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1.  Commercial sex and risk of HIV, syphilis, and herpes simplex virus-2 among men who have sex with men in six Chinese cities 
BMC Infectious Diseases  2016;16:765.
Background
Men who have sex with men (MSM) are at high risk of HIV and sexually transmitted infections (STIs) in China and globally. Engaging in commercial sex put them at even greater risk. This study estimated the prevalence of HIV/STIs among three subgroups of MSM: MSM who sold sex (MSM-selling), MSM who bought sex (MSM-buying), and non-commercial MSM (NC-MSM) and evaluated the relationship between commercial sex and HIV/STIs.
Methods
We conducted a cross-sectional survey among MSM in six Chinese cities (Shenyang, Ji’nan, Changsha, Zhengzhou, Nanjing, and Kunming) from 2012 to 2013. Data on socio-demographics and sexual behaviors were collected. Serological tests were conducted to detect HIV, syphilis, and human simplex virus type 2 (HSV-2).
Results
Of 3717 MSM, 6.8% were engaged in commercial sex. The overall prevalence of HIV, syphilis and HSV-2 infections was 11.1, 8.8 and 12.1%, respectively. MSM-selling had higher prevalence of HIV (13.4%), syphilis (12.1%) and HSV-2 (17.9%) than NC-MSM (10.9, 8.7 and 11.9% for HIV, syphilis and HSV-2, respectively), though the differences are not statistically significant. Among MSM-selling, HIV prevalence was significantly higher for those who found sex partners via Internet than those did not (19.4% vs. 8.1%, P = 0.04). Compared to NC-MSM, MSM-selling were more likely to use recreation drugs (59.3% vs. 26.3%), have unprotected anal intercourse (77.9% vs. 61.7%), and have ≥10 male sex partners (46.2% vs. 6.2%) in the past 6 months (each P < 0.05).
Conclusions
All three subgroups of MSM in six large Chinese cities have high prevalence of HIV/STIs. Those who sell sex only have a particularly high risk of acquiring and transmitting disease, and therefore, they should be considered as a priority group in HIV/STIs surveillance and intervention programs.
Electronic supplementary material
The online version of this article (doi:10.1186/s12879-016-2130-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12879-016-2130-x
PMCID: PMC5178086  PMID: 28003032
Men who have sex with men; Commercial sex; HIV; Sexually transmitted infection China
2.  Prevalence and risk factors of HIV and syphilis, and knowledge and risk behaviors related to HIV/AIDS among men who have sex with men in Chongqing, China 
Journal of Biomedical Research  2015;30(2):101-111.
Abstract
High HIV prevalence and incidence burdens have been reported in men who have sex with men (MSM) in Chongqing, China. We aimed to estimate the prevalence of HIV and other sexually transmitted infections (STIs), to appraise the knowledge and risk behaviors related to HIV/AIDS among MSM, and to analyze the possible causes of deviation between behavior and knowledge to make better strategies. We recruited 617 MSM from February to July in 2008 by using a respondent-driven sampling (RDS) method in Chongqing, China. Through the collection of questionnaire-based data and biological testing results from all objects, we launched a cross-sectional survey. STATA/SE was used for data analysis by frequency, ANOVA, rank sum test and logistic regression models. MSM with syphilis (OR=4.16, 95%CI: 2.35-7.33, P<0.0001) were more likely to be HIV infected. Being a company employee (OR=3.64, 95%CI: 1.22-10.08, P<0.0001) and having bought male for sex (OR=3.52, 95%CI: 1.10-11.32, P < 0.034) were associated with a higher probability of syphilis. MSM with younger age, higher education and greater monthly income had a higher mean knowledge score. MSM who had HIV testing had a higher mean knowledge score than those who never had. Students, venues for finding sex partners by Internet and homosexuals in MSM had a higher mean knowledge score compared to other occupations, venues for finding sex partners and sexual orientation. There is an urgent need for delivery of barrier and biomedical interventions with coordinated behavioral and structural strategies to improve the effect of HIV interventions among MSM.
doi:10.7555/JBR.30.20150057
PMCID: PMC4820887
HIV/AIDS; men who have sex with men; Chongqing; China
3.  Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis 
PLoS Medicine  2011;8(8):e1000444.
A systematic review by Laith Abu-Raddad and colleagues collates and analyzes the epidemiology of HIV among men who have sex with men in Middle Eastern and North African countries.
Background
Men who have sex with men (MSM) bear a disproportionately higher burden of HIV infection than the general population. MSM in the Middle East and North Africa (MENA) are a largely hidden population because of a prevailing stigma towards this type of sexual behavior, thereby limiting the ability to assess infection transmission patterns among them. It is widely perceived that data are virtually nonexistent on MSM and HIV in this region. The objective of this review was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA.
Methods and Findings
This was a systematic review of all biological, behavioral, and other related data on HIV and MSM in MENA. Sources of data included PubMed (Medline), international organizations' reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and various other institutional documents. This review showed that onsiderable data are available on MSM and HIV in MENA. While HIV prevalence continues at low levels among different MSM groups, HIV epidemics appear to be emerging in at least few countries, with a prevalence reaching up to 28% among certain MSM groups. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in several countries. The high levels of risk behavior (4–14 partners on average in the last six months among different MSM populations) and of biomarkers of risks (such as herpes simplex virus type 2 at 3%–54%), the overall low rate of consistent condom use (generally below 25%), the relative frequency of male sex work (20%–76%), and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread.
Conclusions
This systematic review and data synthesis indicate that HIV epidemics appear to be emerging among MSM in at least a few MENA countries and could already be in a concentrated state among several MSM groups. There is an urgent need to expand HIV surveillance and access to HIV testing, prevention, and treatment services in a rapidly narrowing window of opportunity to prevent the worst of HIV transmission among MSM in the Middle East and North Africa.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
AIDS first emerged in the early 1980s among gay men living in the US. But, as the disease rapidly spread, it became clear that AIDS also affects heterosexual men and women. Now three decades on, more than 30 million people are infected with HIV, the virus that causes AIDS. HIV is most often spread by having unprotected sex with an infected partner and, globally, most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM, a term that encompasses homosexual, bisexual, and transgender men, and heterosexual men who sometimes have sex with men). In some countries, male-to-male sexual contact remains the most important transmission route. Moreover, although the global prevalence of HIV infection (the proportion the world's population infected with HIV) has stabilized, the prevalence of HIV infection among MSM seems to be increasing in multiple countries and new and resurgent HIV epidemics among MSM populations are being frequently reported.
Why Was This Study Done?
In the US and the UK, the MSM population is visible and has helped to raise awareness about the risks of HIV transmission through male-to-male sexual contact. In many other countries, MSM are much less visible, fearing discrimination, stigmatization (being considered socially unacceptable) or arrest. In the Middle East and North Africa (MENA, a geographical region that encompasses countries that share historical, socio-cultural, linguistic and religious characteristics), MSM are the most hidden HIV risk group. Consequently, very little is known about HIV transmission patterns among MSM in MENA. Indeed, it is widely thought that there is virtually no information available on the epidemiology (causes, distribution, and control) of HIV among MSM in this region. In this systematic review and data synthesis, the researchers use predefined search criteria to identify all the published and unpublished data on the epidemiology of HIV among MSM in MENA and combine (synthesize) these data to produce a coherent picture of the HIV epidemic in this potentially key group of people for HIV transmission in this region.
What Did the Researchers Do and Find?
The researchers identified 26 articles and 51 other country-level reports and sources of data that included data on the prevalence of male-to-male sexual contact, HIV transmission, levels of high-risk behavior, and the extent of knowledge about HIV among MSM in MENA. The prevalence of HIV infection among MSM was low in most countries but high in others. For example, the infection rate in Pakistan was 27.6% among one MSM group. Importantly, there was some evidence of increasing HIV prevalence and emerging epidemics among MSM in the region. Thus, by 2008, MSM transmission was responsible for more than a quarter of notified cases of HIV in several countries. Worryingly, MSM were involved in several types of HIV-related high risk behavior. For example, they had, on average, between 4 and 14 sexual partners in the past six months, their rates of consistent condom use were generally below 25% and, in some countries, MSM frequently reported injecting drug use, another common mode of HIV transmission. In addition, 20%–75.5% of MSM exchanged sex for money and contact between MSM and female sex workers and other female sexual partners was often common. Finally, although the level of basic knowledge about HIV/AIDS was high, the level of comprehensive knowledge was limited with a high proportion of MSM perceiving their risk of contracting HIV as low.
