Potential bridges for HIV infection to men who have sex with men in Guangzhou, China

Possible increase in HIV and syphilis prevalence among men who have sex with men in Guangzhou, China: results from a respondent-driven sampling survey

A respondent-driven sampling survey was conducted to investigate HIV related serological and behavioral characteristics of men who have sex with men (MSM) in Guangzhou, China, and to identify associated factors potentially driving the epidemic. Respondent-Driven Sampling Analysis Tool and SPSS were used to generate adjusted estimates and to explore associated factors. Three hundred seventy-nine eligible participants were recruited. The adjusted prevalence of HIV and current syphilis infection are 5.2% and 17.5% respectively. 60.3% have unprotected anal sex in the past 6 months. Unprotected anal sex, having receptive anal sex and current syphilis infection are significant factors associated with HIV infection. The potential for a rapid rise of HIV and syphilis infections among MSM in Guangzhou exists. Targeted interventions with voluntary counseling and testing (VCT) and sexually transmitted infection (STI) services are needed to address the epidemic, with a focus on such subgroups as those of with current syphilis, and non-official Guangzhou residence status.

Risk behaviour and HIV prevalence among men who have sex with men in a multiethnic society: a venue-based study in Kuala Lumpur, Malaysia

This research aimed to determine HIV prevalence, risk behaviour and knowledge of transmission methods among men who have sex with men (MSM) in Kuala Lumpur, Malaysia. Venue-day-time sampling (VDTS) was applied to identify venues where men congregate to solicit sex from other men. Participants recruited from clubs, massage parlours, saunas and one park self-completed a computerized behavioural questionnaire, were administered an oral rapid HIV test and given the opportunity to return later to receive full counselling and learn their HIV status. A total of 517 men were enrolled into the study. The majority were Malays (47.0%) and Chinese (43.7%). Twenty tested HIV positive (3.9%). Significant predictors of HIV infection included having unprotected anal sex with a casual partner (44.9% of participants, odds ratio [OR] = 2.99; 95% confidence interval [CI] 1.13-7.90; P = 0.027), having unprotected receptive anal sex (27.9%, OR = 2.71; 95% CI 1.10-6.54; P = 0.030) and having group sex (33.3%, OR = 3.95; 95% CI 1.55-10.09; P = 0.004). One in five participants (20.1% and 19.5%) did not believe that HIV could be transmitted through insertive or receptive anal sex, respectively. Risk behaviour is high and knowledge of HIV transmission methods was low among MSM in Kuala Lumpur. Future prevention efforts should focus on providing risk reduction education to this community.

Primary syphilis cases in Guangdong Province 1995-2008: opportunities for linking syphilis control and regional development

BACKGROUND

Syphilis cases have risen in many parts of China, with developed regions reporting the greatest share of cases. Since syphilis increases in these areas are likely driven by both increased screening and changes in sexual behaviours, distinguishing between these two factors is important. Examining municipal-level primary syphilis cases with spatial analysis allows a more direct understanding of changing sexual behaviours at a more policy-relevant level.

METHODS

In this study we examined all reported primary syphilis cases from Guangdong Province, a southern province in China, since the disease was first incorporated into the mandatory reporting system in 1995. Spatial autocorrelation statistics were used to correlate municipal-level clustering of reported primary syphilis cases and gross domestic product (GDP).

RESULTS

A total of 52,036 primary syphilis cases were reported over the period 1995-2008, and the primary syphilis cases increased from 0.88 per 100,000 population in 1995 to 7.61 per 100,000 in 2008. The Pearl River Delta region has a disproportionate share (44.7%) of syphilis cases compared to other regions. Syphilis cases were spatially clustered (p = 0.01) and Moran's I analysis found that syphilis cases were clustered in municipalities with higher GDP (p = 0.004).

CONCLUSIONS

Primary syphilis cases continue to increase in Guangdong Province, especially in the Pearl River Delta region. Considering the economic impact of syphilis and its tendency to spatially cluster, expanded syphilis testing in specific municipalities and further investigating the costs and benefits of syphilis screening are critical next steps.

Syphilis and HIV seroconversion among a 12-month prospective cohort of men who have sex with men in Shenyang, China

BACKGROUND

Cross-sectional studies have found a high prevalence of syphilis and HIV infection among men who have sex with men (MSM) in China.

