JMIR FORMATIVE RESEARCHSong et al

Original Paper

HIV Prevalence and Risk Factors Among Young Men Who Have
Sex With Men in Southwest China: Cross-sectional Questionnaire
Study
Liping Song1*, PhD; Xiangyuan Yu1*, MSc; Bing Su2, MSc; Wen Kui Geng3, BA; Guanghua Lan4, PhD; Xiangjun
Zhang5, PhD
1School of Public Health, Guilin Medical University, Guilin, China

2

Department of Clinical Psychology, Qingdao Mental Health Center, Qingdao, China

3

Guangxi Zhuang Autonomous Region Health and Family Planning Commission, Nanning, China

4

Guangxi Zhuang Autonomous Region Center for Disease Prevention and Control, Nanning, China

5

Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN,
United States*these authors contributed equally

Corresponding Author:
Xiangjun Zhang, PhD
Department of Clinical Pharmacy and Translational Science
College of Pharmacy
University of Tennessee Health Science Center
881 Madison Avenue
Memphis, TN, 38163
United States
Phone: 1 901 448 1763
Email: zxj@nevada.unr.edu

Abstract
Background: Previous studies showed an increase in HIV prevalence among young men who have sex with men aged 25 years
or younger in China.
Objective: This study aimed to assess HIV prevalence and associated factors among young men who have sex with men in the
Guangxi Zhuang Autonomous Region.
Methods: This study was conducted in 4 cities (Guilin, Liuzhou, Beihai, and Nanning) in the Guangxi Zhuang Autonomous
Region between June 2014 and May 2016. Participants were reached through web-based and site recruitment approaches.
Laboratory tests were performed to detect HIV and syphilis infections. A self-administered questionnaire was used to collect datafrom 632 eligible young men who have sex with men.
Results: The prevalence of HIV and syphilis was 9.3% (59/632) and 11.4% (72/632), respectively. Multivariable logistic analysis
showed that ethnic minority (adjusted odds ratio [AOR] for Han Chinese vs other minorities 0.28, 95% CI 0.11-0.71, P=.007),
receptive sexual positioning in the past 6 months (AOR 2.94, 95% CI 1.32-6.53, P=.008), current syphilis infection (AOR for
individuals without vs those with infection 0.38, 95% CI 0.19-0.75, P=.005), inconsistent condom use in the past 6 months (AOR
1.91, 95% CI 1.06-3.45, P=.03), and psychotropic drug use before last anal intercourse (AOR 16.70, 95% CI 2.34-119.18, P=.005)
were independently associated with HIV infection.
Conclusions: There is an urgent need to scale up HIV and syphilis interventions in young men who have sex with men. Somesubgroups might need specific attention for HIV prevention, including ethnic minority men, individuals with a history of sexuallytransmitted infections, and individuals who have been engaging in receptive anal sex.
(JMIR Form Res 2023;7:e37344) doi: 10.2196/37344
KEYWORDS
HIV; young men who have sex with men; syphilis; sexually transmitted infection; ethnic minority

