Are Wives of Gay Men Becoming the Next Target of HIV Infection in China?

Abstract

To the Editor Homosexual exposure has become the primary route of HIV transmission in China.1–4 National HIV prevalence among men who have sex with men (MSM) was 6.3% in 2011,5 a 4.5-fold increase from 1.4% in 2001.6 Most (87.0%) infected cases remained undiagnosed.7 Marriage is a social, cultural, and familial obligation in China.8 Among the 3.1 to 6.3 million Chinese MSM,9 17% is currently married to a female, leading to a tongqi (“wives of MSM” in Chinese) population of 0.5 to 1.1 million.10 The actual population size would be much larger (2.5–5.0 million) because more than 80% Chinese MSM would eventually enter a heterosexual marriage during their lifetime.11 Tongqi is highly vulnerable to HIV infection owing to their unprotected sexual contacts with their highly at-risk husbands.10,12 Unprotected sex is naturally a mean for reproduction but also an important indication of husbands’ fidelity to their wives.13 Chinese women are not empowered to negotiate safe sex.14 Most husbands (88.8%) are not willing to disclose their homosexual identity to their wives.15 Even in cases of disclosure, most tongqi are reluctant to divorce because of their marriage commitment, financial dependence on husbands, fears of losing child custody, and perceived psychological adversities that a divorce might bring to their children.16 Shame, harassment, and isolation are common experiences among tongqi who choose to divorce.17 “Tongqi Family,” the first grassroots organization for tongqi was established in 2009. The organization provides psychological counseling, consolation, and legal advices for divorce to tongqi. Two years later, another grassroots organization “Guangzhou Gay Relatives Club” organized an event named “Voices from Tongqi” on the eve of 2011 World AIDS Day, which actively advocated for the rights of tongqi and communicated the issues and dilemma tongqi are facing.18 Although remained small and officially unregistered, these organizations represent an emerging platform for accessing this vulnerable population. “Know your epidemic, know your response” is of paramount importance in developing timely and appropriate HIV policies and prevention strategies.19 Paradoxically, by no means the Chinese health stakeholders can know the epidemic in tongqi, if this population are not even identifiable by themselves. The problem boils down to the willingness of disclosure of tongqi’s gay husbands, which is substantially hindered by stigma, rejection, estrangement, and lack of family support they experience. Unless stigma against homosexuality and traditional familial expectation of marriage change, tongqi will continue to be an invisible population that bears the consequences of high-risk behaviors of others. The 100% condom programs among bisexual MSM may have the most direct impacts on reducing HIV transmission through bisexual exposure. Interventions such as providing premarital counseling for MSM, promoting regular HIV testing targeted bisexual and married MSM, advocating safe sex in extramarital sex, stigma removal, and facilitating disclosure should be included in the existing programs for MSM.20 Incorporating the emerging tongqi organizations into the HIV sentinel surveillance system may provide access to epidemiological insights that inform responses to the epidemic. Strong governmental support is necessary to strengthen tongqi organizations to facilitate potential HIV interventions. Eric P.F. Chow, MPH The Kirby Institute University of New South Wales Sydney, NSW, Australia Melbourne Sexual Health Centre Alfred Hospital Melbourne, VIC, Australia Central Clinical School Faculty of Medicine Nursing and Health Sciences Monash University Melbourne, VIC, Australia Fung Kuen Koo, PhD Sydney Nursing School University of Sydney Sydney, NSW, Australia Lei Zhang, PhD The Kirby Institute University of New South Wales Sydney, NSW, Australia [email protected]