Internet use and risk behaviours: an online survey of visitors to three gay websites in China

Providing HIV testing in men who have sex with men through a gay social networking app in China: A qualitative interview study with multisectoral service providers

Objective

We explored the feasibility of app-based HIV testing services (AHTS) among men who have sex with men (MSM) according to the perspectives of testing service providers.

Methods

Twenty-one current or previous AHTS providers participated in a semi-structured interview which explored the facilitators and barriers to AHTS. Ten participants originating from the Center for Disease Control and Prevention (CDC) and 11 from the non-governmental organization (NGO) in Shijiazhuang, China took part in this study. Interviews was transcribed verbatim, and the socioecological model (SEM) was applied to thematic analysis.

Results

Twenty-one participants from AHTS services commented on the integration of online appointment schedules into HIV testing services. AHTS was deemed a convenient and efficient method for MSM and service providers to choose their preferred location and times. Moreover, it allowed for important HIV-related information to be accessed online and targeted toward at-risk individuals. Participants thought MSM may feel unsure about personal information security being stored within a privatized app and was considered a barrier to AHTS's usability. As such, they believed establishing a government-led national online platform for AHTS would allow for greater trust from MSM, rather than a social media app.

Conclusion

By linking booking services to an online platform, AHTS was deemed a convenient and efficient method for HIV testing services, especially for young MSM who are familiar with smartphone applications. To improve the use of these services, AHTS apps should focus on ensuring the confidentiality of personal information and internet security to build trust between MSM and service providers.

Moderating effect of illicit drug use on the relationship between sexual behaviours and prevalence of HIV or sexually transmitted infections

INTRODUCTION AND AIMS

We aimed to: (i) investigate sexual behaviours, substance use, HIV and sexually transmitted infections (STI) prevalence among a population of men who have sex with men (MSM) in Taiwan; and (ii) examine the moderating effects of substance use in the relationship of sexual behaviours and HIV and STI diagnosis.

DESIGN AND METHODS

We used the Taiwan 2013 Internet MSM Sex Survey conducted cross-sectionally online. We examined the association between sexual behaviours and HIV and STIs using logistic regression models. We then assessed the moderating effects of substance use between specific sexual behaviours and HIV and STI using interaction term.

RESULTS

Among the 2020 MSM participants, 5.5% of them had reported having been diagnosed with HIV and 7.4% with STIs. Reporting having a sex partner found online, having unprotected anal sex with a casual male partner, alcohol and illicit drug use were all significantly associated with HIV and STI diagnosis. Those reporting having sex with partners found via mobile apps were more likely to report being HIV positive as a function of illicit drug use. A similar finding was evident for STIs. Interestingly, alcohol had no moderating effects in similar analyses.

DISCUSSION AND CONCLUSIONS

This study sheds light on future development of interventions that target at mobile apps which better integrate drug prevention and HIV prevention programs for the MSM population.

Online HIV prevention intervention on condomless sex among men who have sex with men: a web-based randomized controlled trial

Background

Given the widespread use of the Internet among men who have sex with men (MSM) and high risk of Internet-facilitated sexual behaviors, Internet-based interventions to reduce sexual risk are urgently needed.

Methods

We recruited 1,100 participants from online and randomly assigned to two groups. One group received online HIV intervention services. Online HIV intervention was developed through mix-method formative research, measures included scenarios experiencing intervention and HIV information dissemination. Self-reported condomless anal sex with a male in the past three months was measured to evaluate the intervention effect.

Result

Of the 1,100 participants, the majority were aged between 21 and 30 years old (62%), had a college degree or higher (80%), were single (88%), and self-identified as homosexual (78%). The estimated risk difference of condomless sex with a male in the past three months between groups was 9.3% (95% confidence interval (CI): 1.1, 17.5%). Using multiple imputations intention-to-treat, the estimated risk difference was 8.9% (95%CI: 1.2, 16.6%). Modification effects were found between intervention and characteristics including: educational attainment (p = 0.012), marital status (p = 0.005) and awareness of AIDS-related knowledge (p = 0.010).

Conclusion

Internet appears to be a promising approach to disseminate HIV prevention amongst MSM. Interactive online intervention appeals to MSM and poses a great potential for reducing HIV risky behavior.

Trial registration

ChiCTR1800014260 (retrospectively registered 2 Jan, 2018).

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4251-5) contains supplementary material, which is available to authorized users.

Evaluation of Different Recruitment Methods: Longitudinal, Web-Based, Pan-European Physical Activity Through Sustainable Transport Approaches (PASTA) Project

Background

Sufficient sample size and minimal sample bias are core requirements for empirical data analyses. Combining opportunistic recruitment with a Web-based survey and data-collection platform yields new benefits over traditional recruitment approaches.

Objective

This paper aims to report the success of different recruitment methods and obtain data on participants’ characteristics, participation behavior, recruitment rates, and representativeness of the sample.

Methods

A longitudinal, Web-based survey was implemented as part of the European PASTA (Physical Activity through Sustainable Transport Approaches) project, between November 2014 and December 2016. During this period, participants were recruited from 7 European cities on a rolling basis. A standardized guide on recruitment strategy was developed for all cities, to reach a sufficient number of adult participants. To make use of the strengths and minimize weakness, a combination of different opportunistic recruitment methods was applied. In addition, the random sampling approach was applied in the city of Örebro. To reduce the attrition rate and improve real-time monitoring, the Web-based platform featured a participant’s and a researchers’ user interface and dashboard.

Results

Overall, 10,691 participants were recruited; most people found out about the survey through their workplace or employer (2300/10691, 21.51%), outreach promotion (2219/10691, 20.76%), and social media (1859/10691, 17.39%). The average number of questionnaires filled in per participant varied significantly between the cities (P<.001), with the highest number in Zurich (11.0, SE 0.33) and the lowest in Örebro (4.8, SE 0.17). Collaboration with local organizations, the use of Facebook and mailing lists, and direct street recruitment were the most effective approaches in reaching a high share of participants (P<.001). Considering the invested working hours, Facebook was one of the most time-efficient methods. Compared with the cities’ census data, the composition of study participants was broadly representative in terms of gender distribution; however, the study included younger and better-educated participants.

