HIV risks among gay- and non-gay-identified migrant money boys in Shanghai, China

Preferences and access to community-based HIV testing sites among men who have sex with men (MSM) in Côte d'Ivoire

OBJECTIVE

Measuring access and preferences to Men who have Sex with Men focused community-based HIV testing sites (MSM-CBTS) in Côte d'Ivoire.

DESIGN

A respondent-driven sampling telephone survey.

SETTING

National survey conducted in 2018 in Côte d'Ivoire.

PARTICIPANTS

518 MSM aged over 18 years old.

PRIMARY AND SECONDARY OUTCOME MEASURES

Knowledge, practices, satisfaction and preferences regarding MSM-CBTS. Factors associated with MSM-CTBS access or knowledge and with HIV testing venue preferences were examined.

RESULTS

Only half of the respondents (47%) reported knowing of an MSM-CBTS. Of these, 79% had already attended one. Both knowing of and ever visiting an MSM-CBTS were significantly associated with a higher number of HIV tests performed in the past 12 months and having disclosed sexual orientation to one family member.In terms of preferences, 37% of respondents said they preferred undifferentiated HIV testing sites (ie, 'all patients' HIV testing sites), 34% preferred MSM-CBTS and 29% had no preference.Those who reported being sexually attracted to women, being bisexual and those who did not know an MSM non-governmental organisation were less likely to prefer MSM-CBTS. MSM who preferred undifferentiated HIV testing sites mentioned the lack of discretion and anonymity of community-based sites and the desire to avoid the gaze of others.

CONCLUSION

Community-based HIV testing is well suited for MSM who identify as homosexual and those close to the MSM community, while maintaining undifferentiated HIV testing is essential for others. Both types of activities need to be maintained and developed. Healthcare professionals in undifferentiated HIV testing sites need to be properly trained in the non-judgemental reception of MSM.

Syndemic Health Disparities and Sexually Transmitted Infection Burden Among Black Men Who Have Sex with Men Engaged in Sex Work in the U.S

Black men who have sex with men (MSM) engaged in sex work (BMSM-SW) experience elevated HIV and sexually transmitted infection (STI) prevalence. Further, BMSM-SW have been shown to have higher rates of syndemic psychosocial health conditions which contribute to HIV risk behavior and incidence, and poorer care outcomes than other groups of men who have sex with men. However, syndemic perspectives have not been applied to understanding past-year STI burden among BMSM-SW in the U.S. Sexually active Black MSM ≥ 18 years old were recruited from Black Pride events in six U.S. cities (n = 4421) between 2014 and 2017. Multivariable logistic regressions assessed correlates of past-year sex work engagement; whether BMSM-SW had higher odds of syndemic conditions; and whether BMSM-SW had higher odds of self-reported, past-year STI diagnoses. Structural equation models assessed relationships between sex work engagement, syndemic conditions, and STI controlled for sociodemographics and number of sexual partners. A total of 254 (5.7%) Black MSM reported past-year sex work, of whom 45.3% were HIV positive. BMSM-SW were significantly more likely to be Hispanic, to report past-year bisexual behavior, and to report annual income < $10,000. In multivariable models, BMSM-SW were significantly more likely to report intimate partner violence, assault victimization, polydrug use, and depression symptoms; they were also more likely to report past-year gonorrhea, chlamydia, and syphilis. Syndemic conditions mediated the relationship between past-year sex work and past-year STI burden, constituting a significant indirect effect. BMSM-SW in the U.S. face severe biopsychosocial health disparities. Interventions developed for BMSM engaged in sex work are lacking. Our results suggest that interventions containing safer sex work education and sex-positive biobehavioral HIV/STI prevention alongside substance use, mental health, employment, and education components will be most effective.

HIV incidence and sexual behavioral correlates among 4578 men who have sex with men (MSM) in Chengdu, China: a retrospective cohort study

Background

The prevalence of HIV among men who have sex with men (MSM) in southwest China is still increasing. This study aimed to investigate the trend in HIV incidence and its associated risk factors among MSM in Chengdu, China.

Method

Incidence data were collected from the largest local non-governmental organization (NGO) serving MSM in Chengdu between 2012 and 2018, while information on sexual behaviors was collected from 2014. All MSM who received voluntary counseling and testing services (VCT) in the collaborating NGO at least twice during the study period were included. We calculated the HIV incidence density among MSM every 2 years and the overall incidence rate. A Cox proportional hazards regression model was employed to identify risk factors for HIV infection.

Result

A total of 4578 HIV-negative participants were included in the cohort. The total incidence density was 5.95 (95% CI: 5.37–6.56)/100 person-years (PYs) between 2012 and 2018. The segmented incidence density was 9.02 (95% CI: 7.46–10.78), 5.85 (95% CI: 4.86–6.97), 5.43 (95% CI: 4.53–6.46), and 3.09 (95% CI: 2.07–4.41)/100 PYs in 2012–2013, 2014–2015, 2016–2017, and 2018, respectively. After adjusting for sociodemographic characteristics, compared to participants without sexual partners within 6 months, MSM with one fixed partner (Adjusted Hazard Ratio, AHR = 1.18, 95% CI: 0.44–3.19) and more than five partners (AHR = 2.24, 95% CI: 0.81–6.20) had increased risk of HIV infection. MSM who used condom inconsistently had a higher risk of HIV infection (AHR = 1.87, 95% CI: 1.46–2.38) compared to consistent condom users.

Conclusion

The decreased HIV incidence density among MSM was potentially related to the successful comprehensive HIV prevention strategies in Chengdu. Multiple male sexual partnerships and inconsistent condom use during anal intercourse were risk factors associated with HIV occurrence.

Reported prevalence of depression or depressive symptoms among men who have sex with men in China, 2004-2018: A systematic review and meta-analysis

BACKGROUND

Depression is a major mental disorder that imposes a considerable burden on health. Men who have sex with men (MSM) are at high risk for depression. Numerous studies have reported the prevalence of depression or depressive symptoms among MSM in China. However, the estimates have varied substantially between studies. This meta-analysis aimed to establish the pooled prevalence of depression or depressive symptoms among Chinese MSM to attract public attention.

METHOD

A systematic search of several electronic databases and a subsequent manual search was performed to identify relevant studies. A random effects model was adopted to calculate the pooled prevalence of depression or depressive symptoms. Heterogeneity between studies and publication bias was also assessed.

RESULTS

A total of 54 articles with a sample size of 21,950 MSM were analysed. The pooled prevalence of depression or depressive symptoms among MSM was 40.0% (95% CI: 37.9%-45.0%). Substantial heterogeneity was observed across individual studies. The pooled summary estimate stratified by screening instruments and cutoff scores ranged from 19.0% to 60.2%. Subgroup analysis indicated that survey dates, sampling method, HIV infection status and occupation can partially contribute to the between-study heterogeneity.

LIMITATIONS

The findings should be interpreted with caution because of several limitations related to the heterogeneity across studies, sampling method and quality assessment.

CONCLUSIONS

Overall, the reported prevalence of depression or depressive symptoms among Chinese MSM was fairly high. The study suggested that more attention and effective intervention programmes are urgently provided to prevent and improve mental health issues among Chinese MSM.

Sexual orientation and social network size moderate associations between stigma and problematic alcohol use among male sex workers in the US Northeast: an observational study

Background Stigma is associated with poor health among sexual minority individuals. However, no studies have examined the relationship between stigma and problematic drinking among male sex workers (MSWs). This study examined the relationship between sex work stigma and problematic alcohol use among MSWs.

METHODS

Using baseline data from a cohort of 98 MSWs in the US Northeast enrolled between 2015 and 2016, we used logistic regression to examine associations between sex work stigma and hazardous drinking (Alcohol Use Disorders Identification Test (AUDIT) score ≥8) and sex work while drunk, and tested whether sexual orientation (gay vs non-gay identified) and social network size moderated these associations.

RESULTS

Almost half the sample (n = 46; 44%) reported hazardous drinking and 56 MSWs (57%) reported engaging in sex work while drunk. Sex work stigma was associated with hazardous drinking (adjusted odds ratio (aOR) 1.2, 95% confidence interval (CI) 1.05-1.36). Sexual orientation marginally moderated this relationship (P = 0.07), such that it was only significant among gay-identified MSWs (aOR 1.91, 95% CI 1.11-3.28), not among non-gay MSW. Similarly, sexual orientation moderated the effect of sex work stigma on sex work while drunk (P = 0.02), which was only significant among gay-identified MSWs (aOR 1.65, 95% CI 1.05-1.60). Social network size also moderated the effect of sex work stigma on sex work while drunk (P = 0.02), which was only significant among MSWs with small networks (aOR 1.26, 95% CI 1.00-1.58), suggesting large networks can be protective.

