HIV trends and related risk factors among men having sex with men in mainland China: findings from a systematic literature review

The purpose of this study was to assess trends in the HIV epidemic and risk factors for HIV infection among men having sex with men (MSM) in mainland China. A literature review was conducted. Data from studies regarding HIV prevalence, syphilis infection and risk behavior, were pooled into three chronological stages. The independent correlates of HIV infection were gathered in order to guide the development of future interventions. HIV prevalences were 2.5% (95%CI 1.8-3.7), 1.8% (95%CI 1.1-2.9) and 3.3% (95%CI 2.0-5.3) before 2004, during 2004 to 2005 and 2006 to 2007, respectively. About two-thirds of MSM had multiple male sex partners during the previous six months (P6M), and more than one third of MSM engaged in unprotected anal intercourse (UAI) during last sex. Only UAI among commercial sex workers declined significantly. More than one quarter of MSM had female partners in P6M and the proportion having multiple female partners declined. The rates of unprotected vaginal sex had a downward trend. The prevalence of injecting drug use was low and remained the same. The number of lifetime male sexual partners and the frequency of anal sex in P6M were independently associated with HIV infection; UAI was correlated to the number of male partners, buying sex from males, being part of a mobile population, prior HIV testing and having a prior sexually transmitted disease (STD). We conclude intervention programs targeting UAI and multiple partners are urgently needed to control the HIV epidemic among MSM in mainland China.     

HIV vulnerabilities and coercive sex at same-sex sexual debut among men who have sex with men in Beijing,China

Few studies have examined coercive sex and HIV vulnerabilities among men who have sex with men (MSM) in China. The present study seeks to compare individual characteristics between MSM who did and did not experience coercive sex at their MSM sexual debut and to identify HIV risk factors correlated with coercive sex at MSM sexual debut. In 2007, we recruited 167 MSM in Beijing, China by peer-referred social network sampling. Each participant then completed self-administered questionnaires regarding their sexual experiences and practices. Results show that 14% of participants reported coercive sex at MSM sexual debut, of whom 48% reported recent unprotected anal intercourse (UAI). Coercive sex at MSM sexual debut was significantly associated with UAI [adjusted odds ratio (AOR): 5.38, 95% confidence interval: 1.95–14.87] and lifetime number of male sex partners (AOR: 7.25, 95% CI: 2.39–22.01). Coercive sex is harming MSM in China and should be immediately addressed by researchers, public health officials, and MSM community stakeholders.     

Results from Two Online Surveys Comparing Sexual Risk Behaviors in Hispanic,Black, and White Men Who Have Sex with Men

Many men who have sex with men (MSM) are among those who increasingly use the internet to find sexual partners. Few studies have compared behavior by race/ethnicity in internet-based samples of MSM. We examined the association of race/ethnicity with HIV risk-related behavior among 10,979 Hispanic, black, and white MSM recruited online. Significant variations by race/ethnicity were found in: age, income level, sexual orientation, number of lifetime male and female sexual partners, and rates of unprotected anal intercourse (UAI). Black and Hispanic men were more likely to report anal intercourse during the last sexual encounter, but white men were more likely to report UAI. In multivariate analysis, UAI was associated with HIV infection and sex with a main partner. Significant risk behavior variations by race/ethnicity were found. Research is needed to better target online interventions to MSM who engage in UAI or have other risk factors for transmitting or acquiring HIV.     

Being high and taking sexual risks: findings from a multisite survey of urban young men who have sex with men.

Adolescent and young adult males who have sex with men (MSM) remain at high risk of HIV infection. Many sexual risk factors have been identified, yet the role of substance use remains controversial. We assess the extent to which urban young MSM report being "high" on drugs or alcohol during sex and the association between being "high" and unprotected anal intercourse (UAI). During summer 2000, 3,075 MSM aged 15-25 years completed a 20-minute interview for the Community Intervention Trial for Youth Project. Participants were asked about their last sexual contact with main and nonmain partners, including whether they were "high on drugs or alcohol." 18.6% of MSM with a main partner reported being high during their last sexual encounter; 25.0% reported UAI. Among men with a nonmain partner, 29.3% reported being high, and 12.3% reported UAI. Being high was associated with unprotected receptive anal intercourse with nonmain partners (odds ratio = 1.66, p = .02). HIV prevention should include messages about the potential dangers of drinking and drug use in situations where sexual encounters with nonmain partners may occur.     

