Factors Associated with Unprotected Anal Intercourse Among Male Students Who Have Sex with Men in Three Northern Regions of China
The prevalence of human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) in China has been on the rise. Specifically, male students who have sex with men (SMSM) represent a unique subgroup within the MSM population that has shown increasing rates of HIV infection. This study focuses on the factors associated with unprotected anal intercourse (UAI) among SMSM in three northern regions of China: Beijing, Tianjin, and Shijiazhuang. UAI is a significant risk factor for HIV transmission, and understanding the factors that contribute to this behavior is crucial for developing targeted prevention strategies.
Background and Context
HIV prevalence among MSM in China has increased dramatically over the past two decades. From 0.9% in 2003, it rose to 8.0% in 2015. Among SMSM, the number of HIV infections among students aged 15 and older quadrupled from 527 cases in 2008 to 2,695 cases in 2014, with male-to-male sexual transmission being the primary driver. A meta-analysis further revealed that HIV prevalence among SMSM increased from 3.0% in 2003–2006 to 5.2% in 2012–2016. This trend underscores the need to address risky sexual behaviors, particularly UAI, among SMSM to curb the spread of HIV.
Beijing, Tianjin, and Shijiazhuang are home to a large number of universities and colleges, making them key areas for studying SMSM. Previous studies in these cities have highlighted the increasing rates of HIV transmission among SMSM. For example, in Tianjin, the HIV antibody positive detection rate among SMSM increased from 0.95% in 2012 to 4.03% in 2016. In Beijing, over 85% of newly diagnosed HIV-infected students in 2016 were infected through male homosexual transmission. Despite these alarming statistics, few studies have explored the factors associated with UAI among SMSM in these regions.
Study Design and Methods
This study was conducted from November 2018 to January 2019 in Beijing, Tianjin, and Shijiazhuang. It employed an unmatched case-control design based on a cross-sectional survey. Participants were recruited through three non-governmental organizations (NGOs) that work closely with the MSM community in these cities. Eligible participants were biologically male, aged 18 or older, full-time students, and had engaged in anal intercourse with a man in the past six months. Individuals previously diagnosed with HIV were excluded from the study.
Participants were divided into two groups: cases (those who reported UAI in the past six months) and controls (those who did not report UAI in the past six months). Data were collected through self-administered electronic questionnaires, which included detailed demographic and behavioral information. Variables assessed included age, education level, sexual orientation, preferred sexual position, number of anal sexual partners, substance use before sex, self-perceived HIV risk, and characteristics of first anal intercourse.
Results
A total of 511 SMSM were included in the study, with 210 (41.1%) reporting UAI in the past six months. The proportion of SMSM reporting UAI was 43.5% in Beijing, 43.8% in Tianjin, and 34.9% in Shijiazhuang. The mean age of participants was 20.07 years, with 59.7% in middle grade (sophomore or junior) and 91.8% identifying as homosexual. Approximately 65.2% of participants reported having two or more sexual partners in the past six months.
Univariate and multivariate logistic regression analyses identified several factors associated with increased odds of UAI. These included having sexual partners at least 10 years older (odds ratio [OR] = 2.277, 95% confidence interval [CI]: 1.380–3.756), using vacant capsules before sexual activity (OR = 3.858, 95% CI: 1.472–10.106), having a self-perceived moderate HIV risk (OR = 2.128, 95% CI: 1.403–3.227), and engaging in unprotected first anal intercourse (OR = 2.236, 95% CI: 1.506–3.320).
Discussion
This study provides valuable insights into the factors associated with UAI among SMSM in three northern regions of China. The findings highlight the need for targeted interventions to address these risk factors and reduce the prevalence of UAI in this population.
Age-Discordant Relationships
One of the key findings was the association between age-discordant relationships and increased odds of UAI. Approximately 18.2% of participants reported having anal intercourse with a partner at least 10 years older in the past six months. SMSM who had older sexual partners were 2.2 times more likely to engage in UAI compared to those who did not. This is consistent with previous studies that have shown that older partners are more likely to engage in UAI and may have a higher likelihood of being HIV-positive. Younger SMSM often lack the agency to negotiate condom use in these relationships, particularly when older partners provide emotional or material support. Interventions should focus on empowering younger SMSM to make informed decisions about condom use in age-discordant relationships.
Substance Use
Substance use before sexual activity was another significant factor associated with UAI. While less than 6% of participants reported using vacant capsules, those who did were nearly four times more likely to engage in UAI. Vacant capsules, which cause excitation and hallucinations, may impair judgment and reduce condom awareness during sexual activity. The neurotoxic effects of these substances also pose serious health risks, including insomnia, anxiety, and even death from acute heart failure. Efforts to reduce drug use among SMSM, particularly the use of vacant capsules, are essential for mitigating the risk of UAI.
Self-Perceived HIV Risk
Self-perceived HIV risk was also associated with UAI. Participants who perceived themselves to be at moderate risk of HIV infection were more than twice as likely to engage in UAI compared to those who perceived themselves to be at low risk. Interestingly, those who perceived themselves to be at high risk were not significantly more likely to engage in UAI. This suggests that moderate-risk individuals may recognize their risk but lack sufficient motivation to change their behavior. Strengthening risk awareness education and promoting consistent condom use, regardless of perceived risk, is crucial for reducing UAI among SMSM.
First Anal Intercourse
The characteristics of first anal intercourse were also a significant predictor of UAI. SMSM who did not use a condom or took it off during their first anal intercourse were 2.2 times more likely to engage in UAI in the past six months. This highlights the importance of early sexual education and the promotion of habitual condom use. Comprehensive sexual education programs that emphasize the importance of condom use from the first sexual encounter can help reduce risky sexual behaviors among SMSM.
Limitations
This study has several limitations. First, the use of a convenience sample may limit the generalizability of the findings. However, efforts were made to recruit a diverse set of participants from multiple cities and venues. Second, the factors assessed in this study were based on preliminary surveys and general MSM studies, which may have excluded other relevant factors. Third, the self-reported nature of the data may be subject to reporting bias, although the anonymity of the survey and the involvement of trusted NGOs likely mitigated this issue. Finally, the retrospective design of the study limits the ability to establish causal relationships between risk factors and UAI. Future prospective studies are needed to further explore these associations.
Conclusion
This study highlights the significant prevalence of UAI among SMSM in Beijing, Tianjin, and Shijiazhuang and identifies several key factors associated with this risky behavior. Age-discordant relationships, substance use, self-perceived HIV risk, and unprotected first anal intercourse were all found to increase the odds of UAI. Targeted interventions that address these factors, including empowering younger SMSM in relationships, reducing drug use, and improving HIV risk awareness, are essential for reducing the burden of risky sexual behaviors in this population. Comprehensive sexual education programs that promote consistent condom use from the first sexual encounter can also play a critical role in preventing HIV transmission among SMSM.
doi.org/10.1097/CM9.0000000000000311
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