CONCLUSIONS

Gay MSWs may be particularly vulnerable to alcohol-related effects of stigma. Future interventions should consider engaging social networks to curb problematic drinking among MSWs.

The UCL-Lancet Commission on Migration and Health: the health of a world on the move

With one billion people on the move or having moved in 2018, migration is a global reality, which has also become a political lightning rod. Although estimates indicate that the majority of global migration occurs within low-income and middle-income countries (LMICs), the most prominent dialogue focuses almost exclusively on migration from LMICs to high-income countries (HICs). Nowadays, populist discourse demonises the very same individuals who uphold economies, bolster social services, and contribute to health services in both origin and destination locations. Those in positions of political and economic power continue to restrict or publicly condemn migration to promote their own interests. Meanwhile nationalist movements assert so-called cultural sovereignty by delineating an us versus them rhetoric, creating a moral emergency.

In response to these issues, the UCL-Lancet Commission on Migration and Health was convened to articulate evidence-based approaches to inform public discourse and policy. The Commission undertook analyses and consulted widely, with diverse international evidence and expertise spanning sociology, politics, public health science, law, humanitarianism, and anthropology. The result of this work is a report that aims to be a call to action for civil society, health leaders, academics, and policy makers to maximise the benefits and reduce the costs of migration on health locally and globally. The outputs of our work relate to five overarching goals that we thread throughout the report.

First, we provide the latest evidence on migration and health outcomes. This evidence challenges common myths and highlights the diversity, dynamics, and benefits of modern migration and how it relates to population and individual health. Migrants generally contribute more to the wealth of host societies than they cost. Our Article shows that international migrants in HICs have, on average, lower mortality than the host country population. However, increased morbidity was found for some conditions and among certain subgroups of migrants, (eg, increased rates of mental illness in victims of trafficking and people fleeing conflict) and in populations left behind in the location of origin. Currently, in 2018, the full range of migrants’ health needs are difficult to assess because of poor quality data. We know very little, for example, about the health of undocumented migrants, people with disabilities, or lesbian, gay, bisexual, transsexual, or intersex (LGBTI) individuals who migrate or who are unable to move.

Second, we examine multisector determinants of health and consider the implication of the current sector-siloed approaches. The health of people who migrate depends greatly on structural and political factors that determine the impetus for migration, the conditions of their journey, and their destination. Discrimination, gender inequalities, and exclusion from health and social services repeatedly emerge as negative health influences for migrants that require cross-sector responses.

Third, we critically review key challenges to healthy migration. Population mobility provides economic, social, and cultural dividends for those who migrate and their host communities. Furthermore, the right to the highest attainable standard of health, regardless of location or migration status, is enshrined in numerous human rights instruments. However, national sovereignty concerns overshadow these benefits and legal norms. Attention to migration focuses largely on security concerns. When there is conjoining of the words health and migration, it is either focused on small subsets of society and policy, or negatively construed. International agreements, such as the UN Global Compact for Migration and the UN Global Compact on Refugees, represent an opportunity to ensure that international solidarity, unity of intent, and our shared humanity triumphs over nationalist and exclusionary policies, leading to concrete actions to protect the health of migrants.

Fourth, we examine equity in access to health and health services and offer evidence-based solutions to improve the health of migrants. Migrants should be explicitly included in universal health coverage commitments. Ultimately, the cost of failing to be health-inclusive could be more expensive to national economies, health security, and global health than the modest investments required.

Finally, we look ahead to outline how our evidence can contribute to synergistic and equitable health, social, and economic policies, and feasible strategies to inform and inspire action by migrants, policy makers, and civil society. We conclude that migration should be treated as a central feature of 21st century health and development. Commitments to the health of migrating populations should be considered across all Sustainable Development Goals (SDGs) and in the implementation of the Global Compact for Migration and Global Compact on Refugees. This Commission offers recommendations that view population mobility as an asset to global health by showing the meaning and reality of good health for all. We present four key messages that provide a focus for future action.

Prevalence and Trends of HIV, Syphilis, and HCV in Migrant and Resident Men Who Have Sex with Men in Shandong, China: Results from a Serial Cross-Sectional Study

Background

Migrant men who have sex with men (MSM) have a higher predisposition for HIV transmission. We aimed to determine and compare the prevalence and trends of HIV, Syphilis, and HCV between migrant and resident MSM in Shandong, China.

Methods

A serial cross-sectional study was conducted in eight cities in Shandong, China from 2010 to 2014. The surveys collected information on demographics, HIV-related knowledge, and HIV-related behaviors including the serologic status of HIV, syphilis, and HCV. Bivariate and multivariable logistic regressions were used to determine differences between migrant and resident MSM.

Results

The overall prevalence of HIV among the 15,705 MSM (14120 were resident, 1580 were migrant and 5 were missing) was 2.6%, with an increase of 1.0% in 2010 to 4.4% in 2014. Prevalence of HIV was higher among migrant MSMs (5.5%) compared to resident MSMs (2.3%). Compared to residents, migrants also had higher prevalence of syphilis (7.5% vs 4.9%) and HCV (1.1% vs 0.6%). We found that there was an increase in the proportion of migrant MSM engaging in anal sex [adjusted OR (AOR) = 1.41 in migrants vs 1.12 in residents], condom use during last anal sex (AOR = 1.14 in residents, P for trend = 0.32), consistent condom use (AOR = 1.04 residents, P for trend = 0.11) and drug use (AOR = 1.51 in migrants and 1.29 among residents). Except in the year 2011, receiving some health services in last year was significant for people who were HIV-positive compared to negative. (P for trend <0.05).

Conclusions

Prevalence of HIV increased in resident as well as migrant MSMs. The migrant MSMs had higher STIs compared to resident MSMs and therefore, should be targeted for effective interventions aimed at reducing their risk behaviors. Deeper understanding of the role of migration in health issues is required for combating the persistently high and gradually increasing HIV burden in MSM in China.

Human Trafficking and Emerging Sex Risk Environments in Vietnam: A Preliminary Profile of a Sex Work "Shared House"

Young male sex workers (YMSW) in Vietnam have high rates of HIV and STIs, yet have poor access to healthcare due low knowledge, stigma, and economic constraints. In the process of implementing a Sexual Health Promotion intervention to engage YMSW in Ho Chi Minh City in healthcare, we identified a unique sex work venue, known as a "Shared House," in which YMSW provide sex under the direction of a manager who negotiates the terms of the transaction directly with the client. Survey data reveal that compared with YMSW recruited in other locations, those interviewed in Shared Houses reported lower levels of substance use, less contact with the police, and fewer nights spent sleeping in pubic places. However, observational data and informal interviews with YMSW in Shared Houses revealed that the majority were trafficked through third-party brokers who connect youth with Shared House managers for the explicit purpose of sex work. These YMSW had little or no control over their sex work transactions and very low levels of knowledge regarding transmission of HIV and STIs. Further research is needed in these and other venues in which young men are trafficked for sex work.

High-risk behaviour and HIV infection risk among non-local men who have sex with men with less than a single year's residence in urban centres: a multicentre cross-sectional study from China

OBJECTIVES

Traditionally, subjects' migration status has usually been defined on the basis of their registered residency status. We attempted to redefine migration based on the duration of residency in their cities of migration and to explore more precisely the impact of migration on HIV infection risk in men who have sex with men (MSM).

METHODS

A multisite cross-sectional study was conducted during 2012-2013 in seven Chinese cities. Questionnaire surveys were conducted and blood was drawn to test for antibodies to HIV, syphilis and herpes simplex virus-2 (HSV-2). MSM who were unregistered local residents and had resided in their cities of migration for ≤1 or >1 year were defined as migrant MSM, or transitional MSM, respectively.

RESULTS

Compared with transitional MSM and local MSM, migrant MSM had poorer HIV knowledge and higher rates of high-risk behaviour, including earlier sexual debut, multiple sexual partners, participation in commercial sex and recreational drug use. Multivariate logistic regression analysis showed that HIV prevalence among migrant MSM was higher than local MSM (p<0.05). This relationship, however, did not hold for transitional MSM and local MSM (p>0.05). Male sex work, recreational drug use, syphilis infection and HSV-2 infection were independently associated with HIV infection among migrant MSM.

CONCLUSIONS

Non-local MSM with shorter residence were at greater risk of HIV acquisition. More focus should be placed on HIV behavioural interventions targeting non-local MSM with temporary residence.

Targeting vulnerable populations: a synthetic review on alcohol use and risky sexual behaviour among migrant populations

Background

Research has demonstrated a link between alcohol use and risky sexual behaviour among different types of migrant populations. Therefore, research investigating risk factors associated with alcohol consumption among them is a public health priority. This review aimed to explore the intersection between migration, alcohol consumption and risky sexual behaviour.

