Sexual Behaviors And Networks Among College Students Men Who Have Sex With Men Of Gansu Province

Abstract

Aims: In order to understand sexual networks and risk behaviors among college students men who have sex men (MSM) and provide tailored interventions for them. Methods: From November 2020 to July 2021, we conducted a cross-sectional study of college students MSM in Gansu province. Participants were recruited through 15 colleges/universities from 5 cities of Gansu province (Lanzhou, Qingyang, Gannan, Tianshui, and Zhangye cities, as well as Zang Autonomous Prefecture). And participants were eligible if they: (1) were born biologically as a male and self-identified as a male, (2) were currently studying at colleges or universities which located in Gansu province, (3) had sex with a man in last year (oral sex, anal intercourse, or both), and (4) were aged 16 or older. Participants were recruited into this study via a broadcast advertisement placed on "Blued", and Human Immunodeficiency Virus (HIV) voluntary counseling and testing (VCT). Every participant was given a unique survey link to complete anonymously with the support of investigators using the "Wenjuanxing". All of the study participants were informed of the purpose of this study, and information about socio-demographics, HIV-related knowledge, HIV-test, sexual behaviors and networks were collected. Logistic regression models were used to assess relations between variables and sexual risk behaviors and sexual network size. To further assess sexual networks differences between different partner type, Chi square tests were conducted. Software Cytoscape was used to depict sexual networks. Results：A total of 502 participants are included, 68.13% aged less than 21, 90.24% were Han nationality, 22.91% majored in engineering, 50.60% not registered residence in Gansu, 62.15% lived in urban, 73.11% self-identified as homosexual, 39.44% were self-aware of sexual attraction to the same sex during their junior high school years, 34.46% were versatile position, and 83.27% answered at least 6 correctly on the MSM questionnaire, 90.23% answered at least 6 appropriate responses of the young student questionnaire, 71.31% learned about HIV-related knowledge in fewer than five paths, 46.81% ever tested for HIV. And participants indicated that their first sexual intercourse was at 18.19 ± 3.09 years old, 9.76% engaged in group sex, 62.95% used condom during last anal sex

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Among 502 study participants, 27.29% sexual debuted before age of 18. And among those who engaged in group sex, 40.82% sexual debuted before age of 18. As the results shown, men who aged less than 21 were more likely to report sexual debut before age of 18 (aOR=2.34,95%CI: 1.393.93); majored in arts were more likely to report sexual debut before age of 18 (aOR=2.00, 95%CI: 0.96-4.19); self-identified as heterosexual were more likely to report sexual debut before age of 18 (aOR=5.30, 95%CI: 1.42-19.76); self-awareness of sexual attraction to the same sex during undergraduate and above were less likely to sexual debut before age of 18 (aOR=0.20, 95%CI: 0.06- 0.66); sexual debut with a woman were more likely to report sexual debut before age of 18 (aOR=2.93, 95%CI: 1.17-7.37); never engaged in casual sex were less likely to report sexual debut before age of 18 (aOR=0.61, 95%CI: 0.38-0.97); engaged in group sex were more likely to report sexual debut before age of 18 (aOR=1.96, 95%CI: 0.99-3.88).

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Among 502 study participants, 45.82% engaged in casual sex. And among those who engaged in group sex, 88.76% engaged in casual sex. Men who were non-Han nationality were more likely to engage in casual sex (aOR=2.18, 95%CI: 1.09-4.37); compared to oral sex, both receptive position, insertive and versatile position were more likely to engage in casual sex (aOR0=4.14, 95%CI: 1.80-9.52;aOR1=2.12,95%CI: 1.02-4.44;aOR0.5=4.08, 95%CI: 1.99-8.36); test for HIV were more likely to engage in casual sex (aOR=1.94, 95%CI: 1.28-2.95); ever engaged in group sex were more likely to engage in casual sex (aOR=6.49, 95%CI: 2.08-20.25). Among 502 study participants, 79.48% engaged in anal sex. And among those who ever tested for HIV, 90.64% engaged in anal sex. Men who higher than age of 21 were more likely to engage in anal sex (aOR=2.03, 95%CI: 1.07-3.86); test for HIV were more likely to engage in anal sex (aOR=4.05, 95%CI：2.32-7.08); sexual debut with a woman were less likely to engage in anal sex (aOR=0.25, 95%CI: 0.10-0.63); never engaged in casual sex were less likely to engage in anal sex (aOR=0.25, 95%CI: 0.13-0.47).

