom had cancer ... there was no way out ... She had to earn money quickly, and eventually became a miss. It has been four years since then. Now she is a mommy, and doesn’t need to work that hard. [Female aged 27]

In this bar, if a client offers 400-500 yuan, he can ask a miss to go out. But the miss needs to pay 100 yuan to the mommy. [Male aged 21]

Little white faces are those who spend women’s money by having sex with the women. They often come to pick up the misses when the misses are off work. The little white faces don’t work. The misses will give them their money. [Male aged 21]

The ages of misses were described as ranging upward from the early teens. Although many were single, some were said to be married:

To be honest, a lot of the women living in this neighborhood are selling sex ... . They all make a living selling sex. And they do that openly, they do that in the name of a hair salon ... . Most of them are married ... They come to make money; their husbands stay home. [Male aged 29]

A girl working in a Karaoke bar in Beijing described her introduction to commercial sex:

The first time it was with a client too. At that time, I was still a virgin [chuckles]. I was 17. The client was same age as me, but he was very rich—very, very rich. Then I thought ‘this man is good’, so I didn’t care—it was making money anyway, so I did it. [Female aged 19]

She further described her experiences of being arrested and her perceptions of the contradictions between the law and reality:’!

When I was in there [the police station], I said to myself, ‘when I get out I will do it never again [engage in commercial sex].’ I felt like I was locked in a big cage, felt like an animal in the zoo. I think what they did was really too much. Sometimes, I think if I were more educated, I definitely would sue them. But now I am not able to do this, to persuade others about these things. It is really contradictory, isn’t it? They allow you to open [Karaoke bars], but they still want to arrest you. Why don’t they just shut down all the Karaoke bars in China, all the bars, there will be no bar and no misses? You allow them to stay open, but you come to arrest them. What is the meaning of this? Or you just seal off all the bars, and then there would be no misses. [Female aged 19]

Some women disclosed frequent encounters with violence and forced sex. A woman working in a bar narrated an episode involving her and her coworkers:

They were all gangsters; they came to take all our misses off. Some misses didn’t want to go; they burned the misses with cigarettes. I was able to escape, but most of the sisters didn’t make it. They [the gangsters] took all the sisters to a garage and raped them. [Female aged 27]

A young man who has been working in the cities for a few years described his friend’s experience with “misses”:

Last year, he had 3000 yuan of year-end bonus, so he went to [name of a part of the city reputed] for misses and stayed there for a week. When he returned, he had spent all his money. He also often goes to the dance club, and knows how to fool girls ... [Male aged 25].

HIV/STI Prevention—“I don’t know what is transmitted. I don’t care. I think I do well with my personal hygiene”

Much fear is expressed regarding STDS and HIV, and knowledge regarding prevention is poor. Although migrants were aware of the risk of disease from “the misses,” misinformation about risks and precautionary measures abounded:

A strong mind to resist it [STD or HIV]. [Female aged 30]

Sterilize everything, the bed sheets, the towels, cups. We have a warning sign at the door [of the sauna], it says ‘STD and AIDS patients stop here’. [Male aged 24]

Only those who are messy in their personal relationships will be infected with STD. [Male aged 25]

Only rich people can be infected with HIV. [Male aged 20]

After a person [with AIDS] dies, you cannot bury him; you have to burn him. You know the virus and bacteria will spread in the air. [Female aged 24]

Although occasionally a respondent would spontaneously cite condoms as a necessary precaution, their role in HIV prevention appeared to be rather poorly understood. Men and women seemed to view “prevention” as primarily concerning pregnancy rather than HIV or STI infection. Thus, if they were protected by an oral or intrauterine contraceptive, they did not feel the need for additional protection:

I already have a girl, then a boy; we don’t want a third one. So I had a ring. No protection is needed. [Female aged 28]

We wanted to have some protection, but she was afraid that her body shape would be distorted by the pills, and was afraid the pills would do harm to the baby in the future. So there is no other protection. [Male aged 25]

Several migrants noted that generally they did not make a conscious decision to refrain from using a condom—they simply didn’t consider it one way or the other:

We don’t even think about protection at all. Because we are all working away from our hometowns, and are very busy, it is really hard to get a chance to meet each other ... who will think of protection at all? Besides, we don’t live together, and there is no appropriate place available. A couple can’t afford to rent an apartment. It must be several people to share a room. If they go to the boy’s home, they are not married yet. It is not good to live in their parents’ home, and thus there is no fixed place. So, they only use condoms very occasionally. [Male aged 24]

I feel it [a condom] is a barrier for the emotional communications between us, I don’t know how to put it. I feel there must be a trust between us. [Male aged 23]

The theme of powerlessness appeared in many of the discussions; migrants in general, women more specifically, and misses operated from a position of limited power. This theme had significant implications for condom use. Women frequently expressed dependency or even helplessness with regard to decisions concerning condoms:

How do I know [where to obtain a condom], I never bought one myself. [Female aged 23]

[Talking about her first sexual experience when she was 20] I was very afraid [to be pregnant], but I knew nothing, very naïive. I didn’t know anything, and I dared not ask others. I myself blushed when I mentioned it. And he knew nothing either. [Female aged 24]

A young wife, whose husband frequently engaged in the services of “misses,” expressed her confusion, knowing that she should protect herself, but believing her assigned role in life was to support her husband:

His women must be those dirty women. So when he is with me, I feel very uncomfortable. So I ask him to use protection. But sometimes I feel I am so weak before him ... I am so below him, I think he has done so much for me, and I should not ask him for more— for such tiny things, you know. I can sacrifice myself for him; I don’t care what others think of me; I just want him to be good to me. If only for those tiny things, and he wants to do [have sex with me], I can’t reject him. I don’t want him to feel upset ... [Female aged 24]

If migrants in general feel a lack of control and females feel underpowered compared to men, the misses in particular have little control over what will happen to them in a sexual encounter. A young male described a recent experience of his friend with a miss.

[His friend reported that:] ‘After the miss and I talked and settled the business, the miss gave me a condom, and I said I wouldn’t use it. Why should I use it? It is not comfortable at all!’ The misses had no choice ... [Male aged 25]

Corroborating this story, a young miss reported that she rarely uses condoms:

It is rare [to use condom]—about once every two or three months ... . For my boyfriend, we are in good relationship ... we know each other very well, so we don’t use [a condom]. [Female aged 19]

HIV-Related Stigma—“See now you got this disease—you really deserve it”

The difficulties and discrimination that the migrants themselves had faced in the cities did not appear to have resulted in increased tolerance or understanding on their part of those succumbing to disease or misfortune. They exhibited strong feelings of rejection for persons infected with HIV or other STDs. Participants provided innumerable stories of the rapid decline in one’s life after infection with a STI:

He got syphilis ... Now nothing good is happening to him. He could not have a second child ... Later on, all people in the village knew what had happened to him .... People said he paid a life time of regret for a short moment of happiness and he lost his reputation. He was able to do nothing good for himself. [Female aged 30]

Everybody was wary of him, people are afraid of being infected. They said ‘he has the disease, so the chair he has sat on, you should not sit on, or you will be infected.’ Everybody is wary of him, and looks down upon him. [Male aged 23]

There are three [STD patients] in my village; all had messed up outside. Among the three, one is single, the other two are married. One got it in Hubei, and he did not tell his wife when he returned home. So his wife got it, and later on, their child got it too. What a big loss of face! His wife had a big fight with him, and he wanted to divorce. The fights were big; and they fought every day. Later on, they divorced. His wife was really upset; she was so upset that she drank pesticide. She drank the poisonous pesticide! There was no way out .... [Female aged 30]

Such intolerance was even explicit within family members. One man related that his sister-in-law had acquired a STI:

All people, including family members and friends looked down upon her. People criticized her for having a messy relationship, saying she deserved it. I myself said the same words to her, I said ‘you should lead a life like a good person, and should not do those kinds of things, see now, you got this disease; you really deserved it!’ [Female aged 35]

Intolerance was expressed as isolation and keeping distance from those infected. When asked if they would allow a friend who had a STI in their homes, many respondents were wary:

I might let him in, but in my heart I will think ’ughhe is sick’; AIDS is certainly horrible ... I will keep a distance [from a patient with HIV] and stand far away from him. [Male aged 23]