Methods

This article is a synthetic review of empirical studies on the association of alcohol and high-risk sexual behaviour among different types of the migrant populations, focusing on measurable outcomes generated from quantitative data. A descriptive analysis generated from global and situational studies was used to interpret the reviewed research and to discuss critically the factors that drive migrants to engage in alcohol consumption and high-risk behaviour.

Results

This review found out that there is a significant and positive association between global and situational alcohol use and several outcomes of risky sexual behaviour among different types of migrant populations. This association was however mainly observed at high quantities and frequencies of alcohol use, mainly among male migrants, and was often tied to a specific situation or context, for instance the type of sexual partner, the level of mobility and to environmental factors such as living arrangements and entertainment venues.

Conclusions

The study supports previous research that alcohol use is associated with risky sexual behaviour among different types of migrant populations. Therefore, future interventions should target mobile, male migrant heavy drinkers. Additional research is needed using more event-level and longitudinal methodologies that overcome prior methodological limitations.

HIV/STIs risks between migrant MSM and local MSM: a cross-sectional comparison study in China

Background. Internal migration plays a significant role in China’s HIV epidemic. However, few studies have directly compared migrant men who have sex with men (MSM) with local MSM with regard to HIV/sexually transmitted infections (STIs) risks.

Methods. We conducted a study in Guangzhou, China, with the aim of understanding the differences in HIV/STIs risks between migrant MSM and local MSM. A cross-sectional study was conducted among 273 migrant MSM and 249 local MSM in Guangzhou, China. Their behavioral and serologic data on HIV/syphilis were collected and compared between the two groups. A multivariate logistic regression was used to estimate the associations between HIV/STIs risks and migratory status.

Results. Migrant MSM, compared to local MSM, have higher odds of reporting unprotected anal intercourse (UAI) (OR = 1.4; 95% CI [0.9–2.0]) and having multiple homosexual partners (OR = 1.2; 95% CI [0.8–1.8]). A lower rate of condom use at homosexual debut was reported in migrant MSM than in local MSM (OR = 0.7; 95% CI [0.5–0.9]). Migrant MSM have less odds of reporting HIV/STIs testing in the previous 6 months relative to local MSM (OR = 0.5; 95% CI [0.4–0.8]). In addition, migrant MSM demonstrated a lower level of HIV knowledge than local MSM (OR = 0.4; 95% CI [0.2–0.8]).

Conclusion. Migrant MSM are more likely to engage in sexual risk behaviors, report a lower level of HIV knowledge and have less access to HIV/STIs testing. Further comprehensive interventions targeting migrant MSM are urged.

Estimating self-reported sex practices, drug use, depression, and intimate partner violence among MSM in China: a comparison of three recruitment methods

Men who have sex with men (MSM) are the group at highest risk for HIV in China. Researchers have used various recruitment methods to reach this population hidden from the hetero-normative culture. To inform future recruitment strategies, we compared estimates of socio-demographic characteristics, HIV risk behaviors, depression, and intimate partner violence (IPV) across three samples of MSM and money boys in Shanghai, China. Data were collected from three community-based samples of MSM and money boys (n = 1352) recruited via respondent-driven sampling (RDS) (n = 404), community popular opinion leaders (CPOL) (n = 385), and Internet and venue-based sampling (VBS) (n = 546). Different recruitment methods generated samples with statistically significant differences among a number of socio-demographic characteristics, sexual behaviors, drug use, depression scores, and exposure to IPV. Specifically, RDS participants had lower education (p = .002), income levels (p < .001), and were more likely to report condomless sex with a woman (p < .001). CPOL participants were younger (p < .001), more likely to report lifetime condomless anal sex (p = .009), more than 10 male partners in the past 30 days (p < .001), and were less likely to experience violence by a male intimate partner (p = .001). VBS participants had lowest depression score (p = .005) and were more likely to report lifetime drug use (p = .003). Our findings reinforce that each recruitment method may reach a sub-group of MSM with a specific risk profile, so multiple methods may be needed to obtain a representative sample of MSM. Interventions may use specific recruitment methods to target certain segments of the MSM population.

Prevalence of and disparities in HIV-related sexual risk behaviours among Chinese youth in relation to sexual orientation: a cross-sectional study

Background: The aim of this study was to calculate the prevalence rate of HIV-related sexual risk behaviours (HSRB) among Chinese youth and determine whether there was an association between sexual orientation and HSRB. Methods: This study used a nationally representative survey of youth aged 15-24 years in China. Population numbers, prevalence, and proportions were calculated where appropriate. χ2 tests were used to determine the difference within categorical variables. Multivariate logistic regression was used to calculate the adjusted odd ratios (AOR) and 95% confidence interval (CI). Results: The rate of any HSRB among sexually active youth was 79.43%, and the most common HSRB was lack of condom use during the first sexual experience (66.02%). After adjusting for demographic and socioeconomic variables (sex, age, residence, living with parents or not, father's education and annual family income), non-heterosexual orientation was found to significantly increase the odds of HSRB (AOR = 2.42, 95% CI: 1.16-5.05). Conclusions: Non-heterosexual youth are at a higher risk of partaking in HSRB. The high prevalence of HSRB indicates the insufficiency of sex education for Chinese youth, especially for non-heterosexual youth. Greater efforts should be made to increase reproductive and sexual health services for Chinese youth.

Together we have fun: native-place networks and sexual risk behaviours among Chinese male rural-urban migrants

Some scholars argue that the maintenance of social networks contributes to the lower prevalence of deviant behaviours and fewer adverse health effects among migrants. But others suggest that if migrants are embedded in homogeneous networks, such networks may enable the formation of a deviant subculture that promotes risk taking. Facing this dilemma, the present study investigates how native-place networks influence sexual risk behaviours (SRBs), specifically the pursuit of commercial sex and condomless sex with sex workers, for male rural-urban migrants. Using a multi-stage sample of 1,591 male rural-urban migrants from two major migrant-influx cities within China, we assessed migrants' general friend network ties and native place networks (townsmen in migrants' local networks) and tested their associations with SRBs. Multiple logistic regression analyses indicate that native-place network ties are associated with paying for sex (OR = 1.33, p < 0.001) and condomless sex with sex workers (OR = 1.33, p < 0.001), while general friendship network ties reduce such risks (OR = 0.74, p < 0.001; OR = 0.84, p < 0.01) even after controlling for demographic background, housing conditions, length of stay, health beliefs and behaviours, and spousal companionship. Our findings suggest that native-place networks among Chinese male rural-urban migrants are associated with SRBs because homogenous networks may serve as a platform for the emergence of a deviant subculture that promotes risk behaviours. A Virtual Abstract of this paper is available at: https://www.youtube.com/watch?v=3Wg20I6j8XQ.

Validity of the CAGE questionnaire for men who have sex with men (MSM) in China

BACKGROUND

Detection of heavy drinking among men who have sex with men (MSM) is crucial for both intervention and treatment. The CAGE questionnaire is a popular screening instrument for alcohol use problems. However, the validity of CAGE for Chinese MSM is unknown.

METHOD

Data were from three waves of cross-sectional assessments among general MSM (n=523) and men who sell sex to other men ("money boys" or MBs, n=486) in Shanghai, China. Specifically, participants were recruited using respondent-driven, community popular opinion leader, and venue-based sampling methods. The validity of the CAGE was examined for different cutoff scores and individual CAGE items using self-reported heavy drinking (≥14 drinks in the past week) as a criterion.

RESULTS

In the full sample, 75 (7.4%) of participants were classified as heavy drinkers. 32 (6.1%) of general MSM and 43 (8.9%) of MBs were heavy drinkers. The area under curve statistics for overall sample was 0.7 (95% CI: 0.36-0.77). Overall, the sensitivities (ranging from 18.7 to 66.7%), specificities (ranging from 67.5 to 95.8%), and positive predictive values (ranging from 14.1 to 26.4%) for different cutoff scores were inadequate using past week heavy drinking as the criterion. The ability of CAGE to discriminate heavy drinkers from non-heavy drinkers was limited.

CONCLUSIONS

Our findings showed the inadequate validity of CAGE as a screening instrument for current heavy drinking in Chinese MSM. Further research using a combination of validity criteria is needed to determine the applicability of CAGE for this population.

A new public health context to understand male sex work

Background

Researching male sex work offers insight into the sexual lives of men and women while developing a more realistic appreciation for the changing issues associated with male sex work. This type of research is important because it not only reflects a growing and diversifying consumer demand for male sex work, but also because it enables the construction of knowledge that is up-to-date with changing ideas around sex and sexualities.