 

Among 291 study participants, 36.08% used Rush. And among those who engaged in group sex, 66.67% used Rush. Men who majored in arts were more likely to report Rush use (aOR=3.08, 95%CI: 1.14-8.35); not registration in Gansu were less likely to report Rush use (aOR=0.53, 95%CI: 0.30-0.94); self-identified as heterosexual were more likely to report Rush use (aOR=10.20, 95%CI: 1.33-78.10); insertive and versatile position were more likely to report Rush use (aOR1=2.43, 95%CI: 1.01-5.87; aOR0.5=2.34, 95%CI: 1.03-5.29); sexual debut after age of 18 were less likely to report Rush use (aOR=0.42, 95%CI: 0.22-79); never engaged in casual sex were less likely to report Rush use (aOR=0.41, 95%CI: 0.23-0.76); ever engaged in group sex were more likely to report Rush use (aOR=3.28, 95%CI: 1.39-7.73).

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Among 291 study participants, 40.21% engaged in UAI. And among those who learned about HIV-related knowledge in less than five paths, 87.62% engaged in UAI. Men who majored in arts were more likely to engaged in UAI (aOR=3.53, 95%CI: 1.28-9.69); not registration in Gansu were more likely to engaged in UAI (aOR=1.97, 95%CI: 1.14-3.43);had an increasing way of acquiredHIV-related knowledge were less likely to engaged in UAI (aOR=0.47, 95%CI: 0.26-0.87);sexual debut with a woman were less likely to engaged in UAI (aOR=0.06, 95%CI: 0.01-0.63);sexual debut after age of 18 were less likely to engaged in UAI (aOR=0.42, 95%CI: 0.22-0.79).

 

A total of 1936 sexual partner were reported by 339 study participants, and the median sexual network size was 3 (IQR: 1-6). There were no significant differences in condom use among different partner type ( 2=1.79, P=0.41); significant differences were found in knowledge with serostatus among different partner type ( 2=81.04, P<0.001); significant differences were found in Rush use among different partner type ( 2=53.49, P<0.001); significant differences were found in the composition of sexual partners among different partner type ( 2=7.43, P<0.02).

 

Among 339 study participants, 57.23% had a sexual network size ≥3. And among those who sexual debut before 18 years old, 74.72% had a sexual network size ≥3. As the results shown, men who majored in science or engineering or agriculture or medicine were more likely to have a bigger sexual network size (aOR=1.85, 95%CI：1.05-3.28); engaged in anal sex were more likely to have a bigger sexual network size (aOR0=2.46, 95%CI: 0.97-6.25; aOR1=2.90, 95%CI: 1.24-6.76; aOR0.5=2.68, 95%CI: 1.18-6.09); had an increasing way of acquired HIV-related knowledge were less likely to have bigger a sexual network size (aOR=0.45, 95%CI: 0.26-0.77); never test for HIV were less likely to have a bigger sexual network size (aOR=0.58, 95%CI: 0.34-0.99); sexual debut after age of 18 were less likely to have a bigger sexual network size (aOR=0.38, 95%CI: 0.20- 0.70); ever had group sex were more likely to have bigger a sexual network size (aOR=12.82, 95%CI: 2.79-58.86)

 

Conclusions: ⑴ Sex education among college students MSM in Gansu province should be enhanced, and we should take effective measures to help them transform health knowledge into healthy behaviors. ⑵ Sexual risk behaviors, such as Rush use, sexual debut before 18 years old, casual sex, UAI were extremely common among college students MSM. In addition, we found sexual debut before age of 18 was associated with later sexual risk behaviors, it suggests that sex education should be taken as soon as possible in primary school and middle school, so that schoolbased sex education can play an important role in reducing sexual risk behaviors and reducing HIV transmission. ⑶ Most of study participants with a large number of sexual partners and multiple sexual partner types. Carry out peer education for college students MSM who with a large number of sexual partners, which can help HIV-related educations transmitted to MSM who are hard to reach through sexual network, and reducing sexual risk behaviors.