Predictors of unprotected sex among men who have sex with men in Beijing, China

To estimate the prevalence of HIV and syphilis and to assess the predictors of unprotected anal intercourse (UAI) among men who have sex with men (MSM) in Beijing, a community-based survey recruited MSM in 2005 through internet advertisement, community outreach, and peer referral. Demographic, sexual, and HIV risk behavioral information were collected. Serospecimens were tested for HIV and syphilis infections. Of the 526 participants, 3.2% were HIV-positive, 11.2% syphilis-positive, 50% and 43.3% had UAI with regular and casual sex partners, respectively. Participants practicing UAI with regular male partners were independently associated with lower monthly income (adjusted odds ratio-AOR, 1.7; 95% CI, 1.0-3.0) and encountering male sex partners at bathhouses, public washrooms, and parks (AOR, 2.2; 95% CI, 1.0-4.9). Participants practicing UAI with casual male partners were associated with encountering male sex partners at bathhouses, publics washrooms, and park (AOR, 3.0; 95% CI, 1.8-5.2) and more male sex partners having receptive anal intercourse (AOR, 1.8; 95% CI, 1.1-2.9), and was inversely associated with receiving money for sex with men (AOR, 0.3; 95% CI, 0.2-0.7). Professional male sex workers were less likely to practice UAI in Beijing, suggesting the benefits of educational outreach to date. Further education, condom promotion, and prevention of sexually transmitted infections should be intensified urgently to combat the rising HIV epidemic among MSM in Beijing.     

Sexual sensation seeking,sexual compulsivity,and high-risk sexual behaviours among gay/bisexual men in Southwest China

High-risk sexual behaviours (HRSBs), such as having male casual sexual partners (MCSPs) and unprotected anal intercourse (UAI), are combined with a high prevalence of HIV infection among gay/bisexual men. Sexual sensation seeking (SSS) and sexual compulsivity (SC), which are intrapersonal factors, were observed to have associations with HRSB among gay/bisexual men in Western nations. The aim of the study was to examine the relationships between SSS, SC, socio-demographic factors, and HRSB (defined as having MCSP and UAI with MCSP) among self-identified gay and bisexual men in Southwest China. The study was cross-sectional, with a sample of 436 respondents. And their mean age was 24.5 years. The results confirmed that SSS, SC, and sexual attitude are associated with both having MCSP and UAI with MCSP in the Chinese cultural context, among the subgroup of men who have sex with men. Being older, not a student, and having transactional sex in the last 6 months were independently associated with having MCSP. Lower educational level, unemployed, having a relationship with a man, and an unsure HIV status were independently associated with UAI with MCSP. This study indicates that SSS and SC are cross-cultural personality traits related to HRSB. The results of this study may shed light on HIV prevention among gay/bisexual men in China.     

Drug use, high-risk sex behaviors, and increased risk for recent HIV infection among men who have sex with men in Chicago and Los Angeles

We examined how drugs, high-risk sexual behaviors, and socio-demographic variables are associated with recent HIV infection among men who have sex with men (MSM) in a case-control study. Interviewers collected risk factor data among 111 cases with recent HIV infection, and 333 HIV-negative controls from Chicago and Los Angeles. Compared with controls, cases had more unprotected anal intercourse (UAI) with both HIV-positive and HIV-negative partners. MSM with lower income or prior sexually transmitted infections (STI) were more likely to be recently HIV infected. Substances associated with UAI included amyl nitrate ("poppers"), methamphetamine, Viagra (or similar PDE-5 inhibitors), ketamine, and gamma hydroxybutyrate (GHB). Cases more frequently used Viagra, poppers, and methamphetamine during UAI compared with controls. In multivariate analysis, income, UAI with HIV-positive partners, Viagra, and poppers remained associated with recent HIV seroconversion. Better methods are needed to prevent HIV among MSM who engage in high-risk sex with concurrent drug use.     