METHODS

A total of 218 HIV-negative MSM participated in this prospective cohort study. Interviewer-administered questionnaires were completed, and blood samples were obtained for HIV and syphilis testing, both upon enrollment and at 12-month follow-up.

RESULTS

Of enrolled participants, 56% (122) were retained for the full 12-month follow-up period. The cohort had an HIV incidence density of 5.4 (95% CI: 2.0-11.3)/100 person-year (PY) and a syphilis incidence density of 38.5(95% CI: 27.7-50.2)/100 PY. Having syphilis (odds ratio [OR]: 11.4, 95% CI: 1.2-104.7) and more than 5 male sexual partners within the past 12 months (OR: 6.5, 95% CI: 1.1-39.8) were independent risk factors for HIV seroconversion (each P < 0.05). Being married (OR: 3.5, 95% CI: 1.4-8.2) and having more than 5 male sexual partners within the past 12 months (OR: 4.7, 95% CI: 2.0-6.2) were risk factors for syphilis seroconversion, while age > or =30 (OR 2.1, 95% CI 0.7-9.5) and having recently engaged in unprotected receptive anal sex (OR: 2.4, 95% CI: 0.7-13.1) were marginally associated with syphilis seroconversion.

CONCLUSION

The high incidence rates of HIV and syphilis in the Shenyang MSM community are significant cause for concern. The seroconversion rate for syphilis, in particular, indicates the high prevalence of high-risk sexual behaviors and the potential for increased HIV transmission. Appropriate interventions that address MSM-specific issues, including stigma, pressures from traditional society, and bisexual behavior, need to be tailored to inform and empower MSM in order to prevent HIV and syphilis in this community.

A review of the epidemiology of HIV infection and prevention responses among MSM in Asia

OBJECTIVE

To review the epidemiology of HIV infection and prevention responses among men who have sex with men (MSM) in Asia.

METHODS

A review of the existing scientific literature and governmental and non-governmental reports regarding the epidemiology of HIV infection and prevention responses among MSM in Asia.

RESULTS

Data show that HIV infection is now widespread among MSM throughout Asia. With the exception of the Philippines and Timor Leste, all countries for which information is available show epidemics of HIV infection among MSM, particularly in urban areas. Double-digit HIV prevalence among MSM is found in cities in China, Taiwan, India, Myanmar and Thailand. Incidence data, although scarce, confirm the ongoing transmission of HIV among MSM. Reports of new HIV diagnoses in MSM have been increasing in recent years, particularly in the developed economies of East Asia. HIV prevention responses have started in most Asian countries, but while the exact coverage and investment of such responses remain unclear, coverage seems to be far from the 60-80% level needed to have an effect on the HIV epidemic. Both Government and donor investment in prevention programs for MSM remain inadequate, especially when compared with the contribution of male-to-male transmission to the overall burden of the HIV epidemic.

CONCLUSION

Enlarged HIV prevention coverage and increased financial investment are necessary to reduce the spread of HIV infection among MSM in Asia.

Correlates of incident infections for HIV, syphilis, and hepatitis B virus in a cohort of men who have sex with men in Beijing

Recent data suggest that the prevalence of HIV/syphilis infections among men who have sex with men (MSM) in China increased rapidly. This cohort study was to assess the correlates of the incident infections for HIV, syphilis, and hepatitis B virus (HBV) among sexually active and HIV-negative MSM in China. A cohort of 507 HIV-seronegative MSM was recruited from November 2006 to February 2007. Sociodemographics, sexual and drug use behaviors, uptake of HIV-prevention services, and HIV, syphilis, and HBV seroconversions were assessed at 6- and 12- month follow-up. The incidence rates were 2.6 per 100 person-years for HIV, 16.9 per 100 person-years for syphilis, and 3.3 per 100 person-years for HBV. Multivariate Cox regression analyses showed that syphilis infection (hazard ratio [HR] = 3.6; 95% confidence interval [CI]: 1.1-11.6) and no perceived risk of HIV infection (HR = 6.0; 95% CI: 1.6-22.7) were independently associated with HIV seroconversion. Predictors for syphilis seroconversion included less education (HR = 1.87; 95% CI: 1.1-3.3), found male sex partners through bathhouses/public washrooms/parks (HR = 2.19; 95% CI: 1.2-4.0), drank alcohol 4 or more times monthly (HR = 1.95; 95% CI: 1.1-3.6), and had sexually transmitted diseases (HR = 2.65; 95% CI: 1.5-4.5). The only predictor for incident HBV seroconvension was having more male sex partners in the past 3 months (HR = 11.8; 95% CI: 1.5-90.4). Alarmingly high incidence rates of HIV, syphilis, and HBV were found among MSM concurrently with high prevalent risky behaviors and low uptakes of health care services. The findings of this study underscore the urgent needs for a comprehensive intervention strategy to curtail the rapid spread of HIV, syphilis, and HBV.