What Do These Findings Mean?
These findings indicate that there is considerable and increasing data about HIV transmission and risk behavior among MSM in MENA. However, the quality of this evidence varies greatly. Little has been collected over time in individual populations and, because only the visible part of the MSM populations in many MENA countries has been sampled, these findings may not be representative of all MSM in this region. Nevertheless, these findings suggest that HIV epidemics are emerging among MSM in several MENA countries. Importantly, the high levels of risk behaviors practiced by many MSM in MENA mean that MSM could become the pivotal risk group for HIV transmission in this region in the next decade. There is, therefore, an urgent need to expand HIV surveillance and access to HIV testing, prevention and treatment services among MSM in this region to limit the size of the HIV epidemic.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000444.
Information about the status of the HIV epidemic in the Middle East and North Africa can be found in the World Bank/UNAIDS/WHO report Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: Time for strategic action
Information about the global HIV epidemic among men who have sex with men can be found in the World Bank report The Global HIV Epidemics among Men Who Have Sex with Men
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including information on HIV transmission and transmission in gay men and other MSM and on safer sex
Information is available from Avert, an international AIDS charity, on all aspects of HIV/AIDS, including information on HIV, AIDS and men who have sex with men and on HIV and AIDS prevention (in English and Spanish)
The US Centers for Disease Control and Prevention also have information about HIV/AIDS among men who have sex with men (in English and Spanish)
doi:10.1371/journal.pmed.1000444
PMCID: PMC3149074  PMID: 21829329
4.  An Intervention to Reduce HIV Risk Behavior of Substance-Using Men Who Have Sex with Men: A Two-Group Randomized Trial with a Nonrandomized Third Group 
PLoS Medicine  2010;7(8):e1000329.
In a randomized trial of a behavioral intervention among substance-using men who have sex with men, aimed at reducing sexual risk behavior, Mansergh and colleagues fail to find evidence of a reduction in risk from the intervention.
Background
Substance use during sex is associated with sexual risk behavior among men who have sex with men (MSM), and MSM continue to be the group at highest risk for incident HIV in the United States. The objective of this study is to test the efficacy of a group-based, cognitive-behavioral intervention to reduce risk behavior of substance-using MSM, compared to a randomized attention-control group and a nonrandomized standard HIV-testing group.
Methods and Findings
Participants (n = 1,686) were enrolled in Chicago, Los Angeles, New York City, and San Francisco and randomized to a cognitive-behavioral intervention or attention-control comparison. The nonrandomized group received standard HIV counseling and testing. Intervention group participants received six 2-h group sessions focused on reducing substance use and sexual risk behavior. Attention-control group participants received six 2-h group sessions of videos and discussion of MSM community issues unrelated to substance use, sexual risk, and HIV/AIDS. All three groups received HIV counseling and testing at baseline. The sample reported high-risk behavior during the past 3 mo prior to their baseline visit: 67% reported unprotected anal sex, and 77% reported substance use during their most recent anal sex encounter with a nonprimary partner. The three groups significantly (p<0.05) reduced risk behavior (e.g., unprotected anal sex reduced by 32% at 12-mo follow-up), but were not different (p>0.05) from each other at 3-, 6-, and 12-mo follow-up. Outcomes for the 2-arm comparisons were not significantly different at 12-mo follow-up (e.g., unprotected anal sex, odds ratio = 1.14, confidence interval = 0.86–1.51), nor at earlier time points. Similar results were found for each outcome variable in both 2- and 3-arm comparisons.
Conclusions
These results for reducing sexual risk behavior of substance-using MSM are consistent with results of intervention trials for other populations, which collectively suggest critical challenges for the field of HIV behavioral interventions. Several mechanisms may contribute to statistically indistinguishable reductions in risk outcomes by trial group. More explicit debate is needed in the behavioral intervention field about appropriate scientific designs and methods. As HIV prevention increasingly competes for behavior-change attention alongside other “chronic” diseases and mental health issues, new approaches may better resonate with at-risk groups.
Trial Registration
ClinicalTrials.gov NCT00153361
Please see later in the article for the Editors' Summary
Editors' Summary
Background
AIDS first emerged in the early 1980s among gay men living in the US. As the disease spread around the world, it became clear that AIDS also affects heterosexual men and women. Now, three decades on, more than 30 million people are infected with HIV, the virus that causes AIDS. HIV is most often spread by having unprotected sex with an infected partner and, globally, most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM, a term that encompasses gay, bisexual, transgendered, and heterosexual men who sometimes have sex with men) and, in several high-income countries, male-to-male sexual contact remains the most important HIV transmission route. In the US, for example, more than half of the approximately 50,000 people who become infected with HIV every year do so through male-to-male sexual contact.
Why Was This Study Done?
In countries where MSM are the group at highest risk of HIV infection, any intervention that reduces HIV transmission in MSM should have a major effect on the overall HIV infection rate. Among MSM, sexual behaviors that increase the risk of HIV infection (for example, not using a condom, having anal sex, having sex with a partner of unknown HIV status, and having sex with many partners) are associated with the use of alcohol and noninjection drugs (for example, inhaled amyl nitrite or poppers) during or shortly before sexual encounters. In this study (Project MIX), the researchers investigate whether a group-based behavioral intervention reduces sexual risk behavior in substance-using MSM.
What Did the Researchers Do and Find?
The researchers recruited substance-using MSM from four US cities who had had risky sex at least once in the past 6 months. Participants were randomized to a cognitive-behavioral intervention or to an attention-control group; a third, nonrandomized group of MSM formed a standard HIV counseling and testing only group. All the groups had HIV counseling and testing at the start of the study and completed a questionnaire about their substance use and sexual risk behavior during their most recent anal sex encounter. The cognitive-behavior group then received six weekly 2-hour group sessions focused on reducing substance use and sexual risk behavior by helping the men change their thinking (cognition) and behavior regarding sexual risk taking. The attention-control group received six group sessions about general MSM issues such as relationships, excluding discussion of substance use, and sexual risk behavior. The participants in both of these groups completed the questionnaire about their substance use and sexual risk behavior again at 3, 6, and 12 months after the group sessions; the participants in the standard HIV counseling and testing group completed the questionnaire again about 5 months after completing the first questionnaire (to control for the time taken by the other two groups to complete the intervention). At baseline, about 67% of the participants reported unprotected anal sex and 77% reported substance use during their most recent anal sex encounter with a nonprimary partner. At the 3-month follow-up, the incidence of sexual risk behavior had fallen to about 43% in all three groups; the incidence of substance use during sex had fallen to about 50%. Risk taking and substance use remained at these levels in the intervention and attention-control groups at the later follow-up time points.
What Do These Findings Mean?
These findings suggest that this cognitive-behavioral intervention is no better at reducing sexual risk taking among substance-using MSM than is an unrelated video-discussion group or standard HIV counseling and testing. One explanation for this negative result might be that brief counseling is especially effective with people who are ready for a change such as MSM willing to enroll in an intervention trial of this type. Alternatively, just being in the trial might have encouraged all the participants to self-report reduced risk behavior. Thus, alternative scientific designs and methods might be needed to find behavioral interventions that can effectively reduce HIV transmission among substance-using MSM and other people at high risk of HIV infection. Importantly, however, these findings raise the question of whether more extensive, multilevel interventions or broader lifestyle and positive health approaches (rather than single-level or single-subject behavioral interventions) might be needed to reduce sexual risk behavior among substance-using MSM.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000329.
Information is available from the US Department of Health and Human Services on HIV prevention programs, research, and policy
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including information on HIV transmission and transmission in gay men and other MSM, on substance abuse and HIV/AIDS, and on safer sex
Information is available from Avert, an international AIDS nonprofit, on all aspects of HIV/AIDS, including information on HIV, AIDS, and men who have sex with men and on drink, drugs, and sex (in English and Spanish)
The US Centers for Disease Control and Prevention also have information for the public and for professionals about HIV/AIDS among men who have sex with men (in English and Spanish)
The US National Institute on Drug Abuse has information on HIV/AIDS and drug abuse, including a resource aimed at educating teenagers about the link between drug abuse and the spread of HIV in the US (in English and Spanish)
doi:10.1371/journal.pmed.1000329
PMCID: PMC2927550  PMID: 20811491
5.  HIV and Syphilis Prevalence Among Men Who Have Sex With Men: A Cross-Sectional Survey of 61 Cities in China 
The prevalence of human immunodeficiency virus and syphilis among men who have sex with men in China is high, yet the 2 epidemics are largely geographically separate. Characteristics of the overall population surveyed as well as segments within this population are described.
