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Literature review on HIV and AIDS, education and marginalization

The theme of the 2010 GMR on Reaching and Teaching the Most Marginalized has particular relevance for the IATT on Education as marginalization is a cause of HIV risk and vulnerability, and often a consequence of being HIV-positive. Children affected by AIDS can face particular challenges in accessing educational opportunities, ensuring regular school attendance, and continuing their studies. Teachers are given an important responsibility in ensuring that children and young people acquire essential knowledge, skills and attitudes for HIV prevention. Moreover, in higher prevalence settings teachers are seen as pivotal in ensuring that pupils affected and infected as a result of the epidemic have access to care and support. In a meeting with members of the GMR Team in February 2009, the following areas of input were suggested: Children affected and infected by HIV and AIDS as a significant group of the most marginalized; Examination of the education policy, teaching and learning processes and curricula - their marginalizing and de-marginalizing impact on learners in a world with HIV and AIDS; Estimating the teaching needs, costing the efforts to reach the most marginalized, due to HIV and AIDS; Teachers as learners i.e. how training programmes are or are not preparing teachers to teach the most marginalized; Schools as centres for care and support for those marginalized by HIV and AIDS - service provision and referral. This document responds to these suggested areas of input, and includes: A synthesis of related evidence and programmatic experience; Suggested figures and tables; Case studies from different regions and on different thematic areas; A full reference list for further consultation.

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Home > TMC > DISSERTATIONS > Literature review of estimation of prevalence rate of HIV/AIDS in India using population survey and sentinel surveillance based data

Literature review of estimation of prevalence rate of HIV/AIDS in India using population survey and sentinel surveillance based data

Kanan Garg , The University of Texas School of Public Health

HIV/AIDS is a treatable although incurable disease that presents immense challenges to those infected including physical, social and psychological effects. As of 2009, an estimated 2.4 million people were living with HIV or AIDS in India, 0.3% of the country's population. In India, it is difficult to not only treat but also to track because it is associated with socio-economic factors such as illiteracy, social biases, poor sanitation, malnutrition and social class. Nevertheless, it is important to know the prevalence of HIV/AIDS for several reasons. At the individual level, the quality of life of people living with HIV/AIDS is markedly lower than their counterparts without the disease and is associated with challenges. At the community level, it is important to identify high risk groups, monitor prevention efforts, and allocate appropriate resources to target programs for the reduction of transmission of HIV.

Subject Area

Epidemiology|South Asian Studies

Recommended Citation

Garg, Kanan, "Literature review of estimation of prevalence rate of HIV/AIDS in India using population survey and sentinel surveillance based data" (2012). Texas Medical Center Dissertations (via ProQuest) . AAI1518774. https://digitalcommons.library.tmc.edu/dissertations/AAI1518774

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Health care workers and HIV/AIDS: a critical review of the literature

• PMID: 8607045
• DOI: 10.1016/0277-9536(95)00030-b

This paper reviews the extensive literature which looks at the impact of HIV/AIDS on health care workers (HCWs). The knowledge and attitudes of HCWs toward people with HIV/AIDS and other relevant attitudes, for example those regarding male homosexuality have been widely studied whereas attitudes to intravenous drug use are perhaps under-investigated. Three major themes of the literature are examined. These are fear of infection, beliefs about the right to refuse care and the stresses associated with caring for HIV positive people. A number of educational interventions which attempt to change HCWs attitudes and beliefs are reviewed. Some notable gaps in the literature are identified. Neglected areas include attitudes to women, people of colour and consideration of the organizational and societal factors mediating the impact of HIV upon healthcare workers. Limitations of the research techniques used are identified and future implications for health care workers are considered.

