Men who have sex with men (MSM) are at high risk for infection with human immunodeficiency virus type 1 (HIV-1) because of risk behaviors such as multiple partners and unprotected anal intercourse (UAI). Approximately 5% to 10% of all new HIV-1 infections are transmitted by male homosexual behaviors globally.1 The HIV epidemic in China is currently spreading from high risk groups to the general population. The high risk behaviors in MSM and the relatively large size of this population suggest that they have the potential to significantly contribute to an increasing HIV-1 epidemic in China.2 The latest HIV-1 estimates from China indicate that 11% of the approximately 700 000 infected individuals were infected through homosexual transmission, which has increased from 7.3% in 2005.3,4
Increasing numbers of MSM have used the Internet to solicit interactions.5,6 Data from a study survey of conventional venues in 6 Chinese cities revealed that a commonly available method of soliciting sex was through the Internet.7 A study which surveyed chat rooms and e-mail interactions revealed that nearly 70% of MSM met one another through the Internet, and approximately 67% practiced anal sex without a condom.8 A London study revealed differences between MSM recruited online and offline in certain characteristics including age, education, number of male partner(s) in given period, risky sexual behaviors, and HIV status.9,10 Such differences were important in the development of effective and appropriate interventions.
The objective of this study is to examine the differences likely to exist between MSM recruited through conventional venues and the Internet.
Sampling and recruitment
Research among hard-to-reach groups such as MSM has typically been based on convenience rather than probability samples.11 A cross-sectional study was performed between November 12 and November 27, 2005 to collect data through questionnaires among MSM at popular MSM gathering arenas and at a gay-oriented website built by a local MSM volunteer organization (the Night Cat Volunteer Group) in Changsha, the capital city of the Hunan Province in China. Eligible study participants were men who had lived in Changsha for at least 3 years and had anal and/or oral sex with men during this time period. MSM recruited offline were interviewed in homosexual bars, saunas, baths, night clubs, tea bars, public toilets, parks, and other popular venues through volunteers from the Night Cat Volunteer Group in Changsha. Men who participated in the study were asked to complete a short, anonymous, self-administered questionnaire during study introduction. Volunteers obtained verbal informed consent from the study participants. MSM recruited online were accessed through Internet chat rooms on the Night Cat Volunteer Group website. Individuals were invited to participate in the investigation and participants completed the study questionnaire in an online forum. All participants were given a bottle of lubricant and a box of condoms as compensation for their contribution.
The questions provided in both the online survey and the self-administered questionnaires were identical. Individuals provided information on their age, education, marital status, and to classify their sexual orientation. Individuals were questioned about their knowledge of HIV-1, AIDS, and HIV-1/AIDS-associated resources. Individuals were also asked several AIDS-related questions, and were queried about HIV-1 counseling and testing. They were asked whether they had had UAI or sex with women in the previous 3 months.
Characteristics derived from offline and online questionnaires were compared. Descriptive analyses were conducted to illustrate socio-demographic characteristics, sexual orientation, and sex-related risk behaviors in both populations. Analysis of variance (ANOVA), the Mann-Whitney test, and Logistic regression were performed to compare the differences in age, education, the number of sexual partners, and the proportion of UAI between online and offline samples. A P value less than 0.05 was considered statistically significant.
A total of 352 eligible men from the offline population were invited to participate in the survey, and 291 of those individuals completed questionnaires. Similarly, 116 men from the online population were invited to participate in the survey, with 109 individuals completing questionnaires. Questionnaires were examined for validity for study inclusion, and 270 offline questionnaires and 102 online questionnaires were included in the study.
Results of online and offline sample comparisons are presented in Table 1. Men who surveyed through online were significantly younger (mean age 25 years, P <0.001), and more likely to be unmarried (79.4%, P <0.001). They had significantly less access to HIV counseling (10.2%, P=0.034) and testing (52.0%, P=0.037). However, there were no significant differences in the use of these services. Online participants had a significantly younger age at first intercourse with a man (mean age 20.08 years, P=0.002). They were also less likely to have sexual intercourse with males (63.7%, P=0.007), had fewer male sexual partners (mean 3.98 partners, P=0.030) in the last 3 months, and were more likely to have UAI (58.1%, OR 3.132, 95% CI 1.586-6.184, P=0.001) after adjusting for age, education, marital status, sexual orientation, knowledge on HIV/AIDS, AIDS hotline telephone use, and HIV testing. Online participants were significantly less likely to have sexual relations with women (19.6%, P=0.001).
