HIV related behaviours and attitudes among Chinese men who have sex with men in Hong Kong: a population based study

OBJECTIVE: This study was conducted in order to determine the prevalence of men having sex with men (MSM) and their HIV related behaviours and attitudes among Chinese men in Hong Kong. METHODS: A large scale, random, population based, anonymous telephone survey of 14 963 men between the ages of 18-60 was conducted. The overall response rate was approximately 57%. RESULTS: Of the respondents, 4.6% had ever engaged in MSM activity. In the 6 months preceding the survey, 2.0% had engaged in MSM behaviours (active MSM) and 0.5% reported having engaged in anal sex MSM behaviours. Among anal sex MSM, consistent condom use was 42.9% with male non-commercial sex partners and even lower with male commercial sex partners (35.7%). Approximately 11% of anal sex MSM and 4.1% of the non-anal sex MSM had contracted an STD in the last 6 months. The prevalence of HIV testing was only 20.6% among anal sex MSM and 11.9% among non-anal sex MSM. CONCLUSIONS: Active MSM in Hong Kong are at high risk of HIV infection. The belief of low vulnerability to HIV is prevalent among active MSM in Hong Kong with only 2.0% believing that their chances of HIV infection as being "very likely."     

T-ACASI reduces bias in STD measurements: the National STD and Behavior Measurement Experiment

BACKGROUND: Although telephone surveys provide an economical method for assessing patterns of diagnosed sexually transmitted diseases (STDs) and STD-related behaviors in populations, the requirement that respondents report such information to human telephone interviewers introduces an opportunity for substantial reporting bias. Telephone computer-assisted self-interviewing (T-ACASI) surveys substitute a computer for human interviewers when asking sensitive questions. METHODS: A randomized experiment was embedded in a telephone survey that drew probability samples of the populations of the United States (N = 1543) and Baltimore city (N = 744). Respondents were randomly assigned to have sensitive questions asked either by a T-ACASI computer or by a human telephone interviewer. RESULTS: Respondents interviewed by a T-ACASI computer were more likely to report STD symptoms [dysuria, genital sores, genital discharge, and genital warts; adjusted odds ratios (ORs) = 1.5-2.8] and a diagnosis of gonococcal or chlamydial infection during the past year (adjusted ORs = 3.6 and 6.1). T-ACASI respondents with a main sex partner in the past year were more likely to report that their partner has had an STD (adjusted OR = 2.4). For some measurements, the impact of T-ACASI was strongest among younger and less-educated respondents. When sampling weights were applied to project National STD and Behavior Measurement Experiment results to the populations of the United States and Baltimore, we found that reliance on data obtained by human interviewers would underestimate the annual incidence of chlamydial and gonococcal infections in these populations by factors of 2.4 to 9.7. CONCLUSIONS: Compared with human telephone interviewers, T-ACASI surveys obtain increased reporting of STD symptoms, infections, and STD-related behaviors.     

Disclosure of HIV status to sex partners and sexual risk behaviours among HIV-positive men and women, Cape Town, South Africa

BACKGROUND: The HIV epidemic continues to amplify in southern Africa and there is a growing need for HIV prevention interventions among people who have tested HIV positive. METHODS: Anonymous surveys were completed by 413 HIV-positive men and 641 HIV-positive women sampled from HIV/AIDS services; 73% were <35 years old, 70% Black African, 70% unemployed, 75% unmarried, and 50% taking antiretroviral treatment. RESULTS: Among the 903 (85%) participants who were currently sexually active, 378 (42%) had sex with a person to whom they had not disclosed their HIV status in the previous 3 months. Participants who had not disclosed their HIV status to their sex partners were considerably more likely to have multiple partners, HIV-negative partners, partners of unknown HIV status and unprotected intercourse with non-concordant sex partners. Not disclosing their HIV status to partners was also associated with having lost a job or a place to stay because of being HIV positive and feeling less able to disclose to partners. CONCLUSIONS: HIV-related stigma and discrimination are associated with not disclosing HIV status to sex partners, and non-disclosure is closely associated with HIV transmission risk behaviours. Interventions are needed in South Africa to reduce the AIDS stigma and discrimination and to assist people with HIV to make effective decisions on disclosure.     

