As a case-control study, this study design is well organized, and proves that having more than 52 and above sexual partners in their lifetime and visiting 5 and above FSW in the last three years are too many for elderly men from rural China becoming HIV-positive. Becoming HIV-positive among elderly men is not related with sexual desire change and sexual identity. As groups visiting FSW in their lifetime, risks of HIV infection do not come from their unmarried statuses, neither from whom they live with, even not from migration experiences.
It is not suddenly that elderly men become HIV-positive, but rather delayed detections. In this study, around 80 percent of the respondents from both groups had migration experience. Back to 1980s, they were 20-50-year-old, sexually active, and migrated alone, easy to be involved in high-risk sexual behaviors such as visiting FSW and having sex with men to fulfil their emotional and sexual needs[10, 18, 20–24, 27].
Without doubt, HRHE helps elderly men avoid becoming HIV-positive. Rather than from informal channel(other), getting HRHE from formal channels (health workers from CDC, health workers from township health center/village doctors) helps elderly men avoid HIV infection. However, comparing with having multiple sexual partners and visiting FSW, the protective role of HRHE is small.
In this study, 2 of 99 cases (2.02%) and 2 of 88 controls(2.27%) were MSM, a little higher than national level(1.73%). 2 of 2 MSM cases self-reported as heterosexual, and 2 of 2 controls self-reported as bisexual. All of them were MSM/W. MSM in China are facing stigma and family pressure to get married and have children that make HIV(+) MSM transmit HIV infection from their homosexual partners[29, 38] to their wives .
The current study should be noted self-report behavior information. Face-to-face interviews may heighten socially desirable responses such as low report of high-risk sexual behaviors. In order to confront the problems, our interviewers were well trained, interviews were conducted in separate rooms, and local slangs were used.
Moreover, in-depth interviews were conducted by skilled medical staffs from County A CDC for case group, but by well-trained young male interviewers for control group. Informational bias due to different types of interviewers was inevitable, and would overestimate the difference between two groups. In order to minimize the bias, interviewers were trained by same trainers, only well interviewers conducted the in-depth interview, and interviewers followed the same in-depth procedure.
Though we conduct census among HIV (+) elderly male population, due to limited sample size, we can’t confirm our suspicion about the role of homosexual behavior in HIV infection among elderly men. We will continue to conduct researches to confirm our suspicion.