Discussion

This paper discusses a range of issues emerging in the male sex industry. Notably, globalisation and technology have contributed to the normalisation of male sex work and reshaped the landscape in which the male sex industry operates. As part of this discussion, we review STI and HIV rates among male sex workers at a global level, which are widely disparate and geographically contextual, with rates of HIV among male sex workers ranging from 0% in some areas to 50% in others. The Internet has reshaped the way that male sex workers and clients connect and has been identified as a useful space for safer sex messages and research that seeks out hidden or commonly excluded populations.

Future directions

We argue for a public health context that recognises the emerging and changing nature of male sex work, which means programs and policies that are appropriate for this population group. Online communities relating to male sex work are important avenues for safer sexual messages and unique opportunities to reach often excluded sub-populations of both clients and male sex workers. The changing structure and organisation of male sex work alongside rapidly changing cultural, academic and medical discourses provide new insight but also new challenges to how we conceive the sexualities of men and male sex workers. Public health initiatives must reflect upon and incorporate this knowledge.

Epidemiological and molecular characteristics of HIV infection among money boys and general men who have sex with men in Shanghai, China

To examine and compare the epidemiological and molecular characteristics of HIV infection between money boys (MBs) and general men who have sex with men (MSM) in Shanghai, China. Using a venue-based sampling strategy, a total of 535 MSM including 226 MBs and 309 general MSM were recruited to participate in a cross-sectional survey including a face-to-face questionnaire interview and HIV testing. Genotyping of HIV-1 pol gene was performed for HIV-positive participants. Compared with general MSM, MBs reported more sexual partners, more alcohol and drug use and more sex after alcohol or drug use. HIV prevalence was 10.7% overall, 14.6% for MBs and 7.8% for general MSM (p=0.011). Two independent multiple logistic regression analyses indicated that HIV infection was positively associated with non-Han ethnicity (Odds Ratio [OR]=4.79, 95% Confidence Interval [CI]: 1.08-21.28) and sex after drug use in the past 6months (OR=3.59, 95% CI: 1.50-8.61) among MBs, and with sex after drug use in the past 6months (OR=3.38, 95% CI: 1.10-10.34) among general MSM as well. HIV-1 pol gene was successfully amplified and sequenced for 52 (91.2%) of HIV-positive participants. Of them, 53.8% were genotyped as CRF01_AE, 36.5% as CRF07_BC and 9.6% as subtype B. Two CRF01_AE subtype-infected participants (3.8%), a 50years old MB and a 24years old general MSM, harbored viruses with a M46L mutation conferring resistance to protease inhibitors (PI). MSM particularly MBs in Shanghai, China were at high risk of HIV infection, underscoring an urgent need for joint intervention efforts for drug use and sexual behaviors. HIV drug resistance surveillance is also warranted although the relatively low prevalence of HIV drug resistance implies the effectiveness of current antiretroviral treatment regimen.

Factors associated with loss-to-follow-up during behavioral interventions and HIV testing cohort among men who have sex with men in Nanjing, China

BACKGROUND

Behavioral interventions (BIs) remained the cornerstone of HIV prevention in resource-limited settings. One of the major concerns for such efforts is the loss-to-follow-up (LTFU) that threatens almost every HIV control program involving high-risk population groups.

METHODS

To evaluate the factors associated with LTFU during BIs and HIV testing among men who have sex with men (MSM), 410 HIV sero-negatives MSM were recruited using respondent driven sampling (RDS) in Nanjing, China during 2008, they were further followed for 18 months. At baseline and each follow-up visits, each participant was counseled about various HIV risk-reductions BIs at a designated sexually transmitted infection (STI) clinic.

RESULTS

Among 410 participants recruited at baseline, altogether 221 (53.9%) were LTFU at the 18-month follow-up visit. Overall, 46 participants were found to be positive for syphilis infection at baseline while 13 participants were HIV sero-converted during the follow-up period. Increasing age was less (Adjusted Odds Ratio(aOR) of 0.90, 95% confidence Interval (CI) 0.86-0.94) and official residency of provinces other than Nanjing (AOR of 2.49, 95%CI 1.32-4.71), lower level of education (AOR of 2.01, 95%CI 1.10-3.66) and small social network size (AOR of 1.75, 95%CI 1.09-2.80) were more likely to be associated with higher odds of LTFU.

CONCLUSION

To improve retention in the programs for HIV control, counseling and testing among MSM in Nanjing, focused intensified intervention targeting those who were more likely to be LTFU, especially the young, less educated, unofficial residents of Nanjing who had smaller social network size, might be helpful.

Drug use and sexual behaviors among MSM in China

BACKGROUND

This study explores patterns of drug use and related correlates among a sample of men who have sex with men (MSM) and men who sell sex to other men (aka "money boys") in China.

OBJECTIVES

Data were collected from MSM and money boys (MBs) in Shanghai, China using a Community Popular Opinion Leader (CPOL) research design with a self-administered cross-sectional survey to: (1) describe drug use and drug use correlates and (2) examine relationships between drug use and sexual behaviors in general MSM and MBs.

METHODS

The sample consisted of 402 MSM (203 MBs) who live in Shanghai, China. Descriptive statistics and regression analyses were used to explore associations between drug use and sexual behaviors and make comparisons between MBs and general MSM.

RESULTS

MBs reported using more drugs in the last week, 3 months and ever; sex after using drugs, and unprotected sex after using drugs more frequently than general MSM. Additionally, many MBs reported receiving free drugs from their clients and those who did receive free drugs were very likely to report having unprotected sex.

CONCLUSIONS

It is crucial to increase research and include Chinese MSM and their drug use in the Chinese policy conversation. These data suggest that drug use and sexual behaviors after drug use among Chinese MSM differ widely based upon selling sex and separate intervention strategies may be appropriate.

Global burden of HIV among men who engage in transactional sex: a systematic review and meta-analysis

BACKGROUND

Men who engage in transactional sex, the exchange of sex for money, goods, or other items of value, are thought to be at increased risk of HIV, but there have been no systematic attempts to characterize HIV burden in this population. We undertook a systematic review and meta-analysis to quantify the burden in this population compared with that of men in the general population to better inform future HIV prevention efforts.

METHODS

We searched seven electronic databases, national surveillance reports, and conference abstracts for studies of men who engage in transactional sex published between 2004-2013. Random effects meta-analysis was used to determine pooled HIV prevalence and prevalence ratios (PR) for the difference in HIV prevalence among men who engage in transactional sex as compared to general population men.

FINDINGS

Of 66 studies included representing 31,924 men who had engaged in transactional sex in 28 countries, pooled biological assay-confirmed HIV prevalence was 10.5% (95% CI = 9.4 to 11.5%). The highest pooled HIV prevalence was in Sub-Saharan Africa (31.5%, 95% CI = 21.6 to 41.5%), followed by Latin America (19.3%, 95% CI = 15.5 to 23.1%), North America (16.6%, 95% CI = 3.7 to 29.5%), and Europe (12.2%, 95% CI = 6.0 to 17.2%). Men who engaged in transactional sex had an elevated burden of HIV compared to the general male population (PR = 20.7, 95% CI = 16.8 to 25.5).

CONCLUSIONS

The global burden of HIV is disproportionately high among men who engage in transactional sex compared with the general male population. There is an urgent need to include this population in systematic surveillance as well as to scale-up access to quality HIV prevention programs.

Utilization of cessation resources among HIV-positive and HIV-negative men who smoke and who have sex with men in Chengdu, China

INTRODUCTION

Given the implications for smoking among individuals living with HIV and the high rates of smoking and HIV among men who have sex with men (MSM) in China, we examined differences in prior use of and future interest in various cessation resources among MSM smokers with or without HIV.

METHODS

We conducted a cross-sectional survey of 381 MSM; HIV status was provided by 350 MSM, and complete data was provided by a total of 344 (188 HIV-positive and 156 HIV-negative) current smokers (past 30 days) recruited by a nongovernmental organization in Chengdu in 2012-2013. Participants reported tobacco and alcohol use; psychosocial factors; past-year quit attempts; health care provider interactions on smoking; and prior use of and interest in cessation resources.

RESULTS

Smokers living with HIV were more likely to have used behavioral interventions (p < .001) and pharmacotherapy (p = .033). Those who were HIV-positive were also more interested in behavioral interventions (p = .002) and pharmacotherapy (p = .008). Correlates of interest in behavioral interventions in the regression model included lower cigarette consumption (p = .011), higher confidence in quitting (p = .035), greater likelihood of attempting to quit in the past year (p = .026), and being HIV-positive (p = .008). Correlates of interest in pharmacotherapy included greater depressive symptoms (p = .047) and being HIV-positive (p = .015).

CONCLUSIONS

Smokers living with HIV were more likely to have ever attempted to quit smoking, to have used cessation resources, and to be interested in using cessation aids. These findings indicate the promise of greater dissemination of cessation resources, particularly if Chinese clinical practices are strengthened to offer cessation support.