Sexual risk behaviors and HIV infection among men who have sex with men who use the internet in Beijing and Urumqi, China

OBJECTIVES

To assess HIV and syphilis infections among men who have sex with men who use the internet (MSMUI) and their risk behaviors.

METHODS

In 2007, 429 MSMUI were recruited via the internet in Beijing and Urumqi, China. A questionnaire was administered, and a blood specimen was collected and tested for HIV and syphilis.

RESULTS

Median age of participants was 25 years. Median number of lifetime sexual partners was 10. 90.7% ever had sex with a cyber friend. Rates of condom use in the last oral, insertive, and receptive anal sex were 9.1%, 66.3%, and 60.4%, respectively. Infection rates of HIV, syphilis, and HIV/syphilis coinfection were 4.8%, 11.4%, and 1.7%, respectively. Factors associated with HIV infection were being < or =24 years [odds ratio (OR) = 2.85, 95% confidence interval (CI): 1.05 to 7.75], syphilis positive (OR = 4.78, 95% CI: 1.68 to 13.58), used non-water-based liquid as lubricant (OR = 8.03, 95% CI: 1.03 to 62.52), and having bleeding gums or oral ulcers during condom-free oral sex (OR = 3.17, 95% CI: 1.13 to 8.88).

CONCLUSIONS

MSMUI engage in high-risk sexual behaviors and have a high prevalence of HIV and syphilis infections. The internet is the predominant venue for the majority of MSMUI to find sexual partners. It is urgent to implement effective intervention programs targeting this group.

HIV/STD prevalence among men who have sex with men in Chengdu, China and associated risk factors for HIV infection

OBJECTIVE

To assess the prevalence of HIV and selected sexually transmitted diseases (STDs) among men who have sex with men (MSM) in Chengdu, China, and the risk factors associated with HIV infection.

METHODS

A cross-sectional study using a snowball sampling method was conducted from March to July 2007. Participants were asked to complete a questionnaire about sexual history, high-risk behaviors, STD infection history, HIV knowledge and testing, and an assessment of depression. Blood samples were taken for antibody testing for HIV, herpes simplex virus 2 (HSV-2), and syphilis.

RESULTS

A total of 538 MSM were recruited, and 513 (95.4%) consented to complete the questionnaire. HIV, HSV-2, and syphilis prevalence were 9.1%, 24.7%, and 28.1%, respectively. The rate of consistent condom use was low and varied by types of sexual partners. The highest was with casual male partners (38.6%), and the lowest was with wife or girl friend (17.8%). Money boys were 6 times more likely to be infected with HIV compared with clerks/students. Infection with either HSV or syphilis increased the risk of HIV infection more than 4-fold.

CONCLUSIONS

The prevalences of HIV and STDs were high among MSM in Chengdu. To prevent HIV/STDs, campaigns promoting condom use are needed not only to boost the frequency of condom use but also to educate MSM about proper condom use.

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.

Prevalence and correlates of HIV and syphilis infections among men who have sex with men in Chongqing Municipality, China

OBJECTIVE

To examine the prevalence and correlates of HIV/syphilis infections and sexually transmitted diseases (STDs) among men who have sex with men (MSM) in Chongqing, China.

METHOD

Cross-sectional surveys were conducted to provide information, including sociodemographics, sexual and drug use behaviors, HIV knowledge, and HIV-related services in 2006 and 2007, respectively. Multiple methods, including venue-based recruitment, community outreach, Internet advertisements, and peer referral, were used to identify men in Chongqing willing to participate in this study.

RESULTS

Of the 1692 participants, 10.8% were HIV-infected (range by district: 7.0%-15.0%), 8.6% were syphilis-infected, and 15.3% self-reported STD-related symptoms. HIV infection was associated with older age, recruitment from bathhouses/saunas, less education, more male sex partners, sex with a woman in the past 6 months, syphilis infection, and STD-related symptoms. Syphilis infection was associated with older age, less education, inconsistent condom use with a man, STD-related symptoms, and HIV infection. STD-related symptoms were associated with older age, being of nonlocal residency, inconsistent condom use with a humans, having ever paid for sex with a humans, HIV infection, and being from District 1.