Prevalence and Correlates of Unprotected Anal Intercourse Among Hong Kong Men Who Have Sex with Men Traveling to Shenzhen, China

In China, the HIV prevalence among men who have sex with men (MSM) has been increasing sharply. A total of 195 Hong Kong MSM having had sex with men in Shenzhen, a mainland China city separated from Hong Kong by a border, were recruited from some randomly selected gay venues in Shenzhen. Participants were face-to-face and anonymously interviewed. The results showed that in the last six months, respectively 62.1, 84.6, and 31.3 % of the participants from Hong Kong had had sex with commercial sex partners (CSP), non-regular partners (NRP) and regular partners (RP) in Shenzhen. The prevalence of unprotected anal intercourse (UAI) with these three types of sex partners was respectively 29.8, 27.9, and 78.7 %. Factors associated with UAI with any MSM in Shenzhen in the last six months included perceived chances of contracting HIV, perceived non-availability of condoms, giving money/gifts to Shenzhen MSM sex partners, and perception that MSM partners in Shenzhen would not always insist on condom use (multivariate OR = 2.9–13.90, p < 0.05), whilst factors of inverse associations included university education, having had sex with NRP but not with CSP and RP in Shenzhen and self-efficacy of insisting on condom use (multivariate OR = 0.04–0.22, p < 0.05). In sum, the prevalence of having multiple types of male sex partners and UAI was high. This was especially true when anal sex with RP was involved. Cross-border HIV prevention is greatly warranted. It should ensure condom availability and modify perceptions toward UAI.     

MSM中HIV感染者无保护肛交行为及其影响因素分析

目的了解男男性行为人群（MSM）中艾滋病病毒（HIV）感染者的无保护肛交性行为的状况,分析其影响因素,为开展针对性干预活动防止＂二代传播＂提供信息。方法对＂全国男男性行为人群艾滋病综合防治试点＂工作数据库中,HIV感染者的信息进行分析,描述研究对象的社会人口学和高危性行为特点,并分析无保护肛交性行为的影响因素。结果共获得MSM中HIV感染者的有效样本754人,梅毒检出率为28.9%。最近6个月内无保护肛交发生率为67.4%。与无保护肛交发生有关的危险因素是在当地居住时间超过6个月,经常到浴池、公园等场所寻找性伴,以及最近1年内未接受过艾滋病相关服务。结论 MSM中HIV感染者的无保护肛交行为发生率、梅毒感染率高,构成艾滋病进一步传播流行的风险,亟待在该人群中开展针对性行为干预。     

Factors associated with unprotected sexual intercourse with steady male, casual male, and female partners among men who have sex with men in Barcelona, Spain.

To increase understanding of the HIV epidemic among MSM in Barcelona, anonymous questionnaires were completed by 640 MSM recruited in the city in 2002. The prevalence of unprotected anal intercourse (UAI) with casual male partners in the prior 12 months was higher among self-reported HIV-positive men (confirmed through saliva testing) than among men who were HIV-negative or of unknown serostatus (35% vs. 20%, p < .01). The prevalence of UAI with steady male partners was substantially lower among HIV-positive men than other men (28% vs. 60%, p < .01). In multivariate analyses, UAI with casual partners was more likely among HIV-positive individuals; those who used drugs before sex; perceived less acceptance of their sexual orientation by family, friends, or coworkers; and were less concerned about HIV prevention because of antiretroviral therapy (ART). UAI with steady partners was more likely among HIV-negative men with seroconcordant partners, those living with a partner, and men less concerned about HIV prevention because of ART. Findings indicate a need for prevention programs targeting HIV-positive MSM in Barcelona. Attention to substance use and attitudes about HIV prevention are needed for MSM in general.     