Audio computer assisted interviewing to measure HIV risk behaviours in a clinic population

OBJECTIVES: To examine whether audio computer assisted survey interviewing (ACASI) influenced responses to sensitive HIV risk behaviour questions, relative to interviewer administration of those questions (IAQ), among patients attending a sexually transmitted infection (STI) clinic and whether the impact of interview mode on reporting of risk behaviours was homogeneous across subgroups of patients (defined by age, sex, and previous STI clinic experience). METHODS: 1350 clinic patients were assigned to complete a detailed behavioural survey on sexual risk practices, previous STIs and symptoms, condom use, and drug and alcohol use using either ACASI or IAQ. RESULTS: Respondents assigned to ACASI were more likely to report recent risk behaviours such as sex without a condom in the past 24 hours (adjusted OR = 1.9), anal sex (adjusted OR = 2.0), and one or more new partners in the past 6 months (adjusted OR = 1.5) compared to those interviewed by IAQ. The impact of ACASI varied by sex but, contrary to expectations, not by whether the patient had previously visited an STI clinic. Mode of survey administration made little difference within this population in reports of STI knowledge, previous STIs, STI symptoms, or illicit drug use. CONCLUSION: ACASI provides a useful tool for improving the quality of behavioural data in clinical environments.     

Prevalence of bisexual behaviors among men who have sex with men (MSM) in China and associations between condom use in MSM and heterosexual behaviors

OBJECTIVES: This study investigated the prevalence of bisexual behaviors and marital status among Chinese men who have sex with men (MSM) and the associations between MSM's condom use and their heterosexual behaviors. METHODOLOGY: Eight hundred ninety-six adult males in Yunnan Province, China, who reported to ever have engaged in MSM behaviors were interviewed. Data were acquired through the China-UK HIV/AIDS Prevention and Care Project from 2003 to 2006. RESULTS: Of all respondents, one-third had ever been married, 59% had ever engaged in bisexual behaviors, and 31% had done so in the past 6 months. High prevalence of inconsistent condom use was reported in heterosexual behaviors (71.9%), as well as with those who had engaged in MSM sexual behaviors in the past 6 months (30.8% with commercial sex workers and 54.7% with noncommercial sex partners) in the past 6 months. Those who did not use condoms with MSM partners were also more likely than others to not use condoms with their female sex partners (FSP). Those who had voluntary counseling and testing services were more likely than others to have used a condom in the last episode of sex with their FSP (multivariate odds ratio = 1.66). CONCLUSIONS: The clustering of unprotected sexual behaviors with male and FSP among bisexual MSM is revealed. The bridging effects of the risk for human immunodeficiency virus transmission from the MSM population to the female population are evident.     

HIV treatment adherence and unprotected sex practices in people receiving antiretroviral therapy

BACKGROUND: Poor HIV treatment adherence can result in the development of drug resistant strains of HIV and HIV positive people may transmit drug resistant virus to their sex partners. OBJECTIVE: To examine the association between HIV treatment adherence and sexual risk behaviour practices in people living with HIV-AIDS. METHODS: Surveys and interviews with 255 men and women living with HIV and receiving antiretroviral therapy. RESULTS: People who were currently taking antiretroviral medications and missed at least one dose of their medications in the past week scored significantly higher on a hopelessness scale and reported more current use of marijuana. People who had been non-adherent also reported significantly more sex partners, greater rates of unprotected vaginal intercourse, and less protected sex behaviours including less protected sex with partners who were HIV negative or of unknown HIV status. CONCLUSIONS: Associations between HIV treatment adherence and sexual transmission risk behaviours indicate the need for comprehensive and integrated health behaviour interventions for people living with HIV-AIDS.     

