Health risk perception and behavioral decision-making among online-dating MSM in Shandong, China: perspectives on HIV and new psychoactive substances

Abstract

Background

Online dating has become a dominant channel for men who have sex with men (MSM) to seek sexual partners in China, exacerbating dual public health challenges of HIV transmission and new psychoactive substances (NPS) abuse. This study aims to explore the perceptions of MSM regarding the risks and harms associated with HIV and NPS in the context of online dating.

Methods

From April to July 2023, MSM were recruited from eight cities in Shandong Province using a combination of snowball sampling, venue-based recruitment, and online methods. A questionnaire survey was conducted to collect demographic information, NPS usage, sexual behavior, and online dating activities of the participants. Blood samples were also collected for HIV and syphilis antibody testing. Missing data were imputed using multiple imputation. Two separate multivariate binary logistic regression models were constructed to identify factors associated with two dependent variables: (1) HIV self-perceived risk and (2) NPS harm awareness among online-dating MSM.

Results

A total of 2,785 online-dating MSM were included in the study. Among them, 37.8% (1,052) perceived their risk of HIV infection as low or negligible, while 10.8% (302) believed that using NPS posed little or no harm to their health. Multivariate logistic regression analysis indicated that MSM with a college education or higher (aOR = 1.202, 95%CI: 1.009–1.431), who engaged in anonymous dating (aOR = 1.298, 95%CI: 1.071–1.574), had no pre-sex HIV testing with online partners in the past 6 months (P6M) (aOR = 1.780, 95%CI: 1.489–2.128), consistently used condoms during sex with online partners in the P6M (aOR = 2.004, 95%CI: 1.693–2.371), syphilis positivity (aOR = 1.957, 95%CI: 1.289–2.971), and had used NPS (aOR = 1.989, 95%CI: 1.687–2.344) were more likely to perceive a high risk of HIV infection. Additionally, MSM younger than 25 years (aOR = 1.649, 95%CI: 1.131–2.405), those with an Shandong registration (aOR = 1.997, 95%CI: 1.179–3.382), those with adequate HIV knowledge (aOR = 3.483, 95%CI: 1.723–7.041), those who do not engaged in group sex in the P6M (aOR = 1.531, 95%CI: 1.097–2.138), those who do not engaged in anonymous dating (aOR = 1.733, 95%CI:1.329–2.261), those who reported inconsistent condom use with online partners in the P6M (aOR = 1.554, 95%CI: 1.208–1.998), and those who had not used NPS (aOR = 1.371, 95%CI: 1.071–1.754) were more likely to have a low awareness of NPS harms.

Conclusions

Online-dating MSM in Shandong Province have insufficient HIV self-perception risk and NPS harm awareness, compounded by anonymous partnering and cognitive-behavioral dissonance. It is recommended to implement subpopulation-targeted interventions, increase warning education, promote informed partnering practices, strengthen NPS harm awareness campaigns targeting youth, reinforce online regulation and health education, leverage online platforms and community organizations to expand intervention coverage, and achieve coordinated HIV prevention and control.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-23153-w.

Background

Globally, men who have sex with men (MSM) remain disproportionately affected by HIV, exhibiting a 23-fold higher risk of acquiring HIV compared to the general population in 2022 [1]. In China, as of December 2024, surveillance data reported that there were 1.355 million people living with HIV/AIDS [2]. Among new infections reported last year, homosexual transmission accounted for 25.2% [2]. This epidemiological pattern is particularly evident in Shandong Province, where sexual transmission constituted 97.7% of existing HIV cases as of October 2022, of which 70.6% were specifically attributed to MSM [3]. The proliferation of online dating platforms, favored by MSM for their anonymity (i.e., users conceal real-world identities through pseudonyms, non-disclosure of personal identifiers, and avoidance of location tracking, thereby decoupling online behaviors from offline identities) and accessibility, has amplified transmission risks [4]. In Shandong, 81.32% of MSM reported seeking sexual partners through digital platforms [5], with studies demonstrating significantly higher rates of condomless intercourse in online encounters compared to offline interactions [6, 7].