Substance use and HIV-risk behaviors among HIV-positive men who have sex with men in China: repeated measures in a cohort study design

Global literature revealed that seropositive men who have sex with men (MSM) posed an even higher risk compared to their seronegative counterparts. Identifying risk factors that contribute to HIV-risk behaviors will help to curb the rapid HIV transmission among this group. Our hypothesis was that MSM with substance use were more likely to conduct HIV-risk behaviors, even after accounting for repeated measures. In the current study, we employed a cohort study design by following a group of 367 HIV-positive MSM up to four visits for one year to collect information regarding their sexual behaviors and history of substance use in the past three months. We used Generalized Estimating Equations (GEE) models to account both within- and between-subject variation when assessing associations between substance use and HIV-risk behaviors. A total of 367 MSM were included at the baseline with a mean age of 29.6 years. After accounting for potential confounders and time-varying effects, our models indicated that drug and alcohol use increase HIV risks at the population level by increasing risks of drinking alcohol before sex, having unprotected sex with men and seropositive partners, having more lifetime female sex partners and having a higher number of male sexual partners in the past three months. The current study is one of the first studies with repeated measures to evaluate the association between substance use and sexual risk behaviors among MSM in China. Findings in the current study have several implications for future research. We call for more rigorous study design for future research to better capture changes of risky behaviors among this at-risk population.     

Sociodemographic and risk behavior characteristics associated with unprotected sex with women among black men who have sex with men and women in New York City

The objectives of this cross-sectional study were to compare sociodemographic and risk behavior characteristics between black men who have sex with both men and women (MSMW) and those who have sex with men only (MSMO) and assess factors associated with having any unprotected vaginal and/or anal intercourse (UVAI) with women in the last 3 months. Data from 326 black men who reported recent unprotected anal intercourse with a man in an HIV behavioral intervention study in New York City were analyzed. Baseline characteristics were compared between MSMW and MSMO, and factors associated with having any UVAI in the past 3 months with women among MSMW were evaluated. In total, 26.8% reported having sex with both men and women in the last 3 months. MSMW were less likely to be HIV infected, use amyl nitrates, and have unprotected receptive anal sex with most recent male partner. MSMW were more likely to be over 40 years old and use heroin. A total of 55.6% of MSMW reported having UVAI with women in the last 3 months. Compared to MSMW having only protected sex, MSMW having any UVAI with women were less likely to be HIV infected and to disclose having sex with men to female partners; they were more likely to have greater than four male sex partners in the last 3 months. In conclusion, HIV prevention interventions among black MSMW should directly address the risk of HIV transmission to both their female and male partners. Disclosure of bisexuality to female partners may be an important component of future prevention efforts.     

深圳地区MSM性伴数量及影响因素分析

目的了解深圳地区男男性行为人群（MSM）性伴数量,分析其影响因素。方法应用同伴推动抽样（RDS）法进行抽样调查,收集MsM人群人口学和性伴数等资料。用SAS软件对数据进行Poisson回归分析。结果共抽样调查351例MSM。最近半年,仅31．4％MSM没有肛交性伴或保持单一性伴,25．9％没有口交性伴或保持单一性伴：28．5％有女性性伴,其中11．4％有多个女性性伴。职业为娱乐场所从业人员和曾做过男男性工作者（MB）,是MSM肛交性伴数和口交性伴数的共同危险因素。除此之外,HIV风险感知越高,艾滋病知识得分越高,MSM口交性伴数越多。结论对该人群有针对性的干预行动已刻不容缓,以有效阻断HIV传播和蔓延。     

Self-reported sexual behaviour and HIV risk taking among men who have sex with men in Fortaleza, Brazil.

OBJECTIVES: To describe and identify sociodemographic and behavioural characteristics and other factors related to high-risk behaviour for HIV infection of men who have sex with men (MSM) living in Fortaleza, Brazil. METHODS: A survey was carried out among 400 MSM aged 14-65 years and recruited through the snowball technique or in gay-identified venues. A semi-structured questionnaire was conducted among them. Logistic regression analysis was used to model the dichotomous outcome (high risk or low risk). RESULTS: Forty-four per cent of the participants reported engaging in high-risk sexual behaviour in the previous year. MSM less informed about AIDS, reporting more sexual partners, reporting at least one female partner in the previous year, having anal sex as the favourite way to have sex, and having great enjoyment of unprotected anal sex were more likely to be engaged in risky behaviour. Twenty-three per cent of participants reported at least one sexual contact with women during the previous year. Two-thirds of men who had unprotected sex with their female partners also had unprotected anal sex with their male partners. CONCLUSIONS: A large proportion of MSM in Fortaleza still remain at elevated risk for contracting HIV infection. The factors predictive of high-risk sexual behaviour are significant in spreading HIV infection among the MSM population and also among their female partners. The lifestyles of these men are different to those of men from other parts of Brazil or outside the country. Preventive interventions need to be culturally and socially specific in order to be effective.     