Conclusions

We observed that offering a mixed recruitment approach was highly effective in achieving a high participation rate. The highest attrition rate and the lowest average number of questionnaires filled in per participant were observed in Örebro, which also recruited participants through random sampling. These findings suggest that people who are more interested in the topic are more willing to participate and stay in a survey than those who are selected randomly and may not have a strong connection to the research topic. Although direct face-to-face contacts were very effective with respect to the number of recruited participants, recruiting people through social media was not only effective but also very time efficient. The collected data are based on one of the largest recruited longitudinal samples with a common recruitment strategy in different European cities.

Linking young men who have sex with men (YMSM) to STI physicians: a nationwide cross-sectional survey in China

BACKGROUND

Many young men who have sex with men (YMSM) are reluctant to seek health services and trust local physicians. Online information seeking may encourage YMSM to identify and see trustworthy physicians, obtain sexual health services, and obtain testing for sexually transmitted infections (STIs). This study examined online STI information seeking behaviors among Chinese YMSM and its association with offline physician visits.

METHODS

We conducted a nationwide online survey among YMSM through WeChat, the largest social media platform in China. We collected information on individual demographics, sexual behaviors, online STI information seeking, offline STI testing, and STI physician visits. We examined the most commonly used platforms (search engines, governmental websites, counseling websites, generic social media, gay mobile apps, and mobile medical apps) and their trustworthiness. We assessed interest and willingness to use an MSM-friendly physician finder function embedded within a gay mobile app. Logistic regression models were used to examine the correlation between online STI information searching and offline physician visits.

RESULTS

A total of 503 men completed the survey. Most men (425/503, 84.5%) searched for STI information online. The most commonly used platform to obtain STI information were search engines (402/425, 94.5%), followed by gay mobile apps (201/425, 47.3%). Men reported high trustworthiness of information received from gay mobile apps. Men also reported high interest (465/503, 92.4%) and willingness (463/503, 92.0%) to use a MSM-friendly physician finder function within such apps. Both using general social media (aOR =1.14, 95%CI: 1.04-1.26) and mobile medical apps (aOR =1.16, 95%CI: 1.01-1.34) for online information seeking were associated with visiting a physician.

CONCLUSION

Online STI information seeking is common and correlated with visiting a physician among YMSM. Cultivating partnerships with the emerging mobile medical apps may be useful for disseminating STI information and providing better physician services to YMSM.

Linking young men who have sex with men (YMSM) to STI physicians: a nationwide cross-sectional survey in China

BACKGROUND

Many young men who have sex with men (YMSM) are reluctant to seek health services and trust local physicians. Online information seeking may encourage YMSM to identify and see trustworthy physicians, obtain sexual health services, and obtain testing for sexually transmitted infections (STIs). This study examined online STI information seeking behaviors among Chinese YMSM and its association with offline physician visits.

METHODS

We conducted a nationwide online survey among YMSM through WeChat, the largest social media platform in China. We collected information on individual demographics, sexual behaviors, online STI information seeking, offline STI testing, and STI physician visits. We examined the most commonly used platforms (search engines, governmental websites, counseling websites, generic social media, gay mobile apps, and mobile medical apps) and their trustworthiness. We assessed interest and willingness to use an MSM-friendly physician finder function embedded within a gay mobile app. Logistic regression models were used to examine the correlation between online STI information searching and offline physician visits.

RESULTS

A total of 503 men completed the survey. Most men (425/503, 84.5%) searched for STI information online. The most commonly used platform to obtain STI information were search engines (402/425, 94.5%), followed by gay mobile apps (201/425, 47.3%). Men reported high trustworthiness of information received from gay mobile apps. Men also reported high interest (465/503, 92.4%) and willingness (463/503, 92.0%) to use a MSM-friendly physician finder function within such apps. Both using general social media (aOR =1.14, 95%CI: 1.04-1.26) and mobile medical apps (aOR =1.16, 95%CI: 1.01-1.34) for online information seeking were associated with visiting a physician.

CONCLUSION

Online STI information seeking is common and correlated with visiting a physician among YMSM. Cultivating partnerships with the emerging mobile medical apps may be useful for disseminating STI information and providing better physician services to YMSM.

Spatial Analysis of the Human Immunodeficiency Virus Epidemic among Men Who Have Sex with Men in China, 2006-2015

Background

Studies have shown a recent upsurge in human immunodeficiency virus (HIV) burden among men who have sex with men (MSM) in China, especially in urban areas. For intervention planning and resource allocation, spatial analyses of HIV/AIDS case-clusters were required to identify epidemic foci and trends among MSM in China.

Methods

Information regarding MSM recorded as HIV/AIDS cases during 2006-2015 were extracted from the National Case Reporting System. Demographic trends were determined through Cochran-Armitage trend tests. Distribution of case-clusters was examined using spatial autocorrelation. Spatial-temporal scan was used to detect disease clustering. Spatial correlations between cases and socioenvironmental factors were determined by spatial regression.

Results

Between 2006 and 2015, in China, 120 371 HIV/AIDS cases were identified among MSM. Newly identified HIV/AIDS cases among self-reported MSM increased from 487 cases in 2006 to >30 000 cases in 2015. Among those HIV/AIDS cases recorded during 2006-2015, 47.0% were 20-29 years old and 24.9% were aged 30-39 years. Based on clusters of HIV/AIDS cases identified through spatial analysis, the epidemic was concentrated among MSM in large cities. Spatial-temporal clusters contained municipalities, provincial capitals, and main cities such as Beijing, Shanghai, Chongqing, Chengdu, and Guangzhou. Spatial regression analysis showed that sociodemographic indicators such as population density, per capita gross domestic product, and number of county-level medical institutions had statistically significant positive correlations with HIV/AIDS among MSM.