Parallel to these behavioral risks, new psychoactive substances (NPS)—synthetic compounds designed to mimic traditional illicit drugs (e.g., synthetic cannabinoids, cathinones)—have emerged as the predominant drugs of abuse in China, surpassing traditional substances (e.g., heroin, cocaine) among the 1.124 million registered drug users in 2022 [8]. Unlike traditional substances, NPS are often marketed as “legal highs” (currently legal substances) with rapidly evolving chemical structures to evade regulatory control [9]. Shandong Province reflects this national trend, with 27.48% of MSM reporting NPS use in 2021 [5], predominantly Rush (88.0%) and Zero Capsule (18.4%) [10]. Pharmacological analyses reveal that NPS exacerbate sexual risk-taking behaviors through dopaminergic hyperactivity, correlating with increased rates of multiple sexual partnerships, group sex, and unprotected anal intercourse among users [11]. This biobehavioral synergy drives outcomes: MSM who used NPS in Shandong had a 4.8-fold increased risk of new HIV infections compared to non-users, and those with sexually transmitted infections (STIs) were 2.77 times more likely to use NPS than non-users [12]. Therefore, the abuse of NPS poses new challenges for HIV prevention and intervention efforts in Shandong Province.

Self-risk perception, defined as an individual’s subjective assessment of both the likelihood and severity of harm from a specific threat [13], serves as a critical predictor of health behavior. This concept aligns with the Health Belief Model (HBM) [14], which posits that perceived susceptibility and severity of a threat directly influence protective actions. In the context of HIV and NPS use prevention, this cognitive appraisal directly shapes behavioral decision-making [15, 16]. However, empirical evidence reveals low risk perception among MSM. For instance, a multi-city U.S. study showed that 74% of MSM perceived their risk of HIV infection to be low [17]. This phenomenon is pronounced in Shandong Province, where 51.1% of MSM perceived low or no risk of HIV infection in 2022 [18]. When it comes to NPS, although 93.1% of MSM recognize NPS addiction potential [18], this awareness rarely translates into an accurate perception of harm. Neurocognitive studies have demonstrated that long-term NPS use impairs prefrontal cortical function, potentially disrupting individuals’ capacity for risk assessment [19]. Moreover, the anonymity of online platforms exacerbates the risk of HIV infection. Collectively, these findings underscore the urgency of investigating self-risk perception dynamics among online-dating MSM, and is essential for designing targeted interventions and breaking the transmission chain of HIV and NPS.

In recent years, despite global evidence on HIV risk perception among MSM, limited studies focus on the intersection of online dating and NPS use in resource-limited settings like China, where stigma and platform anonymity amplify risks [20, 21]. This study aims to explore the characteristics of HIV self-risk perception and NPS harm awareness among online-dating MSM in Shandong Province, and to explore the factors influencing these perceptions. The goal is to provide scientific support for enhancing risk awareness and promoting healthy behaviors among this population, offering new perspectives and methods for HIV and NPS use prevention and control, and thereby safeguarding the physical and mental health of MSM as well as public health security.

Methods

Study design and participant recruitment

This cross-sectional study was conducted from April to July 2023 across eight cities in Shandong Province (Jinan, Qingdao, Zibo, Weifang, Yantai, Linyi, Rizhao, and Jining), selected based on geographical representation (eastern, central, and western regions) and their established HIV surveillance infrastructure. With the assistance of MSM community-based organizations, participants were recruited using a combination of snowball sampling, venue-based recruitment and online methods. Inclusion criteria: Males aged ≥ 16 years who self-reported engaging in same-sex sexual behaviors (oral or anal sex) in the past year and provided informed consent to participate in the survey and serological testing. Individuals who had sought same-sex partners online within the past 6 months (P6M) were included in the analysis. This study was approved by the Medical Ethics Committee of the Shandong Provincial Center for Disease Control and Prevention (Approval Number: SDJK(K)2024-048-01).

Sample size calculation

The sample size was determined according to the National HIV Sentinel Surveillance Implementation Plan (2022 Revision) [22], which calculates the minimum required sample size using the formula for cross-sectional studies: N = Z²_α/2p (1-p) / d², where Z_α/2 = 1.96 (95% confidence level), p = 5% (HIV prevalence), and d = 5% (margin of error). The minimum required sample size per city was 384. To address potential challenges in field implementation and ensure robust estimates for low prevalence populations, the national guideline recommends a standardized sample size of 400 participants per sentinel site. Following this recommendation, we recruited 400 participants in each city.

