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Abstract
Objectives To describe socio-demographic, behavioural and other characteristics associated with HIV testing behaviour among men who have sex with men (MSM) in Jinan, China.
Methods A cross-sectional survey was conducted among MSM (N=500) in Jinan in 2008 using respondent-driven sampling—a method used worldwide to reach hidden high-risk populations. Bivariate and multivariate analyses, adjusted for the sampling method, were conducted to identify correlates of not having an HIV test.
Results Overall, 80.7% (95% CI 75.0% to 85.0%) of MSM in Jinan have not had an HIV test in the past 12 months. In the multivariate analyses, having not visited the local Centers for Disease Control and Prevention's website (AOR 5.59, 95% CI 2.62 to 11.95), being over the age of 35 years (AOR 3.77, 95% CI 1.19 to 11.93) and self-identified as bisexual or unsure (AOR 3.85, 95% CI 2.16 to 6.85) are significantly associated with having not had an HIV test. In addition, married men are slightly less likely to have not been tested compared to single men (AOR 0.38, 95% CI 0.17 to 0.85). Those who report meeting their sex partners at high-risk venues are two times more likely to have not had an HIV test (AOR 2.02, 95% CI 0.97 to 4.21).
Conclusions Targeted, culturally appropriate and innovative interventions to increase HIV testing uptake should be a top priority for HIV prevention among MSM in China.
- Men who have sex with men
- HIV/AIDS
- testing and counselling
- China
- gay men
- HIV testing
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Introduction
The HIV epidemic in China has shifted from injection drug use to sexual transmission of HIV, which accounts for more than 70% of new infections.1 Men who have sex with men (MSM) contribute an increasing proportion of new infections from 12.7% in 2007 to 32.5% in 2009.2 Recent studies have documented dramatic increases in HIV prevalence and alarmingly high HIV incidence among MSM.3 4 A nation-wide study targeting over 18 000 MSM in 61 cities reported an average HIV prevalence of 4.9% with prevalence up to 20% in several southwestern urban areas.2
Unrecognised infections, due to low prevalence of HIV testing, could be one of the driving forces of ongoing HIV transmission among Chinese MSM. Individuals unaware of their HIV status may engage in high-risk sex under the erroneous assumption that they are HIV negative and can be more infectious than those receiving treatment because of higher viral load.5 6 Currently, confidential HIV testing is offered for free at HIV voluntary counselling and testing (VCT) clinics and for a fee at health care settings in China. Testing rates in the past year are very low among Chinese MSM ranging from only 10–30% at most.7 8 Moreover, very high rates of sexual risk behaviours were observed among this population.3 4 8 As such, it is reasonable to expect that a majority of new infections among Chinese MSM may be attributed to unrecognised infections. It has been suggested that the ‘test and treat’ approach would significantly curtail the HIV epidemic among high-risk populations in different settings.9
However, there has been a lack of data on correlates of HIV testing among Chinese MSM. In this report, we describe socio-demographic, behavioural and other characteristics associated with HIV testing behaviour among MSM in Jinan, China.
Methods
Respondent-driven sampling (RDS) was used to recruit MSM participants in 2008. Five seed participants were screened and selected from 25 members of a MSM volunteer group who were diverse in terms of educational attainment, marital status, occupation and income. Details of the RDS methodology and recruitment procedures have been described elsewhere.3 10 Eligible participants were men aged 18 years or older, have had sex with men in the past 12 months, currently living or working in Jinan and were in possession of a valid recruitment coupon (ie, issued by the study and was verified unused). Participants were surveyed by trained interviewers using structured questionnaires. An incentive of 30 RMB (4.5 US$) was given for completing the survey and another 30 RMB for recruiting three participants. The study was approved by the Jinan Centers for Disease Control and Prevention (CDC) Institutional Review Board.
HIV testing behaviour was measured by asking participants whether they have had an HIV test in the past 12 months. Potential correlates examined are (1) socio-demographics, including age, marital status, resident status, education attainment, occupation, monthly income and sexual orientation; (2) behavioural characteristics, including age of sexual debut, recent sexual risk behaviours with both male and female partners, sexual role during anal sex, whether having exchanged sex for money in the past 6 months and a history of sexually transmitted diseases (STDs); and (3) other variables, including gay social network size, perception of risk for HIV infection and whether participants have visited the local CDCs MSM-focused prevention website.