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Introduction
Men who have sex with men are one of the key and mostvulnerable populations in the HIV epidemic [1]. The homosexualtransmission rates of annually reported HIV cases in China
increased from 2.5% in 2005 to 25.8% in 2014 [2,3], and the
new cases of HIV infection among men who have sex with men
increased from 487 in 2006 to over 30,000 in 2015 [4].
Epidemiological studies have also demonstrated that HIV
prevalence among men who have sex with men has been risingin many Chinese cities in recent years [5-9]. For example, HIVprevalence among men who have sex with men in the capital
city of Beijing increased from 0.4% in 2007 to 9.9% in 2010[10-12] and doubled from 8.5% in 2008 to 16.8% in 2009 in
Chongqing in southwest China [13-15]. Young men who havesex with men who are aged 25 years or younger are a subgroupof particular concern as they usually have high HIV prevalence[16] and incidence [17] due to unprotected anal intercourse[18-20] and multiple sexual partnerships [19,20]. One study
investigated HIV and syphilis infections among young men
who have sex with men who were 16-25 years old in 4 cities in
China and found the prevalence of HIV and syphilis to be 6.7%
and 8.3%, respectively, in 2008 [16]. Using a prospective cohort
design, 1 study reported an HIV incidence rate of 6.7 per 100
person-years among young men who have sex with men inurban areas of China in 2010 [17]. Factors that were associatedwith young men who have sex with men’s HIV infection inprevious literature included nonstudent status, low HIV
transmission knowledge, and syphilis infection [16,17]. Further,a meta-analysis study reported rates of having unprotected analintercourse and having multiple sexual partners in the last 6months for young men who have sex with men were as high as
65.2% and 58.2%, respectively [20]. Although particularattention needs to be paid to HIV epidemiology and behavioral
intervention in young men who have sex with men, the previous
literature relatively lacks current data and evidence to better
understand the behavioral characteristics of young men who
have sex with men in relation to HIV infection.
The previous literature reported some factors that could explain
the high HIV prevalence and incidence in the young men who
have sex with men group. Men who have sex with men
commonly face stigma issues, which prevent them fromdisclosing of their sexual orientation in Chinese culture [21,22].
Therefore, it was very hard to reach out to them for HIV
prevention and intervention purposes [22,23], thus, HIV risk
behaviors remained high, such as unprotected anal intercourse
among Chinese men who have sex with men [23]. Therefore,
young men who have sex with men showed a higher prevalenceof recent HIV infection and a higher HIV incidence than men
who have sex with men, who are aged 25 years and older [24].
The Guangxi Zhuang Autonomous Region, which is located insouthwest China, has a large proportion of minority groups.
Ethnic minorities accounted for 37.5% of the total population;of them, the Zhuang ethnicity accounted for 31.4% of the total
population in 2020 [25]. Moreover, Guangxi is one of the 6
provinces and autonomous regions with the highest HIV
prevalence in China. Historically, injection drug use was theprimary cause of the HIV epidemic in Guangxi [26].
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Song et al
Furthermore, recent surveillance data showed that there has
been a growing HIV prevalence among young men who havesex with men aged 25 years and younger [26]. To better
understand the HIV epidemic among young men who have sex
with men with the goal of designing appropriate interventions,
we conducted a cross-sectional study to characterize the severityof the HIV epidemic and risk factors among young men who
have sex with men in Guangxi Zhuang Autonomous Region.

Methods
Study Design and ParticipantsThis cross-sectional study was conducted in 4 cities (Guilin,
Liuzhou, Beihai, and Nanning) in the Guangxi Zhuang
Autonomous Region between June 2014 and May 2016. The
eligibility criteria for participation included being a male; having
self-reported anal sex with men in the past year; being aged 18
to 25 years; and being willing and able to provide consent forparticipation in this study. Participants were recruited by staff
from the Centers for Disease Control and Prevention (CDC) in
4 cities through web-based or site recruitment. We also used asnowball sampling procedure. Research staff who had
experience working with men who have sex with men
communities posted study recruitment information throughcommonly used social media platforms for men who have sex
with men, such as QQ and WeChat. They also visited men who
have sex with men gathering venues periodically to distributestudy flyers and recruit participants, such as wine bars, danceclubs, coffee or tea shops, bath, sauna, massage, or pedicurerooms, and parks. The recruitment materials had the study
information and local clinics’ location, phone number, and officehours. Potential participants could contact or visit the clinics tolearn more about the study and participate in it. Participants
were encouraged to distribute study recruitment flyers to theirsocial networks.

Data Collection
A self-administered structured questionnaire was usedanonymously to collect data by research staff from the CDC in
4 cities. The questionnaire collected the following data:social-demographics (age, marital status, ethnicity, education,
residence, and occupation), sexual behaviors (condom use in
the last anal intercourse and in the past 6 months, number ofanal sex and sexual positioning—insertive, receptive, orversatile—in the past 6 months, history of drug use andintravenous drug use, commercial sex, history of sexuallytransmitted disease [STD] in the past 12 months), etc. A written
informed consent form was signed by the participants at
recruitment. Each participant received 50 Yuan RMB(approximately US $8) upon completion of the survey.