Measures

Independent variables

A structured questionnaire was adapted from Attachment 2.1 (Questionnaire for MSM) of the National HIV Sentinel Surveillance Implementation Plan (2022 Revision) [22]. Modifications included adding sections on online dating practices and risk perception assessments. The full questionnaire is provided in Supplementary File 1. This questionnaire was administered to collect data on demographic characteristics (age, marital status, sexual orientation, ethnicity, residency, education level), sexual behaviors (group sex, commercial sex, heterosexual encounters), online dating practices (anonymous interactions, pre-sex HIV testing, condom use with online partners), HIV-related knowledge, NPS usage, and engagement with HIV-related prevention services. NPS users were defined as individuals reporting use of methamphetamine, ketamine, ecstasy, rush poppers, or other synthetic psychoactive substances within the past year. HIV knowledge was assessed through eight questions regarding HIV transmission, prevention, and misconceptions. Participants were classified as having “adequate knowledge” if they correctly answered ≥ 6 questions [23]. The utilization of HIV-related prevention services was evaluated based on whether participants had received any of the five relevant prevention services in the past year (peer education, HIV counseling and testing, community-based drug maintenance therapy, needle and syringe provision and exchange, or receipt of free condoms).

Blood samples were collected for serological testing. HIV antibodies were initially screened using an enzyme-linked immunosorbent assay kit (ELISA; Yingkexinchuang, China). Positive samples underwent confirmatory testing with a secondary ELISA (ShanghaiKehua, China). Syphilis antibodies were screened via ELISA (Yingkexinchuang) and confirmed using the toluidine red unheated serum test (TRUST; BeijingWantai, China). A positive result in both tests was considered confirmatory for antibody positivity.

Dependent variables

Self-perception of HIV risk was assessed using the question: “How would you rate your current risk of contracting HIV?” Responses included: none, low, moderate, high. For analysis, responses were dichotomized into low risk (none/low; coded as 0) and high risk (moderate/high; coded as 1). Similarly, NPS harm awareness was evaluated with the question: “How harmful do you believe NPS use is to your health?” Responses were categorized as low harm (none/low; 0) and high harm (moderate/high; 1).

Statistical analysis

All statistical analyses were performed using SPSS (web version 26.0). Descriptive statistics summarized categorical variables as frequencies and proportions. Missing data were addressed using the Multiple Imputation by Chained Equations (MICE) method, which imputes missing values based on observed data patterns. Variables imputed included group sex in the P6M, commercial sex with man in the P6M, and consistent condom use with online partner in the P6M. Five imputed datasets were generated, and there were no significant different results between the imputations and the original data, then pooled estimates were calculated. Sensitivity analyses comparing results before and after imputation revealed no significant differences (Supplementary File 2). Two separate multivariate binary logistic regression models were constructed to identify factors associated with two dependent variables: (1)HIV self-perceived risk and (2) NPS harm awareness. Variables with P < 0.10 in univariate analyses were included in the multivariate models, this threshold was selected to retain potential predictors while avoiding model overfitting. Multicollinearity was assessed using variance inflation factors (VIF < 5) to ensure that the selected variables do not exhibit collinearity issues. Statistical significance was set at P ≤ 0.05 (two-tailed).

Results

Basic demographic characteristics

In this study, a total of 3,235 MSM were recruited, among whom 2,787 MSM sought sexual partners through online dating platforms. After excluding two participants with incomplete risk perception data, 2,785 individuals were included in the analysis. As shown in Table 1, the mean age was 32.96 ± 10.22 years (mean ± SD). The majority were single/separated (71.5%, 1,991), self-identified as homosexual (78.0%, 2,172), and had Shandong Province residency (90.5%, 2,520). Over two-thirds (69.4%, 1,932) attained college-level education or higher, and 57.6% (1,605) reported using NPS in the past year.

Table 1.

Descriptive, univariate and multivariate results of HIV self-perceived risk among online-dating MSM in Shandong, China