Background. Human immunodeficiency virus (HIV) has rapidly spread among men who have sex with men (MSM) in China in recent years; the magnitude of the epidemic is unclear. We sought to test 3 hypotheses: (1) The prevalence of both HIV and syphilis among MSM in China is high, (2) the 2 epidemics each have unique geographical distributions, and (3) demographic and sexual behavior characteristics are different among segments of the MSM population in China.
Methods. A total of 47 231 MSM from 61 cities in China participated in a cross-sectional survey conducted from February 2008 to September 2009. Demographic and behavioral data were collected and analyzed and blood samples tested for HIV and syphilis. Three subgroups among the broader MSM sample were described. Main outcome measures were HIV and syphilis prevalence.
Results. An overall prevalence of 4.9% (2314/47 231; 95% confidence interval [CI], 4.7%–5.1%) for HIV and 11.8% (5552/47 231; 95% CI, 11.5%–12.0%) for syphilis was found. Syphilis-positive MSM had the highest HIV prevalence, 12.5% (693/5552; 95% CI, 11.6%–13.4%). However, correlations between HIV and syphilis prevalence were found in only 3 of 6 geographical regions (Northwest: r = 0.82, P = .0253; East: r = 0.78, P = .0004; and South-central: r = 0.63, P = .0276). Three subgroups—nonlocal MSM, Internet-using MSM, and female-partnering MSM—were found to have different profiles of characteristics and behaviors.
Conclusions. HIV and syphilis prevalences among MSM in China are high and the 2 epidemics are largely separate geographically. Three segments of the Chinese MSM population each have different demographic and sexual risk “profiles” that suggest high potential for bridging infection across geographies, generations, and sexes.
doi:10.1093/cid/cit210
PMCID: PMC3689345  PMID: 23580732
HIV; syphilis; MSM; China
6.  Correlates of Incident Infections for HIV, Syphilis, and Hepatitis B Virus in A Cohort of Men Who Have Sex with Men in Beijing 
AIDS Patient Care and STDs  2010;24(9):595-602.
Abstract
Recent data suggest that the prevalence of HIV/syphilis infections among men who have sex with men (MSM) in China increased rapidly. This cohort study was to assess the correlates of the incident infections for HIV, syphilis, and hepatitis B virus (HBV) among sexually active and HIV–negative MSM in China. A cohort of 507 HIV-seronegative MSM was recruited from November 2006 to February 2007. Sociodemographics, sexual and drug use behaviors, uptake of HIV-prevention services, and HIV, syphilis, and HBV seroconversions were assessed at 6- and 12- month follow-up. The incidence rates were 2.6 per 100 person-years for HIV, 16.9 per 100 person-years for syphilis, and 3.3 per 100 person-years for HBV. Multivariate Cox regression analyses showed that syphilis infection (hazard ratio [HR] = 3.6; 95% confidence interval [CI]: 1.1–11.6) and no perceived risk of HIV infection (HR = 6.0; 95% CI: 1.6–22.7) were independently associated with HIV seroconversion. Predictors for syphilis seroconversion included less education (HR = 1.87; 95% CI: 1.1–3.3), found male sex partners through bathhouses/public washrooms/parks (HR = 2.19; 95% CI: 1.2–4.0), drank alcohol 4 or more times monthly (HR = 1.95; 95% CI: 1.1–3.6), and had sexually transmitted diseases (HR = 2.65; 95% CI: 1.5–4.5). The only predictor for incident HBV seroconvension was having more male sex partners in the past 3 months (HR = 11.8; 95% CI: 1.5–90.4). Alarmingly high incidence rates of HIV, syphilis, and HBV were found among MSM concurrently with high prevalent risky behaviors and low uptakes of health care services. The findings of this study underscore the urgent needs for a comprehensive intervention strategy to curtail the rapid spread of HIV, syphilis, and HBV.
doi:10.1089/apc.2010.0083
PMCID: PMC2957630  PMID: 20731610
7.  HIV and syphilis prevalence trends among men who have sex with men in Guangxi, China: yearly cross-sectional surveys, 2008–2012 
BMC Infectious Diseases  2014;14:367.
Background
Men who have sex with men (MSM) represent the fastest growing key population for incident HIV cases in China. We examined five consecutive years of HIV and syphilis prevalence and risk factors data among MSM in Guangxi Province with the second highest estimated number of people living with HIV/AIDS (PLWHAs) in China in 2011.
Methods
We collected demographic and behavioral data from national sentinel surveillance and HIV/syphilis blood samples in five annual cross-sectional surveys from 2008 to 2012. We analyzed HIV and syphilis prevalence trends stratified by social/behavioral characteristics.
Results
HIV prevalence climbed steadily from 1.7% (95% confidence interval [CI]: 1.0 to 3.0) in 2008 to 3.7% (95% CI: 3.0 to 5.0) in 2012. Syphilis prevalence increased steadily from 5.1% (95% CI: 4.0 to 6.0) in 2008 to 8.4% (95% CI: 7.0 to 10.0) in 2012. HIV prevalence rose notably among MSM who were ≤25 years of age, never married, did not engage in sexual intercourse with women in the past six months, and had not been tested for HIV in the past year. Syphilis prevalence rose notably among MSM who were >25 years of age, ever married or living with a partner, and engaged in sexual intercourse with women in the past six months. HIV prevalence was much higher in MSM with current syphilis than without. Finally, current syphilis was the most significant predictor of HIV infection, and age was the most significant predictor of syphilis infection.
Conclusions
HIV and the syphilis prevalence expansion among MSM suggest an urgent public health prevention challenge for Guangxi provincial health officials. Risk factors for each infection differed such that all MSM, each of whom might be at risk of HIV, syphilis or both, should be targets for heavy intervention.
doi:10.1186/1471-2334-14-367
PMCID: PMC4091643  PMID: 24993252
HIV; Syphilis; Prevalence trends; MSM; China; Guangxi Province
8.  A cross-sectional study of HIV and syphilis infections among male students who have sex with men (MSM) in northeast China: implications for implementing HIV screening and intervention programs 
BMC Public Health  2011;11:287.
Background
China has 76.2 million high school and college students, in which the number of reported HIV/AIDS cases is increasing rapidly. Most of these cases are attributed to male-to-male sexual contact. Few studies have explored HIV prevalence and behavioural characteristics of Chinese male students who have sex with men (MSM).
Methods
A cross-sectional study of MSM high school and college students in Liaoning Province was conducted. Data were collected through face-to-face interviews and blood specimens were obtained and tested for HIV and syphilis.
Results
There were 436 eligible participants. HIV and syphilis prevalence was 3.0% and 5.0%, respectively. In multivariate analysis, sexual orientation known by family members (OR: 7.3; 95% CI: 1.5-34.6), HIV/AIDS information obtained from clinical doctors (OR: 6.7; 95% CI: 1.7-25.9), HIV/AIDS information obtained through free educational services and materials such as voluntary counseling and testing (VCT) and condom distribution services (OR: 0.2; 95% CI: 0.4-1.0), inconsistent condom use (OR: 5.7; 95%: 1.3-25.3), sexual partner experienced anal bleeding after insertive anal intercourse (OR: 6.8; 95% CI: 1.6-28.4), and history of illegal drug use (OR: 18.9; 95% CI: 2.2-165.3) were found to be significantly associated with HIV infection.
Conclusions
Greater effort should be made towards stemming the HIV and syphilis epidemics among Chinese student MSM. Immediate screening and comprehensive interventions towards student MSM should be implemented in order to curb the spread of HIV. Family and school-based interventions should be considered to target this educated, yet vulnerable, population.
doi:10.1186/1471-2458-11-287
PMCID: PMC3112122  PMID: 21554742
HIV; syphilis; China; men who have sex with men (MSM); high school students; college students
9.  The Epidemic of HIV, Syphilis, Chlamydia and Gonorrhea and the Correlates of Sexual Transmitted Infections among Men Who Have Sex with Men in Jiangsu, China, 2009 
PLoS ONE  2015;10(3):e0118863.
Background
In China, the HIV/AIDS epidemic is expanding among men who have sex with men (MSM). As independent risk factors of HIV infection, the epidemics of Chlamydia (CT) and Gonorrhea (NG) in MSM were not well studied, particular for the risk factors of these infectious. The objectives of current reported study were to understand the dynamics of HIV and other sexual transmitted infections (STIs) among MSM in Jiangsu, China, and to measure factors that correlated with STIs.