Conclusions

Assorted spatial analyses revealed an increasingly concentrated HIV epidemic among young MSM in Chinese cities, calling for targeted health education and intensive interventions at an early age.

Faster and Riskier? Online Context of Sex Seeking Among Men Who Have Sex With Men in China

BACKGROUND

Many men who have sex with men (MSM) seek sex partners online, creating barriers and opportunities for human immunodeficiency virus prevention. The purpose of this study was to examine the characteristics of MSM and the risks associated with seeking sex through websites, gay apps, and both platforms in China.

METHODS

Data were collected through a cross-sectional online survey from September through October 2014 from 3 large gay Web portals. Sociodemographic information, sexual behaviors, and online sex seeking behaviors were measured. Multinomial logistic regression was performed to compare sexual risk behaviors among website users, gay app users, and men who used both platforms.

RESULTS

Of the 1201 participants, 377 (31.4%) were website-only users, 487 (40.5%) were gay app-only users, and 337 (28.0%) were men who used both platforms. These 3 MSM subgroups have distinct sociodemographic characteristics. Overall, 57.6% of participants reported having engaged in condomless anal sex with their last male partner in the past 6 months, but there was no significant difference in condomless sex between the 3 groups. Men who used both platforms viewed more sexually transmitted disease-related messages than website-only users (adjusted odds ratio, 2.19; 95% confidence interval, 1.57-3.05).

CONCLUSIONS

Condom usage behaviors were unaffected by the medium through which sexual partners were found. However, the high frequency of condomless sex suggests that websites and gay apps are both risk environments. This study suggests using multiple platforms for human immunodeficiency virus/sexually transmitted disease social media interventions may be useful.

Seeking Male Sexual Partners via Internet and Traditional Venues among Chinese Men Who Have Sex with Men: Implications for HIV Risk Reduction Interventions

The dynamic nature of finding male sexual partners (sex-finding) among Chinese men who have sex with men (MSM) may play a substantial role in the HIV epidemic. We compared characteristics and behaviors of MSM who mostly sought sex via the Internet versus traditional venues in a cross-sectional survey among 3588 Chinese MSM. We assessed the sociodemographic predictors and compared high-risk behaviors of using Internet versus traditional venues for sex-finding. Compared to non-Internet MSM, Internet-user MSM were more likely to have been: younger, currently single, better educated, health-insured, with higher income, with Beijing residency ('Hukou'), living longer in the city, HIV-positive, ever using drug and engaging in condomless receptive anal sex. Internet sex-finding users were less likely to be sexually active for longer duration, drink alcohol, drink alcohol before sex, or ever have sex with women. Knowledge of differential characteristics of various sex-finding MSM can help design targeted interventions.

High prevalence of HIV among men who have sex with men in Zhejiang, China: a respondent-driven sampling survey

OBJECTIVES

To examine the prevalence of HIV and risk behaviours among men who have sex with men (MSM) and to explore the feasibility of using respondent-driven sampling in this population in order to conduct customised interventions among MSM in the future.

DESIGN

Cross-sectional study.

SETTING

Zhejiang, China.

PARTICIPANTS

1316 MSM.

PRIMARY AND SECONDARY OUTCOME MEASURES

HIV prevalence rates and factors associated with HIV infection; sociodemographic and behavioural information of participants, syphilis prevalence rates.

RESULTS

The adjusted prevalence of HIV and syphilis were 13.8% and 11.4%, respectively. Multivariate analysis showed that higher educational level, support treatment of HIV, negative syphilis are protective factors of HIV infection. MSM who had heterosexual behaviour before and whose primary sexual partner was HIV-positive were less likely to be infected with HIV compared with their counterparts, while frequency of sexual behaviour with primary sexual partner was positively associated with HIV infection.

CONCLUSIONS

This survey confirmed a high HIV prevalence among MSM in Zhejiang province. MSM are extremely vulnerable to HIV infection and comprehensive interventions are urgently needed to slow the spread of HIV among MSM.

A comparison between respondent-driven sampling and time-location sampling among men who have sex with men in Shenzhen, China

Men who have sex with men (MSM) are a key population for HIV control and prevention in China. It is difficult to acquire representative samples of this hidden population. Respondent-driven sampling (RDS), based on peer referral, and time-location sampling (TLS) based on random selection of venue-day-time periods, are among the most commonly used sampling methods. However, differences in HIV-related characteristics of MSM recruited by these two methods have not been fully evaluated. We compared sociodemographics, risk behaviors, utilization of HIV-related intervention services, and HIV/syphilis infection rates between samples of 621 RDS MSM and 533 TLS MSM in Shenzhen, China in 2010. We found that the HIV prevalence was comparable in RDS and TLS MSM. TLS recruited larger proportions of more marginalized MSM than RDS: MSM recruited by TLS were older, less educated and more likely to be migrants (without Shenzhen hukou registration), to be non-gay identified and to engage in risky sexual behaviors. On the other hand, MSM recruited by TLS were more likely to have been covered by HIV-related intervention services. To conclude, in Shenzhen, TLS is more effective to reach the marginalized population of MSM. But because TLS can only reach MSM who physically attend venues and HIV-related intervention services are already commonly available at gay venues in Shenzhen, RDS is more informative for allocating prevention efforts than TLS. Furthermore, researchers and public health authorities should take into account the different sample compositions of RDS and TLS and apply sampling methods consistently when evaluating trends over time.

Comparing Samples of Men Who Have Sex with Men Recruited Online and in Venues, Jiangsu Province, China, 2013

PURPOSE

Two common methods to sample men who have sex with men (MSM) for HIV research are venue- and internet-based approaches. However, it is unclear which is best to sample Chinese MSM.