Study Variable	Descriptive results			Univariate results		Multivariate results
	Total (%)	Low self-perception	High self-perception	OR (95%CI)	P	aOR (95%CI)	P
Age(years)
< 25	645(23.2)	241(37.4)	404(62.6)	1.000
25–35	1091(39.2)	440(40.3)	651(59.7)	0.883(0.722–1.078)	0.221
≥ 35	1049(37.7)	371(35.4)	678(64.6)	1.090(0.889–1.336)	0.406
Marital status
Married	794(28.5)	311(39.2)	483(60.8)	1.000
Single/Separated	1991(71.5)	741(37.2)	1250(62.8)	1.086(0.917–1.286)	0.338
Sexual orientation
Homosexual	2172(78.0)	821(37.8)	1351(62.2)	1.000
Bisexual  or others	613(22.0)	231(37.7)	382(62.3)	1.005(0.835–1.209)	0.958
Residency (Province)
Shandong	2520(90.5)	958(38.0)	1562(62.0)	0.896(0.688–1.167)	0.417
Non-Shandong	265(9.5)	94(35.5)	171(64.5)	1.000
Education
High school  or lower	853(30.6)	350(41.0)	503(59.0)	1.000		1.000
College or higher	1932(69.4)	702(36.3)	1230(63.7)	1.219(1.034–1.438)	0.019*	1.202(1.009–1.431)	0.039*
Knowledge of HIV
< 6	2743(98.5)	1042(38.0)	1701(62.0)	1.000		1.000
≥ 6	42(1.5)	10(23.8)	32(76.2)	1.960(0.960–4.004)	0.065	1.999(0.950–4.206)	0.068
Group sex in the P6M a
Yes	583(21.1)	240(41.2)	343(58.8)	1.000		1.000
No	2185(78.9)	800(36.6)	1385(63.4)	1.216(1.008–1.466)	0.041*	1.023(0.834–1.256)	0.827
Commercial sex with man in the P6M a
Yes	319(11.6)	135(42.3)	184(57.7)	1.000		1.000
No	2431(88.4)	891(36.7)	1540(63.3)	1.303(1.024–1.658)	0.032*	1.188(0.917–1.538)	0.192
Anonymous during online dating
Yes	2179(78.2)	782(35.9)	1397(64.1)	1.436(1.196–1.723)	< 0.001***	1.298(1.071–1.574)	0.008**
No	606(21.8)	270(44.6)	336(55.4)	1.000		1.000
Ever had a test for HIV before sex with online partner in the P6M
Yes	1855(66.6)	791(42.6)	1064(57.4)	1.000		1.000
No	930(33.4)	261(28.1)	669(71.9)	1.906(1.608–2.259)	< 0.001***	1.780(1.489–2.128)	< 0.001***
Consistent condom use with online partner in the P6M a
Yes	1447(52.0)	451(31.2)	996(68.8)	1.794(1.537–2.094)	< 0.001***	2.004(1.693–2.371)	< 0.001***
No	1336(48.0)	599(44.8)	737(55.2)	1.000		1.000
Received HIV-related prevention services in the past year
Yes	2679(96.2)	1024(38.2)	1665(61.8)	1.000		1.000
No	106(3.8)	28(26.4)	78(73.6)	1.724(1.111–2.673)	0.015*	1.321(0.835–2.090)	0.234
HIV status
Positive	77(2.8)	21(27.3)	56(72.7)	1.639(0.987–2.723)	0.056	1.536(0.902–2.614)	0.114
Negative	2708(97.2)	1031(38.1)	1677(61.9)	1.000		1.000
Syphilis status
Positive	136(4.9)	32(23.5)	104(76.5)	2.035(1.359–3.048)	0.001**	1.957(1.289–2.971)	0.002**
Negative	2649(95.1)	1020(38.5)	1629(61.5)	1.000		1.000
Having used NPS
Yes	1605(57.6)	508(31.7)	1097(68.3)	1.847(1.581–2.158)	< 0.001***	1.989(1.687–2.344)	< 0.001***
No	1180(42.4)	544(46.1)	636(53.9)	1.000		1.000

^a Sample size vary across variables due to missing data. Specific missing counts are as follows: group sex in the P6M (n = 17), commercial sex with man in the P6M (n = 35), and consistent condom use with online partner in the P6M (n = 2). ***,P < 0.001.**,P < 0.01.*,P < 0.05. OR, odds ratio; aOR, adjusted odds ratio; CI, confidence interval; P6M, past 6 months

Sexual behavior and online dating practices

During the past year, 96.2% (2,679) of participants accessed HIV prevention services. Within the past 6 months (P6M), 21.1% (583) engaged in group sex, 11.6% (319) participated in commercial sex, 78.2% (2,179) maintained anonymity with online partners, 66.6% (1,855) underwent pre-sex HIV testing during each sexual encounter, and 52.0% (1,447) reported consistent condom use.