Methods
In order to gain more participants, a multisite cross-sectional study design was used in our study, by using convenience-sampling to recruit MSM in two Changzhou and Yangzhou, Jiangsu, China, between the July and October of 2009.
Results
In this comprehensive survey involving MSM in two cities of Jiangsu province of China, the prevalence of STIs of CT (6.54%), NG (3.63%), syphilis (20.34%) and HIV (11.62%) were measured. Overall, the STIs prevalence (CT, NG or syphilis) for the participants in our study was 26.39%, meanwhile, 3.4% (14 out of the 413) participants had at least two kinds of STIs. Meeting casual partners at parks, public restrooms or other public areas, having had anal sex with men in the past six months, having had STI symptoms in the past year were positively correlated with STIs positive, with adjusted ORs of 4.61(95%CI 1.03–20.75), 1.91(95%CI 1.14–3.21) and 2.36(95%CI 1.07,5.24).
Conclusion
Our study findings reiterate the fact that Chinese MSM are highly susceptible to acquiring syphilis, CT, NG and HIV, and there is an urgent need for intervention targeted towards this population. Behavioral measures should constitute an important part of the targeted intervention. Furthermore, the already implemented preventive and diagnostic services for HIV should be expanded to include syphilis CT and NG, too.
doi:10.1371/journal.pone.0118863
PMCID: PMC4361608  PMID: 25775451
10.  Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000–2006: A Systematic Review 
PLoS Medicine  2007;4(12):e339.
Background
Recent reports of high HIV infection rates among men who have sex with men (MSM) from Asia, Africa, Latin America, and the former Soviet Union (FSU) suggest high levels of HIV transmission among MSM in low- and middle-income countries. To investigate the global epidemic of HIV among MSM and the relationship of MSM outbreaks to general populations, we conducted a comprehensive review of HIV studies among MSM in low- and middle-income countries and performed a meta-analysis of reported MSM and reproductive-age adult HIV prevalence data.
Methods and Findings
A comprehensive review of the literature was conducted using systematic methodology. Data regarding HIV prevalence and total sample size was sequestered from each of the studies that met inclusion criteria and aggregate values for each country were calculated. Pooled odds ratio (OR) estimates were stratified by factors including HIV prevalence of the country, Joint United Nations Programme on HIV/AIDS (UNAIDS)–classified level of HIV epidemic, geographic region, and whether or not injection drug users (IDUs) played a significant role in given epidemic. Pooled ORs were stratified by prevalence level; very low-prevalence countries had an overall MSM OR of 58.4 (95% CI 56.3–60.6); low-prevalence countries, 14.4 (95% CI 13.8–14.9); and medium- to high-prevalence countries, 9.6 (95% CI 9.0–10.2). Significant differences in ORs for HIV infection among MSM in were seen when comparing low- and middle-income countries; low-income countries had an OR of 7.8 (95% CI 7.2–8.4), whereas middle-income countries had an OR of 23.4 (95% CI 22.8–24.0). Stratifying the pooled ORs by whether the country had a substantial component of IDU spread resulted in an OR of 12.8 (95% CI 12.3–13.4) in countries where IDU transmission was prevalent, and 24.4 (95% CI 23.7–25.2) where it was not. By region, the OR for MSM in the Americas was 33.3 (95% CI 32.3–34.2); 18.7 (95% CI 17.7–19.7) for Asia; 3.8 (95% CI 3.3–4.3) for Africa; and 1.3 (95% CI 1.1–1.6) for the low- and middle-income countries of Europe.
Conclusions
MSM have a markedly greater risk of being infected with HIV compared with general population samples from low- and middle-income countries in the Americas, Asia, and Africa. ORs for HIV infection in MSM are elevated across prevalence levels by country and decrease as general population prevalence increases, but remain 9-fold higher in medium–high prevalence settings. MSM from low- and middle-income countries are in urgent need of prevention and care, and appear to be both understudied and underserved.
From a systematic review, Chris Beyrer and colleagues conclude that men who have sex with men in the Americas, Asia, and Africa have a markedly greater risk of being HIV-infected than does the general population.
Editors' Summary
Background.
AIDS (acquired immunodeficiency syndrome) first emerged in the early 1980s among gay men living in New York and California. But, as the disease rapidly spread around the world, it became clear that AIDS also affected heterosexual men and women. Now, a quarter of a century later, 40 million people are infected with human immunodeficiency virus (HIV), the organism that causes AIDS. HIV is most often spread by having unprotected sex with an infected partner and in sub-Saharan Africa, the region most badly hit by HIV/AIDS, heterosexual transmission predominates. However, globally, 5%–10% of all HIV infections are thought to be in men who have sex with men (MSM, a term that encompasses gay, bisexual, transgendered, and heterosexual men who sometimes have sex with men), and in several high-income countries, including the US, male-to-male sexual contact remains the most important HIV transmission route.
Why Was This Study Done?
In the US, the MSM population is visible and there is considerable awareness about the risks of HIV transmission associated with sex between men. In many other countries, MSM are much less visible. They remain invisible because they fear discrimination, stigmatization (being considered socially unacceptable), or arrest—sex between men is illegal in 85 countries. Consequently, MSM are often under-represented in HIV surveillance systems and in prevention and care programs. If the AIDS epidemic is going to be halted, much more needs to be known about HIV prevalence (the proportion of the population that is infected) among MSM. In this study, the researchers have done a systematic review (a type of research where the results of existing studies are brought together) on published reports of HIV prevalence among MSM in low- and middle-income countries to get a better picture of the global epidemic of HIV in this population.
What Did the Researchers Do and Find?
The researchers found 83 published studies that reported HIV prevalence in 38 low- and middle-income countries in Asia, Africa, the Americas, and Eastern Europe. When the results were pooled—in what statisticians call a meta-analysis—MSM were found to have a 19.3-times greater chance of being infected with HIV than the general population. This is described as a pooled odds ratio (OR) of 19.3. The researchers also did several subgroup analyses where they asked whether factors such as injection drug use (another risk factor for HIV transmission), per capita income, geographical region, or the HIV prevalence in the general population were associated with differential risk (increase in odds) of HIV infection compared to the general population. They found, for example, that in countries where the prevalence of HIV in the general population was very low (less than 1 adult in 1,000 infected) the pooled OR for MSM compared to the general population was 58.4; where it was high (more than 1 adult in 20 infected), the pooled OR for MSM was 9.6.
What Do These Findings Mean?
These findings indicate that MSM living in low- to middle-income countries have a greater risk of HIV infection than the general populations of these countries. The subgroup analyses indicate that the high HIV prevalence among MSM is not limited to any one region or income level or to countries with any specific HIV prevalence or injection drug use level. Although the small number and design of the studies included in the meta-analysis may affect the numerical accuracy of these findings, the clear trend toward a higher HIV prevalence of among MSM suggests that HIV surveillance efforts should be expanded to include MSM in those countries where they are currently ignored. Efforts should also be made to include MSM in HIV prevention programs and to improve the efficacy of these programs by investigating the cultural, behavioral, social, and public policy factors that underlie the high HIV prevalence among MSM. By increasing surveillance, research, and prevention among MSM in low- to middle-income countries, it should be possible to curb HIV transmission in this marginalized population and reduce the global burden of HIV.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040339.
The International Lesbian and Gay Association provides a world legal map on legislation affecting lesbian, gay, bisexual, and transgendered people
The International Gay and Lesbian Human Rights Commission provides a page called Off the Map: How HIV/AIDS Programming is Failing Same-Sex Practicing People in Africa
The American Foundation for AIDS Research (amfAR) has launched their MSM initiative, which is focused on providing support to front-line community groups working on providing services and doing research focused on HIV among MSM in lower income-settings
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including a list of organizations that provide information for gay men and MSM
Information is available from Avert, an international AIDS charity, on HIV, AIDS, and men who have sex with men
The US Centers for Disease Control and Prevention provides information on HIV/AIDS and on HIV/AIDS among men who have sex with men (in English and Spanish)
doi:10.1371/journal.pmed.0040339
PMCID: PMC2100144  PMID: 18052602
11.  Prevalence of Consensual Male–Male Sex and Sexual Violence, and Associations with HIV in South Africa: A Population-Based Cross-Sectional Study 
PLoS Medicine  2013;10(6):e1001472.
Using a method that offered complete privacy to participants, Rachel Jewkes and colleagues conducted a survey among South African men about their lifetime same-sex experiences.