 

Key words: AIDS; MSM; college students; sexual risk behaviors; sexual networks

 

Chapter 1 Introduction

1.1 Research Background

1.1.1 Overview of the AIDS Epidemic

In 1981, Gottlieb et al. discovered a new virus that can cause human immune system defects in men who have sex with men in the United States. The virus was officially named HIV (Human Immunodeficiency Virus) in 1982, and the disease caused by HIV infection is called Acquired Immunodeficiency Syndrome (AIDS) [1-3]. After HIV invades the human body, it destroys the body's immune system, causes tissue and organ damage, causes various opportunistic infections, tumors, etc., and ultimately leads to death. As of 2020, there are 37.7 million HIV-infected and AIDS patients (HIV/AIDS) living worldwide, with a total of 1.5 million new infections throughout the year and 680,000 deaths from AIDS-related diseases [4]. Since the first local HIV infection was detected in drug addicts in Ruili Drug Rehabilitation Center in Yunnan Province in 1989, AIDS has spread rapidly in my country. As of 2020, there are 1.053 million people living with HIV/AIDS in my country, and the infection rate of the entire population is about 9.0/10 000[5]. In 2019, the new HIV infection rate in my country was 5.1/100 000. Overall, the AIDS epidemic in my country is at a low prevalence[6].

The disease burden of HIV/AIDS in my country has been increasing. The HIV/AIDS mortality rate has increased from 0.08/100 000 in 1990 to 1.79/100 000 in 2019, accounting for 84.06% of the deaths from legal infectious diseases and 0.21% of the total deaths in 2019[6-9].

1.1.2 Changes in the transmission of AIDS
The latest data from the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) show that only in Eastern Europe and Central Asia do intravenous drug users (IDUs) account for more than 50% of new HIV infections worldwide, while in other regions, sexual transmission is the main route of transmission [10].
From the late 1980s to the mid-1990s, AIDS was mainly transmitted in my country through the sharing of unclean needles by IDUs; in the late 1990s, blood transmission became the main route of transmission; in 2007, the proportion of newly reported HIV/AIDS cases through sexual transmission exceeded blood transmission for the first time, and gradually increased from 42.3% in 2007 to 97.5% in 2020, of which heterosexual transmission accounted for 4.2% and homosexual transmission accounted for 23.3% (see Figure 1-1) [9, 11].

 

 

1.1.3 MSM and AIDS

Men who have sex with men (MSM) refer to men who have sex with the same sex, also known as male homosexuals, men who have sex with men, etc., including homosexuals, bisexuals and heterosexuals.
Anal intercourse is the most common sexual behavior among MSM, but the rectal mucosa is easily damaged during anal intercourse, creating opportunities for HIV transmission[12-14]. MSM also have a variety of high-risk behaviors such as multiple types of sexual partners, a large number of sexual partners, substance abuse, and casual sex[15, 16]. In addition, unprotected anal intercourse (UAI) is an important way for MSM to express intimacy. Therefore, the risk of MSM contracting HIV is 25 times that of the general population[4].

Among the newly reported HIV/AIDS cases in my country each year, the proportion of male homosexual transmission continues to increase, from 2.5% in 2006 to 23.3% in 2020; according to national AIDS sentinel surveillance data, the HIV infection rate among MSM in my country continues to rise, from 0.9% in 2003 to 8.0% in 2015 (see Figures 1-2) [9, 17, 18].