METHODS

We conducted side-by-side comparisons of time-location sampling (TLS) and an online sample of MSM in Nanjing, China.

RESULTS

TLS-recruited MSM tended to be older and of lower socio-economic status compared to online-recruited MSM, whereas online-recruited MSM reported higher risk behavior and lower frequency of HIV testing.

CONCLUSION

Significant differences were observed between the two separate samples. Without a gold standard, the choice of sampling method or recruitment approach should be guided by the segment of the population targeted to be reached.

A mixed-methods study on the acceptability of using eHealth for HIV prevention and sexual health care among men who have sex with men in China

Background

Human immunodeficiency virus (HIV) infection disproportionately affects men who have sex with men (MSM). Over half of all HIV-positive MSM in China may not know their HIV status. Mobile phones and Web interventions (eHealth) are underutilized resources that show promise for supporting HIV education, testing, and linkage to care.

Objective

This mixed-methods study among MSM in China assessed technology utilization and eHealth acceptability for sexual health care.

Methods

We conducted in-depth interviews and an online survey. Qualitative analyses informed the development of the Internet survey, which was administered through two popular MSM websites. Bivariate and multivariate analysis assessed characteristics of MSM interested in eHealth for sexual health care.

Results

The qualitative sample included MSM across a range of ages, education, marital status, sexuality, and HIV testing experience. Qualitative findings included the importance of the Internet as the primary source of information about sexual health, HIV and other sexually transmitted diseases (STDs), use of the Internet to enable HIV testing opportunities by facilitating connections with both the gay community and health care providers, and mixed perceptions regarding the confidentiality of eHealth tools for sexual health. Among the Internet sample (N=1342), the average age was 30.6 years old, 82.81% (1098/1342) were single, and 53.42% (711/1331) had completed college. In the past 3 months, 38.66% (382/988) had condomless sex and 60.53% (805/1330) self-reported having ever tested for HIV. The majority of men owned computers (94.14%, 1220/1296) and mobile phones (92.32%, 1239/1342), which many had used to search for HIV/STD information and testing sites. In multivariate analysis, interest in using computers or mobile phones to support their sexual health care was associated with being a student, prior use of computers or mobile phones to search for general health information, prior use of computers or mobile phones to search for HIV/STD information, and confidentiality concerns.

Conclusions

MSM in this sample had high utilization of technology and interest in eHealth despite confidentiality concerns. Future eHealth interventions can thoughtfully and creatively address these concerns as a priority for successful implementation.

Virtual versus physical spaces: which facilitates greater HIV risk taking among men who have sex with men in East and South-East Asia?

Increasing use of the Internet to seek sex partners is accompanied by rising HIV infections among men who have sex with men (MSM) in East and South-East Asia. We examined whether the Internet facilitates greater HIV risk taking among MSM in the region. A cross-sectional sample of 9,367 MSM was recruited via the Internet in 2010. We compared socio-demographic and HIV-related behavioral characteristics among MSM who met sex partners on the Internet only, who met sex partners offline only, and who met sex partners through both. Multinomial logistic regression was used to identify independent correlates that were associated with differences in where participants met their male sex partners. Compared to MSM who met partners offline only, those who met partners online only were less likely to have multiple male sex partners, have paid for sex, have consumed recreational drugs, and have used alcohol before sex. MSM who met partners both online and offline appeared to be the riskiest group that they were more likely to have multiple male sex partners, have engaged in UIAI, and have consumed alcohol before sex. These findings suggest that social networking websites alone do not facilitate greater HIV risk taking among MSM. Rather, they provide additional venues for MSM who already engage in HIV-related high risk behaviors to seek sex partners. The Internet offers incredible opportunities to reach large numbers of MSM in East and South-East Asia for HIV prevention and research. Web-based outreach and prevention activities are needed to reach these men. In addition, mobile and application-based interventions should also be developed and disseminated.

Case finding advantage of HIV rapid tests in community settings: men who have sex with men in 12 programme areas in China, 2011

We sought to describe the advantage of rapid tests over ELISA tests in community-based screening for HIV among men who have sex with men (MSM) in urban areas of China. Data of 31,406 screening tests conducted over six months in 2011 among MSM across 12 areas were analyzed to compare the differences between those receiving rapid testing and ELISA. Rapid tests accounted for 45.8% of these screening tests. The rate of being screened positive was 7.2% among rapid tests and 5.3% for ELISA tests (χ(2 )= 49.161, p < 0.001). This advantage of rapid test in HIV case finding persisted even when socio-demographic, behavioural, screening recruitment channel and city were controlled for in logistic regression (exp[beta] = 1.42, p < 0.001, 95% CI = 1.27,1.59). MSM who received rapid tests, compared with those tested by ELISA, were less likely to use condoms during last anal sex (50.8% vs. 72.3%, χ(2 )= 1706.146, p < 0.001), more likely to have multiple sex partners (55.7% vs. 49.5%, χ(2 )= 238.188, p < 0.001) and less likely to have previously undergone HIV testing (38.8% vs. 54.7%, χ(2 )= 798.476, p < 0.001). These results demonstrate the robustness of the advantage of rapid tests over traditional ELISA tests in screening for MSM with HIV infection in cooperation with community-based organizations in urban settings in China.

Prevalence of unprotected anal intercourse in men who have sex with men recruited online versus offline: a meta-analysis

Background

Men who have sex with men (MSM) are a high risk population for human immunodeficiency virus (HIV) infection. Our study aims to find whether MSM who were recruited online had a higher prevalence of self-reported unprotected anal intercourse (UAI) than those who were recruited offline.

Methods

A meta-analysis was conducted from the results of published studies. The analysis was stratified by the participants’ geographic location, the sample size and the date of the last reported UAI.