HIV, sexually transmitted infections, and risk behaviours in male commercial sex workers in Sydney

OBJECTIVES: To assess prevalence of HIV and sexually transmitted infections (STIs), risk behaviours, and demographics in male commercial sex workers (CSWs)/prostitutes in Sydney. METHODS: Retrospective, cross sectional study with two comparison groups. Demographic, behavioural, and morbidity data were analysed from standardised medical records of patients attending a public STI and HIV service in Sydney between January 1991 and March 1998. Two comparison groups were used: female CSWs and non-CSW working homosexual men who attended over the same time. RESULTS: 94 male CSWs, 1671 female CSWs, and 3541 non-CSW working homosexual men were included. The prevalence of HIV in male CSWs tested (6.5%) was significantly greater than in female CSWs (0.4%, p = 0.0001), but less than in non-CSW homosexual men (23.9%, p < 0.0001). Genital warts occurred significantly more frequently in male CSWs than in comparison groups. Prevalence of other STIs was similar in all groups. Male CSWs saw significantly fewer clients per week than female CSWs and male and female CSWs used condoms with almost all clients. Male CSWs reported significantly more non-work sexual partners than female CSWs and non-CSW homosexual men and were significantly more likely to have unprotected penetrative sex with their non-work partners than non-CSW homosexual men. Injecting drug use was significantly more frequent in male CSWs than in both comparison groups. CONCLUSIONS: Although male CSWs use condoms with clients, they are more likely to practise unsafe sex with non-work partners (especially women) and inject drugs than female CSWs and non-CSW homosexual men. Some men with HIV are working within the commercial sex industry. Targeted health education to encourage safer drug use and safer sex outside work is needed.     

Behavioral surveillance surveys of the male clients of female sex workers in Hong Kong: results of three population-based surveys

BACKGROUND: Male clients of female sex workers (FSWs) are an important group vulnerable to HIV infection. GOALS: The goal was to administer and assess behavioral surveillance surveys of male clients of FSWs in Hong Kong. STUDY DESIGN: Three population-based telephone surveys of males aged 18 to 60 were conducted from 1998 to 2001 (n=5159). RESULTS: Of all respondents, about 10.8% to 14% had patronized FSWs in the previous 6 months. Among male clients of FSWs, about 25% did not always use condoms, 4% to 6% had contracted a sexually transmitted disease, 16% had undergone HIV antibody testing, and 20% or more reported having four or more sex partners in the previous 6 months. There was no improvement in condom use over time. Cross-border (from Hong Kong to mainland China) commercial sex was common. CONCLUSION: The level of risk behaviors associated with male clients of FSWs remained substantial. The overall effectiveness and coverage of relevant prevention programs were questioned.     

AIDS risk behaviours and correlates in teenagers attending sexually transmitted diseases clinics in Los Angeles.

OBJECTIVE--Of all age groups, teenagers have the highest rates of sexually transmitted diseases. Therefore, it is particularly important to target interventions at this group. Teenagers attending STD clinics are at particularly high risk since behaviours that lead to an STD can also result in the transmission of HIV. The goal of this study was to collect information concerning the prevalence and correlates of high-risk behaviours in this population as a first step in the design of an effective intervention programme. METHODOLOGY--Face-to-face interviews were conducted with patients attending five STD clinics operated by the Los Angeles County Department of Health Services. RESULTS--In the exclusively heterosexual teenage subgroup (N = 100, 55% Hispanic, 28% African-American, 10% White), males became sexually active at a younger age than females (14 years vs 14.9 years, p < 0.02), had more partners in the last 12 months (4.1 vs 2.0, p < 0.003), more "steady" partners (2.2 vs 1.4, p < 0.02) and more life time partners (14.1 vs. 4.1, p < 0.001). Only 10.0% of males and 3.8% of females reported consistent condom use with steady partners and 36% of both male and female respondents with non-steady partners. The decision to use condoms during vaginal sex was most likely made by the respondent, whereas the decision not to use condoms was most likely a joint decision. CONCLUSIONS--An intervention aimed at improving sexual communication regarding condom use could increase this behaviour among many adolescents, since only few teenagers in our sample perceived condom use as unpleasant.     