 

 

1.1.4 College students and AIDS

⑴ The number of college students in my country continues to expand

The Statistical Bulletin on the Development of National Education in 2020 pointed out that my country's gross enrollment rate in higher education has gradually increased from 40.0% in 2015 to 54.4% in 2020. In 2020, the total number of college students in my country reached 41.83 million, an increase of 1.81 million over the previous year; there were 3.1396 million postgraduate students, an increase of 275,900 over the previous year, including 466,500 doctoral students and 2.673 million master's students; there were 32.8529 million ordinary undergraduate and junior college students, an increase of 2.5377 million over the previous year; there were 7.7729 million adult undergraduate and junior college students, an increase of 1.0873 million over the previous year; there were 8.4645 million online undergraduate and junior college students, a decrease of 11.39% over the previous year. 10,000 people[19].

 

⑵ College students have poor knowledge of sexuality and diverse sexual behaviors

The 2019-2020 National College Students' Sexual and Reproductive Health Survey Report pointed out that the average score of college students' sexual knowledge in my country was only 4.16 points (out of 9 points), and less than 1/3 (31.84%) of them passed the test (6 points or above were considered passing). 8.18% of college students did not even answer a single question correctly. More than 2/3 (68.44%) of college students actively searched for sexual knowledge online, and only 52.04% of college students received sex education at school. The average age of college students' first sexual intercourse was 18.52 years old, and college students' acceptance of premarital sex and temporary sex continued to increase. The proportion of college students who had sexual intercourse also gradually increased. By the time they graduated from college, more than half of the students (52.85%) had engaged in penetrative sex. Among college students who had engaged in sexual intercourse, boys had an average of 3.78 sexual partners, 1.5 more than girls. In addition, the sexual behaviors of college students have also become diversified. In the first year, 2.12% of them have had anal sex, and this proportion has risen to 13.37% in the fourth year[20].

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⑶ The AIDS epidemic among college students is not optimistic

From 2010 to 2019, the new HIV/AIDS infection rate among young students fluctuated between 0.05% and 0.09%. The number of newly reported cases among young students increased year by year from 794 in 2010 to 3,422 in 2019. A total of 23,307 cases of young students were reported in the past ten years, mainly in the 18-22 age group. The main route of infection was male-to-male transmission, with a male-to-female sex ratio of 33.9:1. Since 2015, there have been about 3,000 new cases of HIV/AIDS among young students each year, and the growth trend has slowed down, but the 15-17 age group has shown a rapid upward trend [21].

 

⑷ The AIDS prevention and control policy among college students is constantly changing

According to the prevalence of AIDS among college students in my country, it can be divided into the overseas importation period, the spread period, and the growth period. The focus of AIDS prevention and control policies in colleges and universities in different periods is different. Importation period (1985-1989): During this period, except for four Chinese hemophiliacs infected by imported factor VIII preparations, all other HIV/AIDS cases were imported cases. Therefore, international students are the key population for AIDS prevention and control policies in colleges and universities. In 1986, the former Ministry of Health and the State Education Commission jointly issued the "Notice on Conducting AIDS Testing on Foreign Students" [22]. In 1987, six ministries and commissions jointly issued the "Several Provisions on AIDS Monitoring and Management" [23], requiring international students who have been staying in China for more than one year to undergo HIV testing within one month of enrollment.

Spread period (1989-2005): During this period, AIDS gradually spread in my country, and cases began to appear among college students in my country. In 1993, the National Education Commission formulated the "Basic Requirements for College Students' Health Education", which for the first time explicitly required that AIDS-related knowledge be included in college health education[24]; in 1995, the Ministry of Education issued the "Notice on Strengthening AIDS Prevention Education and Carrying out AIDS Prevention and Control Publicity Week Activities" and the "Prescription for School Health Education for AIDS Prevention", which for the first time put forward requirements for school health education for AIDS prevention from the perspective of the competent department[25]; in 2002, the Ministry of Education and the former Ministry of Health jointly issued the "Notice on Strengthening School Health Education for AIDS Prevention", which pointed out that schools did not pay enough attention to AIDS prevention health education and lacked technical support, so the "Basic Requirements for School Health Education for AIDS Prevention" were formulated, requiring that AIDS prevention health education be included in the college teaching plan, and the health department should also provide various technical support and services to schools[26].