Predictors of HIV disclosure to secondary partners and sexual risk behavior among a high-risk sample of HIV-positive MSM: results from six epicenters in the US

This study sought to identify predictors of HIV disclosure and serodiscordant unprotected anal intercourse (SDUAI) among HIV-positive men who have sex with men (MSM). Between January 2005 and April 2006, 675 HIV-positive MSM were recruited into the Positive Connections intervention trial held in six US cities with intentional over-sampling of HIV-positive MSM of Color (74%) and men engaging in unprotected anal intercourse (UAI) in the previous year. Baseline survey data showed 30 and 31%, respectively, of participants disclosed to none or some of their secondary sex partners in the last 90 days. Greater disclosure to secondary partners was associated with having fewer sexual partners, being extremely out as MSM, longer HIV diagnosis, knowledge of CD4 count, detectable viral load and being white. Disclosure to all secondary partners was associated with lower SDUAI. Recommendations for prevention for HIV-positive MSM include the promotion of serodisclosure to all secondary partners and increasing comfort with, and outness about, one's sexuality.     

High levels of unprotected sex with men and women among men who have sex with men: a potential bridge of HIV transmission in Beijing, China.

China is experiencing an emerging HIV epidemic among men who have sex with men (MSM). We investigated sexual risk, risk perception, HIV and condom knowledge, and utilization of prevention services in the first large sample of MSM recruited in Beijing. Four hundred eighty-two MSM were sampled from September 2001 to January 2002. Forty-nine percent of participants reported unprotected anal intercourse with men during the previous 6 months. However, only 15% perceived they are at risk for HIV and many had misconceptions about HIV transmission routes and limited knowledge about condoms. Less than one quarter obtained free condoms (24%) and condom lubricants (19%) in the past 2 years. Multiple logistic regression analysis showed that unprotected insertive anal intercourse was associated with not having a Beijing residence card, having six or more male sexual partners, not having sex with women, having a lifetime history of sexually transmitted diseases (STDs), and having never tested for HIV. Unprotected receptive anal intercourse was independently associated with having six or more male sexual partners, not having sex with women, having a lifetime history of STDs, having never tested for HIV, and having less exposure to HIV prevention services. In addition, 28% reported having sex with both men and women during the previous 6 months, and 11% had unprotected intercourse with both men and women. This finding suggests that MSM are a potential bridge of HIV transmission to heterosexual women (or vice versa) and that addressing the HIV prevention needs of MSM may benefit the wider population.     

Discussions of viral load in negotiating sexual episodes with primary and casual partners among men who have sex with men

Recent studies suggest that people living with HIV with lower viral load are at reduced risk for transmitting HIV to their sexual partners. As information about the association between viral load and risk for HIV transmission disseminates throughout high-risk communities, viral load discussions may be used more often as a risk reduction strategy. The overall purpose of this study was to determine the frequency of viral load discussions and unprotected anal intercourse (UAI) in primary and casual sexual partnerships among men who have sex with men (MSM). An online survey was completed by 326 MSM (82% Caucasian, 62% college educated, 7% HIV-positive or thought they were HIV positive) in January 2011. Results showed that viral load discussions occurred in 93% of primary partnerships in which at least one partner was HIV-positive; UAI was reported with 46% of all primary partners and 25% of serodiscordant primary partners with whom viral load was discussed. Viral load discussions occurred in 53% of the three recent sexual episodes with casual sex partners with whom participants had either sex with once or had sex with multiple times in the past three months. UAI was more common in sexual encounters with casual sex partners when viral load was not discussed than when viral load was discussed (75% v. 56% of encounters). The finding that casual sexual episodes that did not include viral load discussions had a higher percentage of UAI than those that did include viral load discussions suggests either that men who do not discuss viral load may be higher risk-takers than men who do, or that the former are less adept at negotiating safer sex with casual sex partners than men who do discuss viral load. More research is needed to understand the role of viral load discussions in negotiating sexual activities among MSM.     