The association between gang involvement and sexual behaviours among detained adolescent males

OBJECTIVE: Data were collected from 270 detained male adolescents (aged 14-18 years) to determine the association between ever having been in a gang and a range of sexual behaviours such as sexual activity, male condom use, sex with multiple partners, and drug use during sex. METHODS: Participants answered survey questions using audio computer assisted self interviewing (A-CASI) procedures, which assessed demographic, family factors, history of gang membership, and sexual behaviours. RESULTS: Multiple logistic regression analyses, controlling for demographic, socioeconomic status, and family factors, indicated that adolescents who reported having been in a gang, relative to their peers reporting no gang involvement, were 5.7 times more likely to have had sex, 3.2 times more likely to have got a girl pregnant, and almost four times more likely to have been "high" on alcohol or other drugs during sexual intercourse, have had sex with a partner who was "high" on alcohol or other drugs, or have had sex with multiple partners concurrently. CONCLUSIONS: Findings suggest that having been in a gang can discriminate between levels of STI associated risk behaviours among an otherwise high risk population-detained adolescent males.     

Don't ask, don't tell: patterns of HIV disclosure among HIV positive men who have sex with men with recent STI practising high risk behaviour in Los Angeles and Seattle

OBJECTIVES: A high incidence of HIV continues among men who have sex with men (MSM) in industrialised nations and research indicates many MSM do not disclose their HIV status to sex partners. Themes as to why MSM attending sexually transmitted infection (STI) clinics in Los Angeles and Seattle do and do not disclose their HIV status are identified. METHODS: 55 HIV positive MSM (24 in Seattle, 31 in Los Angeles) reporting recent STI or unprotected anal intercourse with a serostatus negative or unknown partner from STI clinics underwent in-depth interviews about their disclosure practices that were tape recorded, transcribed verbatim, coded, and content analysed. RESULTS: HIV disclosure themes fell into a continuum from unlikely to likely. Themes for "unlikely to disclose" were HIV is "nobody's business," being in denial, having a low viral load, fear of rejection, "it's just sex," using drugs, and sex in public places. Themes for "possible disclosure" were type of sex practised and partners asking/disclosing first. Themes for "likely to disclose" were feelings for partner, feeling responsible for partner's health, and fearing arrest. Many reported non-verbal disclosure methods. Some thought partners should ask for HIV status; many assumed if not asked then their partner must be positive. CONCLUSIONS: HIV positive MSM's decision to disclose their HIV status to sex partners is complex, and is influenced by a sense of responsibility to partners, acceptance of being HIV positive, the perceived transmission risk, and the context and meaning of sex. Efforts to promote disclosure will need to address these complex issues.     

HIV risk profile of male street youth involved in survival sex

OBJECTIVES: To compare HIV risk factors of male street youth involved in survival sex with those of their never involved peers and to describe the sexual activities of the involved youths. METHODS: From 2001 to 2003, street youth aged 14-23 years were recruited from street youth agencies in Montreal, Canada. Information was collected on sociodemographic characteristics, substance use, and sexual behaviours. Involvement in survival sex was defined as having ever exchanged sex for money, gifts, drugs, shelter, or other needs. Logistic regression was used to identify HIV risk factors associated with involvement in survival sex. RESULTS: Among the 542 male participants recruited, 27.7% reported involvement in survival sex. HIV risk factors independently associated with such involvement were injection drug using partners (modulated by length of homelessness), unprotected oral sex with male partners, steroid injection, history of sexual abuse, and drug injection. Among involved youths, 32.0% had only female clients, 41.3% only male clients, and 26.7% had clients of both sexes. Unprotected sexual activities were common with clients. However, even more risks were taken with non-commercial sexual partners. CONCLUSIONS: Male street youth involved in survival sex are at higher risk for HIV than their non-involved peers not only because of their unprotected commercial sexual activities. They have multiple other HIV risks related to non-commercial sexual activities, drug injection, and sexual abuse. All these risks need to be addressed when providing sexual health interventions for this population.     