Growth period (2006-present): During this period, the number of newly reported HIV/AIDS cases among college students increased rapidly, and was mainly transmitted through homosexual sex. In 2006, the State Council promulgated the "Regulations on the Prevention and Treatment of AIDS" (revised in 2019)[27], which means that AIDS prevention and control has entered the legal stage since then. In 2007, the former Ministry of Health and the Ministry of Education issued the "Basic Knowledge for the Prevention of AIDS among Youth"[28], which listed 10 AIDS-related health knowledge that young people need to master. In 2011, the Ministry of Education and the former Ministry of Health issued the "Opinions on Further Strengthening AIDS Prevention Education in Schools"[26], requiring that comprehensive AIDS prevention and control knowledge and knowledge of voluntary blood donation be included in school education and teaching plans to ensure that by 2015, more than 90% of college students will master comprehensive AIDS prevention and control knowledge. In 2015, the General Office of the former National Health and Family Planning Commission and the General Office of the Ministry of Education issued the "Establishing an Epidemic Reporting System and Further Strengthening AIDS Prevention and Control in Schools"[29], pointing out that the AIDS epidemic among students has increased rapidly, and the main transmission route is male homosexual transmission. Some schools have not done a good job in AIDS prevention education, and require further strengthening of AIDS prevention and control in schools. In 2017, the Ministry of Education issued the "Opinions on Further Strengthening AIDS Prevention and Control in Schools"[29], which pointed out that the AIDS epidemic among students has increased rapidly, and the main transmission route is male homosexual transmission. Some schools have not done a good job in AIDS prevention education, and require further strengthening of AIDS prevention and control in schools. In 2017, the Ministry of Education issued the "Guidelines for Health Education in Regular Institutions of Higher Education"[30], requiring colleges and universities to introduce HIV/AIDS counseling and testing services to college students, and advocated the elimination of discrimination against HIV/AIDS. In 2019, the National Health Commission and ten other ministries and commissions jointly issued the "Notice on Issuing the Implementation Plan for Preventing the Spread of HIV/AIDS (2019-2022)"[31], requiring colleges and universities to set up an HIV/AIDS prevention and control leading group headed by school leaders, and that the knowledge rate of young students on HIV/AIDS prevention and control should reach more than 95%. In 2019, the Ministry of Education and the National Health Commission jointly issued the "Notice on Effectively Strengthening AIDS Prevention Education in Schools in the New Era"[32], requiring the use of a combination of online and offline methods to carry out education and guidance, improve the knowledge rate of HIV/AIDS among students, and enhance self-protection awareness and skills. Colleges and universities should install free HIV self-testing reagents and condom self-service distribution devices on campus.

 

⑸ High-risk sexual behaviors of MSM among college students

In my country, male students receiving undergraduate and junior college education account for about 50.0% of the total number of students, and MSM among college students account for about 3.96% of the total number of male college students. Based on this, it is estimated that there are about 830,000 MSM among college students in my country at present[33]. MSM among college students are in their sexually active period, with relatively open sexual attitudes and behaviors, but they are not aware of the risk of HIV infection and are prone to high-risk sexual behaviors.
The age of first anal intercourse (anal sex) shows a clear downward trend. The median age of first anal intercourse for MSM in my country has dropped from 33 years old for those born between 1940 and 1959 to 18 years old for those born between 1990 and 1996[34]. The first sexual behavior of MSM has a great impact on their future sexual behavior. MSM who have sexual behavior before adulthood are more likely to have high-risk sexual behavior in their future sexual life[35].
The use rate of aphrodisiac substances is high. Sexual enhancement substances such as Rush are rapidly becoming popular among MSM. Rush can help the penis erect, prolong the duration of sexual intercourse, relax the anal sphincter, relieve the user's pain during anal intercourse, and enhance sexual pleasure [36, 37]. 16.7% of young student MSM have used Rush in the past three months. After using sexual enhancement substances, their sexual frequency increased, condom use decreased, and they were more likely to engage in high-risk behaviors such as multi-person sexual intercourse [37].
The Internet provides convenience for finding sexual partners. Male dating software (such as Blued) has broadened the channels for MSM to make friends, and has also become the main way for college MSM to find sexual partners, promoting the occurrence of various high-risk behaviors such as temporary sex and UAI, and increasing their risk of HIV infection [38-40].
The number of sexual partners is large and relatively complex. Among college MSM, 79.4% have 2 or more sexual partners, 19.7% have heterosexual partners, and 4.9% have commercial partners; 58.2% have regular partners, 46.7% have temporary partners, and 39.5% have two types of male sexual partners at the same time; 16.8% have only students as their past sexual partners, 35.0% have only social partners, and 48.2% have both [41, 42].