Healthcare provider intervention on smoking and quit attempts among HIV-positive versus HIV-negative MSM smokers in Chengdu, China

Given the implications for smoking among HIV-positive individuals and high smoking and HIV rates among men who have sex with men (MSM) in China, we examined sociodemographic, smoking-related, psychosocial, and substance use factors in relation to HIV status; receiving some sort of healthcare provider intervention regarding smoking; and having made a quit attempt in the past year in a sample of MSM smokers in Chengdu. We conducted a cross-sectional survey of 381 MSM smokers recruited by a nongovernmental organization in Chengdu in 2012-2013. Of these, 350 disclosed their HIV status and 344 (188 HIV-positive and 156 HIV-negative) provided completed data. Half (50.0%) reported at least one quit attempt in their lifetime; 30.5% reported a quit attempt in the past year. The majority (59.4%) reported that a healthcare provider had intervened in some way (assessed smoking, advised quitting, provided assistance), most commonly by assessing smoking status (50.0%). HIV-positive individuals were more likely to report a healthcare provider intervening on their smoking (p < .001). Those who received provider intervention were more likely to have attempted to quit ever (p = .009) and in the past year (p < .001). Those HIV-positive were more likely to have attempted to quit since diagnosis if a provider had intervened (p = .001). Multivariate regression documented that being HIV-positive (p < .001), greater cigarette consumption (p = .02), less frequent drinking (p = .03), and greater depressive symptoms (p = .003) were significant correlates of healthcare provider intervention. Multivariate regression also found that healthcare provider intervention (p = .003), older age (p = .01), and higher autonomous motivation (p = .007) were significant correlates of attempting to quit in the past year. Given the impact of healthcare provider intervention regarding smoking on quit attempts among MSM, greater training and support is needed to promote consistent intervention on smoking in the clinical setting among HIV-positive and HIV-negative MSM smokers.

Mediation effect of perceived behavioural control on intended condom use: applicability of the theory of planned behaviour to money boys in China

BACKGROUND

Money boys (MBs) are male sex workers who sell sex to men who have sex with men. The objectives of this study were to assess (a) the sexual HIV risk of MBs; (b) the ability of the theory of planned behaviour (TPB) to predict MBs' intentions to use condoms; and (c) the manner in which TPB constructs (attitudes towards condom use, subjective norms and perceived behavioural control) combine to influence condom use intentions.

METHODS

Participants came from 10 MB-frequented clubs in two cities in China. Multiple regression and path analytic models were used to test inter-relationships among the TPB constructs.

RESULTS

Seventy-eight percent of the 122 MB participants reported having used condoms for every anal sex act. About one-third reported having had female sexual partners in the past 2 months; of these MBs, half (53%) used condoms for every sex act. A revised model using TPB constructs accounted for 52% of the variance of condom use intentions and revealed that perceived behavioural control was a mediator in pathways beginning with attitudes and ending with condom use intentions, and beginning with subjective norms and ending with intentions.

CONCLUSIONS

The findings suggest that a revised model of TPB applies to condom use intentions among Chinese MBs. It may be appropriate to adapt HIV interventions that are grounded in TPB and that have been shown to be effective elsewhere for use with Chinese MBs. HIV interventions for this population should give perceived behavioural control and its predictors special consideration.

Vulnerability to sexual violence and participation in sex work among high-end entertainment centre workers in Hunan Province, China

BACKGROUND

China has seen a proliferation of entertainment centres that are frequented by business people. Employees at these centres often are young, female rural-to-urban migrants who may be vulnerable to sexual violence and exploitation.

METHODS

Data for this study were collected using a self-administered survey among male and female employees in two high-end entertainment centres in Changsha, Hunan Province, China. We used logistic regression to examine predictors of violent and potentially exploitative experiences (partner violence, forced sex and transactional sex). Predictors included gender, ever having a same-sex partner, migration variables and employment characteristics.

RESULTS

Participants reported high levels of partner violence (16.0% ever and 9.0% in the past 3 months) and forced sex (13.9% ever and 5.5% in the past 3 months). Nineteen percent reported sex work in the past 3 months. In the multivariate regressions, ever having had a same-sex partner was associated with higher odds of ever having experienced partner violence (odds ratio (OR)=7.8, P<0.001), partner violence in the past 3 months (OR=9.0, P<0.001), ever having had transactional sex (OR=6.0, P<0.001) and transactional sex in the past 3 months (OR=5.2, P=0.001). After adjusting for transactional sex, the association between having had a same-sex partner and partner violence remained significant. Neither gender nor migration status was associated with any of the outcomes.

CONCLUSION

High-end entertainment centre workers in China are at risk for sexual violence and should be targeted with employment-based interventions.

Male-on-male intimate partner violence and sexual risk behaviors among money boys and other men who have sex with men in Shanghai, China

BACKGROUND

Intimate partner violence (IPV) is known to increase HIV risk among heterosexual women, but less is known about IPV and HIV among men who have sex with men (MSM), with almost no data from non-Western countries. This study examined the prevalence of IPV and links between IPV and HIV risks among MSM in Shanghai, China.

METHODS

A cross-sectional sample of 404 money boys (male sex workers) and other MSM were recruited via respondent-driven sampling.

RESULTS

Overall, 51% of the sample reported emotional, physical, or sexual abuse from a male sexual partner. Money boys reported more overall abuse than did other MSM, and more were likely than other MSM to report experiencing multiple types of abuse. MSM who reported violence or abuse from male partners reported more overall sexual risk behavior, and specifically, more unprotected sex and more sex linked to alcohol and other substance use. The association between experience of abuse from male partners and increased HIV risk did not differ between money boys and other Chinese MSM.

CONCLUSIONS

We conclude that violence and abuse from male partners are highly prevalent among Chinese MSM, and that experience of violence from male sexual partners is linked to increased HIV risk. HIV prevention targeting Chinese MSM must address the increased risk associated with experience of male-on-male IPV. Future research should explore links between HIV risk and MSM's perpetration of violence against male partners, as well as exploring the role of violence in the male-female relationships of men who have sex with and men and women.

HIV incidence and associated factors in a cohort of men who have sex with men in Nanjing, China

BACKGROUND

Many surveys conducted in recent years reported the increasing trend of HIV infection among men who have sex with men (MSM), but limited data exists on HIV incidence by cohort study in China.

METHODS

A 6-month prospective cohort study was conducted. A total of 397 MSM found HIV seronegative at baseline study were followed-up for 6 months starting from May 2007 and re-evaluated seroconversions of HIV at 6 months. Questionnaire interviews were conducted to collect information about risk behaviors.

RESULTS

Of the 397 MSM who were found seronegative at the baseline study, 286 (72.0%) received the HIV antibody testing at month 6; 7 of them showed HIV seroconversions, yielding an incidence of 5.12 per 100 person-years. Significant predictors of seroconversion (Poisson regression analyses) included duration being MSM >10 years (relative risks [RR] = 3.08, 95% CI: 1.53-6.20), recruiting male sex partner mostly at saunas (RR = 2.35, 95% CI:1.09-5.08), positive syphilis diagnosis made at the baseline study (RR = 2.82, 95% CI: 1.31-6.09), having multiple male sex partners in the last 6 months (RR = 2.54, 95% CI: 1.18-5.49), having at least 1 casual male sex partner in the last 6 months (RR = 2.17, 95% CI: 1.00-4.70), and having unprotected anal sex with a regular male sex partner in the last 6 months (RR = 2.22, 95% CI: 1.10-4.49).

CONCLUSIONS

The incidence of HIV among MSM is very high; many new infections would hence occur in China. Effective interventions are warranted. The risk factors reported in this study give some insights for designing relevant prevention programs.

A syndemic including cigarette smoking and sexual risk behaviors among a sample of MSM in Shanghai, China

OBJECTIVES

We explored possible correlates of cigarette smoking and their associations with levels of smoking among a sample of Chinese men who have sex with men (MSM). We also explored the syndemic associations of substance use and psychosocial problems on sexual risk behaviors.

METHODS

Cross-sectional data collection from 404 MSM in Shanghai, China.

RESULTS

MSM exhibit a high prevalence of smoking (66.3%). Both light and heavy smoking were associated with alcohol and drug use, depression, intimate partner violence, sexual attitudes, and gay identity (though the associations for light smokers were moderate compared to those for heavy smokers).

CONCLUSIONS

Our findings indicate the presence of a health syndemic among MSM, and suggest that smoking prevention and cessation and other substance abuse interventions should be integrated into efforts preventing sexual risk behaviors among MSM.