HIV and syphilis infection status

The prevalence of HIV positivity was 2.8% (77), and syphilis positivity was 4.9% (136).

Health risk perception

HIV self-perceived risk

Among online-dating MSM, 37.8% (1,052) perceived their risk of HIV infection as low or negligible, while 62.2% (1,733) perceived their risk of HIV infection as moderate or high.

NPS harm awareness

Among online-dating MSM, 89.2% (2,483) believed that using NPS posed moderate or high harm to their health, while 10.8% (302) believed that using NPS posed little or no harm to their health.

Factors associated with HIV self-perceived risk

Univariate analysis revealed significant differences in HIV self-perceived risk across education level, NPS use, group/commercial sex, anonymous interactions, pre-sex HIV testing, condom use, prevention service uptake, and syphilis status (P < 0.05; Table 1). Multivariable logistic regression showed that college education or higher (aOR = 1.202, 95%CI: 1.009–1.431), anonymous dating (aOR = 1.298, 95%CI: 1.071–1.574), no pre-sex HIV testing with online partners in the P6M (aOR = 1.780, 95%CI: 1.489–2.128), consistent condom use with online partners in the P6M (aOR = 2.004, 95%CI: 1.693–2.371), syphilis positivity (aOR = 1.957, 95%CI: 1.289–2.971), and NPS use (aOR = 1.989, 95%CI: 1.687–2.344) were more likely to have high HIV self-perceived risk.

Factors associated with NPS harm awareness

As shown in Table 2, NPS harm awareness varied significantly by age, residency, HIV knowledge, group sex, anonymous interactions, condom use, prevention services uptake, and NPS use (P < 0.05). In the adjusted multivariate model, MSM younger than 25 years (aOR = 1.649, 95%CI: 1.131–2.405), those with an Shandong registration (aOR = 1.997, 95%CI: 1.179–3.382), those with adequate HIV knowledge (aOR = 3.483, 95%CI: 1.723–7.041), those who do not engaged in group sex in the P6M (aOR = 1.531, 95%CI: 1.097–2.138), those who do not engaged in anonymous dating (aOR = 1.733, 95%CI:1.329–2.261), those who reported inconsistent condom use with online partners in the P6M (aOR = 1.554, 95%CI: 1.208–1.998), and those who had not used NPS (aOR = 1.371, 95%CI: 1.071–1.754) were more likely to have a low NPS harm awareness.

Table 2.

Descriptive, univariate and multivariate results of NPS harm awareness among online-dating MSM in Shandong, China