Results

Based on fourteen studies, MSM who were recruited online (online-based group) reported that 33.9% (5,961/17,580) of them had UAI versus 24.9% (2,700/10,853) of MSM who were recruited offline (offline-based group). The results showed that it is more likely for an online-based MSM group to have UAI with male partners than an offline-based MSM group [odds ratio (OR) = 1.35, 95% CI = 1.13-1.62, P < 0.01]. The subgroup analysis results also showed that the prevalence of UAI was higher in the European subsample (OR = 1.38, 95% CI = 1.17-1.63, P < 0.01) and in sample sizes of more than 500 individuals (OR = 1.32, 95% CI = 1.09-1.61, P < 0.01) in the online group compared to the offline group. The prevalence of UAI was also significantly higher when the time of the last UAI was during the last 3 or more months (OR = 1.40, 95% CI = 1.13-1.74, P < 0.05) in the online group compared to the offline group. A sensitivity analysis was used to test the reliability of the results, and it reported that the results remained unchanged and had the same estimates after deleting any one of the included studies.

Conclusions

A substantial percentage of MSM were recruited online, and they were more inclined to engage in UAI than MSM who were recruited offline. Targeted interventions of HIV prevention programs or services are recommended when designing preventive interventions to be delivered via the Internet.

Using online social media for recruitment of human immunodeficiency virus-positive participants: a cross-sectional survey

Background

There are many challenges in recruiting and engaging participants when conducting research, especially with HIV-positive individuals. Some of these challenges include geographical barriers, insufficient time and financial resources, and perceived HIV-related stigma.

Objective

This paper describes the methodology of a recruitment approach that capitalized on existing online social media venues and other Internet resources in an attempt to overcome some of these barriers to research recruitment and retention.

Methods

From May through August 2013, a campaign approach using a combination of online social media, non-financial incentives, and Web-based survey software was implemented to advertise, recruit, and retain participants, and collect data for a survey study with a limited budget.

Results

Approximately US $5,000 was spent with a research staff designated at 20% of full-time effort, yielding 2034 survey clicks, 1404 of which met the inclusion criteria and initiated the survey, for an average cost of US $3.56 per survey initiation. A total of 1221 individuals completed the survey, yielding 86.97% retention.

Conclusions

These data indicate that online recruitment is a feasible and efficient tool that can be further enhanced by sophisticated online data collection software and the addition of non-financial incentives.

The Randomized Response Technique Application in the Survey of Homosexual Commercial Sex among Men in Beijing

BACKGROUND

Traditional survey methods may cause refusals to respond or untruthful replies when encounter the sensitive questions. The Randomized Response Technique (RRT) is designed to decrease social desirability bias and obtain reliable estimates. This study aimed to apply these new methods on the sensitive questions survey.

METHODS

Simmons model was applied in the survey of issues relevant to commercial sex among men who have sex with men (MSM) in Beijing, China. Stratified two-stage sampling and stratified random sampling were applied.

RESULTS

During July to December 2010 in Beijing, the commercial sex proportion among MSM was 0.051(95% CI: 0.017, 0.085), its estimated variance was 3.01×10(-4). The last male condom use rate during commercial sex was 0.778(95% CI: 0.746, 0.810), its estimated variance was 2.6×10(-4).

CONCLUSION

We have introduced new approaches for the sensitive question survey among MSM. The new approaches are proved to be reliable and valid.

Strong propensity for HIV transmission among men who have sex with men in Vietnam: behavioural data and sexual network modelling

OBJECTIVES

Survey data from men who have sex with men (MSM) in Asian cities indicate ongoing and drastic increases in HIV prevalence. It is unknown which behavioural factors are most important in driving these epidemics. We aimed to analyse detailed sexual behaviour data among MSM in Vietnam and to model HIV transmission using improved assumptions on sexual network structure.

SETTING

Vietnam.

PARTICIPANTS

Internet-using men who had ever had sex (any type) with a man, aged ≥18 years and living in Vietnam. The study was cross-sectional, population-based and performed in 2012, using online respondent-driven sampling. The Internet-based survey instrument was completed by 982 participants, of which 857 were eligible. Questions included sociodemography and retrospective sexual behaviour, including number of unprotected anal sex (UAS) acts per partner.

PRIMARY AND SECONDARY OUTCOME MEASURES

Estimated basic reproductive number over 3 months as a function of transmission risk per UAS act; frequency distributions of number of UAS partners and UAS acts during last 3 months.

RESULTS

36% (CI 32% to 42%) reported UAS at least once during the last 3 months. 36% (CI 32% to 41%) had ever taken an HIV test and received the result. UAS partner numbers and number of UAS acts were both highly skewed and positively correlated. Using a weighted configuration model, taking into account partner numbers, frequency of UAS and their correlations, we estimated the basic reproductive number (R0) over 3 months. The results indicated rapid transmission over a wide range of values of per-act transmissibility.

CONCLUSIONS

Men with multiple partners had unexpectedly high UAS frequency per partner, paired with low HIV testing rates. The study highlights the importance of collecting data on frequency of UAS acts and indicates the need to rapidly scale-up HIV prevention services and testing opportunities for MSM in Vietnam.

Correlates of consistent condom use among men who have sex with men recruited through the Internet in Huzhou city: a cross-sectional survey

Background

There is growing evidence that men who have sex with men (MSM) are currently a group at high risk of HIV infection in China. Our study aims to know the factors affecting consistent condom use among MSM recruited through the internet in Huzhou city.

Methods

An anonymous cross-sectional study was conducted by recruiting 410 MSM living in Huzhou city via the Internet. The socio-demographic profiles (age, education level, employment status, etc.) and sexual risk behaviors of the respondents were investigated. Bivariate logistic regression analyses were performed to compare the differences between consistent condom users and inconsistent condom users. Variables with significant bivariate between groups’ differences were used as candidate variables in a stepwise multivariate logistic regression model. All statistical analyses were performed using SPSS for Windows 17.0, and a p value < 0.05 was considered to be statistically significant.