There were no significant differences between online and offline samples in access to HIV/AIDS educational resources when adjusted for age and education. The top five resources were: television (86.6%), newspapers and periodicals (77.3%), books (67.8%), the Internet (62.5%), broadcast (57.1%), information from friends (31.9%), free pamphlets (30.3%), road-side ad-columns (22.4%), doctors (11.8%), and consultation (8.4%).
There were no significant differences between online and offline samples in correctly answering AIDS-related questions when adjusted for age and education. Only 71.8% of the participants knew that "people can protect themselves by correctly using a condom every time when having sex intercourse" and 79.9% knew that "you can not tell if a healthy-looking person is infected with HIV". Fewer than half of the respondents (46.6%) knew that "HIV could not be transmitted by mosquito bites" (Table 2).
There were no significant differences between online and offline samples on reasons for lack of condom use during anal sex with a male partner. The reasons for UAI included the following: "either he or I was reluctant to", "condom was not available", "I do not know", "I forgot", "lubricant was not available", "other reasons", and no response.
Our study supports the online behavioral research among MSM is feasible and productive for the gathering of relevant data.8-10,12-14A total of 109 men completed the online survey from a single MSM-oriented website.
There were limitations to our study. Selection bias was generated since online participants were recruited from a single website, which might limit the communication regarding sexual behaviors.15 This type of communication might be more thorough through email and other sites. Additionally, offline study participants may have visited gathering venues with different frequencies at different times and may have been affected by natural factors such as seasonal variance and holiday times. Therefore, our results may not be generalizable to the entire Chinese MSM population.
Our results may not be representative of the whole MSM population in Changsha as we were only able to sample individuals who were willing to communicate with the volunteers. We may be underestimating both the online and offline individuals because of lack of responses or identification. The internet offers an important approach in the conduction of behavioral research since it can reach some gay and bisexual men at high risk for HIV and STDs who are not easily accessible in conventional venues.
Men who engaged in our survey through online were younger and more likely to engage in anal sex with men, similar to a 2001 Beijing study.8 Such individuals had fewer sexual partners but reported high-risk sexual behaviors similar to a previous London-based study. Individuals who were surveyed through online were younger since the majority of internet users were younger and more educated.
Men surveyed offline had similar numbers of male partners and a similar proportion of high-risk behaviors as other surveys conducted in Chinese populations.7,16-25
Our data suggest that misconceptions about AIDS-related issues exist in the Chinese MSM population. These misconceptions were present regardless of source population or education. Few individuals had access to AIDS hotline telephone numbers, counseling, or HIV test request centers. Many MSM (58.7%) used the Internet to acquire knowledge on HIV and many men (42.9%) using such online services often visited community venues. This suggested that the MSM online population should be closely monitoring as a high HIV risk group. The reasons for lack of condom use should also be closely examined.
Many MSM marry and have children due to traditional family and marriage values in China. Many men conceal their homosexuality, and therefore many MSM in China are sexually active with both men and women.21,23,26 However, further information must be collected on the frequency of condom use among men engaged sex with both men and women in order to estimate the risk of MSM as a bridging population for HIV transmission from MSM to the general population.
This investigation would not have been possibly finished without the cooperation of respondents who were willing to participate in the investigation and the volunteer group. We are grateful to the Night Cat Volunteer Group for their kind assistance.
1. Liu H, Yang H, Li X, Wang N, Liu H, Wang B, et al. Men who have sex with men and human immunodeficiency virus/sexually transmitted disease control in China. Cell Res 2005; 15: 858-864.
2. State Council AIDS Working Committee Office and UN Theme Group on HIV/AIDS in China. A Joint Assessment of HIV/AIDS prevention, treatment and care in China (2004). 2004: 6.
3. Ministry of Health, People's Republic of China Joint United Nations Programme on HIV/AIDS World Health Organization. 2005 Update on the HIV/AIDS epidemic and response in China. National Center for AIDS/STD Prevention and Control, China CDC. 2006. 2.
4. State Council AIDS Working Committee Office and UN Theme Group on HIV/AIDS in China. A joint assessment of HIV/AIDS prevention, treatment and care in China (2007). 2007. 4.
5. Cooper A, Scherer C, Boies S, Gordon B. Sexuality on the Internet: from sexual exploration to pathological expression. Prof Psychol Res Pract 1999; 30: 154-164.