Risk behaviors related to heterosexual transmission from HIV-infected persons. Supplement to HIV/AIDS Surveillance Study Group

BACKGROUND: To monitor heterosexually acquired HIV infection, it is important to understand transmission from persons infected with HIV to their sex partners. GOAL: To describe sexual behaviors of persons infected with HIV that are related to transmission. STUDY DESIGN: Cross-sectional interviews were conducted from January 1995 to December 1998. RESULTS: Of 4743 heterosexual respondents who had known about their HIV infection for 1 year or longer, 42% were not sexually active and 13% had one sex partner with HIV; the remaining 2099 comprised the sample for analysis. Most respondents were male, black, and of low socioeconomic status. Approximately 60% reported one or more sexual risk behavior. Steady partner's HIV status was the strongest predictor in most models for risk behaviors; those with a partner who was not infected were significantly less likely than those with an infected partner to report any sexual transmission risk behavior (P < 0.05). CONCLUSIONS: The findings point to a continued need to focus on behavioral prevention measures that reduce the heterosexual transmission of HIV.     

Heterosexual transmission of HIV in China: a systematic review of behavioral studies in the past two decades

OBJECTIVE: The objective of this study was to address the role of heterosexual transmission of HIV in China. GOAL: The goal of this study was to explore the prevalence of unsafe sex and the likelihood of HIV spread heterosexually from core populations to others. STUDY: The authors conducted a review of behavioral studies. RESULTS: Drug users were more likely to be involved in higher-risk sexual behaviors than were those who abstained from using drugs. Most female drug users (52-98%) reported having engaged in commercial sex. Most female sex workers (FSWs) and individuals with sexually transmitted diseases (STDs) had concurrent sexual partners. Many continued to have unprotected sex after noticing STD symptoms in themselves or their sexual partners. From 5% to 26% of rural-to-urban migrants had multiple sexual partners and 10% of males patronized FSWs during migration. CONCLUSIONS: Factors such as high rates of FSW patronage, low rates of condom use during commercial sex, having sex with both commercial and noncommercial sexual partners, and high rates of STD infection may promote a heterosexual epidemic in China.     

Simultaneous use of multiple condoms among male Cambodian military personnel visiting female sex workers

OBJECTIVES: To estimate the prevalence of simultaneous use of multiple condoms (SUMC) and identify the characteristics of the multiple condoms users. STUDY DESIGN: Cross-sectional survey among military men from a purposively selected Cambodian military region. Military men were interviewed face to face. RESULTS: From the 1638 respondents, 40% never had sex with female sex workers (FSWs), 55% had used condom(s), and 5% had unprotected sex at their last encounter with a FSW. Among those reporting sex with FSWs, 21% had used multiple condoms simultaneously at their last sex with a FSW. CONCLUSION: Compared with single condom users, multiple condom users were younger, had lower rank, had first sex more recently, had lower knowledge of HIV transmission, had received less HIV peer-education sessions, were more likely to have visited multiple FSWs, and were more likely to have sought their HIV serostatus. As it is unknown if SUMC increases or decreases condom effectiveness, more research is needed to investigate the effect of SUMC on condom failure rates.     

Associations between internet sex seeking and STI associated risk behaviours among men who have sex with men

OBJECTIVE: This exploratory study identified associations between internet sex seeking and HIV associated risk behaviours among a high risk sample of men who have sex with men (MSM). METHODS: A cross sectional survey of men attending a sex resort was conducted. Of 164 men asked to participate, 91% completed a self administered questionnaire. The questionnaire assessed demographic variables and (using a 3 month recall period) men's HIV associated sexual risk behaviours. Potential confounding variables were assessed and controlled, as needed, by multivariate analysis. RESULTS: Men currently resided in 14 states. One sixth reported being HIV positive. 57% of the men reported using the internet to seek sex. Differences in critical behaviours (unprotected anal sex and number of partners) were not found. However, compared to those not seeking sex by internet, men using the internet to meet sex partners were more likely to report fisting (adjusted odds ratio = 3.3, p = 0.04), having group sex (prevalence ratio (PR) = 1.2, p = 0.0001), using poppers during sex (PR = 1.94, p = 0.0001), and using ecstasy during sex (PR = 2.7, p = 0.04). Internet sex seeking men were also significantly more likely to report meeting sex partners in bathhouses (PR = 2.2, p = 0.0001), bars (PR = 1.5, p = 0.001), parks (PR = 3.2, p = 0.006), and circuit parties (PR = 8.9, p = 0.007). CONCLUSION: Among MSM attending a sex resort, those using the internet to seek sex partners may have modestly elevated risks for acquiring or transmitting sexually transmitted infections. Subsequent studies should investigate the utility of using the internet as forum for promoting safer sex behaviours among high risk MSM.     