Publication types

• Acquired Immunodeficiency Syndrome / psychology
• Empirical Research
• HIV Infections / psychology*
• HIV Infections / transmission
• Health Knowledge, Attitudes, Practice*
• Health Personnel / education
• Health Personnel / psychology*
• Infectious Disease Transmission, Patient-to-Professional
• Information Dissemination
• Internationality
• Refusal to Treat

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HIV/AIDS Behavioral Interventions in China: A Literature Review and Recommendation for Future Research

Department of Social and Behavioral Health, School of Rural Public Health, Texas A&M Health Science Center, 1266 TAMU, College Station, TX 77843, USA

Xiaoming Li

Prevention Research Center, Carman and Ann Adams, Department of Pediatrics, School of Medicine, Wayne State University, Michigan, USA

In the past two decades, China has witnessed an alarming increase of HIV/AIDS epidemic. Meanwhile, a number of HIV prevention interventions have been conducted. This study reviews existing studies in literature on behavioral interventions on HIV/AIDS in China. Of 25 studies we identified, most have been concentrated in South and South–West China, mainly targeting injection drug users and female sex workers. The most commonly used intervention strategy was individual-oriented HIV-related knowledge education and behavioral skill training. All studies reported positive intervention effects including improved HIV-related knowledge, increased condom use, reduced needle sharing, and reduced STI. Literature also suggests a lack of intervention among other at-risk populations such as MSM, migrant workers, and non-injecting drug users, lack of studies with rigorous evaluation design, inadequate follow-up, limited outcome measurement, and lack of multi-faceted structural interventions. The existing intervention studies document strong evidence of controlling HIV/AIDS epidemic through effective behavioral intervention. More efforts are needed to control the growing HIV/AIDS epidemic in China. Future studies need to employ more rigorous methodology and incorporate environmental or structural factors for different populations at risk of HIV infection in China.

Introduction

The second and third decades of the AIDS epidemic have witnessed substantial progress in the primary and secondary prevention of HIV/AIDS, including behavioral risk reduction interventions, early detection programs, and sustained treatment initiatives ( UNAIDS 2007 ). Over the past decade, there has been a precipitous decline in deaths due to HIV/AIDS in the US and other developed countries, attributable to advances in both treatment and prevention ( Holtgrave 2005 ). However, in the most populous country of China, the HIV virus is still spreading rapidly. In the past two decades, China has witnessed an alarming increase of HIV epidemic, as the number of HIV infection cases has been increasing by more than 30% annually ( Grusky et al. 2002 ). In 2007, the Chinese Ministry of Health reported in its biennial HIV/AIDS epidemic update that the estimated number of HIV infection cases had reached 700,000, and exhibited new epidemiological trend ( China Ministry of Health (CMOH) & World Health Organization (WHO) 2007 ). Historically, intravenous drug use (IDU) and commercial blood/plasma collection were the primary sources of HIV infection in China; but in recent years, infection through sexual transmission is growing the fastest. Sexually transmitted cases have increased from 7.2% in 2002 to 43.6% in total infections by the end of 2005 ( CMOH et al. 2006 ). In 2007, heterosexual transmission of HIV has accounted for 44.7% of new infection cases and become the dominant mode of HIV transmission. Meanwhile, the infection rate among men who have sex with men (MSM) is increasing rapidly. Although the proportion of reported HIV/AIDS cases attributable to IDU decreased, HIV prevalence among IDUs increased ( Liu et al. 2006 ). Overall, the male to female ratio of the HIV infected is decreasing, and there is a notable shift in the HIV epidemic from rural to urban, from ethnic minorities to the majority Han ( China Ministry of Health (CMOH) & World Health Organization (WHO) 2007 ). The number of persons infected may be comparatively low for a country of 1.3 billion population; but the continuously growing HIV epidemic and the new epidemiological trend suggest the necessity and urgency of firmer actions and more effective programs.