HIV-Related Knowledge
We also assessed HIV-related knowledge using a scale of 8questions, and each question has 3 options (true, false, andunsure). Sample questions were “Can an HIV-infected person
be recognized in appearance?” “Would mosquito bites spread
HIV?” “Would a person be infected by eating together with an
HIV-infected person?” and “Can a person reduce the risk of
HIV transmission by using condoms correctly in every sexual
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JMIR FORMATIVE RESEARCH
behavior?” Participants got 1 point for each correct answer and0 points otherwise. The total score for this scale ranged from 0
to 8, with a score of ≥6 indicating participants have good HIV
knowledge [27]. The Cronbach for the scale reliability was .731,
which indicates the scale has acceptable internal consistency.

Serological Tests
Venous blood samples were collected from all participants andtested for HIV and syphilis. HIV screening was conducted using
an enzyme-linked immunosorbent assay (ELISA, Vironostika
HIV-1 Microelisa System; BioMe´rieux), and a positive casewas confirmed by the HIV-1/2 Western blot assay (HIV Blot
2.2 WB; Genelabs Diagnostics). Syphilis tests were conductedby ELISA and rapid plasma regain testing (diagnosis test;
Shanghai Kehua, China). A participant who had positive results
for both ELISA and rapid plasma regain testing was considered
to have a current syphilis infection.

Statistical Analysis
SPSS (version 19.0; SPSS Inc) was used for the data analyses.
We calculated means and SDs for continuous variables andfrequencies (%) for categorical variables. Chi-square tests wereconducted to assess the associations between HIV infection andcategorical independent variables. We conducted stepwise
multivariate logistic regression analyses to identify factors thatwere related to HIV infection [9]. The multivariable analysis
model included marginally significant variables with a valueof P≤.05 in the bivariate analysis (chi-square test). The thresholdfor statistical significance was set at P≤.05.

Ethical Considerations
Ethical approval was obtained for this study from theinstitutional review board of the Ethics Committee at Guilin
Medical University on March 1, 2013. A signed written
informed consent form was obtained from all participants prior
to their participation.

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Song et al

Results
Among the 651 men who have sex with men who enrolled inthis study, 632 were eligible young men who have sex withmen, and 19 participants were aged beyond the range of 18 to
25 years. Therefore, we only included 632 participants in the
final analyses.
Table 1 presents the sociodemographic characteristics of thestudy sample. Participants had an average age of 22 years and70.6% (446/632) of them were of Han ethnicity and 23.4%(148/632) were of Zhuang ethnicity. More than half of theparticipants had college-associated or higher education (367/632,
58.1%). Most participants (27/632, 95%) were unmarried, and73.9% (467/632) of them have been living in Guangxi for morethan 2 years. About one-third of the participants (238/632,
37.7%) were students. Moreover, approximately 6% (38/632)
of participants had a history of an STD in the past 12 months.
A few participants had a history of drug use (11/632, 2%) andpsychotropic drug use before the last anal intercourse in the past
6 months (5/632, 1%). Regarding sexual behaviors, for anal
sexual positioning in the past 6 months, 39.2% (248/632) ofparticipants reported insertive, 33.9% (214/632) reported
receptive, and 26.9% (170/632) reported versatile positioning.
A majority of participants used a condom in the last analintercourse (414/632, 65.5%), and more than half of theparticipants (325/632, 51.4%) used a condom every time in ananal intercourse in the past 6 months. Less than one-third(191/632, 30.2%) of participants engaged in anal intercourse
twice or more in the last week. Furthermore, some participants
had commercial sex with a male (106/632, 16.8%), sex with afemale (70/632, 11%), or were currently syphilis infected(72/632, 11%). Only 7% (43/632) of the participants received
less than 6 points on the HIV knowledge scale.