Please see later in the article for the Editors' Summary
Background
In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus.
Methods and Findings
In a cross-sectional study conducted in 2008, men aged 18–49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (n = 92) of participants reported a lifetime history of any consensual sexual activity with another man; 9.6% (n = 164) reported any sexual victimization by a man, and 3.0% (n = 51) reported perpetrating sexual violence against another man. 85.0% (n = 79) of men with a history of consensual sex with men reported having a current female partner, and 27.7% (n = 26) reported having a current male partner. Of the latter, 80.6% (n = 21/26) also reported having a female partner. Men reporting a history of consensual male–male sexual behavior are more likely to have been a victim of male-on-male sexual violence (adjusted odds ratio [aOR] = 7.24; 95% CI 4.26–12.3), and to have perpetrated sexual violence against another man (aOR = 3.10; 95% CI 1.22–7.90). Men reporting consensual oral/anal sex with a man were more likely to be HIV+ than men with no such history (aOR = 3.11; 95% CI 1.24–7.80). Men who had raped a man were more likely to be HIV+ than non-perpetrators (aOR = 3.58; 95% CI 1.17–10.9).
Conclusions
In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
AIDS first emerged in the early 1980s among gay men living in the US, but it soon became clear that AIDS also infects heterosexual men and women. Now, three decades on, globally, 34 million people (two-thirds of whom live in sub-Saharan Africa and half of whom are women) are infected with HIV, the virus that causes AIDS, and 2.5 million people become infected every year. HIV is most often spread by having unprotected sex with an infected partner, and most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM; homosexual, bisexual, and transgender men, and heterosexual men who sometimes have consensual sex with men). Moreover, in the concentrated HIV epidemics of high-income countries (epidemics in which the prevalence of HIV infection is more than 5% in at-risk populations such as sex workers but less than 1% in the general population), male-to-male sexual contact remains the most important transmission route, and MSM often have a higher prevalence of HIV infection than heterosexual men.
Why Was This Study Done?
By contrast to high-income countries, HIV epidemics in sub-Saharan Africa are generalized—the prevalence of HIV infection is 1% or more in the general population. Because male-to-male sexual behavior is criminalized in many African countries and because homosexuality is widely stigmatized, little is known about the prevalence of consensual male–male sexual behavior in sub-Saharan Africa. This information and a better understanding of male–female sexual concurrency (having overlapping sexual relationships with men and women) and of how male-to-male transmission contributes to generalized HIV epidemics is needed to inform the design of HIV prevention strategies for use in sub-Saharan Africa. In addition, very little is known about male-on-male sexual violence. Such violence is potentially important to study because we know that male-on-female violence is associated with increased HIV risk for both victims and perpetrators. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers use data from a population-based household survey to investigate the lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) among men in South Africa and the association of these experiences with HIV infection.
What Did the Researchers Do and Find?
About 1,700 adult men from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces of South Africa self-completed a survey that included questions about their lifetime history of same-sex experiences using audio-enhanced personal digital assistants, a data collection method that provided a totally private and anonymous environment for the disclosure of illegal and stigmatized behavior; 1,220 of them also provided dried blood spots for HIV testing. Ninety-two men (5.4% of the participants) reported consensual sexual activity (for example, anal or oral sex) with another man at some time during their life; 9.6% of the men reported that they had been forced to have sex with another man (sexual victimization), and 3% reported that they had perpetrated sexual violence against another man. Most of the men who reported consensual sex with men, including those with current male partners, reported that they had a current female partner. Men with a history of consensual male–male sexual behavior were more likely to have been a victim or perpetrator of male-on-male sexual violence than men without a history of such experiences. Finally, men who reported consensual oral or anal sex with a man were more likely to be HIV+ than men without such a history, and perpetrators of male-on-male sexual violence were more likely to be HIV+ than non-perpetrators.
What Do These Findings Mean?
These findings provide new information about male–male sexual behaviors, male-on-male sexual violence, male–female concurrency, and HIV prevalence among men in two South African provinces. The precision of these findings is likely to be affected by the small numbers of men reporting a history of consensual male–male sexual behavior and of male-on-male sexual violence. Importantly, because the study was cross-sectional, these findings cannot indicate whether the association between consensual male–male sexual behaviors and increased risk of male-on-male sexual violence is causal. Moreover, these findings may not be generalizable to other regions of South Africa or to other African countries. Nevertheless, these findings suggest that information about the risks of male–male sexual behaviors should be included in HIV prevention strategies targeted at the general population in South Africa and that HIV prevention interventions for South African men should explicitly address male-on-male sexual violence. Similar HIV prevention strategies may also be suitable for other African countries, but are likely to succeed only in countries that have, like South Africa, decriminalized consensual homosexual behavior.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001472.
This study is further discussed in a PLOS Medicine Perspective by Jerome Singh
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, including summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and men who have sex with men, on HIV prevention, and on AIDS in Africa (in English and Spanish)
The US Centers for Disease Control and Prevention also has information about HIV/AIDS among men who have sex with men (in English and Spanish)
Patient stories about living with HIV/AIDS are available through Avert; the charity website Healthtalkonline also provides personal stories about living with HIV
doi:10.1371/journal.pmed.1001472
PMCID: PMC3708702  PMID: 23853554
12.  Increasing HIV and Decreasing Syphilis Prevalence in a Context of Persistently High Unprotected Anal Intercourse, Six Consecutive Annual Surveys among Men Who Have Sex with Men in Guangzhou, China, 2008 to 2013 
PLoS ONE  2014;9(7):e103136.
Introduction
Previous studies have reported a possibly increasing HIV prevalence among men who have sex with men (MSM) in China. However there have been limited systematic analyses of existing surveillance data to learn the trend of HIV prevalence and factors driving the trend. The aims of this study were to examine the trend of HIV prevalence among MSM in Guangzhou and to explore the role of unprotected anal intercourse (UAI) in the trend.
Methods
Snow-ball sampling was applied in the subject recruitment for the annual serological and behavioral surveys among MSM from 2008 to 2013. Data collected in the behavioral survey include demographic information, HIV related sexual behavior with men and women, access to HIV prevention services, and symptoms of sexually transmitted infections. Chi-square test was used to analyze the trend of HIV prevalence. Multivariate logistic regression was conducted to test the factors associated with HIV infection.
Results
HIV prevalence increased significantly from 5.0% in 2008 to 11.4% in 2013 while syphilis prevalence decreased from 17.4% to 3.3% in the same period. UAI rates were high and stable in every single year, ranging from 54.5% to 62.0%. Those who were having UAI (OR = 1.80, 95% confidence interval (CI): 1.26–2.58), being migrants, having more than 10 partners, and infected with syphilis had higher risk for HIV infection.
Conclusions
HIV epidemic is expanding in Guangzhou. The persistently high UAI may have played a major role in the increasing trend of HIV prevalence. Targeted prevention program should be conducted among MSM who are migrants, low educational level, syphilis infected, or having multiple partners to encourage HIV test and change UAI behavior. The general high UAI calls for tailored intervention program to promote healthy culture and form a safe sex social norm in the MSM community.
doi:10.1371/journal.pone.0103136
PMCID: PMC4111575  PMID: 25061936
13.  Burden of HIV and Syphilis: A Comparative Evaluation between Male Sex Workers and Non-Sex-Worker Men Who Have Sex with Men in Urban China 
PLoS ONE  2015;10(5):e0126604.
Background
The increasing burden of sexually transmitted infections (STIs) including HIV and syphilis among male sex workers (MSWs) is a major global concern. The aim of our study was to evaluate the difference between MSWs and non-commercial MSMs in China.
Methods
During 2008-09, in a cross-sectional study, 2618 adult MSM were recruited through respondent-driven and snowball sampling from seven cities of China. Information regarding socio-demographics, risk behaviors, HIV-related knowledge and STI-related symptoms were collected and participants were tested for HIV and syphilis.
Results
Among 2618 participating MSM, 9.97% sold sex to males. HIV prevalence was 7.45% (6.13% among MSWs and 7.59% among non-MSW MSM) and syphilis prevalence was 14.32% (10.73% for MSWs and 14.72% for non-MSW MSM). Compared to non-MSW MSM, MSWs were more likely to be younger (adjusted odds ratio: aOR = 0.91, 95% confidence interval: 95%CI=0.88-0.93), never married (aOR = 4.38, 95% CI = 2.38-6.80), less educated, heterosexual (aOR = 13.04, 95% CI = 6.08-27.95), less knowledgeable regarding HIV (aOR = 0.70, 95% CI=0.51-0.96), experiencing symptoms of STI (aOR = 2.16, 95% CI = 1.47-3.19), engaging in condomless vaginal intercourse (aOR = 2.16, 95% CI = 1.47-3.19) and less likely to engage in condomless anal intercourse (aOR = 0.62, 95% CI = 0.46-0.85).