In the past twenty more years, the Chinese government has gradually shifted from a denial attitude to a more pragmatic and positive attitude toward the HIV/AIDS epidemic. At the first decade of the epidemic (1985–1995), the government had taken a denial attitude toward the disease of “western imperialism” ( Gil 1991 ). A “rehabilitation approach” that was instituted in Maoist era continued to dominate HIV/AIDS prevention and control. Commercial sex workers and drug users were sent to “reeducation centers” or “rehabilitation centers”. Anyone diagnosed with HIV/AIDS was prohibited from entering China or moving within China. Persons living with HIV/AIDS were deprived of their rights of employment, marriage and having children. Homosexual activities were severely stigmatized; carrying condoms was evidence for commercial sex and could lead to an arrest. Despite these strict punitive approaches, HIV virus continued to spread rapidly. Chinese government therefore had received considerable criticism for its response to the epidemic. In 1998, the “Principles for STI/HIV Education and Prevention Messages” was issued jointly by the Ministry of Health and eight other ministries, which indicated that the government was taking a more pragmatic attitude toward the epidemic ( Wu et al. 2007a ). The basic tenet of HIV prevention was knowledge education, assuming people would change their behaviors with better awareness and knowledge. Meanwhile, drug use and commercial sex remained two of the “social evils” that were subject to “fierce crack downs”. With increasing pressure from the growing HIV/AIDS epidemic and from the international community, the Chinese government issued a “Plan of Action for Containment and Control of HIV/AIDS” in 2001 ( Wu et al. 2007a ), which signified the government’s strong commitment to fight the epidemic. Along with the policy shift, increasing funding through central government and international organizations was apportioned, and a number of harm reduction and HIV prevention programs were initiated and gradually scaled-up. In 2006, the “Regulations on AIDS Prevention and Treatment” was issued; it highlighted the prevention intervention among the high-risk populations such as MSM, IDU, sex workers, and former blood/plasma donors (FBD). More programs were implemented since then, including condom promotion, methadone maintenance treatment (MMT), free needle exchange for IDUs, “four free and one care” for HIV positive individuals.

Within such a historical context, over the past 10 years, public health professionals and behavioral scientists have conducted a number of HIV prevention intervention projects. Started in the areas of high HIV prevalence such as Yunnan and Guangxi targeting high risk populations such as IDUs and FSWs, various intervention programs have gradually been implemented in other areas targeting more at-risk populations. For example, in 1996–1997, the National Center for AIDS/STD Prevention and Control in China conducted one of the first community-based trials of HIV prevention intervention, in which condom use was promoted among FSWs ( Wu et al. 2007b ). The study demonstrated feasibility and efficacy of such programs and as a result, condom use has been officially promoted to control the spread of HIV and other STIs among FSWs since 1998 ( Wang 2007 ). Following the initial trial, a larger trial was conducted in multiple sites, which informed the development of guidelines for conducting condom promotion among FSWs nationwide ( Rou et al. 2007 ; Wang 2007 ). The accumulative literature in the past decade has provided preliminary but strong data for controlling the HIV epidemic through effective prevention interventions ( Detels et al. 2007 ).

Even though a remarkable progress in China’s response to the HIV/AIDS epidemic has been made in the past decade, to date, there is no systematic review of the published studies on HIV/AIDS intervention in China. At the critical moment when the global HIV/AIDS epidemic levels off while China’s HIV/AIDS epidemic keeps growing, it is important to review the existing HIV/AIDS intervention efforts and make recommendations for future research. Accordingly, this study systematically reviews literature on HIV/AIDS intervention studies in China with the following objectives: (1) synthesize the published literature on HIV intervention studies in China; (2) compare and summarize the key components of the intervention studies, including location, sampling, design, intervention strategies, and intervention outcomes; and (3) identify gaps in existing literature and make recommendations for future research.

A comprehensive literature search was conducted to identify studies that meet the following selection criteria: (1) studies published in peer-reviewed journals prior to April 2008, (2) HIV/AIDS intervention studies conducted in China (mainland), and (3) empirical studies that report at least one of the following HIV-related outcomes: HIV-related knowledge and perception, sexual practice, condom use, drug use, infection of HIV or STI. Those studies that merely describe the development, implementation or process evaluation of the HIV intervention programs were not included.

Studies were retrieved from the following electronic databases: PubMed, AIDSLine, EBSCO, PsycInfo, and FirstSearch. Each database was searched using various combinations of the following keywords: China, HIV, AIDS, STI(STD), intervention, evaluation (evaluate), effect (effectiveness). In addition, we hand-searched articles from reference sections of the articles regarding HIV/AIDS in China.

A total of 25 articles that met the above selection criteria were identified, among which three were published in Chinese (with English abstract). We herein synthesize and compare the core components of the 25 existing studies, including study locations, target populations, sampling and design, intervention strategies and intervention effects.