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Table 1. Demographic characteristics, sexual behaviors, and HIV knowledge by HIV infection among young men who have sex with men in Guangxi,
China between 2014 and 2015 (N=632).
Variables

Total, n (%)

HIV infection, n (%)
Yes

No

Chi-square (df)

P valueAge (years)
18-20

173 (27.4)

17 (9.8)

156 (90.2)

0.068 (1)

.79

21-25

459 (72.6)

42 (9.2)

417 (90.8)

N/Aa

N/A

Han

446 (70.6)

30 (6.7)

416 (93.3)

12.639 (2).002

Zhuang148 (23.4)

22 (14.9)

126 (85.1)

N/A

N/A

Others38 (6.0)

7 (18.4)

31 (81.6)

N/A

N/A

High school or associated level or below

265 (41.9)30 (11.3)

235 (88.7)

2.125 (1).15College associated level or above

367 (58.1)

29 (7.9)338 (92.1)

N/A

N/A

Unmarried

597 (94.5)

56 (9.4)

541 (90.6)

0.513 (2).773b

Married27 (4.3)

2 (7.4)25 (92.6)

N/A

N/A

Othersc8 (1.3)

1 (1.3)7 (87.5)

N/A

N/A

2 or less

165 (26.1)

18 (10.9)147 (89.1)

0.653 (1).42>2467 (73.9)

41 (8.8)426 (91.2)

N/A

N/A

Student

238 (37.7)

25 (10.5)

213 (89.5)

0.616 (1).43

Nonstudent

394 (62.3)

34 (8.6)360 (91.4)

N/A

N/A

No

594 (94.0)

50 (8.4)

544 (91.6)

8.114 (1)

.004f

Yes

38 (6.0)9 (23.7)

29 (76.3)

N/A

N/A

No

621 (98.3)

56 (9.1)

565 (90.9)

2.372 (1)

.12f

Yes

11 (1.7)

3 (27.3)

8 (72.7)

N/A

N/A

No

627 (99.2)

56 (8.9)571 (91.1)

15.285 (1)

.007b

Yes

5 (0.8)3 (60.0)

2 (40.0)

N/A

N/A

Insertive

248 (39.2)

19 (7.7)229 (92.3)

10.809 (2)0.004

Receptive

214 (33.9)

31 (14.5)

183 (85.5)

N/A

N/A

Versatile

170 (26.9)

9 (5.3)161 (94.7)

N/A

N/A

No

218 (34.5)

20 (9.2)

198 (90.8)

0.010 (1)

.92

Yes

414 (65.5)

39 (9.4)375 (90.6)

N/A

N/A

Ethnicity

Education

Marital status with female

Living duration in Guangxi (years)

Occupation

History of STDd in P12Me

History of drug use

Psychotropic drug use before last anal intercourse

Anal sexual positioning in P6Mg

Condom use in the last anal intercourse

The number of times participants had anal intercourse in the last week0248 (39.2)

21 (8.5)227 (91.5)

3.319 (2).191

193 (30.5)

24 (12.4)

169 (87.6)

N/A

N/A

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Variables

Song et al
Total, n (%)

HIV infection, n (%)

Chi-square (df)

P valueYesNo

191 (30.2)

14 (7.3)

177 (92.7)

N/A

N/A

Never

43 (6.8)

2 (4.7)41 (95.3)

10.056 (2).007

Sometime

264 (41.8)

36 (13.6)

228 (86.4)

N/A

N/A

Every time

325 (51.4)

21 (6.5)304 (93.5)

N/A

N/A

No

526 (83.2)

53 (10.1)473 (89.9)

2.032 (1)

.15

Yes

106 (16.8)

6 (5.7)100 (94.3)

N/A

N/A

No

562 (88.9)

54 (9.6)508 (90.4)

0.447 (1)

.50

Yes

70 (11.1)

5 (7.1)65 (92.9)

N/A

N/A

Negative

560 (88.6)

43 (7.7)

517 (92.3)

15.943 (1)<.001

Positive72 (11.4)

16 (22.2)

56 (77.8)

N/A

N/A

1

192 (30.4)

19 (9.9)173 (90.1)