CONCLUSIONS

HIV and syphilis infections have reached alarmingly high rates in Chongqing's MSM population. Better targeted, in-depth and comprehensive intervention strategies are needed urgently, including education, condom promotion and distribution, STD control, drug use-related intervention, and advocacy for HIV counseling and testing with bridges to HIV prevention and care services. Widespread testing for HIV, syphilis, and other major STDs in this risk group should be considered as measures for control.

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.

Money boys, HIV risks, and the associations between norms and safer sex: a respondent-driven sampling study in Shenzhen, China

Money boys (MBs) are male sex workers who sell sex to men who have sex with men (MSM). This study estimates the proportion of MBs in the Chinese MSM, compares HIV risks between MBs and non-MB MSM, and examines the associations between practicing safer sex and peer norms of condom use. Respondent-driven sampling (RDS) was used to sample 351 MSM in the city of Shenzhen in 2007. The RDS-adjusted proportion of MBs among MSM was 9%. Compared to non-MB MSM, more MBs reported having had multiple male and female sexual partners. Half of MBs and non-MB MSM had consistently used condoms. Both descriptive and subjective norms were positively associated with condom use. The MB proportion of 9% in MSM implies a relatively large population of MBs in China. The association between peer norms and consistent condom use can assist with the development of culturally competent HIV interventions that promote safer sex.

Risk factors for syphilis and prevalence of HIV, hepatitis B and C among men who have sex with men in Beijing, China: implications for HIV prevention

To examine the correlates for syphilis and the prevalence for HIV, hepatitis B, hepatitis C among men-who-have-sex-with-men (MSM) in Beijing, China. A total of 541 MSM was recruited using peer-referral, community outreach, and Internet. Questionnaire-based interviews provided information including, demographics, sexual and other risk behaviors. HIV prevalence was 4.8%, syphilis 19.8%, HCV 0.4% and HBsAg 6.5%. The median number of lifetime male sex partners was ten. In the past 3 months, 20.7% drank alcohol > or =1 times per week. In the past month, 21.3 and 14.6% had unprotected anal intercourse with regular and casual male sex partners, respectively. Syphilis infection was associated with less education, alcohol use, finding male sex partners through bathhouses/public washrooms/parks, and diagnoses of sexual transmitted diseases (STDs). Syphilis is now epidemic among Beijing's MSM. Prevention efforts are urgent as HIV prevalence is already near 5%. Education, condom promotion, STD control, and alcohol-related intervention are needed urgently.

HIV-related behaviors among men who have sex with men in China: 2005-2006

Respectively, 387 and 316 men who have ever had anal or oral sex with men (MSM) in Kunming, China, were interviewed in 2005 and 2006. In both surveys, over 85% reported having had anal sex with noncommercial male sex partners; around 60% had ever had female sex partners; and about 16% engaged in commercial anal sex in the last 6 months. The prevalence of unprotected anal sex decreased over time (last episode of anal sex with noncommercial MSM partner: 37.7% (2005) versus 21.9% (2006) (Adjusted odds ratio [OR] = 0.43); last episode of anal sex with commercial MSM partner, 20.8% (2005) versus 10.8% (2006) (Adjusted OR = 0.50). Some behavioral changes may have occurred. Multivariate analyses showed that study year (OR = 2.24), age (OR = 1.64), marital status (OR = 2.07), and perceived infectivity related to unprotected sex with people living with HIV/AIDS (OR = 0.3) were associated with condom use in the last episode of anal sex with noncommercial MSM partners.

The epidemiology of human immunodeficiency virus infection, sexually transmitted infections, and associated risk behaviors among men who have sex with men in the Mekong Subregion and China: implications for policy and programming

BACKGROUND

Little systematic knowledge is available regarding risk behaviors and the prevalence of human immunodeficiency virus (HIV) and sexually transmitted infections (STI) in populations of men having sex with men (MSM) in the Mekong Subregion and China.

METHODS

Data on HIV/STI prevalence and risk behavior of MSM in the region were collected through Internet searches, were summarized and assessed for their policy and programming implications.

RESULTS

Twenty-four articles, reports and abstracts of research studies were identified for review. High levels of HIV, STI and associated risk behavior were reported among MSM throughout the region. The HIV prevalence among MSM in urban areas varied between 5.5% and 28.3% in Thailand and Cambodia and between 0.0% and 9.4% in Vietnam and China. No HIV/STI prevalence data were available for Lao PDR and Myanmar.