Risk and protective factors related to HIV-risk behavior: a comparison between HIV-positive and HIV-negative young men who have sex with men

The objective of this study was to assess and compare the prevalence of high-risk sexual behaviors among young HIV-negative (n=8064) and HIV-positive (n=171) men who have sex with men (MSM) on predictors of unprotected anal intercourse (UAI). Using venue-based time-space sampling, 8235 MSM aged 15-25 were anonymously surveyed as a part of the Community Intervention Trial for Youth (CITY). The Project was conducted in 13 communities across the USA from 1999 to 2002. Forty percent of HIV-positive men and 34% of HIV-negative men reported that they had UAI in the previous 3 months. HIV-positive MSM were more likely than their uninfected peers to have traded sex within the previous year, to have had sex while high during their last sexual encounter, and to have UAI with a greater number of partners. Multivariate analyses indicated that for HIV-negative men, positive peer norms regarding safer sex and being Black or Latino predicted avoidance of UAI. Among HIV-positive men, having social support for safer sex and positive peer norms predicted avoidance of UAI. Young HIV-positive MSM are a relevant subgroup for prevention because they constitute a significant source from which future infections could be generated.     

Association between risk of acquiring HIV and beliefs and perceptions about the lived experience of HIV/AIDS among HIV-negative or untested men who have sex with men

The study aim was to assess whether the sexual behaviour of HIV-negative or untested men who have sex with men (MSM) was related to their perceptions of what it is like to live with HIV/AIDS, their beliefs or their attitudes to highly active antiretroviral treatments. Any unprotected anal intercourse (UAI) with casual partners was used as the sexual-risk indicator. The study enrolled 261 MSM. There were no significant differences between beliefs, attitudes and perceptions about HIV/AIDS, knowledge of post-exposure prophylaxis (PEP) or exposure to the HIV/AIDS epidemic among those who had had UAI with casual partners and those that had not (P>0.12). Those who considered that low levels of viral load and withdrawing before ejaculation reduced the risk of HIV transmission were significantly more likely to have had UAI with a casual partner (P=0.03). Only a minority of MSM engaging in UAI were optimistic about antiretroviral therapy. The study participants were in general pessimistic about life with HIV/AIDS despite their risk-taking sexual behaviour.     

HIV testing and sexual risks among migrant men who have sex with men: findings from a large cross-sectional study in Beijing,China

Despite the exacerbating HIV transmission among migrant men who have sex with men (MSM) in China, few epidemiological studies explore their HIV testing/risk profiles. We sought to explore sociodemographic/behavioral correlates of HIV/syphilis and HIV testing among migrant MSM. A study was conducted among 3,588 HIV-uninfected MSM. Participants were recruited via short message services, peer referral, web-advertisement and community outreach. HIV/syphilis infections were lab-confirmed. Migrant MSM were more likely to be HIV-infected compared to local MSM. Among 2,699 migrant MSM, HIV testing was associated with older age, living longer in Beijing, having ≥10 lifetime male sexual partners (LMSPs), having insertive anal sex; while being unemployed/retired and having condomless receptive anal sex (CRAS) were associated with a lower odds of HIV testing. Being married, living longer in Beijing, ever testing for HIV and having sex with women were associated with lower HIV odds; while being unemployed/retired, having higher HIV perception, having ≥ 10 LMSPs and having CRAS were associated a higher HIV odds. Increased likelihood of syphilis was associated with older age, being employed, higher HIV perception, having ≥10 LMSPs and having CRAS. Our study provides implications for targeted interventions to tackle HIV/STI risks and improve HIV testing among migrant Chinese MSM.