0.102 (1).75

2+440 (69.6)

40 (9.1)

400 (90.9)

N/A

N/A

<6

43 (6.8)

1 (2.3)42 (97.7)

1.864 (1).17

≥6589 (93.2)

58 (9.8)531 (90.2)

N/A

N/A

≥2
Frequency of condom use in the anal intercourse in P6M

Commercial male sexual

Having sex with female

Current syphilis infection

The number of male sexual partner in P6M

Score of HIV knowledgeaN/A: not applicable.

b

Fisher exact test.

c

Divorced or widowed.

d

STD: sexually transmitted disease.

eP12M: past 12 months.

fContinuity correction.

g

P6M: past 6 months.

Bivariate Analysis of HIV Infection
A total of 9.3% (59/632) of the participants were HIV-infected
and 11.4% (72/632) were syphilis infected. Overall, 2.5%
(16/632) had both HIV and syphilis. The bivariate analysis
results of factors associated with HIV infection are shown in
Table 1.
Participants of Zhuang ethnicity and other ethnicities showed
higher HIV infection proportions than those of Han ethnicity(22/148, 14.9% and 7/38, 18.4% vs 30/446, 6.7%, P=.002).
Participants who used psychotropic drugs in the last analintercourse had a significantly higher HIV infection rate (3/5,
60.0% vs 56/627, 8.9%, P=.007). Moreover, participants withreceptive sexual positioning had a significantly higher HIV
infection rate than those who had insertive or versatile sex(31/214, 14.5% vs 19/248, 7.7% and 9/170, 5.3%, P=.004). In
addition, participants who had ever had an STD in the past 12
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who did not (9/38, 23.7% vs 50/594, 8.4%, P=.004). Participants
with active syphilis had a higher rate of HIV infection thanthose without active syphilis (16/72, 22.2% vs 43/560, 7.7%,
P<.001).

Multivariable Analysis of Factors Associated WithHIV Infection
The results of multivariable logistic regression analyses aredemonstrated in Table 2. The Han ethnic group showed a lower
likelihood of HIV infection than other ethnic groups (AOR 0.28,
95% CI 0.11-0.71, P=.007). HIV infection was associated withreceptive anal sexual positioning in the past 6 months (AOR
2.94, 95% CI 1.32-6.53, P=.008), inconsistent condom use in
the past 6 months (AOR 1.91, 95% CI 1.06-3.45, P=.031), andcurrent syphilis infection (AOR 0.38, 95% CI 0.19-0.75,
P=.005). Although showing statistical significance (AOR 16.70,
P=.005), psychotropic drug use was not considered a variable
that was associated with HIV infection due to the SE of 1.00
and very wide CI of 2.34-119.18.

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Table 2. Factors associated with HIV infection among young men who have sex with men in Guangxi, China between 2014 and 2015.
Variables

βSE

Wald test

AORa (95% CI)

P valueEthnicity

N/Ab

N/A

10.78

N/A

.005

Han

–1.29

0.48

7.22

0.28 (0.11-0.71).007

Zhuang

–.50

0.50

0.99

0.61 (0.23-1.62)

.32

Other

N/A

N/A

N/A

Refc

N/A

N/A

N/A

N/A

Ref

N/A

2.82

1.00

7.89

16.70 (2.34-119.18)

.005

N/A

N/A

9.42

N/A

.009

Insertive

.33

0.44

0.58

1.40 (0.59-3.28).45

Receptive

1.08

0.41

7.00

2.94 (1.32-6.53)

.008

Both

N/A

N/A

N/A

Ref

N/A

Never or sometimes

.65

0.30

4.65

1.91 (1.06-3.45).03

Every time

N/A

N/A

N/A

Ref

N/A

No

–.97

0.35

7.73

0.38 (0.19-0.75)

.005

Yes

N/A

N/A

N/A

Ref

N/A

Psychotropic drug use before last anal intercourseNo
Yes
Anal sexual positioning in P6M

dFrequency of condom use in anal intercourse in P6M

Current syphilis infectiona

AOR: adjusted odds ratio.

b

N/A: not applicable.

cRef: reference.

dP6M: past 6 months.