CONCLUSION

Levels of HIV/STI prevalence and risk behavior among MSM in the Mekong Subregion and China are high. Continued monitoring and surveillance and targeted preventive interventions are necessary to stop the spread of HIV in this vulnerable population.

Willingness to be circumcised for preventing HIV among Chinese men who have sex with men

Male circumcision can reduce the risk of HIV acquisition among heterosexual men, but its effectiveness is uncertain in men who have sex with men (MSM). Additionally, its acceptability among Chinese men is unknown given a lack of history and cultural norms endorsing neonatal and adult circumcision. This study evaluated the willingness to participate in a clinical trial of circumcision among 328 Chinese MSM. Some 11.6% respondents reported having been circumcised, most of them due to a tight foreskin. Of 284 uncircumcised MSM, 16.9% said they were absolutely willing to participate, 26.4% were probably, 28.9% were probably not, and 27.8% were absolutely not; 81% said male circumcision would help maintain genital hygiene. The major motivators for willingness to participate included contribution to AIDS scientific research and getting free medical service. Men also had concerns about ineffectiveness of circumcision in reducing HIV/sexually transmitted infection (STI) risks and side effects of the surgery. Those who did not have a Beijing resident card (adjusted odds ratio [AOR], 1.99; 95% confidence interval [CI], 1.17-3.38), did not find sexual partners through the Internet (AOR, 2.13; 95% CI, 1.21-3.75), and were not concerned about the effectiveness of circumcision (AOR, 2.37; 95% CI, 1.34-4.19) were more likely to be willing to participate in a trial. The study suggests that circumcision is uncommon among Chinese MSM. Considerable community education will be needed in circumcision advocacy among MSM in China. A clinical trial for efficacy among MSM should be considered.

The 2007 Estimates for People at Risk for and Living With HIV in China: Progress and Challenges

OBJECTIVE

To present the methods used for the 2007 estimates for the number of people at risk for and infected with HIV.

DESIGN

: Estimation work took place throughout 2007, led by the National Center for AIDS and Sexually Transmitted Disease Control and Prevention in collaboration with United Nations AIDS and the World Health Organization.

METHODS

The workbook method was used to process prefecture and county-level surveillance data to generate HIV prevalence by risk group for each prefecture, which was in turn imported into the spectrum model to generate estimates of new infections and HIV-related deaths.

RESULTS

The working group estimated that as of 2007, there were 700,000 people living with HIV/AIDS in China, with 50,000 new infections and 20,000 HIV-related deaths in that year. Injection drug use and sexual contact are still primary modes of HIV transmission, with heterosexual contact quickly becoming the dominant route, making up 44.7% of new infections in 2007. The HIV/AIDS epidemic is still highly concentrated in certain areas, with wide variation in prevalence across regions.

CONCLUSIONS

The 2007 estimates are based on the most accurate and local-level data available to date, including case reports, sentinel surveillance data, results from mass screening of key target groups, and special epidemiological studies.

The characterisation of sexual behaviour in Chinese male university students who have sex with other men: a cross-sectional study

Background

The risks for Chinese male university students who have sex with other men (MSM) have not been compared with those for non-MSM students. This information is important for the development of targeted HIV prevention programmes for this population.

Methods

Sexually active MSM and non-MSM students were compared for demographic characteristics, sexual behaviour, and related psychosocial variables using bivariate analyses. The data were a subset drawn from a large-scale cross-sectional questionnaire survey of sexually active male students conducted at two universities in a large city in Zhejiang Province, China, in 2003.

Results

Of 1824 sexually active male students, 68 (3.7%) reported having had sex with a man at least once; 33.8% of these 68 men had also had female partners. Compared with non-MSM students, MSM students were 3–6.5 times more likely to have had sexual encounters with casual or commercial sex partners and were three times less likely to have protected sex in the past year or during their lifetime. They were three to five times more likely to have had multiple partners and 15 times more likely to have had a sexually transmitted disease (STD). In addition, the MSM students knew half as much about HIV and had less condom-decision than did non-MSM students and were two times more accepting of commercial sex. However, the MSM students were twice as aware of the risks for HIV infection.

