title: Prevalence and associated factors of condomless receptive anal intercourse with male clients among transgender women sex workers in Shenyang, China.
abstract: Globally, transgender women sex workers have a high prevalence of HIV and condomless receptive anal intercourse with male clients (CRAIMC). We investigated the prevalence of CRAIMC and factors associated with CRAIMC among transgender women sex workers in China.
  
  
  
  In 2014, we anonymously interviewed 220 transgender women sex workers face to face in Shenyang, China. Those who self-reported as HIV negative or as having unknown HIV serostatus were invited to take up free, anonymous HIV rapid testing (n=183); 90 did so. Using CRAIMC in the last month as the dependent variable, three types of associated factors were investigated, in addition to background factors: feminizing medical interventions, sex work and perceptions related to condom use. Univariate and multiple logistic regression models were fitted.
  
  
  
  Of the participants, 16.8% self-reported as HIV positive and 9.1% were detected to be HIV positive through free HIV testing; 26.8% had had CRAIMC in the last month, 45.5% had performed sex work in other Chinese cities (last year), and 23.2% had had condomless anal intercourse with men who were non-clients. In the adjusted analysis, significant factors associated with CRAIMC (last month) included the following: 1) any feminizing medical intervention performed (adjusted odds ratio, AOR: 2.22); 2) sex-work-related factors, including recruitment of male clients most often at hotels (AOR: 5.02) and charge per episode of transactional sex (201 to 400 RMB, AOR: 0.27; reference group: ≤100 RMB); and 3) perceptions related to condom use, including perceived transgender identity's impact on condomless sex such as wearing feminine attire, concern about exposing their status as a transgender woman to male clients (AOR: 1.20) and perceived self-efficacy of consistent condom use with male clients (AOR: 0.56). Perceived self-efficacy of consistent condom use with male clients fully mediated the association between perceived transgender identity's impact on condomless sex and CRAIMC.
  
  
  
  HIV prevalence among transgender women sex workers was high but probably underestimated. The high prevalence of condomless anal intercourse with male non-clients and high mobility in sex work among this population in China are causes for concern. Risk factors for CRAIMC were multidimensional and should be considered when designing interventions targeting transgender women sex workers. Such interventions are urgently needed.
authors.affiliation: Department of Community Health and Family Medicine, School of Public Health, Shanghai Jiao Tong University, Shanghai, China.
authors.forename: Yong
authors.initials: Y
authors.lastname: Cai
authors.affiliation: Centre for Health Behaviours Research, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.|Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China.
authors.forename: Zixin
authors.initials: Z
authors.lastname: Wang
authors.affiliation: Centre for Health Behaviours Research, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.|Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China; jlau@cuhk.edu.hk.
authors.forename: Joseph Tf
authors.initials: JT
authors.lastname: Lau
authors.affiliation: Centre for Health Behaviours Research, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.
authors.forename: Jinghua
authors.initials: J
authors.lastname: Li
authors.affiliation: Shenyang Consultation Centre of AIDS Aid and Health Service, Shenyang, China.
authors.forename: Tiecheng
authors.initials: T
authors.lastname: Ma
authors.affiliation: Shenyang Consultation Centre of AIDS Aid and Health Service, Shenyang, China.
authors.forename: Yan
authors.initials: Y
authors.lastname: Liu
mesh_terms: D000293:Adolescent; D000328:Adult; D002681:China / Q000453:epidemiology; D017280:Condoms / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000453:epidemiology*; D006801:Humans; D016015:Logistic Models; D008297:Male; D015995:Prevalence; D011477:Sex Work; D012725:Sexual Behavior; D063106:Transgender Persons; D047568:Unsafe Sex; D055815:Young Adult
keywords: China; HIV infection; associated factors; transgender women sex workers; unprotected anal intercourse