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The recent article on scaling up programmes to prevent sexual human immunodeficiency virus (HIV) transmission is timely and addresses a compelling topic.1 However, there are two points that should be emphasized in understanding how to organize an effective response to China’s expanding sexually transmitted HIV epidemic: (i) the heterogeneity within China’s commercial sex industry; and (ii) the unique organizational and social forces that constrain responses.  First, China has >6 million female sex workers (FSWs), based on conservative estimates derived from self-reporting in a population-representative sample.2 Public health and social science research from China suggests that there are distinct typologies of FSW, each with distinct workplaces and sexual risks (Table 1).3 Several studies show that low-income FSWs in China have a higher risk of syphilis and other sexually transmitted infections (STIs), including one systematic review of 72 studies that found a 2-fold increased risk of syphilis among low-income FSWs.4 Yet, there have been few interventions focused on low-income FSWs and methodologically rigorous epidemiological studies are limited.    Table 1  Chinese FSW typologies and their workplace and approximate sexual risk    Second, some sources have described sex work as ‘illegal’ in China, but this does not appreciate the complex relationship between women who sell sex and local authorities. A common Chinese saying is that police have ‘one eye open and one eye closed’ when considering sex work. Male police and other local authorities have many incentives both to curtail and to permit commercial sex.5 A better understanding of these local relationships informed by epidemiology and social sciences could help illuminate strategies for FSW HIV prevention.  Given the remarkable heterogeneity in socio-demographics and sexual risk among FSWs in China, simple policy solutions or importing models from Asian successes should be viewed with caution. Policy solutions for preventing heterosexual HIV that resonate with local FSWs and acknowledge the embedded and highly contextual nature of sexual risk have not been piloted in China and are far from scaling up. More research and programmatic efforts to identify and curb high-risk commercial sex are urgently needed.

The social context of sexual HIV prevention among female sex workers in China