Sexual Behaviors and HIV-Related Knowledge by
Ethnicity
To further understand behavioral and HIV knowledge
differences among ethnic groups, we conducted additional
analyses. As shown in Table 3, there was a marginal level ofstatistical difference in HIV-related knowledge between

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participants of non-Han and those of Han ethnicity (410/446,
91.9% vs 179/186, 96.2%, P=.05). The 2 groups did not differ
in other variables. We also conducted analyses for 3 ethnic
groups: Han, Zhuang, and others. However, 3 groups did not
differ regarding scores of HIV knowledge (see Table S1 in
Multimedia Appendix 1).

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Table 3. Sexual behaviors and HIV-related knowledge by ethnicity group among young men who have sex with men.
Variables

Ethnicity, n (%)

Chi-square (df)

P value

Han

Non-HanNo438 (98.2)

183 (98.4)

0.000 (1)

≥.99a

Yes

8 (1.8)3 (1.6)N/Ab

N/A

442 (99.1)

185 (99.5)

0.000 (1)≥.99a

4 (0.9)1 (0.5)

N/A

N/A

Inconsistent

209 (46.9)

98 (52.7)

1.784 (1).18

Consistent

237 (53.1)

88 (47.3)

N/A

N/A

History of drug use

Psychotropic drug use before last anal intercourse
No
Yes
Condom use in anal intercourse in P6M

c

The number of times participants had anal intercourse in the last week
0165 (37.0)

83 (44.6)

4.102 (2).13

1

137 (30.7)

56 (30.1)

N/A

N/A

2+

144 (32.3)

47 (25.3)

N/A

N/A

No

396 (88.8)

163 (87.6)

0.171 (1)

.68

Yes

50 (11.2)

23 (12.4)

N/A

N/A

No

365 (81.8)

161 (86.6)

2.095 (1)

.15

Yes

81 (18.2)

25 (13.4)

N/A

N/A

Insertive

173 (38.8)

75 (40.3)

0.362 (2).83

Receptive

150 (33.6)

64 (34.4)

N/A

N/A

Versatile

123 (27.6)

47 (25.3)

N/A

N/A

1

136 (30.5)

56 (30.1)

0.009 (1).92

2+310 (69.5)

130 (69.9)

N/A

N/A

No

151 (33.9)

67 (36.0)

0.272 (1)

.60

Yes

295 (66.1)

119 (64.0)

N/A

N/A

<6

36 (8.1)

7 (3.8)3.842 (1).05

≥6410 (91.9)

179 (96.2)

N/A

N/A

No

402 (90.1)

158 (84.9)

3.500 (1)

.06

Yes

44 (9.9)28 (15.1)

N/A

N/A

Having sex with female

Commercial male sexual

Anal sexual positioning in P6M

The number of male sexual partner

Condom use in the last anal intercourse

Score of HIV knowledge

Current syphilis infectionaFisher exact test.

b

N/A: not applicable.

c

P6M: past 6 months.