If my friend becomes infected [with HIV], I will never talk to her again. It does not mean I will dislike her, but everybody is scared of it. I myself will not talk to her again. But for a STD [other than HIV], I would no longer be as close to her as before. Even if I were to talk with her, I wouldn’t be as close to her. [Female aged 19]

Many respondents also indicated a sense of denial, mixed with self-righteousness:

If my friend gets it? No, it is impossible. I don’t have contacts with such people. [Female aged 24]

I think STDS and AIDS are far away from us because all of my friends are up-righteous. [Female aged 29]

DISCUSSION

Over the last decade, when the young migrants in this study have been reaching their teens and early twenties, China has been experiencing some of the most radical societal changes in its history (Hershatter, 1996). Unable to create a meaningful future for themselves in their rural villages or to legally move to the urban area as a fully enfranchised member of society, and confronted with discrimination in their new surroundings, these young adults have stumbled into the morass of a rapidly changing culture in a society steeped in tradition and a spiraling disease epidemic. These rural-to-urban migrants were raised in a culture of intolerance for premarital and extramarital sex and a culture in which sex was not discussed. The exposure of China to the West has assaulted the Chinese with radically different views on sexuality, but often without benefit of the knowledge of associated risks and protection and without a complete cultural shift that permits open and honest discussions and negotiations (Zhang et al., 1999).

The passive role of females in traditional Chinese culture accentuates the risk faced by women who are not supposed to have knowledge of condom use, to initiate condom use, or insist that their partners use condoms. Therefore, premarital pregnancies and abortions are commonly seen in this group. Women are further compromised by their economic dependency on men—who for a variety of reasons are frequently uninterested in using condoms at this stage in the Chinese HIV epidemic. Their vulnerability is further exacerbated by their mobility, limited awareness of HIV/STI, and perceptions of the stigmatizing nature of the disease. Migration in China is “temporary and circulatory,” in the sense that migrants return periodically to their homes, families, and villages (Wu and Zhou, 1996) and work in different cities. Their mobility can be a catalyst of the spread of HIV and other STDs.

This large array of risk factors has multiplied the vulnerability of the migrant population; thus it is important to have a “holistic” perspective in viewing prevention programs designed to target this population. An intervention must be responsive not only to the individual behaviors, but also to the social forces that drive those behaviors. Migrants urgently need effective HIV prevention education including safe sexual practices such as condom usage, HIV knowledge and awareness training. Education should not only address the migrants in the cities, but also their spouses who remain in the rural areas. Social networks based on kinship and native places suggest that peer education in their rural and urban communities might be especially effective. More importantly, the government should improve the migrants’ welfare and social status by abolishing restrictions for migrants and increasing their access to urban facilities such as housing and medical services.

Certain characteristics of this study may serve as limitations for generalizing the findings from this study. For example, the participants were from a convenience rather than a random sample. However, a real random sample is almost impossible among such a mobile population. Because the characteristics of this sample match other migrant studies, we believe that the experiences reported in these data are typical of the migrant population in China. Nonetheless, it should be noted that the migrant population is as diverse as any other population. Migrants in big cities might be quite different from those in small cities. Even within a single city, migrants from different areas may exhibit wide variations in practices and beliefs. Age, gender, and duration of residence may likewise result in important variations in lifestyle and beliefs.

A substantial challenge for HIV and STI prevention efforts in China will be reaching the rapidly growing migrant population. This study, based on interviews from migrants in two major Chinese cities, has suggested a wide range of “enabling” factors for the growth of the HIV epidemic in China. The economic, social, and legal disenfranchisement felt by the migrants is compounded by their lack of specific knowledge and changing cultures. All of these issues must be addressed in prevention intervention programs in China. There is a significant potential for heterosexual spread of STI/HIV among the migrants and their partners back in their rural villages. The potential for spread of HIV is temporarily limited by the relatively low HIV prevalence rate at present. However, experience from other countries has demonstrated how quickly this rate can escalate and once the tipping point is reached, the epidemic quickly spirals out of control (Anderson et al., 2003). There is an urgent need to develop and implement culturally appropriate HIV/STI prevention programs targeting this vulnerable population.