Conclusion

MSM composed 3–4% of the male sexually active university student population studied and was found to be at greater risk than non-MSM students for STD/HIV infection. There is an urgent need for STD/HIV programmes in university health services that take into consideration the sexuality and psychosocial issues of MSM students.

High-risk sexual and drug using behaviors among male injection drug users who have sex with men in 2 Mexico-US border cities

OBJECTIVES

The population of Latino men who have sex with men (MSM) and who are also injection drug users (IDUs) is understudied. We explored risk behaviors of MSM/IDUs compared with other male IDUs in 2 Mexican border cities.

STUDY DESIGN

In 2005, IDUs who had injected within the previous 30 days were recruited using respondent-driven sampling (RDS) in Tijuana and Ciudad Juárez. They underwent antibody testing for HIV, HCV, and syphilis and interviewer-administered surveys. Men were categorized as MSM if they reported > or =1 lifetime male partners. Logistic regression was used to compare MSM/IDUs with non-MSM/IDUs.

RESULTS

A third (31%) of 377 male IDUs were categorized as MSM (47% in Tijuana and 13% in Ciudad Juárez, P <0.01). Combined RDS-adjusted prevalence of HIV and Hepatitis C was 3% (95% CI: 1, 5) and 96%, (95% CI: 94, 99) respectively, while 17% (95% CI: 2, 36) of MSM and 8% (95% CI: 3, 12) of non-MSM tested positive for syphilis antibody. In multivariate logistic regression adjusted for site, MSM/IDUs were more likely than non-MSM/IDUs to have ever used inhalants (OR: 3.4; 95% CI: 1.8, 6.2) or oral tranquilizers (OR: 2.4; 95% CI: 1.3, 4.6), received treatment for a drug problem (OR:1.9; 95% CI: 1.1, 3.2) shared needles in the last six months (OR: 2.1; 95% CI: 1.0, 4.2) and also had higher numbers of lifetime female partners (log-transformed continuous variable, OR: 1.6; 95% CI: 1.2, 2.1).

CONCLUSIONS

In these Mexican cities, the proportion of MSM among male IDUs was high. Compared with other male IDUs, MSM/IDUs were more likely to engage in behaviors placing them at risk of acquiring HIV/STIs. Culturally appropriate interventions targeting Latino MSM/IDUs are warranted.

Accessing men who have sex with men through long-chain referral recruitment, Guangzhou, China

Men who have sex with men (MSM) may account for an increasing proportion of China's HIV epidemic, but remain difficult to access for epidemiological studies due to high stigma. We compare the composition of two samples of MSM obtained in Guangzhou, China. The first survey, conducted in 2004, recruited MSM through convenience sampling. The second survey in 2006 used long-chain referral recruitment in the context of respondent-driven sampling. Compared to convenience sampling, the long-chain referral method included higher proportions of subgroups of MSM thought to be at elevated risk for HIV infection and more difficult to reach, including internal migrants and those engaging in commercial sex. Long-chain referral also recruited more MSM who were under 25 years, unemployed, and had lower education. We conclude that long-chain referral recruitment will be more effective in tracking the leading edge of the epidemic among MSM in China than convenience sampling.

Social discrimination, concurrent sexual partnerships, and HIV risk among men who have sex with men in Shanghai, China

We examined the potential mediating role of sex partner concurrency in explaining associations between experiences of homophobia and financial hardship and HIV risk behavior among a sample of 477 men who have sex with men (MSM) recruited in Shanghai, China from 2004 to 2005. We found significant positive direct associations of experiences of homophobia and financial hardship with having unprotected anal sex with men. These associations were not mediated by male partner concurrency. However, male partner concurrency had a direct effect on having unprotected anal sex with men. Male and female partner concurrency did not mediate the significant association between experiences of homophobia and having unprotected anal/vaginal sex with both men and women, but was positively associated with having unprotected anal/vaginal sex with both men and women. These results suggest that homophobia, financial hardship, and sex partner concurrency should be addressed to help reduce sexual risk for HIV among MSM in China.

Syphilis in China: the great comeback

China is currently witnessing a major resurgence of syphilis from the elimination of the disease in the 1960s to 5.3 per 100,000 people incidence in 2000-2005. The reasons for the elimination and subsequent resurgence of syphilis in China lie at the heart of much public health debate, highlighting both the relationship between politics and public health, and the role of government in controlling disease. Were the Draconian measures to control syphilis during the early Mao years a price worth paying for the effective control? Is the recent resurgence of syphilis an inevitable consequence of economic development and greater freedom for the individual, which will ultimately lead to better health for the majority of the population? Could tougher control measures such as those of the early Mao years be re-introduced in the current social and economic climate in China? In this review, we briefly chart the history of the syphilis epidemic in China, its elimination in the 1960s, and its gradual resurgence in the past two decades. We explore the reasons for this resurgence, and we conclude with a discussion on the options for control.