HIV/AIDS knowledge and high risk sexual practices among southern California Vietnamese.

OBJECTIVES--Vietnamese immigration to the U.S. since the conclusion of the Vietnam war has been substantial and in Orange County, CA, Vietnamese Americans comprise 3% of the population (the largest community in the US). Our objective was to collect data on the HIV/AIDS knowledge, attitudes and self-reported high risk behaviours within this community. METHODS--A survey instrument was administered anonymously in Vietnamese to 532 respondents in their homes. Individuals from three population strata were randomly sampled: men 18 to 35 years old (N = 193); men 36 to 45 years old (N = 137); and women 18 to 35 years old (N = 202). Data were gathered on: (1) degree of acculturation; (2) knowledge and attitudes towards HIV/AIDS; and (3) self-reported sexual and other high risk practices. RESULTS--Survey data indicated that 38% of respondents were very worried about themselves and 83% were worried about a family member getting AIDS. Knowledge about actual modes of HIV transmission was generally accurate, but a substantial minority still believed that HIV can be transmitted through casual contact, and 68% from needles used in hospitals. Women demonstrated less accurate knowledge than men on five key items. Quarantine of the HIV infected was agreed to by 45%. Twenty-nine percent did not believe that the epidemic would affect them personally, and 49% stated that they did not have enough information about AIDS to protect themselves. Regarding sexual practices, 31% reported never having had sex. Of the others, 8% had two or more sexual partners in the prior 12 months. No same sex behaviour was reported. Six percent of men had visited a female prostitute; of these, 24% had visited 2 or more in the prior 12 months; half of encounters in this time period were outside the US. Substantial percentages of sexually active, unmarried respondents indicated that they never use (17-40%) or only sometimes use (10-32%) condoms. Less than 1% had used injection drugs. CONCLUSIONS--Education should be targeted at the Vietnamese community of southern California to improve knowledge that HIV cannot be contracted through casual contact, to convey information about methods for self-protection, and to reduce high risk sexual practices such as unprotected sex, sex with multiple partners and sex with prostitutes.     

HIV/AIDS behavioral surveillance surveys of the cross-border sex-networker population in Hong Kong from 1997 to 2001

BACKGROUND: Mobility is an important risk factor in the spread of HIV. GOAL: The goal was to conduct behavioral surveillance surveys on Hong Kong males crossing the border to mainland China to have sex with female sex workers (FSW) or nonregular female sex partners who were not FSW (NRP). STUDY DESIGN: Four surveys (1997-2001), using a special data collection method, were conducted at the Hong Kong-mainland China border checkpoint (n=5294). RESULTS: Consistently, a notable proportion of the travelers had patronized FSW or had had sex with NRP in the preceding trip to mainland China. Inconsistent condom use was high (> or =40%) and HIV antibody testing was low (<12%). Self-perceived susceptibility of contracting HIV also was low. CONCLUSION: No remarkable improvement on the level of risk behaviors was observed over the study period. Sustained efforts to promote safer sex and awareness of the risk associated with sex-networking are required.     

Sexually transmitted infections and sexual practices in injection drug users and their regular sex partners in Chennai, India

OBJECTIVE: Measuring sexually transmitted infections (STIs) and sexual practices in injection drug users (IDUs) and their regular sex partners. GOAL: Informing HIV intervention programs. DESIGN: Cross-sectional. RESULTS: One percent IDUs and 2% of their regular female sex partners were syphilis infected; 40% (84/211) and 38% respectively (81/211) were infected with HSV-2. 30% IDUs and 5% of their female regular sex partners were HIV positive. Serodiscordant results for syphilis and HSV-2 were noticed. Women having first sex at ageor=38 years had seven times the odds of having any non-HIV-STI. CONCLUSION: Reaching out to IDUs and their female regular sex partners with modified STI management guideline and promoting women-controlled safer sex measures are needed harm-reduction measures.