Results

According to their condom use, sixty-eight respondents were classified into two groups. One is consistent condom users, and the other is inconsistent condom users. Multivariate logistic regression showed that respondents who had a comprehensive knowledge of HIV (OR = 4.08, 95% CI: 1.85-8.99), who had sex with male sex workers (OR = 15.30, 95% CI: 5.89-39.75) and who had not drunk alcohol before sex (OR = 3.10, 95% CI: 1.38-6.95) were more likely to be consistent condom users.

Conclusions

Consistent condom use among MSM was associated with comprehensive knowledge of HIV and a lack of alcohol use before sexual contact. As a result, reducing alcohol consumption and enhancing education regarding the risks of HIV among sexually active MSM would be effective in preventing of HIV transmission.

Sociodemographic and sexual behavior characteristics of an online MSM sample in Guangdong, China

Public health research and interventions often assume that men who have sex with men (MSM) who use the Internet in China have similar characteristics to those in Western countries, though with little empirical evidence. This study aimed to describe and examine the sociodemographic and basic sexual behavioral characteristics of an online sample of MSM in Guangdong, China. In 2010, a total of 1100 MSM were recruited from an lesbian, gay, bisexual, and transgender (LGBT)-oriented website and were asked about their sociodemographic and sexual behavior characteristics. The majority of the participants (77.9%) self-identified as homosexual, and the mean age was 30.0 years (SD = 6.7). About 80% of the participants had attained a college degree and only 4.8% were unemployed. About 60% had a monthly salary of more than CNY 3000 (476 USD), and more than 10% were married. The majority (71.7%) had used condoms in the last anal sex. Nearly half of the participants have never been tested for HIV or other sexually transmitted infections (STIs) (47.3% and 47.7%, respectively). More than 80% were willing to be contacted by researchers after the survey. Findings indicate that the sociodemographic characteristics of Chinese MSM who use the Internet are relatively similar to those in the Western countries. However, Chinese MSM are less likely to self-identify as homosexual and be tested for HIV and other STIs than Western MSM. On a positive note, Chinese MSM would be likely to engage in e-technology research showing potential feasibility of an online HIV/STI intervention.

Barriers to acceptance of provider-initiated testing and counseling among men who have sex with men in Shenyang, China: a cross-sectional study

A high prevalence of HIV infection is present among men who have sex with men (MSM) in China, but many people living with HIV or AIDS (PLWHs) are unaware of their HIV infection status. Provider-initiated HIV testing and counseling (PITC) is a streamlined model that can significantly enhance HIV detection and detect infections earlier. However, PITC has not yet been widely applied, and no studies have been conducted on MSM's attitudes towards PITC in China. In this study, a total of 438 MSM were recruited in Shenyang city. A multivariate logistic regression model showed that certain conditions made MSM more accepting of PITC: those who had attended VCT (voluntary counseling and testing) more than three times (odds ratio [OR]: 2.95, 95% CI: 1.36–6.37), those who considered PITC beneficial for family and friends (OR: 1.91, 95% CI: 1.25–2.92), those who obtained HIV/AIDS knowledge from brochures (OR: 2.52, 95% CI: 1.64–3.87), those who obtained HIV/AIDS knowledge from the Internet (OR: 1.66, 95% CI: 1.07–2.58), and those who were highly aware of their own risk of being infected with HIV (OR: 2.84, 95% CI: 1.37–5.91). To improve acceptance of PITC among MSM in China, stronger efforts are needed to lower the psychosocial barriers to receiving PITC, to promote HIV/AIDS awareness, and to encourage the extension of HIV testing.

Syphilis-related perceptions not associated with risk behaviors among men who have sex with men having regular male sex partner(s) in Nanjing, China

The prevalence of HIV among men who sex with men (MSM)has been increasing sharply in China. The prevalence of unprotected anal intercourse (UAI)among them is very high, especially when male regular sex partners are involved. Many MSM having regular sex partners are engaged in multiple sex partnerships, which often involved UAI. This study interviewed 168 MSM in Nanjing, China, having had anal intercourse with at least one male regular sex partner in the last six months. Amongst the participants, 52.4% reported having had UAI with male regular sex partners whilst 50.0% reported multiple male sex partnerships in the last six months. Multivariate analysis showed that monthly personal income higher than 2000 RMB (multivariate OR = 0.49, 95% CI: 0.26-0.96), HIV antibody testing in the last year (multivariate OR = 0.19, 95% CI: 0.06-0.60), sexual position being both insertive and receptive during anal sex with male sex partners in general (multivariate OR = 0.43, 95% CI: 0.18-0.99; reference group: with receptive position only) were associated with lower likelihoods of UAI. Syphilis-related perceptions, including knowledge, cognitions (perceived susceptibility, perceived severity, self-efficacy in avoiding syphilis infection and perceived infectivity and perceived syphilis-related norms among MSM in general)were not associated with risk behaviors (UAI and multiple male sex partnerships). Our sampled MSM are exposed to very high risk of HIV/STD transmission. We found no association between syphilis-related perceptions and the two types of risk behaviors. Future studies are warranted to understand such associations in the context of sexual intercourse with non-regular sex partners among MSM.

Implementation of web-based respondent-driven sampling among men who have sex with men in Vietnam

Objective

Lack of representative data about hidden groups, like men who have sex with men (MSM), hinders an evidence-based response to the HIV epidemics. Respondent-driven sampling (RDS) was developed to overcome sampling challenges in studies of populations like MSM for which sampling frames are absent. Internet-based RDS (webRDS) can potentially circumvent limitations of the original RDS method. We aimed to implement and evaluate webRDS among a hidden population.

Methods and Design

This cross-sectional study took place 18 February to 12 April, 2011 among MSM in Vietnam. Inclusion criteria were men, aged 18 and above, who had ever had sex with another man and were living in Vietnam. Participants were invited by an MSM friend, logged in, and answered a survey. Participants could recruit up to four MSM friends. We evaluated the system by its success in generating sustained recruitment and the degree to which the sample compositions stabilized with increasing sample size.

