The World Health Organization Representative Office in China (WHO China) used the Communication for Health (C4H) approach to understand why HIV is rising among rural, heterosexual men aged over 60 years, analyse barriers to behaviour change and better understand how to design interventions to address the problem.
HIV remains a public health concern in China despite efforts over the last decades, with annual rates of people newly diagnosed with HIV among the total population continuing to rise. In the past, prevention activities prioritized younger people who were believed to be at higher risk of HIV infection. However, data from a 2020 study published in CCDC Weekly showed that heterosexual men over the age of 60 years, particularly those in more rural locations in China, represent a faster growing and substantial percentage of people living with HIV.
In late 2020, before launching new outreach activities to target this population, WHO China, in collaboration with national partners, carried out qualitative research on the target group’s perceptions and barriers to behaviour change, applying the Communication for Health (C4H) approach.
C4H, a priority initiative of WHO in the Western Pacific Region, recognizes the vital role of communication in achieving positive public health outcomes. C4H is grounded in evidence, using data to understand the barriers and motivating factors for healthy behaviour and to identify audience information needs and preferences.
Taking this approach, the National Center for AIDS/STD Control and Prevention at the Chinese Center for Disease Control and Prevention, with support from WHO China, interviewed 45 men aged 60 and above from three rural areas. Close to half of the participants were living with HIV. The study aimed to understand their levels of knowledge about transmission and prevention, perceptions of and adherence to prevention techniques, and barriers to prevention, testing and treatment services.
The interviews found that HIV-related knowledge among all participants was limited. They reported a lack of information about sexual safety, reluctance to use preventive measures such as condoms and behaviours that carry a higher risk of HIV acquisition. There was also low awareness of and hesitancy to accept the need for active or ongoing HIV testing. One contributing factor is that older men living with HIV reported significant psychological stress as a result of their status due to stigma, discrimination and concerns about potentially infecting family members. Participants living with HIV also reported low levels of compliance with antiretroviral therapy (ART) – with reasons ranging from denial of infection, belief that ART is ineffective and has strong side-effects, and unwillingness to undergo medical treatment against the infection due to their older age.
Following the C4H approach, intervention activities are designed with this deeper understanding of the at-risk group’s characteristics, along with messages that resonate with them and that are delivered through trusted communication channels. The study findings suggested that to improve HIV-related knowledge among older people in rural areas, campaigns should focus primarily on face-to-face communication including community and village lectures, and explanations from healthcare workers, with a secondary focus on simple and clear online content.
Moving forward, the findings will be used to shape interventions that raise awareness of HIV transmission and prevention, influence behaviour change and generate demand for HIV services among this population. Additionally, WHO China is advocating for integration of HIV into a comprehensive health promotion strategy for older people such as in healthy ageing campaigns, as well as integration with hepatitis B and C and noncommunicable disease services, and routine hospital examinations for older people, based on risk assessment.
Using the C4H approach to make informed, evidence-based decisions about the effectiveness of priority outreach and communication interventions, WHO China aims to work with the Government and partners in China to improve sexual safety among older people and ensure “Health For All”.