Study Location

Table 1 lists the key characteristics of the identified 25 HIV/AIDS intervention studies in China. All of these studies were published between 2001 and 2008, with a majority of them being published in 2007 and beyond. Most of the studies were conducted in the areas with high HIV prevalence such as Guangxi, Guangdong, Sichuan (four studies each), Yunnan, Anhui, and Shanghai (three studies each). Other areas included Jiangsu (two studies each), Hainan, Xinjiang, Beijing, Fujian, Henan, and Hubei (one study each).

HIV/AIDS interventions in China

Intv: Intervention group; Cntl: Control group. PY: person year; FSW: female sex workers; IDU: injection drug users; MSM: men having sex with men; Quasi-exp: quasi-experimental study; FU: follow-up; 6 m: 6 months; VCT: Voluntary Counseling and Testing; NGO: Non-government organization

Target Population

FSWs and IDUs were the main target populations of intervention. Among 25 studies, eight studies targeted FSWs ( Ma et al. 2002 ; Lau et al. 2007 ; Li et al. 2006 ; Liao et al. 2006 ; Rou et al. 2007 ; Wu et al. 2007b ; Yang et al. 2005 ; Zhongdan et al. 2008 ), seven studies targeted IDUs ( Chen et al. 2007 ; Des Jarlais et al. 2007 ; Lau et al. 2008 ; Lin et al. 2004 ; Pang et al. 2007 ; Wu et al. 2007a ; Zhao et al. 2005 ), one study targeted HIV sero-discordant couples ( Yang et al. 2001 ), one for health workers ( Wu et al. 2002a ), and one for MSM ( Gao and Wang 2007 ). The remaining eight studies targeted the general population, including four for youths or students ( Cheng et al. 2008 ; Li et al. 2008 ; Tian et al. 2007 ; Wang et al. 2005 ), two for general villagers in the areas with high HIV prevalence ( Tian et al. 2007 ; Wu et al. 2002a ), one for pregnant women ( Khoshnood et al. 2006 ), and one for female factory workers ( Qian et al. 2007 ).

Most of the studies recruited participants from the communities, through convenience or snow-ball sampling, with a few studies recruited participants from in-patient detoxification treatment programs ( Zhao et al. 2005 ) and classrooms ( Cheng et al. 2008 ; Li et al. 2008 ; Wang et al. 2005 ). The sample sizes varied from 90 to 1200. Most of the quasi-experimental studies with open cohorts used community as the unit of group assignment (intervention vs. control) and outcome evaluation ( Lau et al. 2007 ; Lau et al. 2008 ; Lin et al. 2004 ; Tian et al. 2007 ; Wu et al. 2002a ; Wu et al. 2002b ; Wu et al. 2007a ).

The majority of the studies (14 out of 25) utilized an open-cohort sample. In these studies, participants who completed the baseline survey and received the interventions might not be those who completed the post-intervention surveys; the participants of the post-intervention survey were recruited from the communities where the intervention was implemented.

Among the 25 intervention studies, only 11 studies employed closed-cohort sampling strategies for pre- and post-intervention surveys. Among the 11 studies with closed-cohort samples, six studies were conducted among general populations, including three studies among students or youths ( Cheng et al. 2008 ; Li et al. 2008 ; Wang et al. 2005 ), one among factory female workers ( Qian et al. 2007 ), one among pregnant women attending pre-natal clinics ( Khoshnood et al. 2006 ), and one among IDUs in an in-patient detoxification treatment program ( Zhao et al. 2005 ). Only five closed-cohort studies were conducted among hard-to-reach populations such as IDUs and FSWs. These five studies included HIV knowledge education and condom promotion program among 90 HIV sero-discordant couples with a 12-month follow-up rate of 93% ( Yang et al. 2001 ), an HIV/STI risk reduction education and STI testing and treatment among 966 FSWs recruited from STI clinics in Guangzhou with a 6-month follow-up rate of 53% ( Ma et al. 2002 ), a Voluntary Counseling and Testing (VCT) intervention among 400 establishment-based FSWs in Guangxi with a 6-month follow-up rate of 68% ( Li et al. 2006 ), a peer-led HIV risk reduction education among 160 MSM with a 5-month follow-up rate of 75% ( Gao and Wang 2007 ), and a VCT intervention among 226 IDUs in Guangxi with a 3-month follow-up rate of 96% ( Chen et al. 2007 ).