Dating violence among gay men in China

This is the first study on the prevalence of dating violence and threats of being forced to "come out of the closet" among Chinese gay men. Data on social demographic information and the experience of dating violence, including types of abuse, threats of "outing," and the gender of abusers were collected from 418 gay men and 330 heterosexual men by self-administered questionnaires. Mann-Whitney U test, χ(2) test, and multivariate logistic regression analyses were used to test group differences. Up to 32.8% of the gay men had experienced one abuse or more. Among those experiencing abuse, 83.9% of the gay men never told anyone about their abuse. The experience of any form of abuse by gay men was 5.07 times higher than the rate of abuse among heterosexual men controlling for age in logistic regression models. In addition, 12.4% of the gay men have experienced the threat of being outed. Overall, dating violence is more prevalent in gay men than in heterosexuals. Efforts to prevent dating violence, especially among gay men, should be made in China.

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.

Prevalence of HIV infection and associated risk factors among men who have sex with men (MSM) in Harbin, P. R. China

OBJECTIVE

To assess the prevalence of HIV infection and characteristically risk of factors which associated with HIV infection among MSM in Harbin, China.

METHODS

A face-to-face questionnaire interview was conducted among 463 Men Who Have Sex with Men (MSM) who were recruited by the snowball sampling in Harbin from April, 2011 to July, 2011. The questionnaire mainly included demographics, AIDS knowledge, homosexual behavior and the status of intervention in MSM. Blood specimens were obtained and tested for the diagnoses of HIV, syphilis and hepatitis C virus (HCV). Associations between above exposed factors and HIV infection were analyzed using a univariate analysis and forward stepwise logistic regression.

RESULTS

The prevalence of HIV and syphilis was 9.5 and 14.3%. The awareness rate of AIDS was 86.8%. The rate of unprotected sexual behavior was 57.6% of MSM during the past 6 months. The univariate analysis identified that the age (age ≥ 35 years old), cohabitation, more than 10 years of homosexual behavior and more than 10 homosexual partners were risk factors which associated with the HIV infection, and that protected sex during the past 6 months was a protective factor for the HIV infection. The multivariate analysis identified that the duration of homosexual behavior and commercial sexual behavior were independent risk factors which associated with the HIV infection, and the protected sex during the past 6 months was a protective factor for the HIV infection.

CONCLUSION

The prevalence of HIV among MSM in Harbin has been rapidly increasing in the past few years. Targeted, tailored, and comprehensive interventions are urgently needed to prevent the HIV infection from MSM.

Qualitative exploration of HIV-related sexual behaviours and multiple partnerships among Chinese men who have sex with men living in a rural area of Yunnan Province, China

BackgroundThe HIV epidemic has been spreading rapidly among men who have sex with men (MSM) in China. The present study explored the pattern of HIV-related high-risk sexual practices among MSM in a rural Chinese setting. Methods: Data were collected by semistructured in-depth interviews conducted among 15 MSM in Yuxi Prefecture, Yunnan Province, China. Fifteen respondents were recruited through a local non-governmental organisation via purposive sampling. Thematic analysis was used. Results: Technological changes, risk behaviours, social stigma and high migration rates have played a significant role in the spread of HIV among MSM in rural China. The Internet has become the primary channel for soliciting casual sex partners in the MSM community. Bisexuality and having concurrent and multiple sexual partners were common among rural MSM. A large number of sexual partners and low condom use in all MSM partnership types were noted. Due to Chinese cultural traditions and social stigma, Chinese rural MSM were reluctant to disclose their homosexuality. Rural-to-urban migrant MSM were often engaged in the commercial sex trade. Conclusions: Rural MSM is a distinctive and complex population with multiple identities in China. Concurrent multiple sexual partnerships, high mobility and low disclosure rate are the major challenges for HIV prevention and intervention programs in MSM.

HIV and sexually transmissible infections among money boys in China: a data synthesis and meta-analysis

BACKGROUND

Commercial sex workers within the population of men who have sex with men (MSM) in China, known as 'money boys' (MBs), are perceived to be at higher risk for HIV and other sexually-transmissible infections (STIs).

METHODS

We conducted a systematic review and meta-analyses from peer-reviewed literature accessed in two English (PubMed and Embase) and three Chinese databases (CNKI, CQVIP, Wanfang data). A data synthesis exercise was carried out to determine the extent and patterns of behaviours and HIV/STI epidemics. Pooled estimates, with 95% confidence intervals, for each study variable were calculated.

RESULTS

Thirty-two eligible articles (9 in English and 23 in Chinese) were identified. Our analysis indicated that Chinese MBs are generally young, currently employed, at low literacy levels and highly mobile. The prevalence of HIV, syphilis and co-infection among MBs were estimated to be 6.0% (4.2-8.5%), 12.4% (9.9-15.3%) and 2.2% (1.1-4.1%) over the period of 2004-2011. Level of condom use among MBs is generally higher than the broader MSM population (69.2% at last act, and 48.5% consistently over the past 6 months). One-third of the Chinese MBs identified themselves as bisexual and 8.7% (5.6-13.5%) are currently married to a female. Further, 40.9% (34.5-47.7%) of MBs participated in group sex in the past 12 months and 14.8% (10.6-20.3%) concurrently use illicit drugs.

CONCLUSIONS

HIV/STI epidemics have affected Chinese MBs but the evidence suggests that the extent of infections is not greater than among other MSM in China.

Substance Use and Sexual Risks Among General MSM and Money Boys in Shanghai, China

In China, men who have sex with men (MSM) are at high risk for substance use, HIV, and other sexually transmitted infections (STIs). However, there has been little research into their drug use and the sexual behaviors they engage in after drug and alcohol use. Using respondent-driven sampling methodology, this cross-sectional study of 404 MSM described drug use and examined sexual behaviors after drug and alcohol use among general MSM and money boys (those who engage in same-sex commercial sex) in Shanghai, China. Money boys reported using more drugs in the last week, 3 months and ever, and having sex after drinking and sex after using drugs more frequently than general MSM. It is vital to continue research and begin science-based interventions in these high-risk and underserved populations.

Socio-demographic and behavioral correlates for HIV and syphilis infections among migrant men who have sex with men in Beijing, China

Migrant men who have sex with men (MSM) may be particularly vulnerable to sexually transmitted infections (STIs) including HIV. This study examines the rates of HIV and syphilis infections and associated socio-demographic and behavioral factors among migrant MSM in China. Data from 307 migrant MSM were collected in Beijing, China. Blood specimens were collected to test for HIV and syphilis infections. HIV and syphilis rates were 5.9% and 20.2%, respectively. Multivariate logistic regression analyses showed that having ever been married, living a longer period in Beijing, having more sexual partners, and having a foreign MSM friend were significantly associated with HIV infection. Migrating from a rural area, experiencing one's sexual debut at an older age, having a male as first sexual partner, having more sexual partners, and being recruited from peer outreach and social network were associated with syphilis infection. Migrant MSM in China are at high risk for HIV and syphilis infections. HIV prevention programs targeting rural migrant MSM who have been married are needed.

A survey of condom use behaviors and HIV/STI prevalence among venue-based money boys in Shenzhen, China

We examined an at-risk population in China, money boys (MBs), to evaluate their potential role for transmitting HIV and sexually transmitted infections (STIs). Data were collected from 418 MBs selected by time-location cluster sampling, using a self-administered computerized questionnaire and testing a small blood sample for HIV/STIs. One-third (32.1%) of participants self-identified as homosexual, 25.4% heterosexual, 33.5% bisexual, and 9.1% uncertain. Consistent condom use by participants was 70-80% with commercial sex partners, 43.9% with girlfriends, and 60-70% with other non-commercial partners. HIV prevalence was 3.3%; syphilis, 10.5%; and HSV-2, 11.0%; overall prevalence for any was 20.3%. Factors significantly associated with HIV/STIs included being minority (OR = 4.82), having only male partners (OR = 1.92), having more male casual partners in the last 6 months (OR = 1.28), being younger at sexual debut (OR = 1.14), and being older (OR = 1.11). This study emphasizes the importance of developing targeted interventions for MBs, particularly those who are homosexual or minority.

Social network and other correlates of HIV testing: findings from male sex workers and other MSM in Shanghai, China

Although the Chinese government provides free-of-charge voluntary HIV counseling and testing, HIV testing rates among men who have sex with men (MSM) are reported to be extremely low. This study examines the association of structural and psychosocial factors and social network characteristics with HIV testing behaviors among "money boys" and general MSM in Shanghai. Overall, 28.5% of "money boys" and 50.5% of general MSM had never tested for HIV despite high rates of reported HIV risk behaviors. Factors associated with not testing for HIV included: not knowing of a testing site, limited HIV knowledge, low perceived HIV risk, concern about HIV testing confidentiality, being a closeted gay, not using the Internet, and having a small social network or network with few members who had tested for HIV. Future efforts to promote HIV testing should focus on outreach to general MSM, confidentiality protection, decreasing the stigma of homosexuality, and encouraging peer education and support through the Internet and social networks.