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Discussion
With 9.3% (59/632) of young men who have sex with men being
HIV-infected in this sample, this study highlighted that HIV
interventions must pay special attention to young men who havesex with men. Previous studies also showed that young men
who have sex with men had a higher HIV incidence and weremore susceptible to recent HIV infection compared to older
men who have sex with men [24]. For example, Mao et alreported an HIV prevalence of 5.4% for young men who havesex with men and 3.6% for men who have sex with men of otherage groups in 7 Chinese cities [24]. Zou et al reported a 35%
annual increase in the number of university students newly
infected with HIV between 2011 and 2015 [28]. This study
found that some behaviors and status were associated with HIV
infection among young men who have sex with men, such as
receptive sexual positioning, a lower frequency of condom use,and current or previous STDs. Therefore, the results of thisstudy could be used to promote interventions targeting young
men who have sex with men.
Although preexposure prophylaxis is an effective measure toprevent HIV among men who have sex with men [29], it has
not been implemented as a population-level prevention strategy
in China; therefore, HIV prevention among young men who
have sex with men mainly focuses on behavioral interventions
to reduce risk behaviors and promote HIV screening. Safe sex
education must be promoted by targeting young men who havesex with men who are hard to reach. Some prevention channels
can be added to HIV programs in order to reach young men
who have sex with men, such as through peer educators andusing social media and web-based platforms. STD prevention
must be integrated into HIV programs to increase people’s
awareness of these infections. For HIV clinics, STD history
must be asked, and screening tests must be conducted for people
who screen for HIV to enable early detection and early treatmentof possible STDs. Moreover, a stigma reduction campaign isneeded to reduce the HIV stigma in communities and among
the HIV high-risk population. HIV stigma is not only associatedwith low HIV knowledge and risk behaviors but also prevents
people from receiving HIV tests [27]. Stigma reduction efforts
are suggested through various channels, such as social media,
HIV and STD prevention programs, sex education targeting
young men who have sex with men, and HIV clinics, to further
reduce the negative impacts of HIV stigma on HIV prevention
and care.
We also found that ethnic minority groups must be more
vulnerable to HIV infection. A previous study found that men
who have sex with men ethnic minorities had higher rates of
HIV infection and differed from Han ethnicity in some sexual
behaviors [30]. At the same time, ethnic minorities had
significantly higher current syphilis infection rates than the Hangroup. Moreover, consistent with previous studies [31,32],
current syphilis infection may be associated with HIV infection.
Therefore, screening and treatment of syphilis could be enhanced
and be part of HIV prevention strategies. In addition, the 2groups did not differ in sexual behavioral variables but differedin drug use history and drug use before last anal sex. Ethnic
minority groups in Guangxi were historically disproportionally
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Song et alaffected by drugs; it is possible that the differences in HIV
infection rates were due to the effects of injection drug use
among ethnic groups, although HIV infections caused byinjection drug use have shown a decreasing trend in the region
in general. Future studies could further explore the impact ofinjection drug use on ethnic groups and investigate other factorsthat could possibly be associated with the higher HIV infection
rate of non-Han young men who have sex with men in China.
Further, a cultural competency component must be considered
in local drug and HIV prevention programs to ensure the best
programming outcomes, for example, by providing culturalcompetency training to prevention staff, using multiple
languages or dialects on education materials, and having ethnic
representatives participate in the design and implementation ofthese programs.
Consistent with previous studies [31], our findings indicatedthat the history of STDs in the past 12 months was associatedwith HIV infection. The possible reasons for this were thatulcerative STDs, including syphilis and herpes simplex virus
2, can cause ulcers or lesions in the genital and rectal mucosathat could become entrances for the HIV virus [33].
Nonulcerative STDs, including chlamydia and gonorrhea, canincrease the risk of HIV infection by inducing inflammatory
immune cells or potential HIV target cells or causing tiny
perturbations to the integrity of genital and rectal mucosa
epithelium [34-36]. This finding implied that HIV intervention
strategies must pay more attention to people with a history of
STDs. In addition, this study also underlined the importance ofearly diagnosis and treatment of STDs to further reduce thenumber of new HIV infections.
Unprotected anal intercourse was an established factor
associated with HIV infection. In this study, we further foundthat consistent condom use in the past 6 months was a protective
factor for HIV infection. However, 48.6% (307/632) ofparticipants engaged in inconsistent (never or sometimes)
condom use during the anal intercourse in the past 6 months inthis study. Promoting condom use and behavioral intervention
became an urgent need for HIV prevention, especially for thisyoung group, although this group demonstrated generally good
HIV knowledge. This study showed generally higher rates of
HIV and syphilis infection compared to other men who havesex with men studies in China [16]. One reason was that a
considerable proportion of participants engaged in unprotected
anal sexual behavior (using a condom in the anal intercourse
sometimes or never). Guangxi ranked third highest regarding
reported HIV cases [37]. The relatively high number of HIV
cases might further aggravate the HIV epidemic in Guangxi[26]. Highly active antiretroviral therapy demonstrated benefits
not only on HIV treatment but also on HIV prevention [38].
Therefore, early diagnosis and early initiation of treatment are
crucial to detect potential HIV infections and prevent HIV
transmissions. HIV programs must increase awareness of therisk of unprotected sexual behaviors and promote HIV testingand early treatment in young men who have sex with men.
This study had limitations. The study used a convenient
sampling procedure and was conducted in 4 cities in Guangxi.
Caution might be needed when generalizing the results to otherregions and other populations. Due to the hard-to-reach nature
JMIR Form Res 2023 | vol. 7 | e37344 | p. 8
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JMIR FORMATIVE RESEARCHof the population of men who have sex with men, convenient
sampling is widely used in HIV research to achieve a desirable
sample size. This study could not make a causal inference dueto the cross-sectional study design. Future research could adopt
more rigorous study designs to test the causal relationships
between HIV infection and associated factors among young
men who have sex with men. Moreover, although self-reportbias and social desirability bias might potentially affect theaccuracy of the collected data, especially when sensitive
behavioral data are collected, the self-report method is widelyused in behavior-related data collection and HIV research andcould provide first-hand data. Furthermore, due to the small
number of participants who used psychotropic drugs before thelast anal intercourse, the study had a large 95% CI (2.46-125.31)
for this variable in the multivariate analyses. Future researchSong et al
could expand the recruitment of participants with drug use tofurther assess this association.
To our knowledge, this was the first study that explored factors
associated with HIV infection among young men who have sex
with men in Guangxi using a sample with a considerable portionof ethnic minorities. Our findings called attention to the current
HIV and syphilis epidemics among young men who have sex
with men in Guangxi. Efficient prevention and interventions(ie, condom promotion and preexposure prophylaxis) areurgently needed for this group. Moreover, programs must pay
more attention to some groups for HIV prevention, such as
ethnic minority groups, people with low education levels, people
with STDs, and people who engage in unprotected anal sexual
behaviors. HIV stigma reduction and cultural competency arealso 2 components that could be adopted in HIV prevention andcare efforts to further improve program outcomes.