Study Design

Among the 25 intervention studies, 13 studies utilized a single group pre-post study design; the remaining 12 studies utilized a quasi-experimental design with assignment of intervention and control groups. Among the 12 quasi-experimental studies, two studies did not report baseline data but only post-intervention survey results ( Wu et al. 2002a , b ). Most ( n = 19) of the studies reported a single time point follow-up with the follow-up periods ranging from 3 to 18 months. Only six studies reported multiple follow-ups, including four studies with two follow-ups ( Lau et al. 2007 ; Lau et al. 2008 ; Ma et al. 2002 ; Pang et al. 2007 ) and two studies with four or five follow-ups ( Des Jarlais et al. 2007 ; Zhongdan et al. 2008 ). Among these studies with multiple follow-ups, the periods of follow-up varied from 6 to 36 months.

Intervention Strategies

A majority of the existing studies (20 out of 25 or 80%) utilized HIV knowledge and risk reduction education as the intervention approach. Among the 20 HIV education interventions, most were venue-based interventions targeting different audiences. For example, three studies were classroom-based education targeting students or youths ( Lau et al. 2008 ; Li et al. 2008 ; Wang et al. 2005 ). Five were clinic-based education for FSWs, pregnant women, or in-patient IDUs ( Khoshnood et al. 2006 ; Liao et al. 2006 ; Ma et al. 2002 ; Rou et al. 2007 ; Zhao et al. 2005 ). Three were venue-based education for establishment-based FSWs ( Li et al. 2006 ; Wu et al. 2007b ). There were also work-place-based education for factory workers ( Qian et al. 2007 ), gay bar-based education for MSM ( Gao and Wang 2007 ), in-house education for HIV sero-discordant couples ( Yang et al. 2001 ), web-based education for villagers and students ( Tian et al. 2007 ).

To make the traditional intervention approach of HIV knowledge education more effective, several studies enhanced the intervention with components that were responsive to the risk profile of the target population. For example, interventions to reduce sexual risks among FSWs often included the components of STI testing and treatment ( Li et al. 2006 ; Ma et al., 2002 ). Some interventions were delivered via “train the trainers” or peer-led education approaches ( Wu et al. 2002a ; Gao and Wang 2007 ).

Several studies utilized internationally validated intervention programs including VCT ( Chen et al. 2007 ; Khoshnood et al. 2006 ; Li et al. 2006 ), MMT ( Pang et al. 2007 ), needle exchange program (NEP) ( Des Jarlais et al. 2007 ; Lin et al. 2004 ; Wu et al. 2007a ), 100% condom use program (100% CUP) ( Yang et al. 2005 ; Zhongdan et al. 2008 ). All of these programs have been adapted to fit the local population in China.

Intervention Effects

All studies reported significant positive intervention effects, and most studies reported improved HIV knowledge among the participants (for closed cohort studies) or the intervention communities (for open-cohort studies). A majority of studies reported behavioral indicators including 14 studies reporting significant increase in condom use rates. For example, in the study with HIV sero-discordant couples, the consistent condom use rate increased from 2.6% to 71.4% ( Yang et al. 2001 ). The study among FSWs in Guangzhou reported an increase of consistent condom use rate from 30% at baseline to 81% at 6-month follow-up ( Ma et al. 2002 ). The study among establishment-based FSWs in Wuhan reported that condom use in the last sex encounter increased from 60% at baseline to 88.5% at 21-month post-intervention ( Zhongdan et al. 2008 ). Studies targeting IDUs all reported intervention effects in reducing rates of needle-sharing. For example, the NEP in Guangdong Province reported that needle sharing in last month dropped from 48.9% to 20.4% in the intervention group ( Lin et al. 2004 ). The HIV risk reduction education program among IDUs in Sichuan has resulted in a decrease of sharing needles from 54% to 19% ( Lau et al. 2008 ). After the VCT, IDUs in Guangxi reported higher rates of condom use and lower rates of needle sharing (45% to 24%). The MMT program in Sichuan led to a reduction of needle sharing from 69% at baseline to 9% at 12-month follow-up ( Pang et al. 2007 ).

