It wasn’t that long ago that HIV in China was concentrated largely in persons who inject drugs, with Yunnan Province in the southwest as an early epicentre of the epidemic. But in recent years, it’s become clear that HIV infections among men who have sex with men (MSM) are increasing, with HIV in this key population rising quickly as demonstrated by data from improved surveillance across the country. What’s more, syphilis is escalating sharply as well, serving as an ever more accessible gateway for HIV infection. But behind these trends across the MSM population lie complex factors.
“A few earlier studies had sought to establish the linkages between HIV and syphilis among MSM in China, but they had small sample sizes or focused on just a few places, so it was unclear how much their results could be generalized,” explained Dr Wu Zunyou, head of China’s National Center for AIDS/STD Control and Prevention. “Our study, with more than 47,000 subjects and spread across 61 cities, is quite simply the largest study ever conducted anywhere of HIV and syphilis prevalence among MSM, and it is an unusually broad effort with diverse branches of inquiry.”
HIV and Syphilis Prevalence among Men who have Sex with Men: A Cross-Sectional Survey of 61 Cities in China, conducted between February 2008 and September 2009, and published in Clinical Infectious Diseases in 2013, sought to test 3 hypotheses:
- The prevalence of both HIV and syphilis among MSM in China is high;
- the two epidemics each have unique geographical distributions; and
- demographic and sexual behavior characteristics are different among segments of the MSM population in China.
The different segments of the MSM population were categorized as:
- MSM who were not local residents of the city surveyed;
- MSM who used the Internet to find male sex partners; and
- MSM who had at least one female partner in the past six months.
“Basically, we wanted answers to several questions,” said Dr Wu. “What was the extent of HIV and syphilis infection across the MSM population? Would we see different concentrations or patterns of the epidemics in different places? Did different ‘pockets’ of MSM have different sexual habits and hence different levels of HIV and STI risk? Also, what is the best way to define different categories of MSM? The answers we eventually obtained were interesting and informative, but also raised more questions!”
“We welcome the publication of this important study. “It is critical to reach all men who have sex with men who are at risk of being infected by HIV and other sexually transmitted illnesses – as this group constitutes the majority of new HIV infections in China. Studies like this will help us to achieve this,” said Dr Bernhard Schwartländer, WHO Representative in China.
“Tackling the HIV epidemic in China requires both strong partnerships – between health authorities, health care providers, community-based organizations, and people living with HIV. It also requires good information about different at-risk groups. This study is a major contribution,” said Dr Catherine Sozi, Director of UNAIDS Country Office in China.
Escalating epidemics, closely linked – but not everywhere
- The overall prevalence estimate for HIV among MSM in this study was 4.9% -- close to national surveillance estimates at the time of the study (2008-2009), but less than the 6.3% national prevalence estimate for MSM in 2011. This, the authors conclude, demonstrates that the MSM HIV epidemic is expanding rapidly across all parts of the country.
- The overall prevalence estimate for syphilis among MSM in this study was 11.8% -- with MSM aged 50-69 years having the highest syphilis prevalence (23.2%).
- Correlations between HIV and syphilis prevalence were found in only 3 of 6 geographical regions surveyed: Northwest, East and South-central.
- However, syphilis positive MSM had the highest HIV prevalence, 12.5%.
Risk factors and “protective” factors
- Being over 24 years of age, being divorced or widowed, being a non–local resident, having an active syphilis infection, finding sex partners in public bathhouses/saunas, buying sex from men, selling sex to men, and having more than one male sex partner were all associated with a higher probability or risk of having an HIV infection.
- Having a college education, using condoms consistently when having sex with men, and having at least one female sex partner were seen to be “protective” factors for HIV infection.
- There were complex layers contained beneath these broad assertions, however. For example, 68% of MSM who had a female partner would not use a condom even if they knew they were HIV positive, indicating how key populations – in this case MSM – are often a bridge for infection vis-à-vis the general population.
Different types of MSM, different behaviours
The different categories of MSM classified for the purposes of the study also reflect generational, socio-economic and cultural values and trends of China’s changing times, and these in turn translate into different types of behaviours and different types of risks.
- The profile of Internet-using MSM in the study sample was that of young (aged 18–24 years), never-married, college-educated students and professionals who identified themselves specifically as homosexual – reflecting the self-awareness and perhaps even “pride” that the young generation of today feels in one’s sexual identity, as opposed to previous generations who lived (and continue to live) hidden lives. The study found that these younger Internet-using MSM were generally very aware of HIV and how to protect themselves, and condom use was high in this category.
- By contrast, the profile of MSM who have had female partners is generally that of middle-aged (30–49 years), married, junior or senior high school–educated men who self-identify as “bisexual”.
- The profile of non-local MSM falls in between these in many respects as they are of a similar age (18–24 years), marital status (never married) and sexual orientation or identification (homosexual) profile relative to Internet-using MSM, but, similar to female-partnering MSM, have lesser education levels ( junior or senior high school).
- In terms of sexual behavior, a greater proportion of MSM who have female partners reported buying sex from men and a similar proportion of female-partnering and non-local MSM reported selling sex to men.
- HIV knowledge was highest among Internet users, and HIV and syphilis prevalence were highest among non-locals.
“Since the data for this study were collected, HIV and syphilis have escalated even further across China in the MSM population,” Dr Wu reiterated. “Our study complemented national surveillance efforts and provided rich detail on lifestyles, backgrounds and attitudes. The results also provide new avenues for further research. But perhaps the most important contribution of our study is to demonstrate the complexities that exist within key populations, including MSM. We simply cannot generalize, but instead must sift through the many layers that exist within and across a population to truly understand how individual and community behaviour is shaped, how unique these characteristics are. Tackling HIV, syphilis and other STIs is not just about providing healthcare and related services, but about understanding real people, understanding what shapes their lives, and in so doing, treating them with the respect and empathy that everyone deserves.”
Access the China 61 Cities MSM HIV/Syphilis Study at
For more information please contact
Ms WU Linlin
WHO China Office
E-mail: wul@wpro.who.int
Office Tel: +86 10 6532 7191