Results

Twenty starting participants generated 676 participants over 24 recruitment waves. Analyses did not show evidence of bias due to ineligible participation. Estimated mean age was 22 years and 82% came from the two large metropolitan areas. 32 out of 63 provinces were represented. The median number of sexual partners during the last six months was two. The sample composition stabilized well for 16 out of 17 variables.

Conclusion

Results indicate that webRDS could be implemented at a low cost among Internet-using MSM in Vietnam. WebRDS may be a promising method for sampling of Internet-using MSM and other hidden groups.

Feasibility and willingness of using e-technologies for HIV prevention and research targeting Chinese MSM

This pilot study examines the feasibility and willingness for three types of e-technologies for HIV prevention and research among a sample of men who have sex with men (MSM) in Chengdu, China. A total of 605 self-identified MSM (200 HIV seropositive, 405 HIV-) were recruited through a community-based HIV/AIDS service organization and completed a cross-sectional survey. The majority used cell phones for voice and text (99 and 95%), 53% used email, and 83% used Tencent QQ (an instant messaging technology); 54% indicated they would participate in future research studies; and 77% provided contact information for at least one e-technology. In multivariate analyses, those who were not official city residents, those better educated, and those who were HIV seropositive were more likely to provide contact information. This research indicates that MSM in China would be likely to engage in e-technology research and studies should explore these innovative communication methods.

Online sex-seeking, substance use, and risky behaviors in Taiwan: results from the 2010 Asia Internet MSM Sex Survey

We conducted an online behavioral survey to estimate the prevalence of online sex-seeking and substance use behaviors and to compare risky behaviors among men using different venues to seek sex with men. A cross-sectional online survey, the Asia Internet MSM Sex Survey, was conducted online from January 1 to February 28, 2010. Of the 1,645 participants enrolled from Taiwan, 72.4% reported the Internet as the main way of seeking sexual partners, 73.9% had had sex with partners found online, and 16% had used recreational drugs in the previous 6 months. There was no evidence to suggest that men who looked for sex through the Internet were more likely to engage in unprotected anal intercourse with their casual partners than those using other gay venues. Having had online sex partners in the previous 6 months was significantly associated with being young [adjusted odd ratio (AOR) = 0.97, 95% CI: 0.95-0.99], having had no steady partners in the previous year (AOR = 0.24, 95% CI: 0.15-0.39), having had more than five partners in the previous 6 months (AOR = 4.57, 95% CI: 2.95-7.11), having used recreational drugs in the previous 6 months (AOR = 2.24, 95% CI: 1.30-3.87), and having had an STI in the previous 6 months (AOR = 4.24, 95% CI: 1.59-11.30). In conclusion, because the Internet is a popular meeting place for MSM in Taiwan, effective and targeted prevention programs should be developed to minimize the HIV transmission risk in the Internet era.

Factors associated with unprotected receptive anal intercourse with internal ejaculation among men who have sex with men in a large Internet sample from Asia

We examined socio-demographic and behavioral characteristics of men who have sex with men (MSM) residing in Asia and correlates of unprotected receptive intercourse with Internet ejaculation (URAIE). Asia Internet MSM Sex Survey, a behavioral survey of MSM in Asia was conducted from 1 January to 28 February 2010. Data analysis was limited to participants aged 18 or above, biological male, and had one regular or casual sex partner in the past 6 months (n = 10,413). Pearson's Chi-square test, t test and logistic regression were used to examine the correlates of URAIE in the past 6 months, the highest risk sexual behavior sampled. Of 7311 participants who had receptive anal intercourse, 47.5 % had URAIE, which was associated with the following attributes: less than high-school education and pre-college education compared to university (AOR = 1.53, 95 % CI: 1.28, 1.83; AOR = 1.22, CI: 1.08, 1.37), being in the heterosexual marriage (AOR = 1.35, CI: 1.18, 1.56), having regular partners or both regular and casual partners compared to having casual partners (AOR = 2.85, CI: 2.48, 3.27; AOR = 2.32, CI: 2.06, 2.62), HIV-positive compared to HIV-negative status (AOR = 1.39, 95 % CI: 1.08, 1.81), higher perception of HIV risk (AOR = 1.62, CI: 1.34, 1.95), use of recreational drug before sex (AOR = 1.30, CI: 1.14, 1.49), and use of the Internet as the main way to seek sex partners (AOR = 1.21, CI: 1.08, 1.36). MSM from certain Asian countries reported alarming rates of URAIE. The internet can be used as a platform for HIV surveillance and intervention.

A randomized controlled trial to evaluate the relative efficacy of enhanced versus standard voluntary counseling and testing on promoting condom use among men who have sex with men in China

The randomized controlled trial investigated the relative efficacy of an enhanced (EVCT) versus standard (SVCT) voluntary counseling and testing in reducing unprotected anal intercourse (UAI) among men who have sex with men (MSM) in China. 295 participants who recruited by respondent driven sampling methods were randomly allocated to the two arms. In addition to the SVCT, the EVCT group watched a theory-based video narrated by a HIV positive MSM, received enhanced counseling and a reminder gift. As compared to the SVCT group, the EVCT group reported lower prevalence of UAI with any male sex partners (48.4% versus 66.7%, RR = 0.7, ARR = -18.3%, p = 0.010) and with regular male sex partners (52.2% versus 68.9%, RR = 0.8, ARR = -16.7%, p = 0.043) at Month 6, whilst baseline between-group differences were statistically non-significant. Between-group differences in HIV/syphilis incidence were statistically non-significant. Translational research should be conducted to integrate non-intensive enhancements such as the EVCT into regular testing services.

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.