6. Toomey K, Rothenberg R. Sex and cyberspace — virtual networks leading to high-risk sex. JAMA 2000; 284: 485-487.
7. Zhang B, Zeng Y, Xu H, Li X, Zhou S, Liao L, et al. Study on 1389 men who have sex with men regarding their HIV high-risk behaviors and associated factors in mainland China in 2004. Chin J Epidemiol (Chin) 2007; 28: 32-36.
8. Wang Q, Ge L, Ross MW. Sexual risk behaviors among men who have sex with men: an internet outreach sample. China J AIDS/STD (Chin) 2004; 10: 335-337.
9. Elford J, Bolding G, Davis M, Sherr L, Hart G. Web-based behavioral surveillance among men who have sex with men: a comparison of online and offline samples in London, UK. J Acquir Immune Defic Syndr 2004; 35: 421-426.
10. Bolding G, Davis M, Hart G, Sherr L, Elford J. Gay men who look for sex on the Internet: is there more HIV/STI risk with online partners AIDS 2005; 19: 961-968.
11. McGarrigle C, Fenton K, Gill O, Hughes G, Morgan D, Evans B. Behavioral surveillance: the value of national coordination. Sex Transm Infect 2002; 78: 398-405.
12. Ross MW, Tikkanen R, Mansson SA. Differences between Internet samples and conventional samples of men who have sex with men: implications for research and HIV interventions. Soc Sci Med 2000; 51: 749-758.
13. Rhodes S, DiClemente RJ, Cecil H, Hergenrather KC, Yee LJ. Risk among men who have sex with men in the United States: a comparison of an Internet sample and a conventional outreach sample. AIDS Educ Prev 2002; 14: 41-50.
14. Reid D, Weatherburn P, Hickson F, Stephens M. Know the score: findings from the National Gay Men's Sex Survey 2001. London: Sigma Research, 2002. (Accessed February 5, 2004 at http://www.sigmaresearch.org.uk/reports.html.
15. Wang Q, Ross MW. Differences between chat room and e-mail sampling approaches in Chinese men who have sex with men. AIDS Edu Prev 2002; 14: 361-366.
16. Zhang B, Li X, Shi T, Cao N, Hu T. Survey on the high risk behaviors and other AIDS/STI related factors among men who have sex with men (MSM) in mainland China (2001). Chin J Dermatol (Chin) 2002; 35: 214-216.
17. Zhang B, Liu D, Liu X, Hu T. Study on HIV/AIDS high risk behavior and its factors among men who have sex with men in China. J China AIDS/STD Prevent Control (Chin) 2001; 7: 7-10.
18. Shi T, Zhang B, Li X, Hu T, Cao N. Investigation on STI and relevant high risk behaviors in men who have sex with men. China J Leprosy Skin Dis (Chin) 2003; 19: 135-136.
19. Liu H, Liu Y, Xiao Y. A survey on knowledge, attitude, belief and practice related to HIV/AIDS among MSM. J China AIDS/STD Prevent Control (Chin) 2001; 7: 289-291.
20. Choi K, Liu H, Guo Y, Han L, Mandel JS, Rutherford GW. Emerging HIV-1 epidemic in China in men who have sex with men. Lancet 2003; 361: 2125-2126.
21. Ruan Y, Li D, Li X, Qian HZ, Shi W, Zhang X, et al. Relationship between syphilis and HIV infections among men who have sex with men in Beijing, China. Sex Transm Dis 2007; 34: 592-597.
22. Choi K, Gibson D, Han L, Guo Y. High levels of unprotected sex with men and women among men who have sex with men: a potential bridge of HIV transmission in Beijing, China. AIDS Educ Prev 2004; 16: 19-30.
23. Qu S, Zhang D, Wu Y, Zhu H, Zheng X. Seroprevalence of HIV and risk behaviors among men who have sex with men in a northeast city of China. J China AIDS/STD Prevent Control (Chin) 2002; 8: 145-147.
24. Qu S, Zhang D, Wu Y, Zhu H, Cui Y, Zhao D, et al. A survey of knowledge, attitude and practice relate to HIV/AIDS among men who have sex with men in a northeast city of China. J China AIDS/STD Prevent Control (Chin) 2002; 8: 338-340.
25. Li X, Zhang B, Hu T, Liu D, Zhou X. Survey of STD prevalence and related high risk sexual behaviors in Chinese MSM. Chin J Dermatol (Chin) 2001; 34: 189-191.
26. Liu H, Liu Y, Xiao Y. HIV-related knowledge, attitudes, and behavior among men who have sex with men in Beijing, China. Chin J STD AIDS Prev Control (Chin) 2001; 7: 289-291.