Condomless Vaginal Intercourse and Its Associates among Men Who Have Sex with Men in China

RESEARCH ARTICLE Condomless Vaginal Intercourse and Its Associates among Men Who Have Sex with Men in China Hongcheng Shen1, Songyuan Tang1,2, Tanmay Mahapatra3, Joseph D. Tucker2, Shujie Huang1, Bin Yang1, Jinkou Zhao4, Roger Detels3, Weiming Tang1,2* a11111 1 Guangdong Provincial Center for Skin Disease and STI Control, Guangzhou, China, 2 University of North Carolina, Project-China, Guangzhou, China, 3 Department of Epidemiology, School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America, 4 Monitoring and Evaluation Unit, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland * Abstract OPEN ACCESS Citation: Shen H, Tang S, Mahapatra T, Tucker JD, Huang S, Yang B, et al. (2016) Condomless Vaginal Intercourse and Its Associates among Men Who Have Sex with Men in China. PLoS ONE 11(4): e0154132. doi:10.1371/journal.pone.0154132 Editor: Shuang-yong Xu, New England Biolabs, Inc., UNITED STATES Background HIV prevalence has increased rapidly among men who have sex with men (MSM) in China reaching alarmingly high levels in some cities. Bisexual MSM have potential to transmit HIV and syphilis to their female partners through condomless vaginal intercourse (CVI). Thus, estimation of the burden of CVI and identification of its associates seemed necessary to control this cross-gender transmission. Received: January 6, 2016 Accepted: April 8, 2016 Published: April 26, 2016 Copyright: © 2016 Shen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Method In a cross-sectional study, using respondent-driven-sampling and snowball sampling, 2958 MSM were recruited from seven Chinese cities, interviewed and tested for HIV and syphilis. Descriptive analysis of the socio-demographic and behaviors followed by simple and multiple logistic regressions [adjusted for income, city, race and social network size to determine adjusted odds ratio (aOR)] were performed using SAS-9.1. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Results Funding: This work was supported by National Institutes of Health [National Institute of Allergy and Infectious Diseases 1R01AI114310]; UNC-South China STD Research Training Centre [Fogarty International Centre 1D43TW009532]; UNC Center for AIDS Research [National Institute of Allergy and Infectious Diseases 5P30AI050410]; and the UNC Chapel Hill, Johns Hopkins University, Morehead School of Medicine and Tulane University (UJMT) Fogarty Fellowship [FIC R25TW0093]. Among participating MSM, 19.03% were engaged in CVI. Prevalence of HIV and syphilis among participants involved in CVI were 5.86% and 14.74% respectively. MSM who were older [aOR for aged 40–49 = 2.60 (95% CI: 1.54–4.37)], married [aOR = 6.13 (4.95–7.58)], attended primary school or below [aOR = 3.86 (2.26–6.69)], met male partners at spa/bathhouse/sauna/massage parlor [aOR = 3.52 (2.62–4.72)] and had heterosexual orientation [aOR = 13.81 (7.14–26.70)] were more likely to have CVI. Furthermore, correct knowledge regarding HIV [aOR = 0.70 (0.55, 0.88)] and exposure to HIV prevention interventions [aOR = 0.67 (0.54, 0.82)] were negatively associated with CVI. PLOS ONE | DOI:10.1371/journal.pone.0154132 April 26, 2016 1 / 12 CVI among MSM in China Competing Interests: The authors have declared that no competing interests exist. Conclusions CVI was found to be common among MSM in China. To minimize the transmission of HIV and syphilis from bisexual MSM to their relatively female partners, targeted interventions should specifically focus on bisexual MSM especially the older and married subgroups. Introduction Worldwide it has been observed that Men who have Sex with Men (MSM) are quite vulnerable for acquisition of HIV. In all the global geographical regions, median HIV prevalence has crossed 1% among MSM [1]. Moreover, in multiple regions of the world, like in north, south and central America, south and south-east Asia and sub-Saharan Africa, HIV prevalence among MSM has become as high as 14–18% [2]. HIV epidemic among MSM in China is currently being considered as one of the toughest public health challenges that the country is facing [2]. According to the National Sentinel Surveillance data, over the years among MSM in China, HIV prevalence did show a rising trend from 0.9% in 2003 to 6.3% in 2011 while syphilis sero-positivity increased from 2.4% in 2004 to 7.8% in 2011[3]. There are several factors including multiple male sex partners, large network size [3–5] and high proportion of sexual intercourses without condom [6], those increase the potential risk for being infected with HIV and other sexually transmitted diseases (STDs) like syphilis among MSM in China. In the context of the Chinese society, the scenario becomes further complicated for this population resulting from the social pressure on males to meet the perceived masculine responsibility of becoming a father and known high risks for acquisition of HIV and other STDs among MSM [7, 8]. Thus, to comply with the social demand, many MSM marry women, engage in heterosexual activities with them and give birth to babies to conceal their homosexuality and fulfill their social and family responsibilities. This scenario was evident from the data that the proportion of heterosexual marriages among MSM in China has increased from 19.3% in 2008 to 27.9% in 2011[3]. Under this circumstance, Chinese MSM have become a crucial bridge population for the transmission of HIV/STDs from their male partners to their relatively heterosexual female partners through condomless sexual contacts, and to their children through vertical transmission. This hidden cross-gender bridging behavior often results in a relatively non-traceable spread of HIV/STDs, increasing the challenges for the HIV/STD control programs in this country. Bisexual subgroup of MSM population thus required special attention in terms of the coverage of the interventions for the testing and prevention of HIV and other STDs. However, mostly due to their hidden nature, majority of studies involving MSM were focused on HIV/ STD transmission between men and men, while little attention was paid to their potential bridging role in transmission of HIV to general female population [9–11]. Further, to the best of our knowledge, few studies did ever focus upon the associates of condomless vaginal intercourse (CVI) among MSM globally as well as in China, while identification of the factors associated with CVI in this population seemed critical for controlling the epidemics of HIV and other STDs. To address this dearth of information and in order to help public health administrators in designing appropriate HIV prevention strategies, we used the data from a multi-centre cros (...truncated)