A total of eight studies reported bio-markers, including HIV prevalence for five studies ( Des Jarlais et al. 2007 ; Lin et al. 2004 ; Pang et al. 2007 ; Wu et al. 2007a ; Yang et al. 2005 ), four of which were targeting IDUs, and one targeting FSWs. Three studies reported STI ( Ma et al. 2002 ; Li et al. 2006 ; Zhongdan et al. 2008 ), all of which were targeting FSWs. Two studies reporting HIV among IDUs also reported HCV as additional biomarkers ( Lin et al. 2004 ; Wu et al. 2007a ). Most of the interventions led to lower rates of HIV or STI. For example, after the 100% CUP in Jiangsu, the STI rates among local FSWs decreased from 25% to 14% ( Yang et al. 2005 ). The VCT among FSWs in Guangxi led to a higher reduction of STI prevalence in intervention group (44–29%) than control group (44–41%) ( Li et al. 2006 ). The NEPs in China–Vietnam border led to a decrease of HIV prevalence (from 16 to zero per 100 person year) and estimated HIV incidence (from 11 to zero per 100 person year) ( Des Jarlais et al. 2007 ). However, one study reported higher Chlamydia rate in post intervention survey than in pre-intervention, which might be due to open-cohort sampling strategy ( Zhongdan et al. 2008 ).

Existing published studies in the literature document the initial success of HIV/AIDS behavioral prevention intervention in China in the past decade. Effective HIV/AIDS interventions have been conducted in at-risk populations such as FSWs and IDUs as well as general populations such as students and villagers. All studies in this review have reported significant positive intervention effects in increasing HIV-related knowledge, increasing rates of condom use, decreasing rates of HIV risk behaviors, and/or decreasing rates of STI. These findings suggest the potential of behavioral intervention in reducing HIV-related risks and controlling HIV/AIDS epidemic in China.

However, existing studies are limited in numbers and scope in relation to the scale of AIDS epidemic and the size of the population in China. A recent WHO systematic review of behavioral interventions targeting adolescents and young adults in developing countries identified 22 school-based studies ( Kirby et al. 2006 ) and 22 community-based behavioral studies ( Maticka-Tyndale and Brouillard-Coyle 2006 ) that employed experimental or quasi-experimental designs, but none of these studies was conducted in China. The China Ministry of Health recently acknowledged that “target (HIV) intervention work for high-risk population remains stuck at the stage of pilot programs with low coverage” ( CMOH et al. 2006 ).

Of 25 identified studies in this review, all were published after 2001; and a majority of the studies (14 out of 25) were published in 2007 and beyond. Although most of the studies were published within 2 to 3 years after the projection conclusion, we observed some big temporal gap between project conclusion and publication. Some studies were published 5 to 6 years after the study, some were 10 years later. As a matter of fact, one of the first community-based HIV prevention programs was started in 1996–1997 but was not published until 2007 ( Wu et al. 2007b ). Given the changing epidemic and the changing characteristics of the target population and the study site, we call for more speedy data reporting and up-to-date information of the intervention studies.

The limitation in number and scope of the existing HIV/AIDS prevention interventions was exhibited in other aspects, such as limited geographic and population coverage. Even though most of the studies were concentrated in the areas with high HIV prevalence such as Guangdong, Guangxi, Sichuan, Yunnan, and Anhui, the existing literature suggests a geographic concentration which may not appropriately reflect the geographic variation of HIV/AIDS epidemic in China. For example, Xinjiang is a region with the highest HIV infection rate among IDUs compared to other regions, but only one study was reported, and it was one small-scale VCT program among pregnant women attending prenatal clinics ( Khoshnood et al. 2006 ). Take Henan as another example, it is a province with the biggest number of FBD; however, only one study was conducted in Henan, which was a life-planning skill training for high school students ( Cheng et al. 2008 ). Only one study was reported from Beijing (a site of a five-city trial) ( Rou et al. 2007 ), the capital city and one of the largest metropolitans in China. There was also a lack of data in Northern China, northwest China and northeast China. As the HIV virus has spread in all 31 provinces in China, future HIV/AIDS interventions need to be conducted in more diverse locations and multiple sites to reflect the wide geographic variations of the epidemic in China. We also note that a big number of the studies were conducted and reported by China-CDC, and there is a need for a more diversified approach that involves local communities, particularly in the areas most affected by the epidemic.

