To our knowledge, this is the largest epidemiological study to estimate HIV and STD prevalence and describe the related risk behaviours among Chinese male high school and university student MSM. Understanding this population is important in order to design interventions to curb China's HIV epidemic.
The HIV prevalence among this group of Liaoning student MSM was 3.0%, which is over fifty times higher than the Chinese general population (0.057%) . This prevalence is also higher than that reported among MSM students in Beijing (2.3%)  and Hefei(1.7%) . The prevalence of syphilis in this survey (5.0%), however, is lower than that reported among MSM students in Beijing (7.43%)  and Hefei(7.4%) . The prevalences of HIV and syphilis were markedly lower than that reported among MSM of all ages in Shenyang City, Liaoning Province (HIV 5.7% and syphilis 25.4%) .
Although the number of high school and college students is the largest in the world and 3.7%-10.3% of Chinese male college students report engaging in sexual activity with men [16, 18], as yet, there have been few HIV/STD prevention programs that have targeted this vulnerable population. The relatively high prevalence of HIV and syphilis found in this survey demonstrates that it is urgent for the Chinese government to take action and target prevention interventions aimed at this group.
The current study also found a seemingly contradictory phenomenon, those MSM whose sexual orientation was known by family members were more likely to be infected with HIV, while a previous study of Chinese MSM in Hong Kong found that those who were open about their MSM status were more likely to use condoms . It is possible that participants who were HIV positive were already aware of their status and had disclosed their status to their parents. Sexual orientation known by family could also be considered a proxy for openness of sexuality. Future studies should investigate the effects of social support and openness of sexuality on high risk behaviour among Chinese MSM.
Somewhat paradoxically, those who received HIV/AIDS education from a clinician were more likely to be infected with HIV than those who did not receive HIV education from a clinician. Due to the cross-sectional nature of this study, it is difficult to discern if HIV-related knowledge was gained prior to engaging in high risk behaviour. Those who had an STI and were more susceptible to HIV infection may be more likely to see a clinician and obtain HIV/STI prevention information. Overall, HIV/AIDS knowledge was not statistically correlated with HIV infection, which may indicate a low perception of risk. The utilization of free HIV education services and materials such as VCT and condoms distribution services, however, were negatively associated with HIV infection. Comprehensive interventions, which incorporate VCT and the provision of free condoms, should be considered since it appears as though HIV knowledge is not enough to prevent HIV among Chinese student MSM.
Inconsistent condom use with casual male sex partners was found to be independently associated for HIV infection. Low condom usage is of particular concern in this study population since several reported low condom use with female partners and with HIV positive partners. A study in Beijing also reported low condom use among college student MSM . Peer education has been demonstrated to be an effective means of reaching both MSM and student populations to promote healthy behaviours, which may be used to reduce their risk of HIV infection [28–31].
This study also found that bleeding after insertive anal intercourse was associated with HIV infection. A study in Mexico City determined that MSM who bled after anal sex were more likely to be HIV positive compared with those that did not experience bleeding . Ruptured mucous membranes that result from anal sex may facilitate the entry of the virus. MSM should be encouraged to use condoms with water-based lubricants during anal sex in order to minimize the risk of anal and rectal bleeding and general HIV/STD transmission.
The current study found that illegal drug use, but not injection drug use, was independently associated with HIV infection among MSM students. Injection drug use has historically been found to be a primary risk factor for HIV in China , but studies of MSM have also found use of non-injection drugs to be associated with HIV infection. These studies found that methamphetamine, amyl nitrate, and Viagra were the most common drugs associated with HIV infection [34, 35]. The current study did not gather detailed information on types of drugs used, but future interventions should discourage illegal drug use, in general, in order to prevent high risk behaviour resulting from a loss of inhibition.
This study is subject to several limitations. This was a cross-sectional study and therefore temporal associations cannot be inferred. The survey asked questions about sensitive topics and participants may not have felt comfortable answering accurately. In order to minimize recall bias, questions were framed in terms of behaviour in the last 6 months; however, this may not be indicative of usual behaviour. Selection bias may have influenced the results of this study and since the survey subjects were a convenience sample of student MSM who live in Liaoning Province, the results of this study may not be generalizeable to the greater student MSM population. Since participants were asked to recruit their sexual partners there may have been some bias in the HIV and STI estimates. Although multivariate analysis was used to address possible confounding by study variables, it is possible that other confounding occurred by variables not measured in this study.