Factors associated with HIV infection among men who have sex with men in Henan Province, China: a cross-sectional study

Although some HIV prevention interventions have been conducted in the past two decades, China has still entered a critical stage of rapid and widespread increase of the HIV/AIDS epidemic [1, 2]. By 2007 the major groups infected with HIV were injection drug users (IDUs; 38.5%), former blood donors (FPDs; 19.3%) and promiscuous heterosexuals (17.8%) [3]. In 2009, sexual transmission, including both heterosexual and homosexual transmission, has become the dominant route of HIV infection, accounting for more than 70% of the estimated new infections in China [4]. Of particular concern is the increasing HIV prevalence among men who have sex with men (MSM). The percentages of newly reported HIV cases attributable to MSM in China were 0.2% in 2001, 7.3% in 2005, 12.2% in 2007, and 32.5% in 2009 [5].

MSM are disproportionately affected by the HIV pandemic due to social and behavioral factors that increase their vulnerability to HIV infection. Evidence from studies show that MSM are at a high risk for HIV infection in China also because of their high number of different sexual partners and active sexual activities without protection [5]. The traditional Chinese culture does not openly endorse MSM behaviors, and there is strong social pressure against such behavior [6]. Under social pressure, many MSM marry in order to hide their sexual orientation. Therefore, MSM may play a bridging role in the spread of HIV and other STDS from a high-risk population, such as their male sexual partners, to the general population, such as their wives [7–10].

Additionally, high migration rates has been associated with higher risk for HIV infection in MSM [11]. Massive internal migration from rural areas to urban cities, especially large sized and medium-sized cities, resulted in MSM being more socially connected [12, 13]. Zhengzhou, located in the center of China, is an important transportation hub. There are 223 million in the floating population in 2010. It has been broadly reported in rural regions of China that most MSM had sex with casual sexual partners and never used a condom [14]. Therefore, health interventions to reduce high-risk behavior are key to controlling the spread of HIV in the floating population.

The purpose of the study was to identify factors associated with HIV infection among MSM in China, in order to make primary strategies to control the HIV spread in MSM population.

In our study, 49.2% of the respondents self-identified as bisexual, about 46.6% of MSM respondents were married, and the prevalence of married MSM increased to 71.4% or greater among those MSM who were over 30 years old. In China, MSM are a hidden subgroup in mainstream society. Due to stigma, discrimination, denial and ignorance, it is a challenge to identify MSM. They may use marriage as a means to disguise their homosexual behaviors or sexual orientations. High-risk behaviors were common in this population. Only 66.4% of the respondents used a condom during their last sexual intercourse. Consistent condom use was low even with male sexual partners (35.4%). Moreover, the rate of consistent condom use with women was lower than with men. 49.2% of the respondents reported having had sex with women in the past 6 months, and 61.8% did not use a condom in their last sexual intercourse with a female. During sexual intercourse with a female in the past 6 months, most of the respondents sometimes used a condom, and 30.4% of the respondents had never used a condom. The high portion of men who have sex with both men and women could serve as a potential “bridge” for the spread of HIV and other STDs from the high-risk population to their female partners and to the general Chinese population.

Our study suggested that for respondents who were residents of other provinces, the risk of HIV infection was 5.53 times higher. Zhengzhou, the capital city of Henan province, is one of the major cities in middle China. Therefore, it has a much greater nonlocal population. It is difficult to get information to the nonlocal MSM population regarding social support. Our study found that the rates of HIV prevalence was higher than those reported in other districts in China [2, 14, 17, 18]. Therefore, more effective strategies need to be implemented to control the HIV spread in nonlocal populations.

Studies have suggested a positive association between condom use in male-to-male anal intercourse and access to HIV preventives actions [19–26]. Our study also found that condom use in the last sexual intercourse were independently associated with HIV infection. In addition, we found accepting condoms significantly decreased the risk for HIV infection, which indicated that risky sexual behaviors associated with HIV infection could be constrained, in part, by increasing condom distributions. However, based on the results of our study, services utilization was still low in Zhengzhou. Only 30.4% of respondents reported having had an HIV test, and about 50% of respondents received condoms and peer education. Intervention programs for MSM, such as condom promotion and distribution and AIDS advisory and testing, and the distribution of materials on AIDS information need to be made more available and accessible to the MSM population.

Studies have demonstrated the connection between HIV and syphilis infections [27–30]. Our data also indicated a possible correlation between HIV and syphilis infections. After controlling for other risk factors, respondents who had been infected with syphilis were 4 times more likely to be infected with HIV. The high prevalence of syphilis suggested that MSM in Zhengzhou are at a greater risk for HIV infection. Widespread screening for syphilis infections in this risk group should be considered as a measure for control.

Unlike some other countries where drug use was considered as a major risk for HIV spread in the MSM population, only 2 participants in our study used illicit drugs in the past 6 months. It seems that there is little overlap of between the two populations of drug users and MSM in Zhengzhou.

The study has a number of limitations. First, the questionnaire data relying on retrospective self-reports was subject to recall bias. The findings should be interpreted carefully when generalizing the larger MSM population or comparing results from other studies. Second, our study was conducted in a limited area in Zhengzhou, China. Further work that focuses on extending the research into the broader areas in China would be valuable.

Our study indicates that a tailored approach to HIV prevention among MSM in Henan province in China is urgently needed. Some intervention strategies such as education intervention, condom promotion and distribution, and HIV counseling and testing are necessary to control HIV infection among MSM.