Bivariate and multivariate logistic regression analyses were conducted in STATA 9.0 using the RDSAT exported weights for the outcome variable, which adjusted for each individual's network size and recruitment patterns. Variables such as sexual role and place of meeting sex partners were entered into the logistic models as dichotomous yes/no variables. Variables associated with HIV testing status in the bivariate analyses (p<0.1) were included in a multivariate model after controlling for socio-demographic variables.
Results
A total of 500 men were recruited during a 12-week period. The socio-demographic characteristics of the participants were published elsewhere.3 Overall, 80.7% (95% CI 75.0% to 85.0%) of MSM in Jinan have not had an HIV test in the past 12 months. From bivariate analyses, age, education, occupation, sexual orientation, ever diagnosed with a STD, had STD symptoms in the past year, gay social network size and whether having visited the local CDC's prevention website are significantly associated with having not had an HIV test (table 1).
Socio-demographic, behavioural and other correlates of HIV testing among men who have sex with men in Jinan, China (N=500)
In the multivariate analyses (table 1), those who have not visited the local CDC's prevention website are almost six times more likely to have not had an HIV test in the past 12 months (AOR 5.59, 95% CI 2.62 to 11.95). Being over the age of 35 years (AOR 3.77, 95% CI 1.19 to 11.93) and self-identified as bisexual/unsure (AOR 3.85, 95% CI 2.16 to 6.85) are also significantly associated with having not had an HIV test. In addition, married men are slightly less likely to have not been tested compared to single men (AOR 0.38, 95% CI 0.17 to 0.85). Although not statistically significant, those who report meeting their sex partners at high-risk venues (eg, bathhouses) are twice as likely to have not had an HIV test (AOR 2.02, 95% CI 0.97 to 4.21).
Discussion
In this study, we found that less than 20.0% of MSM in Jinan have had an HIV test in the past year. Those who were older, single, self-identified as bisexual/unsure or have not accessed MSM prevention websites were less likely to have obtained an HIV test. In addition, those who sought sex partners at high-risk venues were twice as likely to have not had an HIV test. These correlates also appear to be those associated with higher HIV prevalence among Chinese MSM in previous studies.11 Consistent with the previous finding that married MSM may engage in lower sexual risk, as evidenced by lower rates of HIV infection,3 married MSM were more likely to have been tested suggesting that these men might take precautions to protect their female partners.
Our analysis is not without limitations. First, RDS can only sample MSM who are part of social networks. MSM who limit their interactions with other MSM to anonymous sexual encounters may not be represented. Second, the interviewer-administered survey mode may have introduced social desirability bias. Nonetheless, interviewers were trained to establish rapport with participants and to appropriately probe around sensitive questions. Finally, our analysis is limited to socio-demographic and risk correlates of HIV testing. Despite these limitations, our analysis is among the first to examine correlates of HIV testing among Chinese MSM.
Our findings suggest that targeted, culturally appropriate and innovative interventions to increase HIV testing uptake should be a top priority for HIV prevention among MSM in China. Such interventions can include MSM-specific promotion of VCT by targeting certain socio-demographic groups (eg, social marketing campaigns targeting older MSM and single men). Furthermore, considering that those who accessed CDC's prevention website were more likely to get tested, internet-based interventions hold the potential to effectively reach large numbers of MSM, particularly those who cannot be reached at traditional venues (eg, bisexual men). Finally, although HIV testing is offered for free at VCT clinics, service-related and environmental barriers (eg, confidentiality and stigma) may discourage MSM to access the service.7 To reduce such barriers, HIV testing and counselling services should be expanded into MSM community settings especially at high-risk venues where older or bisexual men are known to frequent.11
Future research on this topic should assess psychosocial and structural factors as they may have a significant impact on HIV testing behaviours and could inform intervention design. Intervention research is also needed to evaluate existing HIV testing programmes and to develop new efficacious interventions for Chinese MSM.
Key messages
Unrecognised infections, due to low prevalence of HIV testing, could be one of the driving forces of ongoing HIV transmission among men who have sex with men (MSM) in China.
Less than 20% of MSM in Jinan, China, reported having had an HIV test in the past year.
Older age, being single, self-identify as bisexual/unsure and having not accessed local Centers for Disease Control and Prevention's prevention website for MSM were significantly associated with lack of testing.
Targeted, culturally appropriate and innovative interventions to increase HIV testing uptake should be a top priority for HIV prevention among Chinese MSM.
References
Footnotes
Funding CW was in part supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD R25HD064426). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NICHD or the National Institutes of Health.
Competing interests None.
Ethics approval The study was approved by the Jinan Center for Disease Control and Prevention Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.