Likewise, there is a lack of heterogeneity in target population. The existing interventions have been primarily concentrated on FSWs (eight studies) and IDUs (seven studies), and with limited data regarding other at-risk populations such as MSM, FBD, HIV sero-discordant couples, migrant workers, male sex workers, and clients of sex workers. In addition, studies are needed to target some groups with multiple risks, for instance, sex workers who are also drug users, FBD who are also engaged in commercial sex.

In addition, there is a lack of cost-effective analysis in the existing literature. Cost-effective analysis can provide convincing evidence that HIV/AIDS prevention intervention is not only efficacious but can produce large economic gains. Such evidence will be conducive to resource allocation, particularly in resource-poor settings. It will also convince the local government to facilitate the collaboration between law enforcement and public health agencies.

Another aspect of the limitation in scope is the lack of scale-up studies. Recently, the Chinese government has started a series of ambitious government-sponsored harm reduction programs. For example, MMT and NEP have moved from pilot stage to scale-up nationwide, and each will have 1,000 programs in 2008 ( Sullivan and Wu 2007 ). Preliminary data regarding the program implementation have been reported ( Liu et al. 2007 ; Sullivan and Wu 2007 ), but evaluation data regarding the effectiveness of the scale-up programs such as their impact on rates of national or regional HIV prevalence were not yet available. We call for evaluation reports of these scale-up programs, ideally from multiple sites.

Such limitations in number and scope in HIV/AIDS prevention intervention studies in China may be attributable to two reasons. First, there may be a potential publication bias in the literature we reviewed. It was possible that only those intervention studies that reported positive intervention effects were reported and published. Second and more importantly, the current limitation in HIV/AIDS prevention intervention studies in China may be mainly the results of limited training and research capacity to conduct field-based (particularly community-based) HIV prevention intervention in China. As several experts pointed out, lack of professional personnel, particularly at local levels, is one of biggest challenges in controlling HIV/AIDS epidemic in China ( He and Detels 2005 ; Wu et al. 2004 ). Therefore, capacity-building in conducting field-based HIV behavioral intervention needs to be prioritized in China’s national agenda of HIV/AIDS epidemic control.

Current studies also revealed some methodological limitations, which represent the lessons learned over the past decade and gaps in the empirical endeavors to explore effective HIV/AIDS behavioral interventions in China.

First, there is a lack of strong sampling strategies that recruit participants to better represent the target populations. The sampling strategies of the existing studies have primarily been convenience sampling or snow-balling sampling, which might not reflect the heterogeneity of the target populations. For example, the studies targeting FSWs have mostly recruited their participants from entertainment establishments. FSWs in China are a heterogeneous group and operate in a multiple-layer hierarchy. FSWs working in the entertainment establishments are in the middle of the spectrum and may be the most accessible group ( Hong and Li 2007 ). FSWs working in the streets or construction sites may be at higher risks of HIV but there is virtually no interventions designed for them. We should acknowledge that several studies targeting IDUs have employed multi-site recruitment (i.e., participants were recruited from several towns or districts across cities or even provinces). Such strategy has demonstrated feasibility and efficacy of implementing standardized programs in different settings.

Second, few studies reported the theoretical framework of the intervention programs. Several studies employed theory-based programs that were proven effective in Western settings (e.g., VCT), few of them reported the cultural adaption process which has been shown critical in adaption of effective programs in different cultural settings ( Wingood and DiClemente 2008 ). One exception was Li and colleagues’ study among college students in Nanjing ( 2008 ), which specifically delineated the theoretical framework and the cultural adaption process of the intervention program “Focus on Kids”. International literature suggests that studies that were built upon validated theories could deliver effective and sustainable effects ( Stanton et al. 1996 ). Future studies need to employ culturally appropriate theoretical framework to guide the design and implementation of the intervention programs.