Acknowledgments
The authors would like to thank Guangxi Centers for Disease Control and Prevention (CDC), Nanning CDC, Liuzhou CDC,
Guilin CDC, and Beihai CDC for their valuable support during the study implementation. This study was supported by the
National Natural Science Foundation of China (NSFC, 81360441).

Authors' Contributions
LS conceived and designed the study in consultation with the other authors. LS designed the questionnaire and study protocol;
GL and WKG collected survey data and supervised biological sample laboratory testing; LS conducted data analyses and drafted
this manuscript; LS and GL interpreted the study results; all authors contributed to writing and editing. All authors reviewed andapproved the final version of the manuscript.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Table S1. Sexual behaviors and HIV-related knowledge by ethnicity among young men who have sex with men.
[PDF File (Adobe PDF File), 100 KB-Multimedia Appendix 1]

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Abbreviations
AOR: adjusted odds ratio
CDC: Centers for Disease Control and Prevention
ELISA: enzyme-linked immunosorbent assay
STD: sexually transmitted disease

Edited by A Mavragani; submitted 16.02.22; peer-reviewed by N Wang, J Mitchell; comments to author 25.05.22; revised version
received 06.09.22; accepted 13.12.22; published 11.01.23
Please cite as:Song L, Yu X, Su B, Geng WK, Lan G, Zhang X
HIV Prevalence and Risk Factors Among Young Men Who Have Sex With Men in Southwest China: Cross-sectional Questionnaire
Study
JMIR Form Res 2023;7:e37344
URL: https://formative.jmir.org/2023/1/e37344
doi: 10.2196/37344
PMID: 36630166©Liping Song, Xiangyuan Yu, Bing Su, Wen Kui Geng, Guanghua Lan, Xiangjun Zhang. Originally published in JMIR Formative
Research (https://formative.jmir.org), 11.01.2023. This is an open-access article distributed under the terms of the Creative
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