Wang et al. BMC Public Health 2011, 11:955 http://www.biomedcentral.com/1471-2458/11/955 STD prevalence is substantially higher than in other tiers,. Our previous study showed a syphilis positive rate of more than 30% in low-tier FSWs, which is much higher than that in middle or high-tier FSWs. Other recent studies in China raised attention due to significant increases in the number of older patients with syphilis or HIV since 2005. Given the rising prevalence rates of STDs, China faces a rapidly increasing risk of HIV infection through sexual transmission (heterosexual and homosexual) from unpro- tected sexual behavior. 323,252 HIV cases were reported in China as of the end of 2009. Furthermore, the number of HIV-positive people indicated by the existing registra- tion system may be only a small proportion of the total number of HIV-infected people. Therefore, identifying the hidden population of HIV-infected people is critical for successful HIV control. Despite efforts to screen high-risk populations for HIV through local CDC out- reach programs and voluntary counseling and testing clinics, HIV-positive individuals are still diagnosed sub- stantially later in their disease course than individuals in North America. Thus, urgent expansion of the WHO- recommended PITC strategy in high-risk cohorts and in high HIV-prevalence locations should be considered. This strategy is cost-effective. As HIV programs are scaled up and technical capacity grows in China, local public STD clinics provide an excellent location for tar- geted HIV testing and prevention. STD clinic attendees represent a major risk group for HIV acquisition and transmission and can easily be approached. Patients at STD clinics may be willing to undergo HIV testing in light of their high risk sexual behaviors and may desire to be tested in the convenient and confidential clinic set- tings. In this study, PITC was well accepted among male STD clinic attendees. The percentage of individuals who agreed to HIV testing was comparable to that reported in another study among tuberculosis patients in China [34]. This pilot study demonstrates that it is feasible to apply PITC-based HIV testing in STD clinics. Currently there are debates on whether PITC is needed. Sixty-seven per- cent (14/21) of the HIV positive patients reported no STD-related symptoms in last year. If they had not parti- cipated in our study, most of them would have remained undiagnosed. PITC could lead to many benefits: increased patient awareness of HIV status, adequate counseling with education on HIV prevention, and earlier access to care with earlier initiation of antiretroviral treatment. STD clinics provide an excellent venue for HIV intervention. At same time, health-care providers need to consider ethical issues. They should inform patients that HIV testing is a routine clinic practice to decrease stigma, but should avoid compulsory testing. They also need to keep patients’ information confidential. In addition, HIV testing must be accompanied by HIV Page 7 of 8 treatment, care, and support, and cannot be implemented in isolation. The limitations of the study are that bias may exist (such as participation, reporting, and recall bias), just as in other cross-sectional studies. The participants of the study attended public STD clinics during a specific per- iod of time. The 46 clinics represented most (more than 75%) of the total outpatient visit in these cities. It should be noted that only 60.6%-68.3% male patients visited public STD clinics when they suspected STD infection [35,36]. Therefore, caution should be taken before gen- eralizing the findings of the study to the entire popula- tion in China. Conclusions There is a high prevalence of STD among male STD cli- ents in China. The prevalence of specific infections var- ied among areas. HIV was found in three of the four investigation provinces. We strongly recommend that PITC should be started in STD clinics because they are good venues for HIV intervention. Acknowledgements Financial support for this research came from the Mega Project of China National Science Research for the 11th Five-year Plan (2008ZX10001-005). Author details 1National Center for STD Control and Prevention, China Centers for Diseases Control and Prevention, Nanjing 210042, China. 2Jiangsu Provincial Centers for Disease Control and Prevention, Nanjing 210009, China. 3Guangdong Provincial Center for Skin Diseases and STD Control, Guangzhou 510500, China. 4Hainan Provincial Center for Skin Diseases and STD Control, Haikou 570206, China. 5Guangxi Centers for Disease Control and Prevention, Nanning 542800, China. Authors’ contributions QQW had full access to all of the data in the study and takes responsibility for the integrity of the data. QQW, XSC, BXW,GJL participated in study concept and design, interpreted results and supervision. YYP provided laboratory support for the project. NJ is the coordinator of the project. QQW and DT were responsible for data analysis and manuscript drafting. XPH, BY, QL, and YJZ supervised the study procedures on site and provided data. All the authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 3 July 2011 Accepted: 26 December 2011 Published: 26 December 2011 References 1. Cohen MS, Henderson GE, Aiello P, Zheng H: Successful eradication of sexually transmitted diseases in the People’s Republic of China: implications for the 21st century. J Infect Dis 1996, 174(Suppl 2): S223-S229. 2. Chen XS, Gong XD, Liang GJ, Zhang GC: Epidemiologic trends of sexually transmitted diseases in China. Sex Transm Dis 2000, 27(3):138-142. 3. Beyrer C: Hidden Epidemic of Sexually Transmitted Diseases in China: Crisis and Opportunity. JAMA 2003, 289(10):1303-1305. 4. 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