Condom use with various types of sex partners by money boys in China

Money boys (MBs) who typically sell sex to males have not yet been extensively studied in China. In this 2009 study, 28 venue-based MBs were interviewed. We analyzed their condom use behaviors with various partners, including male and female clients, male and female casual partners, other MBs and female sex workers, and boyfriends and girlfriends. All participants were aware of the need for using condoms; however, usage with different partner types varied. The longer a relationship with a partner, the less frequent was condom use. A major reason for not using condoms was that they or their partners did not like the loss of sensation due to condom use. Other factors included sexual orientation, age, duration in commercial sex, concerns about HIV/AIDS, attractiveness of partners, and support of "mommies" (brothel supervisors). Both individual- and venue-level interventions are needed to promote condom use, and mommies need to be included in intervention strategies.

Relationship type, condom use and HIV/AIDS risks among men who have sex with men in six Chinese cities

This study is the first to examine the role of partner type in sexual practices of men who have sex with men (MSM) in China. Using cross-sectional self-administered questionnaires (N=692) with MSM in six Chinese cities (Shanghai, Guangzhou, Shenzhen, Xi'an, Dalian and Beijing) in 2008, this paper examines MSM's sexual practices, particularly condom use with different male and female partner types. We categorise sexual partner relationships into five types: partner/spouse, boyfriend/girlfriend, acquaintance, stranger and sex worker and hypothesise that the greater the affective distance between the partners, the greater the likelihood of engaging with intimate act and the lesser likelihood condom use. Results show that respondents had more MSM than heterosexual experiences. Relationships tended to be short-term, multiple (more than two) and concurrent (simultaneously two or more) principally with other men and to a lesser degree with women. Findings reveal that affective distance varied with partner types. Respondents performed more intimate acts (e.g., kissing, caressing) with intimate or stable partners (partner/spouse, boyfriend/girlfriend) than casual or unknown partners (acquaintance, stranger, sex worker). Condom use decreased when the affective distance with a partner increased. We conclude that partner type is a key factor of HIV infection among MSM in China; short-term, multiple and concurrent relationships are clear risk factors. Future research should focus on the subjective varied meanings of relationships, the idea of trust and the dynamics with different relationships to understand HIV infection of MSM in China.

[Knowledge, attitudes and practices related to STD and HIV/AIDS: men having sex with men in Senegal]

BACKGROUND

This study aimed to review knowledge, attitudes and practices related to sexual transmitted diseases (STD) and HIV/AIDS among men who have sex with men (MSM) in Senegal.

METHOD

The study was undertaken from February 1st to June 30th 2007, in three capitals cities in Senegal (one national, and two regional). It concerned the MSM that benefited from at least one of services of an MSM association. Studied variables included socio demographic characteristics, sexual practices, as well as knowledge and attitudes related to STDs and VIH/AIDS. Interviews took place during appointments obtained by direct phone call or by two MSM leaders intermediary. Data were seized and analyzed with Epi2000 Software.

RESULTS

Among 245 registered MSM, 63 had a precise contact (address and/or phone number), and 49 aged in average of 25 years were investigated. Among them, one was illiterate, five studied Koran, seven Arab and 36 French. The socio-professional categories differentiated two officials, two merchants, one mechanic, one fighter, five artists, five restorers, seven tailors, 11 students, and 15 unemployed. The associations, to which 35 HSH belonged, were related to sexuality (66%), religion (20%), social matters (8%) and economy (6%). Sexual habits, according to anal intercourse, differentiated the "Ubbi" or receptive/passive (57%), the "Yoos" or incertif/active (25%), the "Ubbi/Yoos" who play the two roles (14%) and the "neitherUbbi/norYoos" who had other practices than anal (4%). Practices between men, concerned mutual strokes (100%), fellatio (61%) and anal intercourse (49%), counted 45% for remuneration, 35% of multi-unprotected partnership, and 12% of breaking condom. Practices with women were reported by 15 MSM (31%). Concerning STDs, at least one sign was reported by 43 MSM, one transmission way by 42, one mean of protection by 47; and the first recourse was a health system for 36 MSM. The test of HIV/AIDS screening was done by 38 HSH among which 30 withdrew the results. The "Ubby" adhered much more to associations, and practiced less unprotected vaginal intercourses and multi partnerships.

CONCLUSION

Sexual relations between men, in Senegal, constitute a factor of propagation for STDs and HIV/AIDS. Beliefs, values, and popular reactions still limit the big principles (liberty, equality, solidarity, and participation) of preventive and curative care. Therefore, ethics and effectiveness must be conciliated to face more MSM needs, for a better health of the populations.

Prevalence and correlates of alcohol use among a sample of general MSM and money boys in Shanghai, China

The use and misuse of alcohol and their relation to risky sex have received modest scholarly attention in China. This type of research in high HIV/STI groups such as men who have sex with men (general MSM) and men who sell sex to other men ("money boys") (MB) in China is essentially absent. Therefore, the primary purpose of this exploratory study was to describe the types of alcohol consumed and levels of daily alcohol consumption among Chinese general MSM and MB in Shanghai, China. A secondary purpose was to explore demographic, lifetime sexual behavior, and psychosocial correlates of daily consumption levels. The sample consisted of 404 MSM (200 MB) who live in Shanghai, China. Participants were recruited using respondent-driven sampling and filled out a cross-sectional behavioral survey. Where appropriate, comparisons were made between MB and general MSM. Over 73% of participants reported drinking at least moderately every day. MB reported drinking Western red wine and other Western hard liquors (e.g., vodka) more frequently than general MSM. Conversely, general MSM consumed Chinese white wine more frequently than MB. Results from the regression analyses showed that MSM having higher lifetime sexual risks were more likely to drink in excess; though MB with greater social provisions were less likely to drink in excess. These results begin to highlight high levels of drinking and drinking-sexual risk relationships among groups of general MSM and MB and are useful for guiding intervention efforts among high-risk groups in China.

HIV in young men who have sex with men: a review of epidemiology, risk and protective factors, and interventions

Epidemiological studies have found that young men who have sex with men (YMSM) represent the majority of young people infected with HIV annually in the United States. Further, they are one of the few risk groups to show an increase in the rate of infections in recent years. In addition to these disparities in prevalence and infection rates, there is an inequity in prevention and intervention research on this population. The purpose of this article is to review the existing YMSM literature on HIV epidemiology, correlates of risk, and intervention research. The article concludes that promising future directions for basic research include a focus on multiple clustering health issues, processes that promote resiliency, the role of family influences, and the development of parsimonious models of risk. In terms of intervention research, the article suggests that promising future directions include Internet-based intervention delivery, integration of biomedical and behavioral approaches, and interventions that go beyond the individual level to address partnership, structural, community, and network factors.

HIV among people who use drugs: a global perspective of populations at risk

This article examines the epidemiology of HIV among selected subgroups of drug users around the world who are "most at risk"--men who have sex with men, female sex workers, prisoners, and mobile populations. The underlying determinants of HIV infection among these populations include stigma, physical and sexual violence, mental illness, social marginalization, and economic vulnerability. HIV interventions must reach beyond specific risk groups and individuals to address the micro-level and macro-level determinants that shape their risk environments. Public health interventions that focus on the physical, social, and health policy environments that influence HIV risk-taking in various settings are significantly more likely to impact the incidence of HIV and other blood-borne and sexually transmitted infections across larger population groups.

Prevalence and correlates of tobacco use among a sample of MSM in Shanghai, China

INTRODUCTION

Men who have sex with men (MSM) have higher smoking rates than the general population in the United States, but less is known about smoking among MSM in developing countries. Thus, we examined the prevalence and correlates of smoking among MSM in China.

METHODS

We conducted a cross-sectional study of 404 MSM in Shanghai, China (half of whom were male sex workers), recruited through respondent-driven sampling. Assessments included sociodemographics; tobacco, alcohol, and drug use; the Center for Epidemiological Studies Depression Scale (CES-D); the Social Provisions Scale (SPS); and the Lesbian, Gay, and Bisexual Identity Scale (LGBIS).

RESULTS

Smoking prevalence was 65.9% in this sample. Recent smoking (i.e., in the past 3 months) was significantly associated with lower education, greater alcohol use, and higher LGBIS scores, after controlling for important sociodemographics. Among smokers, smoking ≥10 cigarettes per day (CPD), in comparison with <10 CPD, was related to older age and lower LGBIS scores and marginally related to heavy alcohol use. Although bivariate analyses indicated a relationship of CES-D and SPS scores to recent smoking, these factors did not contribute to the regression models.

