These data suggest, first, that it is both possible and practical to conduct HIV/AIDS behavioural surveys in China through internet‐based questionnaires. The internet has been widely used to facilitate inter‐personal contacts in developed countries.2,6,20
It should not be surprising that this convenient mechanism for finding sex quickly makes the internet a new meeting ground for gay men in China that did not exist in the 1990s. The wide use of the gay websites among the Chinese MSM population provides a good opportunity to obtain a large number of participants across geographical and cultural boundaries. In this study, within a period of less than 4 months, nearly 2500 participants from all of the 31 provinces in China provided completed questionnaires.
The MSM gay website users in China appear to represent a young and well‐educated subpopulation with a certain number of students. Approximately 80% of the respondents are less than 30 years old, and more than 75% have a college education or higher. Our findings are consistent with the statistical results of the Chinese internet users conducted by the China internet Network Information Center in 2006, which found that 71.5% of Chinese internet users are less than 30 years old, and 52.8% of them have an education of college or higher.21
It is highly likely that young and well‐educated MSM possess more computer literacy or have more ready access to personal computers than the older population in China.22
This finding is consistent with the “early adopter” profile indicated by studies on new media adoptions in the USA, which indicate that adaptors of new technologies tend to be younger, upscale and better educated than non‐adopters.23
China is experiencing a rapid increase in the use of the internet with 137 million Chinese citizens regularly accessing the internet at least 1 h per week in 2006.21
However, the penetration of the internet in China is low, and the internet development is still at its early stage. Internet technology is more prevalent in large metropolitan areas. Lack of computer skills, low income and low level of education are still barriers to internet access. We found that nearly 40% of the participants access the internet mainly in internet cafes, which is not heavily used in developed countries. This may reflect the fact that some young MSM in China cannot afford to have a computer and internet access at home. The use of internet cafes, which is very cheap (US$0.4 per hour), becomes a good choice for them.
These findings highly indicate that at present internet MSM users in China may represent a group of MSM who are different from those recruited in the traditional gay venues. The online sample is significantly younger and more educated than some community samples in China.8,11,24,25
The current behavioural surveillance strategy among MSM in China, which utilises convenience sampling in traditional gay venues, is not reasonably representative and is affected by the selection bias. The internet may provide a good opportunity to gain access to those MSM who may not be able to be reached in a community setting.
The internet has become an emerging risk environment for HIV/AIDS transmission for the Chinese MSM population.26
The main findings from this study indicate that the online MSM population is highly vulnerable to HIV/AIDS given their low prevalence of consistent condom use and multiple high‐risk sexual behaviours. Over half of them had UAI in the past 6 months, and less than 16% consistently used a condom. Nearly 60% of them had multiple partners in the past 6 months. Seeking sex through the internet has become their main purpose to visit gay websites. The potential for instant interaction with many people in a relatively anonymous fashion enhances the use of the internet for sex‐seeking purposes.4
Effective intervention strategies targeted at increasing condom use and decreasing the number of sexual partners in this population are crucially needed. Studies have indicated that online MSM users showed favourable attitudes to online methods of promoting prevention of STI/HIV.27
In this study, more than one‐third of the respondents indicated that they were using the internet to look for health information. This may represent preventive and health intervention value from a public health perspective in an internet era.
Several studies conducted in Western countries have also indicated that men who sought sexual partners on the internet were more likely to have STD and to have unprotected anal intercourse,28
and thus were at higher risk for HIV than those who did not.4,5,6,7
A study conducted in Hong Kong also found that being an internet sex networker was associated with having contracted a sexually transmitted disease, having more than three sexual partners and having engaged in anal sex.22
Our study shows a gradual decrease in the risk for HIV transmission from the group of seeking sex both on the internet and in gay venues, to the group of internet only and next to the group of seeking sex in other ways.
MSM gay website users who seek sexual partners both in gay venues and on the internet carry the highest risk for HIV transmission and acquisition compared with the other two groups. They are more likely to have UAI and to have multiple and commercial sexual behaviours. It is not difficult to understand this, considering cruising in gay venues and searching on the internet are the most common ways for Chinese MSM to seek sexual partners.16
Thus, those included in these groups are likely to be at the higher end of the spectrum of risk behaviour and to have a high turnover of partners. This study showed nearly half of the online participants visited traditional gay venues, and about 40% of them seek sexual partners there, although 38% of the men reported being tired of cruising there. It indicates that traditional gay venues continually play an important role in the sex‐seeking process in China. Gay venues first emerged in the late 1990s in major cities of China, and then gradually found their way to other cities.16
These venues provide a platform for MSM to communicate and socialise, and also may enhance the transmission of HIV/AIDS. In recent years, free condoms, AIDS‐awareness posters and even safe‐sex‐themed dance/drama performances have been used as tools by owners of gay bars or bath houses to educate patrons about health education and prevention of HIV/AIDS.16
It is assumed that MSM living in Southwestern China (Yunnan, Guangxi, Sichuan, Xinjiang) where drug use is one of the primary reasons for the increasing number of people infected by HIV/AIDS, might be at higher risk for HIV through drug injection than MSM in other regions.29,30
This study, however, indicates that the prevalence of injecting drug use is very low among the MSM population across the country, and no regional difference has been detected. The low prevalence of injecting drug use indicates that currently male–male sex transmission may be still the main mode of HIV transmission among the online Chinese MSM population.
This online study was the first major survey exploring risk behaviours and use of the internet for sex‐seeking purpose among the Chinese MSM population. The sample reported here is obviously biased in that it is a convenience sample of gay website users.17
Although China is experiencing a rapid growth rate in the number of internet users, MSM living in rural areas or lacking basic computer skills would not be in this sample. Selection bias resulting from a convenience cross‐sectional design may limit the generalizability of the research findings. The results of this study therefore can be considered indicative and cannot be generalised to the population of all online MSM users. Data validity and quality is another pervasive challenge for almost all internet‐based surveys. It is very difficult to verify participants' identity and intention to participate and the validity of their responses. With few social and interviewers' constraints, a high rate of missing values emerged in this study. However, the perceived safe and anonymous nature of the internet may help to illicit more information on sensitive questions. Our study showed that some respondents provided very detailed and self‐disclosing information to several open‐ended questions.