Conclusions
High HIV and syphilis prevalence warranted urgent intervention targeting MSWs as a separate sentinel group for efficient surveillance owing to their different distribution from non-MSW MSM. Although male sex workers and non-commercial homosexuals have similar rates of HIV and syphilis, MSWs have different characteristics which should be considered in designing intervention programs targeting them.
doi:10.1371/journal.pone.0126604
PMCID: PMC4427281  PMID: 25961721
14.  The characterisation of sexual behaviour in Chinese male university students who have sex with other men: A cross-sectional study 
BMC Public Health  2008;8:250.
Background
The risks for Chinese male university students who have sex with other men (MSM) have not been compared with those for non-MSM students. This information is important for the development of targeted HIV prevention programmes for this population.
Methods
Sexually active MSM and non-MSM students were compared for demographic characteristics, sexual behaviour, and related psychosocial variables using bivariate analyses. The data were a subset drawn from a large-scale cross-sectional questionnaire survey of sexually active male students conducted at two universities in a large city in Zhejiang Province, China, in 2003.
Results
Of 1824 sexually active male students, 68 (3.7%) reported having had sex with a man at least once; 33.8% of these 68 men had also had female partners. Compared with non-MSM students, MSM students were 3–6.5 times more likely to have had sexual encounters with casual or commercial sex partners and were three times less likely to have protected sex in the past year or during their lifetime. They were three to five times more likely to have had multiple partners and 15 times more likely to have had a sexually transmitted disease (STD). In addition, the MSM students knew half as much about HIV and had less condom-decision than did non-MSM students and were two times more accepting of commercial sex. However, the MSM students were twice as aware of the risks for HIV infection.
Conclusion
MSM composed 3–4% of the male sexually active university student population studied and was found to be at greater risk than non-MSM students for STD/HIV infection. There is an urgent need for STD/HIV programmes in university health services that take into consideration the sexuality and psychosocial issues of MSM students.
doi:10.1186/1471-2458-8-250
PMCID: PMC2503976  PMID: 18647381
15.  Risk factors associated with prevalent and incident syphilis among an HIV-infected cohort in Northeast China 
BMC Infectious Diseases  2014;14:658.
Background
Sexually transmitted infections (STIs) increase HIV infectivity through local inflammatory processes. Prevalent and incident STIs among people who live with HIV/AIDS (PLWHA) are indicators of high-risk sexual behaviors and imply potential spread of HIV. Little is known about the prevalence and incidence of concurrent syphilis and associated risk behaviors among PLWHA in China.
Methods
A retrospective cohort study was conducted among PLWHA who attended the outpatient clinic of a designated AIDS treatment hospital in Shenyang, China, between March 2009 and May 2013. Physical examinations and syphilis serology were conducted at each visit. A questionnaire on demographic characteristics was also collected.
Results
A total of 1010 PLWHA were enrolled, of whom 77.0% were men who have sex with men (MSM). The baseline syphilis prevalence among PLWHA was 19.8% (95% confidence interval [CI]:17.3–22.3%). During follow-up, 78.3% retained in the cohort, and contributed a median follow-up of 9.4 months (interquartile range: 5.9-18.7 months). Syphilis incidence among PLWHA was 18.7 (95% CI: 15.5–21.8) per 100 person years. Mulitvariate logistic analysis showed that receiving antiretroviral therapy (ART) (adjusted OR [aOR] = 0.48), older age (≥40 years vs. ≤24 years, aOR = 2.43), being MSM (aOR = 2.30) and having higher baseline HIV viral load (>100000 copies/mL vs. ≤100000 copies/mL, aOR = 1.56) were independent predictors for syphilis infection among PLWHA at enrollment (p < 0.05 for all). Mulivariate Cox regression found that receiving ART (adjusted hazard ratio [aHR] = 1.81), older age (≥40 years vs. ≤24 years, aHR: 5.17) and MSM status (aHR = 2.68) were independent risk factors for syphilis seroconversion (each p < 0.05).
Conclusions
Syphilis prevalence and incidence were high among PLWHA in Shenyang. A campaign focusing on detection and treatment of syphilis among PLWHA is urgently needed, especially one with a focus on MSM who are at a higher risk for syphilis.
doi:10.1186/s12879-014-0658-1
PMCID: PMC4265485  PMID: 25471736
Retrospective cohort study; Syphilis; Prevalence; Incidence; Antiretroviral therapy (ART)
16.  Changes in Prevalence of HIV or Syphilis among Male Sex Workers and Non-Commercial Men Who Have Sex with Men in Shenzhen, China: Results of a Second Survey 
PLoS ONE  2016;11(12):e0167619.
Background
A previous time-location sampling survey (TLS) was performed in 2008 to evaluate the HIV or syphilis infection rate among male sex workers (MSWs) and non-commercial men who have sex with men (ncMSM) in Shenzhen, China. This is a second TLS performed in 2014. This article describes the findings and changes in the prevalence of HIV and syphilis.
Methods
TLS was used to collect information as a second cross-sectional survey to an earlier TLS assessment. Data on behavior (e.g., sexual history and sexual behavior) were analyzed. Blood specimens were drawn for HIV and syphilis testing. To determine the changes in the prevalence of HIV and syphilis, we analyzed these results and compared them to the results of our first survey.
Results
A total of 965 participants were recruited, including 489 MSWs and 476 ncMSM. Overall, the prevalence of HIV was 9.7%: 2.9% for MSWs and 16.8% for ncMSM (P<0.001). 10.9% of the 965 participants tested positive for syphilis: 4.5% among MSWs and 17.4% among ncMSM (P<0.001). The HIV prevalence in MSWs decreased from 4.5% in 2008 to 2.9% in 2014 (P = 0.143) but increased in ncMSM (7.0% in 2008 vs 16.8% in 2014, P<0.001). Decreased syphilis rates were observed in both MSWs (12.9% in 2008 vs 4.5% in 2014, P<0.001) and ncMSM (20.2% in 2008 vs 17.4% in 2014, P = 0.221).
Conclusions
Overall, there was a decline in the prevalence of HIV and syphilis in MSWs but not in ncMSM. The study indicated the need for continued efforts to improve public health, particularly to counter the rising rate of HIV in ncMSM.
doi:10.1371/journal.pone.0167619
PMCID: PMC5147921  PMID: 27935980
17.  Prevalence of HIV, Syphilis, and Other Sexually Transmitted Infections among MSM from Three Cities in Panama 
Respondent-driven sampling (RDS) was used to conduct a biobehavioral survey among men who have sex with men (MSM) in three cities in the Republic of Panama. We estimated the prevalence of HIV, syphilis, and other sexually transmitted infections (STIs), sociodemographic characteristics, and sexual risk behaviors. Among 603 MSM recruited, RDS-adjusted seroprevalences (95 % confidence intervals) were: HIV—David 6.6 % (2.2–11.4 %), Panama 29.4 % (19.7–39.7 %), and Colon 32.6 % (18.0–47.8 %); active syphilis—David 16.0 % (8.9–24.2 %), Panama 24.7 % (16.7–32.9 %), Colon 31.6 % (14.8–47.5 %); resolved HBV infection—David 10.0 % (4.8–16.8 %), Panama 29.4 % (20.0–38.3 %), and Colon 40.6 % (21.9–54.4 %); herpes simplex virus type 2—David 38.4 % (27.9–48.9 %), Panama 62.6 % (52.8–71.0 %), and Colon 72.9 % (57.4–85.8 %). At least a third of MSM in each city self-identified as heterosexual or bisexual. HIV prevalence is concentrated among MSM. Preventive interventions should focus on increasing HIV and syphilis testing, and increasing promotion of condom awareness and use.