Epidemiology of hepatitis C virus infection among injection drug users in China: systematic review and meta-analysis

OBJECTIVES

Injection drug use (IDU) is the predominant mode of hepatitis C virus (HCV) transmission in China. This paper aims to provide a comprehensive and reliable tabulation of available data on the epidemiological characteristics and risk factors for HCV infection in injection drug users (IDUs) in China to help inform prevention programmes and guide future research.

STUDY DESIGN

Data from articles and reports according to pre-defined criteria on HCV infection rates among IDUs of different regions, genders, ethnic backgrounds and risk factors (injecting practice, needle sharing, long duration, sex behaviour and co-infection status) were abstracted and pooled by meta-analysis. A systematic review was constructed based on both pooled data and representative viewpoints.

METHODS

Ninety-five percent confidence intervals (CI) of infection rates were calculated using the approximate normal distribution model. Odds ratios and 95% CI were calculated by fixed or random effects models. Publication bias was examined using Begg's test and Egger's test. Data manipulation and statistical analyses were undertaken using STATA 7.0 and RevMan 4.2. Epi Info 3.4.3 was used for map construction.

RESULTS

The pooled prevalence of HCV infection among IDUs in China was 61.4% (95% CI 55.7-67.2%), and the epidemic was most severe in Hubei, Yunnan, Guangxi, Hunan and Xinjiang. No significant difference was found in HCV infection rates between male and female IDUs. A significant association was found between HCV infection and ethnic-minority status. IDUs were 9.24 times more likely to be infected with HCV than non-IDUs, while non-IDUs were more likely to be infected with HCV than members of the general population and other risk populations. There was no significant difference in the risk of HCV infection for needle-sharing IDUs and non-needle-sharing IDUs. A longer duration of IDU was associated with increased HCV prevalence. High-risk sexual practices were strongly associated with drug injection behaviours. Co-infection with human immunodeficiency virus (HIV) greatly increased the probability of HCV infection among IDUs, while the probability of hepatitis B virus infection remained similar for HCV-positive and HCV-negative IDUs in China.

CONCLUSIONS

IDU continues to fuel the HCV/HIV epidemics spreading throughout China. Many pragmatic strategies are being implemented but need further evaluation.

HIV prevalence and correlates of unprotected anal intercourse among men who have sex with men, Jinan, China

China's HIV epidemic may be shifting towards predominantly sexual transmission and emerging data point to potential increases in HIV prevalence among men who have sex with men (MSM). There is particular need to assess the extent of risk behavior among MSM outside of China's most cosmopolitan cities. We conducted a respondent-driven sampling survey (N = 428) to measure HIV seroprevalence and risk behavior among MSM in Jinan, China, the provincial capital of Shandong. HIV prevalence was 0.5% (95% confidence interval [CI] 0.1-1.0). Unprotected anal intercourse (UAI) in the last 6 months (reported by 61.4%) was associated with buying or selling sex to a man in the last 6 months, syphilis infection, multiple partners in the last month, low HIV knowledge and migrant status. No participant had previously tested for HIV. Risk for HIV transmission is widespread among MSM throughout China; basic prevention programs are urgently needed.

HIV risks among two types of male migrants in Shanghai, China: money boys vs. general male migrants

OBJECTIVES

To examine HIV/AIDS-related knowledge, attitudes and behaviours among 'money boys' and general male migrants in Shanghai, China.

DESIGN

A quantitative cross-sectional design with self-administered paper-and-pencil instruments was used.

METHODS

A total of 239 money boys were enrolled using community popular opinion leader and respondent-driven sampling methods, and 100 general male migrants were enrolled through venue-based sampling.

RESULTS

Compared to general male migrants, money boys were significantly younger, better educated, more likely to be single, earned a higher income, suffered greater stress, and were less satisfied with life in Shanghai. Both groups had substantial misconceptions about HIV/AIDS, although general male migrants were less well informed. Furthermore, both groups reported low rates of condom use, regardless of who their sexual partners were. Money boys were more likely to use alcohol, had more sexual partners and more casual sex partners, and were more likely to engage in other sexual risks. Moreover, they were likely to be the victims of sexual violence at the hands of their clients. More than half of the money boys had been tested for HIV and 3% self-reported to be HIV-positive, whereas only 1% of the general male migrants had ever been tested and all self-reported to be HIV-negative. Infection with other sexually transmitted diseases was also reported by money boys.