CONCLUSIONS

Smoking rates among MSM in China are higher than MSM in the United States and men in China. Less comfort with one's sexual orientation was related to smoking, particularly light smoking. Heavier alcohol consumption, lower education, and older age were also associated with smoking. Future research should confirm these findings and examine mediators and moderators of these relationships in order to inform cessation interventions and tobacco control policy.

An exploratory survey of money boys and HIV transmission risk in Jilin Province, PR China

This report represents the first exploratory study of Chinese men who provide commercial sex services to other men ("money boys") in Jilin Province, People's Republic of China, through a convenience sample drawn from Changchun and Jilin City. A total of 86 active money boy participants (Changchun, n = 49; Jilin City, n = 37) were surveyed concerning background and demographics, basic HIV transmission knowledge, and sexual practices. The survey indicated that while Jilin Province money boy behavior matches other studies concerning propensity to high risk behavior and significant bridging potential, the Jilin money boys, unlike previous studies, exhibited a high level of basic HIV/AIDS transmission knowledge. In spite of this level of knowledge, none of the participants reported always using a condom in their sexual activities. They also exhibited a high level of awareness of voluntary counseling and testing available in the province, yet relatively few had availed themselves of these services. These preliminary findings will be used as a baseline and springboard for continuing study in the Jilin Province money boy community. Even now, however, it is becoming clear that the dynamics of male commercial sex work may vary greatly depending upon local influences, and will necessitate that future interventions are highly tailored to area-specific circumstances.

Migration and illicit drug use among two types of male migrants in Shanghai, China

Large-scale internal migrations within China have led to speculation of increased drug use, but with little empirical evidence. This cross-sectional study examines the association between migration characteristics and illicit drug use in 100 general male migrants and 239 "money boys" (i.e., male migrants engaging in same-sex transactional sex) in Shanghai, China. Only three general male migrants reported any drug use. Among money boys, lifetime illicit drug use was 12%; Ecstasy and methamphetamine appeared to be the most popular drugs. In addition, depression prevalence was very high among both types of male migrants. Depression was associated with lifetime soft- and hard-drug use, while earning a higher income was associated with lifetime soft-drug use. These findings provide the first set of quantitative evidence of illicit drug use among Chinese male migrants. Although illicit drug use among male migrants is low compared to Western countries, its resurgence after 30 years of drug control gives cause for concern.

Prevalence and correlates of HIV and syphilis infections among men who have sex with men in seven provinces in China with historically low HIV prevalence

OBJECTIVES

To assess HIV and syphilis infection among men who have sex with men (MSM) in Chinese regions with historically low HIV prevalence.

METHOD

A cross-sectional survey was conducted in 20 cities or districts across 4 provinces, 2 autonomous regions, and a municipality. Socioeconomic/behavioral risk factors were measured. Blood samples were tested for HIV via enzyme-linked immunosorbent assay and Western blot confirmation and syphilis via rapid plasma reagin and passive particle agglutination test for detection of Treponema pallidum Antibodies.

RESULTS

Of 4983 MSM participants, 2.9% were HIV infected (range: 0%-15.1%) and 9.8% were syphilis infected (1.3%-29.3%). Syphilis infection was associated with older age [adjusted odds ratio (AOR) = 2.9; 95% confidence interval (CI): 2.0 to 4.3], not being married or cohabiting (AOR = 0.7; 95% CI: 0.5-0.9), less education (AOR = 1.3; 95% CI: 1.0 to 1.7), inconsistent condom use during anal sex with men (AOR = 1.4; 95% CI: 1.0 to 1.8), and living in inner Mongolia (AOR = 23.9; 95% CI: 9.7 to 58.6), Jilin (AOR = 7.9; 95% CI: 3.4 to 18.3), Heilongjiang (AOR = 7.1; 95% CI: 3.1 to 16.6), Liaoning (AOR = 6.1; 95% CI: 2.6 to 14.2), or Chongqing (AOR = 5.9; 95% CI: 2.5 to 13.9). HIV infection was associated with older age (AOR = 3.7; 95% CI: 2.0 to 6.7), less education (AOR = 2.9; 95% CI: 1.8 to 4.7), inconsistent condom use during anal sex with men (AOR = 1.9; 95% CI: 1.2 to 3.2), syphilis infection (AOR = 2.1; 95% CI: 1.3 to 3.4), and living either in Liaoning (AOR = 8.2; 95% CI: 1.1 to 61.4) or Chongqing (AOR = 57.2; 95% CI: 7.9 to 414.4).

CONCLUSIONS

HIV and syphilis have reached alarming rates in China's MSM population, thus, appropriate responses are urgently needed.

Within but without: human rights and access to HIV prevention and treatment for internal migrants

Worldwide, far more people migrate within than across borders, and although internal migrants do not risk a loss of citizenship, they frequently confront significant social, financial and health consequences, as well as a loss of rights. The recent global financial crisis has exacerbated the vulnerability internal migrants face in realizing their rights to health care generally and to antiretroviral therapy in particular. For example, in countries such as China and Russia, internal migrants who lack official residence status are often ineligible to receive public health services and may be increasingly unable to afford private care. In India, internal migrants face substantial logistical, cultural and linguistic barriers to HIV prevention and care, and have difficulty accessing treatment when returning to poorly served rural areas. Resulting interruptions in HIV services may lead to a wide range of negative consequences, including: individual vulnerability to infection and risk of death; an undermining of state efforts to curb the HIV epidemic and provide universal access to treatment; and the emergence of drug-resistant disease strains. International human rights law guarantees individuals lawfully within a territory the right to free movement within the borders of that state. This guarantee, combined with the right to the highest attainable standard of health set out in international human rights treaties, and the fundamental principle of non-discrimination, creates a duty on states to provide a core minimum of health care services to internal migrants on a non-discriminatory basis. Targeted HIV prevention programs and the elimination of restrictive residence-based eligibility criteria for access to health services are necessary to ensure that internal migrants are able to realize their equal rights to HIV prevention and treatment.

Egocentric networks of Chinese men who have sex with men: network components, condom use norms, and safer sex

Research on risk behaviors among men who have sex with men (MSM) is often based on individualistic models of health behavior, but sexual behavior is inherently social in nature and often determined by constituents of social networks. The objective of this study was to examine relationships among social networks, network norms of condom use, and safer sex. A respondent-driven sampling study recruited 350 MSM in the Shenzhen region of China between November and December 2007 and collected information on network components (relations, structures, and functions) and HIV risk behavior among egos (those interviewed) and their network alters. A total of 2385 alters were nominated by the 350 egos. Egos reported an average of 4 nonsexual relation alters and 2 sexual-partner alters. Egos perceived receiving more tangible and emotional support from nonsexual relation alters than from sexual-partner alters. Two thirds (69%) of egos consistently used condoms. Sixty-seven percent of egos reported having 1 or more alters who always encouraged egos to use condoms, 84% had 1 or more alters who consistently used condoms, and 55% had 1 or more alters who insisted on condom use. Both subjective and descriptive norms were positively associated with consistent condom use. Network components were associated with the levels of the two norms. These findings suggest that social network components may activate or strengthen condom use norms within networks, which, in turn, determine consistent condom use among MSM. HIV behavioral interventions need to target the promotion of safer sex practices through enhancing peer norms of condom use within networks.

STIs and HIV among men having sex with men in China: a ticking time bomb?

Over the past 10 years, HIV infection rate has increased annually from 30% to 40% in China, resulting in over 700,000 Chinese living with HIV/AIDS by the end of 2007. The Chinese National Medium and Long-Term Strategic Plan for HIV/AIDS Control and Prevention (1998-2010) identifies the men who have sex with men (MSM) population as a high-risk group for HIV infection. The latest statistics show that MSM account for 11.1% of all HIV/AIDS cases in China, an alarming rising rate in a country with one fourth of the world's population. To help expanding the emerging foundation of scientific and empirical data on Chinese MSM, several multidivisional research initiatives have been initiated. For example, the China National Center for AIDS/STD Prevention and Control recently launched a national study targeting above 26,000 MSM in 61 cities in 2008. Other programs, targeted prevention measures for the estimated 5-10 million-Chinese MSM, including stronger promotion of condom use, expanded coverage and quality of HIV prevention activities, increased access to voluntary HIV counseling-and-testing services, and improved access to treatment for sexually transmitted infections. To complement these initiatives, this article aims to provide a comprehensive review and analysis of the (a) scientific and empirical literature (both in English and Chinese) on HIV/sexually tranmitted infection (STI) prevention targeting Chinese MSM, and (b) existing programmatic and policy efforts targeting Chinese MSM at risk for STIs (including HIV). Finally, four recommendations for future endeavors targeting this high-risk group are drawn from the above analyses.