doi:10.1007/s11524-014-9885-4
PMCID: PMC4134449  PMID: 24927712
HIV; Syphilis; Sexually transmitted diseases; Sexual behavior; Respondent-driven sampling; Sampling hidden populations; Panama
18.  Factors associated with HIV and syphilis co-infection among men who have sex with men in seven Chinese cities 
HIV-syphilis co-infection is often cited as a major reason behind recent resurgence in syphilis prevalence among men who have sex with men (MSM) in China. Most published literatures explore factors associated with either HIV or syphilis, but not their co-infection. We analyzed data from a cross-sectional survey on MSM in seven Chinese cities. Snowball sampling was used to recruit participants for the survey. Socio-demographic and behavioral predictors for HIV-syphilis mono/co-infection were examined using ordinal logistic regression. Factor scores were used to summarize; 1) HIV related knowledge, and 2) access to HIV preventive services. Prevalence of HIV, syphilis, and their co-infection, among 2936 self-identified MSM, were 7.7%, 14.3%, and 2.6%, respectively. In the adjusted analysis, the significant positive correlates of poorer diagnoses (co-infection vs mono- & no infection or co- & mono-infection vs no infection) were −30 to 39 years and ≥40 years age, education up to senior high school, unprotected anal intercourse (UAI), recent STD symptoms, incorrect knowledge about routes of transmission, and access to preventive or counselling/testing services for HIV. For effective control of this dual epidemic, integrated HIV and syphilis surveillance and targeted intervention strategies for Chinese MSM are need of the hour.
doi:10.1177/0956462414531560
PMCID: PMC4198509  PMID: 24737881
HIV; syphilis; coinfection; homosexual; epidemiology
19.  Bisexual Behavior and Infection with HIV and Syphilis Among Men Who Have Sex with Men Along the East Coast of China 
AIDS Patient Care and STDs  2011;25(11):683-691.
Abstract
This study examined the correlates of bisexual behavior and infection with HIV/syphilis among men who have sex with men only (MSM-only) and those who have sex with both men and women (MSMW) in Shandong, China. Cross-sectional surveys probed sociodemographic information, sexual and drug use behaviors, knowledge, and use of prevention services; blood samples were tested for HIV/syphilis status. Of 2996 participants, 39.5% acknowledged being MSMW; 60.5% being MSM-only; 2.5% were HIV-infected with similar rates for MSMW (2.5%) and MSM-only (2.6%); 5.5% syphilis-infected with comparable rates for MSMW (5.6%) and MSM-only (5.5%). In multivariable models, MSMW were more likely than MSM-only to be older, local residents, recruited from outdoor cruising area, drug users, and less likely to have used a condom during last anal sex with a male partner. HIV-infected MSMW were more likely to have syphilis and other sexually transmitted diseases (STDs) and less likely to have received peer education. HIV-infected MSM-only were more likely to be older, nonlocal residents, and have syphilis and other STDs. MSMW with syphilis were more likely to be recruited from Jinan, Qingdao, and Zibo (versus Yantai), infected with HIV, and less likely to have received lubricant promotion. MSM-only with syphilis were more likely to be recruited from Jinan and Qingdao (versus Yantai), drug users, infected with HIV, and have had sex with male partners in the past 6 months. High prevalence of bisexual behavior and HIV/other STDs with common unprotected sex and multiple sexual partners among Shandong's gay community revealed in this study highlighted the importance of bisexuals as a potential epidemiologic bridge. Further research is needed to investigate the impact of bisexual behaviors on population transmission.
doi:10.1089/apc.2010.0371
PMCID: PMC4186825  PMID: 21923416
20.  Risk Factors for HIV/Syphilis Infection and Male Circumcision Practices and Preferences among Men Who Have Sex with Men in China 
BioMed Research International  2014;2014:498987.
Objective. To investigate factors associated with HIV infection and the frequency and willingness of male circumcision among men who have sex with men (MSM) in Chengdu city, China. Methods. A cross-sectional survey provided information on participants' demographics, risk behaviors, circumcision, and uptake of HIV prevention services. Results. Of 570 participants, 13.3% were infected with HIV and 15.9% with syphilis. An estimated 43.0% of respondents reported having unprotected receptive anal intercourse, and 58.9% reported having ≥2 male sexual partners in the past 6 months. Multivariable logistic regression revealed that syphilis, more male sex partners, predominantly receptive anal intercourse, and exclusively receptive male sex were associated with HIV infection. Higher level of education and peer education service were inversely associated with HIV infection. Nearly a fifth (18.0%) of participants were circumcised. More than half of uncircumcised participants expressed willingness to be circumcised. Conclusion. This study reveals a high prevalence of HIV and syphilis among MSM in Chengdu province of China. The frequency of unprotected receptive anal intercourse and multiple male sexual partnerships highlight the urgency for an effective comprehensive HIV prevention strategy. Although the willingness to accept male circumcision (MC) is high, further research is needed to assess the protective effective of MC among MSM.
doi:10.1155/2014/498987
PMCID: PMC3985172  PMID: 24795883
21.  HIV and Syphilis Testing Preferences among Men Who Have Sex with Men in South China: A Qualitative Analysis to Inform Sexual Health Services 
PLoS ONE  2015;10(4):e0124161.
Background
Health services for men who have sex with men (MSM) are inadequate in many areas around the world. HIV and syphilis test uptake remain suboptimal among MSM in China and many other regions. To inform the development of more comprehensive sexually transmitted disease (STD) testing programs among MSM, we collected descriptive data on MSM testing practices and preferences.
Methods
MSM in two large urban Chinese cities were recruited through community-based organizations and clinics to participate in semi-structured interviews. We purposively sampled MSM across a range of sociodemographic characteristics and testing history, and assessed preferences for HIV and syphilis testing in the context of facilitators and barriers to testing and previous testing experiences. Each interview transcript was coded and thematically analyzed using Atlas.ti 7.0.
Results
35 MSM were interviewed. Confidentiality and privacy were the most important factors influencing participants’ decisions about whether and where to get tested. Men preferred rapid testing (results available within 30 minutes) compared to conventional tests where results take several hours or days to return. Participants described concerns about quality and accuracy of rapid tests offered in non-clinical settings such as community-based organizations. Men preferred testing service providers who were MSM-friendly, non-discriminatory, and medically trained. Preferred service center environments included: convenient but discrete location, MSM-friendly atmosphere, and clean/standard medical facilities.
Conclusion
Our data highlight the need for HIV/syphilis testing services that are confidential and inclusive of MSM. Rapid testing in decentralized (i.e. peripheral health facilities and community-level, non-clinical venues) settings provides an opportunity to reach individuals who have not been tested before, but must be accompanied by quality assurance systems and technical competence. Implementation research could further evaluate HIV/syphilis testing programs responsive to MSM preferences.
Short Summary
A qualitative study of MSM in South China found that men preferred rapid STD testing at MSM-focused test centers, but were concerned about test quality assurance and confidentiality.
doi:10.1371/journal.pone.0124161
PMCID: PMC4395264  PMID: 25875336
22.  Prevalence of high-risky behaviors in transmission of HIV among high school and college student MSM in China: a meta-analysis 
BMC Public Health  2015;15:1272.
Background
The aim of this study was to investigate the prevalence of high-risky behaviors, such as unprotected anal intercourse (UAI) in the last 6 months, condom using in their last homosexual anal intercourse, No. of male partners in the last 6 months among high school and college male students who have sex with men (MSM) in China.
Methods
The relevant trials were retrieved up to June 2015 from several public databases, and a meta-analysis was conducted according to the published studies. The estimated rate and its 95 % confidence intervals (CI) of the relevant indexes among high school and college student MSM were collected and calculated using a fixed-effects model (the Mantel-Haenszel method) or a random-effects model (the DerSimonian and Laird method) when appropriate.
Results
A total of 15 studies (18 research data), including 3297 student MSM, were performed in this meta-analysis. The overall results showed that the rate of student MSM who reported having had UAI in the last 6 months was 65.2 % (95 % CI = 60.2 % to 70.1 %), the prevalence of student MSM having more than one male partner in the last 6 months was 58.2 % (95 % CI = 51.1 % to 65.4 %), the rate of student MSM who reported using a condom in their last homosexual anal intercourse experience was 57.5 % (95 % CI = 49.8 % to 65.1 %), the prevalence of student MSM who were infected with HIV was 3.8 % (95 % CI = 2.5 % to 5.1 %), and the rate of student MSM who were infected with syphilis was 4.6 % (95 % CI = 3.8 % to 5.4 %).
Conclusions
There are high UAI prevalence and low condom using rate in the last homosexual anal intercourse experience among high school and college student MSM in China, and corresponding control measures for this group and more effective health education of student MSM are required to prevent HIV or sexually transmitted diseases from spreading to the general population.
doi:10.1186/s12889-015-2614-4
PMCID: PMC4687281  PMID: 26690367
Epidemiology; HIV; Men who have sex with men (MSM); AIDS; Meta-analysis
23.  Sexual Behaviors and HIV/Syphilis Testing Among Transgender Individuals in China: Implications for Expanding HIV Testing Services 
Sexually transmitted diseases  2015;42(5):281-285.