 

1.1.5 Sexual networks are closely related to HIV transmission

Traditional epidemiological studies mainly focus on individual risk behaviors, ignoring the role of sexual networks in HIV transmission. Analyzing sexual networks not only provides new methods for intervening in high-risk behaviors, but also broadens the scope of HIV transmission research [43].
A sexual network refers to a network of people connected by sexual behavior. An individual in a sexual network is a node in the network. The high-risk sexual behavior of a node not only causes them to be infected with HIV, but also causes other members of the network to be infected [44]. The knowledge and attitudes of nodes in a sexual network can affect the occurrence of high-risk behaviors, and the characteristics of sexual networks, such as the size of the sexual network, the type of sexual partners, and the age, gender, ethnicity, and drug use of sexual partners, can also affect the spread of HIV in the sexual network [43, 45, 46]. In addition, analyzing sexual networks can reveal and explain how "bridge" nodes spread the virus from one group to another (Figure 1-3A), and identify nodes with higher transmission risks (Figure 1-3B) and nodes with higher infection risks (Figure 1-3C). Intervention at these key points can effectively reduce the occurrence of high-risk sexual behaviors and the spread of HIV, and achieve the greatest benefits with less investment of resources.

 

 

1.1.6 Overview of MSM among college students in Gansu Province

Gansu Province reported its first case of HIV infection in 1993[47], and since then, the number of newly reported HIV/AIDS cases has increased year by year across the province. As of 2019, a total of 6,663 surviving HIV/AIDS cases were reported in the province, ranking 25th among the 31 provinces, municipalities, and autonomous regions in the country[48].
As of 2020, there were 581,062 undergraduate and junior college students and 48,472 graduate students in Gansu Province[49]. It is estimated that there are about 12,000 MSM among college students in Gansu Province[33]. The HIV/AIDS epidemic among college students in Gansu Province is at a low prevalence level. From 2010 to 2019, a total of 240 cases of HIV/AIDS among young students were reported, of which 75.00% were transmitted through homosexual intercourse[48]. Against the backdrop of a slowdown in the number of new HIV/AIDS cases among young students nationwide, the number of reported cases among college students in Gansu Province has been increasing year by year[48]. High-risk sexual behavior is the main reason for MSM college students to be infected with AIDS, and intervention in their high-risk sexual behavior is urgent. Currently, most studies in the province focus on IV/AIDS, such as epidemic and influencing factor analysis, patient survival analysis, etc. There is no relevant research on MSM college students, so it is urgent to conduct relevant research on MSM college students in Gansu Province, especially on their high-risk sexual behavior and network characteristics.

 

1.2 Research significance

⑴ Theoretical significance

This study fills the gap in the study of sexual behavior and network of MSM college students in areas with low AIDS prevalence, and has important theoretical significance for preventing the spread of AIDS to campuses.

 

⑵ Practical significance

At the same time, this study provides data support for the prevention and control of AIDS among MSM college students in Gansu Province, and has important practical significance for the next step of formulating intervention measures for MSM college students in Gansu Province and guiding the prevention and control of AIDS in Gansu universities.

 

1.3 Research objectives

⑴ To understand the knowledge of AIDS-related knowledge among MSM college students in Gansu Province;
⑵ To understand the occurrence of high-risk sexual behaviors and influencing factors among MSM college students in Gansu Province;
⑶ To understand the characteristics of the sexual network of MSM college students in Gansu Province;
⑷ To understand the scale of the sexual network of MSM college students in Gansu Province and its impact.