Risk behaviors and reasons for not getting tested for HIV among men who have sex with men: an online survey in Peru

BACKGROUND

Men who have sex with men (MSM) account for the greatest burden of the HIV epidemic in Peru. Given that MSM are frequent users of the Internet, understanding the risk behaviors and the reasons for not getting tested among MSM who surf the Internet may improve the tailoring of future online behavioral interventions.

METHODS

From October 2007 to April 2008, we conducted an online survey among users of seven Peruvian gay websites.

RESULTS

We received 1,481 surveys, 1,301 of which were included in the analysis. The median age of the participants was 22.5 years (range 12-71), 67% were homosexual, and the remainder was bisexual. Of survey respondents, 49.4% had never been tested for HIV and only 11.3% were contacted in-person during the last year by peer health educators from the Peruvian Ministry of Health and NGOs. Additionally, 50.8% had unprotected anal or vaginal sex at last intercourse, and a significant percentage reported a condom broken (22.1%), slipped (16.4%) or sexual intercourse initiated without wearing a condom (39.1%). The most common reasons for not getting tested for HIV among high-risk MSM were "I fear the consequences of a positive test result" (n = 55, 34.4%), and "I don't know where I can get tested" (n = 50, 31.3%).

CONCLUSIONS

A small percentage of Peruvian MSM who answered our online survey, were reached by traditional peer-based education programs. Given that among high-risk MSM, fear of a positive test result and lack of awareness of places where to get tested are the most important reasons for not taking an HIV test, Internet interventions aimed at motivating HIV testing should work to reduce fear of testing and increase awareness of places that offer free HIV testing services to MSM.

Using the Internet in Pursuit of Public Sexual Encounters

The current study investigated a subgroup of 112 men who have sex with men who use the Internet in search of partners for sex venue encounters to understand what types of venues they frequent and whether their behaviors are associated with an increased risk of HIV/STI transmission. An initial cluster analysis revealed two patterns of Internet use—low and high frequency—among these men. Although frequency of Internet use to find partners for venue encounters did not cluster with venue attendance, there was a trend among high-frequency Internet users to attend gyms, public bathrooms, and sex clubs more than low-frequency users. Furthermore, high-frequency users attended more venues, preferred venues where multiple partners can be found, and were marginally more likely to engage in unprotected anal sex across venues compared with low-frequency users. Knowing that some venue users initiate venue encounters on the Internet may be useful in targeting appropriate HIV/STI interventions.

When do online sexual fantasies become reality? The contribution of erotic chatting via the Internet to sexual risk-taking in gay and other men who have sex with men

Seeking sexual partners online is associated with sexual risk-taking among men who have sex with men (MSM), but it is not well understood how this use of the Internet is implicated in potential sexual risks. The present study explores whether fantasizing about unprotected anal intercourse (UAI) during online chatting is associated with UAI with partners met online. An online survey of 2058 MSM in France included assessments of UAI with partners met online, responses to erotic chatting about UAI, intentions to use condoms, attitudes regarding UAI, practicing UAI with casual partners, alcohol and drug use with sex and biographical characteristics. While intentions to use condoms with casual partners were high, one-third (32.1%) of respondents reported UAI with partners met online. Responding positively to online chatting about UAI was significantly associated with UAI with partners met online, controlling for intentions, attitudes, behavior and biographic characteristics. These findings suggest that, while MSM may not go online to seek UAI, some engage in online fantasizing about UAI that is associated with possible sexual risk-taking. This speaks critically to the assumption that online fantasizing has no behavioral implications, and underscores the importance of human immunodeficiency virus prevention that addresses the dynamics of online chatting.

HIV-related behavioral studies of men who have sex with men in China: a systematic review and recommendations for future research

HIV prevalence among men who have sex with men (MSM) has increased significantly in China since early 2000, with MSM accounting for 32.5% of the newly infected HIV cases in China in 2009. This study reviews a total of 33 studies published in English literature on MSM in China from 2000 to 2009. Existing studies indicated that frequently MSM in China were married (especially older MSM); a majority were migrants and self-identified as gay. A large and increasing proportion of MSM sought sexual partners online. Sexual risk behaviors among MSM were prevalent, including high rates of unprotected sex, concurrent sexual relationships with both men and women, and commercial sex. Illicit drug use, however, was relatively low among general Chinese MSM, but higher among those engaged in commercial sex with men. The existing literature suggests a lack of socio-behavioral studies, lack of intervention studies specifically targeting MSM, and lack of studies in smaller cities, towns, and rural areas. Future studies need to employ more rigorous research methodology, including longitudinal study design, multiple sampling methods, and common measurements of HIV-related risk behaviors.

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.

Comparing internet-based and venue-based methods to sample MSM in the San Francisco Bay Area

Methods of collecting behavioral surveillance data, including Web-based methods, have recently been explored in the United States. Questions have arisen as to what extent Internet recruitment methods yield samples of MSM comparable to those obtained using venue-based recruitment methods. We compare three recruitment methods among MSM with respect to demographic and risk behaviors, one sample was obtained using time location sampling at venues in San Francisco, one using a venue based like approach on the Internet and one using direct-marketing advertisements to recruit participants. The physical venue approach was most successful in completing interviews with approached men than both Internet approaches. Respondents recruited via the three methods reported slight differences in risk behavior. Direct marketing internet recruitment can obtain large samples of MSM in a short time.

STD prevalence, risky sexual behaviors, and sex with women in a national sample of Chinese men who have sex with men

We describe the behavioral characteristics and sexually transmitted disease (STD) prevalence of Chinese men who have sex with men (MSM) (n = 41) from a national probability sample of men (n = 1861). Most MSM were partnered with females (97%) and had a low rate of consistent condom use (7%). More MSM than heterosexual men self-reported a prior STD and risky sexual behaviors. MSM may act as a bridge for HIV transmission to female partners. Targeted interventions may help prevent a generalized HIV epidemic in China.

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.