Background
HIV and syphilis are disproportionately common among transgender individuals globally, yet few studies have investigated transgender HIV/syphilis risk and testing in low and middle-income nations. We conducted an online survey of men who have sex with men (MSM) and transgender individuals to examine sexual behaviors, and HIV/syphilis testing in China.
Methods
We recruited MSM and transgender individuals from two-major Chinese lesbian, gay, bisexual, and transgender (LGBT) web platforms. Chi-square and logistic regression were used to compare risk behaviors, HIV and syphilis testing history, and prevalence between transgender individuals and other MSM.
Results
Among the 1320 participants, 52 (3·9%) self-identified as transgender. Demographics, including education, employment, and marital status were similar between both groups, while transgender individuals were older. Condomless anal intercourse rate was comparable between the groups. Transgender individuals were less likely to report ever testing for HIV (34·6% VS 62·0%) and syphilis (15·7% VS 31·2%) with adjusted ORs of 0·36 (95% CI 0·20–0·65) and 0·42 (95% CI 0·20–0·91), respectively. We found a trend towards higher HIV prevalence among transgender individuals (11·1% VS5·7%, P=0·12).
Conclusion
Transgender individuals have suboptimal HIV and syphilis testing rates in China. Given the substantial risk behaviors and burden of HIV/STI in the general Chinese MSM population and lack of knowledge about transgender individuals, enhanced HIV/syphilis testing programs for transgender individuals in China are needed.
doi:10.1097/OLQ.0000000000000269
PMCID: PMC4396656  PMID: 25868142
Transgender; HIV; Syphilis; Testing; China
24.  The Comparability of Men Who Have Sex With Men Recruited From Venue-Time-Space Sampling and Facebook: A Cohort Study 
JMIR Research Protocols  2014;3(3):e37.
Background
Recruiting valid samples of men who have sex with men (MSM) is a key component of the US human immunodeficiency virus (HIV) surveillance and of research studies seeking to improve HIV prevention for MSM. Social media, such as Facebook, may present an opportunity to reach broad samples of MSM, but the extent to which those samples are comparable with men recruited from venue-based, time-space sampling (VBTS) is unknown.
Objective
The objective of this study was to assess the comparability of MSM recruited via VBTS and Facebook.
Methods
HIV-negative and HIV-positive black and white MSM were recruited from June 2010 to December 2012 using VBTS and Facebook in Atlanta, GA. We compared the self-reported venue attendance, demographic characteristics, sexual and risk behaviors, history of HIV-testing, and HIV and sexually transmitted infection (STI) prevalence between Facebook- and VTBS-recruited MSM overall and by race. Multivariate logistic and negative binomial models estimated age/race adjusted ratios. The Kaplan-Meier method was used to assess 24-month retention.
Results
We recruited 803 MSM, of whom 110 (34/110, 30.9% black MSM, 76/110, 69.1% white MSM) were recruited via Facebook and 693 (420/693, 60.6% black MSM, 273/693, 39.4% white MSM) were recruited through VTBS. Facebook recruits had high rates of venue attendance in the previous month (26/34, 77% among black and 71/76, 93% among white MSM; between-race P=.01). MSM recruited on Facebook were generally older, with significant age differences among black MSM (P=.02), but not white MSM (P=.14). In adjusted multivariate models, VBTS-recruited MSM had fewer total partners (risk ratio [RR]=0.78, 95% CI 0.64-0.95; P=.01) and unprotected anal intercourse (UAI) partners (RR=0.54, 95% CI 0.40-0.72; P<.001) in the previous 12 months. No significant differences were observed in HIV testing or HIV/STI prevalence. Retention to the 24-month visit varied from 81% for black and 70% for white MSM recruited via Facebook, to 77% for black and 78% for white MSM recruited at venues. There was no statistically significant differences in retention between the four groups (log-rank P=.64).
Conclusions
VBTS and Facebook recruitment methods yielded similar samples of MSM in terms of HIV-testing patterns, and prevalence of HIV/STI, with no differences in study retention. Most Facebook-recruited men also attended venues where VTBS recruitment was conducted. Surveillance and research studies may recruit via Facebook with little evidence of bias, relative to VBTS.
doi:10.2196/resprot.3342
PMCID: PMC4129125  PMID: 25048694
men who have sex with men, MSM; Facebook; venue-based time sampling; online MSM; social media recruitment of MSM
25.  Sexual behaviour, recreational drug use and hepatitis C co-infection in HIV-diagnosed men who have sex with men in the United Kingdom: results from the ASTRA study 
Journal of the International AIDS Society  2014;17(4Suppl 3):19630.
Introduction
Transmission of Hepatitis C virus (HCV) among HIV-positive men who have sex with men (MSM) in the United Kingdom is ongoing. We explore associations between self-reported sexual behaviours and drug use with cumulative HCV prevalence, as well as new HCV diagnosis.
Methods
ASTRA is a cross-sectional questionnaire study including 2,248 HIV-diagnosed MSM under care in the United Kingdom during 2011–2012. Socio-demographic, lifestyle, HIV-related and sexual behaviour data were collected during the study. One thousand seven hundred and fifty two (≥70%) of the MSM who consented to linkage of ASTRA and clinical information (prior to and post questionnaire) were included. Cumulative prevalence of HCV was defined as any positive anti-HCV or HCV-RNA test result at any point prior to questionnaire completion. We excluded 536 participants with clinical records only after questionnaire completion. Among the remaining 1,216 MSM, we describe associations of self-reported sexual behaviours and recreational drug use in the three months prior to ASTRA with cumulative HCV prevalence, using modified Poisson regression with robust error variances. New HCV was defined as any positive anti-HCV or HCV-RNA after questionnaire completion. We excluded 591 MSM who reported ever having a HCV diagnosis at questionnaire, any positive HCV result prior to questionnaire or did not have any HCV tests after the questionnaire. Among the remaining 1,195 MSM, we describe occurrence of new HCV diagnosis during follow-up according to self-reported sexual behaviours and recreational drug use three months prior to questionnaire (Fisher's exact test).
Results
Cumulative HCV prevalence among MSM prior to ASTRA was 13.3% (95% CI 11.5–15.4). Clinic- and age-adjusted prevalence ratios (95% CI) for cumulative HCV prevalence were 4.6 (3.1–6.7) for methamphetamine, 6.5 (3.5–12.1) for injection drugs, 2.3 (1.6–3.4) for gamma hydroxybutyrate (GHB), 1.6 (1.3–2.0) for nitrites, 1.7 (1.5–2.0) for all condom-less sex (CLS), 2.1 (1.7–2.5) for CLS-HIV-seroconcordant, 1.3 (0.9–1.9) for CLS-HIV-serodiscordant, 2.0 (1.6–2.5) for group sex, 1.5 (1.2–1.9) for more than 10 new sexual partners in the past year. Among 1,195 MSM with 2.2 years [IQR 1.5–2.4] median follow-up, there were 7 new HCV cases during 2,033 person-years at risk. Incidence was 3.5 per 1,000 person-years (95% CI 1.6–7.2). New HCV was recorded in 1.3% MSM who used methamphetamine versus 0.5% MSM who did not (p=0.385); 3.7% MSM who injected recreational drugs versus 0.5% MSM who did not (p=0.148); 2.9% MSM who used GHB versus 0.4% MSM who did not (p=0.003); 1.5% MSM who used nitrites versus 0.2% MSM who did not (p=0.019); 1.1% MSM having CLS versus 0.3% MSM who did not (p=0.084); 1.7% MSM having CLS-HIV-serodiscordant versus 0.4% MSM who did not (p=0.069); 0.9% MSM who had CLS-HIV-seroconcordant versus 0.5% MSM who did not (p=0.318); 0.8% MSM who had group sex versus 0.5% MSM who did not (p=0.463); and 1.6% MSM with =10 new sexual partners in the previous year versus 0.2% MSM with no or up to 9 new partners (p=0.015).
Conclusions
Self-reported recent use of recreational and injection drugs, condom-less sex and multiple new sexual partners are associated with pre-existing HCV infection and, with the exception of injection drugs, appear to be predictive of new HCV co-infection among HIV-diagnosed MSM.
doi:10.7448/IAS.17.4.19630
PMCID: PMC4224924  PMID: 25394134

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