Third, there is a limited number of intervention studies that utilized rigorous evaluation methodology (i.e., randomized controlled trial [RCT] or quasi-experimental design). The majority of the studies utilized single group pre-post design or open-cohort design. In community-based HIV prevention intervention, it is a challenge to conduct rigorous RCT. However, several studies have demonstrated feasibility of quasi-experimental design in which the community is the unit of randomization. Some studies evaluated the intervention effect with an open cohort, but without appropriate control of other potential confounders related to the individual, community, and social context of the risk behaviors. Another limitation in research design is the limited follow-up periods which could not demonstrate the long-term effect of the intervention. The majority of the study reported single follow-up with follow-up periods being less than 12 months. Only few studies reported multiple follow-ups or longer periods of follow-up. Future intervention efforts need to employ more rigorous evaluation design with a long-term follow-up.

Fourth, there is a lack of multi-faceted structural interventions. Most of the existing studies have employed individual-oriented HIV knowledge and risk reduction education. Some intervention programs such as “train the trainer” knowledge education, peer-led education, needle social marketing have followed the theories of social network and social norms to disseminate the preventive messages. However, only a limited number of studies have employed structural intervention approaches to address the interpersonal, community and environmental factors. Global literature on HIV/AIDS intervention suggests that multi-faceted or multi-component programs can be more effective than individual-oriented interventions ( Latkin and Knowlton 2005 ). We look forward to a bigger variety of intervention strategies in the future studies.

Fifth, there are limitations in outcome measurement. Only a small number of the existing studies employed biomarkers (current HIV or STI infectious status) as outcome measurements while the majority relied on self-report behavioral outcomes (e.g., condom use, drug use). Self-reported data are subject to many potential biases including recall errors or socially desirable responses. We therefore recommend collecting biomarkers in addition to behavioral measures to validate the effectiveness of the intervention. In addition, among the existing studies that reported behavioral outcomes such as condom use and needle sharing, the measures of these behavioral outcomes varied considerably, which made the comparison across studies difficult. Take condom use as an example, several studies have reported rates of consistent use, while some studies reported rates of ever use; some studies reported condom use in the last three sex acts, while some reported condom use in the last sex act. To increase the accuracy of measurement and comparability of findings across different studies, we recommend intervention studies use culturally appropriate and population-specific standard measures of HIV-related behaviors or at least include an “anchor” set of standardized measures on key behavioral outcomes (e.g., condom use, drug use, needle sharing) for similar study populations.

Sixth, very few studies reported the sustainability of the intervention. One exception was Liao and colleagues’ study among FSWs in Hainan, in which the intervention program was developed into a long-term community-based program for local FSWs ( Liao et al. 2006 ). Future research needs to consider how the intervention program can be developed into a sustainable policy or program for the target population.

To summarize, this study reviews the existing HIV/AIDS intervention studies in China. The significant positive outcomes of the 25 studies provide strong evidence that the HIV/AIDS epidemic in China can be controlled through effective prevention intervention. Existing literature documents the remarkable progress China has made since the past decade; it also suggests a number of areas that need to be improved in the future efforts, particularly in theoretical framework, research design, sampling methodology, and measurement. The HIV/AIDS epidemic in China displays unique epidemiological patterns with low overall infection rates but high prevalence among certain high-risk populations with distinctive geographic variations. Such unique epidemiological characteristics suggest both an urgency of firmer actions and a number of challenges for the implementation of such actions. These challenges include a lack of commitment and collaboration at local government levels, insufficient personnel and infrastructure at local levels, lack of management and evaluation strategies of the nationwide programs, and a strong stigma against HIV/AIDS in the general public and even among the policy makers, health care professionals, and law enforcement agencies ( Detels et al. 2007 ; Wu et al. 2007a ). However, with strong government commitment and the growing experiences from HIV/AIDS interventions in the past decade as documented in the literature and this review, the nation has demonstrated its determinations of controlling the epidemic. Future HIV/AIDS intervention studies that address the above literature gaps will contribute to the efforts to achieve the goal.

Acknowledgments

This study was supported in part by NIH Research Grants R01MH76488 and R01NR10498 by the National Institute of Mental Health and the National Institute of Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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Yan Hong, Department of Social and Behavioral Health, School of Rural Public Health, Texas A&M Health Science Center, 1266 TAMU, College Station, TX 77843, USA.

Xiaoming Li, Prevention Research Center, Carman and Ann Adams, Department of Pediatrics, School of Medicine, Wayne State University, Michigan, USA.

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