CONCLUSIONS

This study suggests an urgent need to implement HIV/AIDS prevention and intervention programs targeting male migrants, especially money boys and their clients. Some recommendations for conducting interventions among the male migrant population in China are suggested.

The development of HIV/AIDS surveillance in China

The strategy for monitoring HIV/AIDS in China has evolved with the epidemic. The national HIV/AIDS surveillance system was established in 1985 and sentinel surveillance started in 1995. Initially, 42 sentinel sites were established to monitor the epidemic among certain high-risk groups, including drug users, female sex workers, STD clinic attendees and long-distance truck drivers in epidemic areas. In the last decade the programme has been considerably expanded. Target groups now also include pregnant women, men who have sex with men (MSM), clients of female sex workers and tuberculosis (TB) patients. By the end of 2006, 393 national and 370 provincial sites report to the National Centre for AIDS/Sexually transmitted disease Control and Prevention. In 2004, a nationwide HIV testing campaign was launched among certain high risk groups, including former plasma donors and injecting drug users. Routine testing in health care settings and detention centres was introduced in 2005. Behavioural surveillance began in 2004 and there were already 159 sites in 27 provinces by the end of 2006. In addition a number of epidemiological surveys have been undertaken among various groups to augment surveillance data. The combination of these comprehensive strategies is used to monitor the HIV/AIDS epidemic and guide policy decision-making. The Chinese experience illustrates how surveillance systems need to be dynamic in order to monitor trends in HIV over time.

Trends in prevalence of HIV, syphilis, hepatitis C, hepatitis B, and sexual risk behavior among men who have sex with men. Results of 3 consecutive respondent-driven sampling surveys in Beijing, 2004 through 2006

BACKGROUND

Studies tracking trends in HIV prevalence and risk behavior among men who have sex with men (MSM) in China are rare. We report on 3 consecutive cross-sectional surveys measuring the prevalence of HIV, other infectious diseases, and related risk behavior among MSM in Beijing in 2004, 2005, and 2006.

METHODS

We applied respondent-driven sampling (RDS) to recruit MSM for a structured face-to-face interview on demographic characteristics and HIV risk-related behavior. Blood specimens were drawn for HIV syphilis, hepatitis B virus, and hepatitis C virus (HCV) testing.

RESULTS

A total of 325 MSM participated in 2004, 427 in 2005, and 540 in 2006. HIV prevalence was 0.4% (95% confidence interval [CI]: 0.1 to 0.8) in 2004, 4.6% (95% CI: 2.2 to 7.6) in 2005, and 5.8% (95% CI: 3.4 to 8.5) in 2006. This apparent rise was accompanied by an increase in syphilis and self-reported history of sexually transmitted diseases (STDs), high prevalence of multiple sex partners, and low consistent condom use. HCV prevalence also increased, from 0.4% (95% CI: 0.1 to 0.8) in 2004 to 5.2% (95% CI: 2.3 to 8.2) in 2006.

CONCLUSIONS

We detected a possible rising prevalence of HIV and related risk behavior among MSM in Beijing using RDS in each of 3 consecutive years. Practical measures, including MSM-friendly HIV testing, STD services, and health provider education, are urgently needed to stop the further spread of HIV in this population.

Co-infection with human immunodeficiency virus and tuberculosis in Asia

Asia has the highest numbers of tuberculosis cases (60% of the global total) and has experienced a marked rise in HIV seroprevalence (22% of the global total) in key subpopulations of these highly populous nations. Thus, co-infected patients are a challenge for practitioners and public health workers alike. The U.S.-Japan Cooperative Medical Science Program is spearheading interdisciplinary collaborations in Asia to address the many outstanding research priorities for HIV-tuberculosis co-infection. There is an urgency to this agenda for many reasons, including the frequency with which tuberculosis accounts for the death of HIV-infected persons in Asia, and the continued rise of multiple drug-resistant Mycobacterium tuberculosis. We review briefly the public health situation in Asia, highlighting research questions from US-Japan-Asian partner joint meetings, and cite salient studies to indicate trends and challenges.