Study Variable	Descriptive results			Univariate results		Multivariate results
	Total (%)	Low harm awareness	High harm awareness	OR (95%CI)	P	aOR (95%CI)	P
Age(years)
< 25	645(23.2)	87(13.5)	558(86.5)	1.622(1.188–2.214)	0.002**	1.649(1.131–2.405)	0.009**
25–35	1091(39.2)	123(11.3)	968(88.7)	1.227(0.915–1.646)	0.172	1.272(0.940–1.721)	0.119
≥ 35	1049(37.7)	92(8.8)	957(91.2)	1.000		1.000
Marital status
Married	794(28.5)	75(9.4)	719(90.6)	0.811(0.616–1.067)	0.135	1.093(0.763–1.565)	0.627
Single/Separated	1991(71.5)	227(11.4)	1764(88.6)	1.000		1.000
Sexual orientation
Homosexual	2172(78.0)	248(11.4)	1924(88.6)	1.334(0.980–1.817)	0.067	1.202(0.848–1.702)	0.301
Bisexual or others	613(22.0)	54(8.8)	559(91.2)	1.000		1.000
Residency (Province)
Shandong	2520(90.5)	286(11.3)	2234(88.7)	1.992(1.184–3.352)	0.009**	1.997(1.179–3.382)	0.010*
Non-Shandong	265(9.5)	16(6.0)	249(94.0)	1.000		1.000
Education
High school  or lower	853(30.6)	90(10.6)	763(89.4)	1.000
College or higher	1932(69.4)	212(11.0)	1720(89.0)	1.045(0.805–1.356)	0.741
Knowledge of HIV
< 6	2743(98.5)	290(10.6)	2453(89.4)	1.000		1.000
≥ 6	42(1.5)	12(28.6)	30(71.4)	3.383(1.713–6.681)	< 0.001***	3.483(1.723–7.041)	0.001**
Group sex in the P6M a
Yes	583(21.1)	49(8.4)	534(91.6)	1.000		1.000
No	2185(78.9)	251(11.5)	1934(88.5)	1.390(1.008–1.918)	0.045*	1.531(1.097–2.138)	0.012*
Commercial sex with man in the P6M a
Yes	319(11.6)	25(7.8)	294(92.2)	1.000
No	2431(88.4)	264(10.9)	2167(89.1)	1.300(0.770–2.195)	0.315
Anonymous during online dating
Yes	2179(78.2)	205(9.4)	1974(90.6)	1.000		1.000
No	606(21.8)	97(16.0)	509(84.0)	1.835(1.414–2.381)	< 0.001***	1.733(1.329–2.261)	< 0.001***
Ever had a test for HIV before sex with online partner in the P6M
Yes	1855(66.6)	210(11.3)	1645(88.7)	1.163(0.898–1.506)	0.253
No	930(33.4)	92(9.9)	838(90.1)	1.000
Consistent condom use with online partner in the P6M a
Yes	1447(52.0)	135(9.3)	1312(90.7)	1.000		1.000
No	1336(48.0)	165(12.4)	1171(87.6)	1.368(1.076–1.738)	0.011*	1.554(1.208–1.998)	0.001**
Received HIV-related prevention services in the past year
Yes	2679(96.2)	297(11.1)	2382(88.9)	2.519(1.018–6.232)	< 0.001***	2.191(0.873–5.499)	0.095
No	106(3.8)	5(4.7)	101(95.3)	1.000		1.000
HIV status
Positive	77(2.8)	10(13.0)	67(87.0)	1.235(0.628–2.427)	0.540
Negative	2708(97.2)	292(10.8)	2416(89.2)	1.000
Syphilis status
Positive	136(4.9)	14(10.3)	122(89.7)	1.000
Negative	2649(95.1)	288(10.9)	2361(89.1)	1.063(0.603–1.873)	0.833
Having used NPS
Yes	1605(57.6)	152(9.5)	1453(90.5)	1.000		1.000
No	1180(42.4)	150(12.7)	1030(87.3)	1.392(1.096–1.768)	0.007**	1.371(1.071–1.754)	0.012*

^a Sample size vary across variables due to missing data. Specific missing counts are as follows: group sex in the P6M (n = 17), commercial sex with man in the P6M (n = 35), and consistent condom use with online partner in the P6M (n = 2). ***,P < 0.001.**,P < 0.01.*,P < 0.05. OR, odds ratio; aOR, adjusted odds ratio; CI, confidence interval; P6M, past 6 months.

Discussion

With the proliferation of online dating platforms, MSM increasingly favor digital partner-seeking due to its unparalleled accessibility, anonymity, and expanded social networks—features that facilitate discreet connections while paradoxically amplifying health risks. Provincial surveillance data from 2021 indicated that 81.32% of Shandong MSM utilized digital platforms for partner-seeking [5], a trend corroborated by our 2023 findings showing an 86.2% adoption rate, demonstrating accelerating platform dependence. This digital shift presents dual effect: while enhancing social connectivity, it exacerbates the transmission risks of HIV and NPS. Notably, the widespread anonymity in online interactions—where 78.2% of participants concealed their identities from digital partners—acts as a key risk amplifier. Online anonymous dating, as a potential driver of high-risk behaviors, increases the complexity of the dating environment and the risk of HIV infection [24]. These findings call for increased attention to and intervention for MSM engaging in online dating, while leveraging digital platforms to expand the reach of such interventions.

Our study found that 37.8% of MSM considered their risk of HIV infection to be low or negligible. However, 48.0% of MSM reported engaging in unprotected sex with online partners, and 21.1% reported engaging in group sex, indicating insufficient risk awareness and a significant disconnect between self-risk perception and actual behaviors. This discrepancy may stem from the “optimism bias” prevalent in developing countries [25], where higher levels of optimism bias may lead high-risk individuals to underestimate their risks and miss opportunities to seek HIV prevention services [26]. Our study also found that higher education was associated with elevated HIV risk perception (aOR = 1.202). While educated individuals often possess greater awareness of HIV transmission routes and prevention strategies, they may engage in broader sexual networks due to increased social mobility or access to digital platforms, amplifying exposure to high-risk encounters [27]. They may also recognize the potential risks associated with high-risk behaviors, and thus self-perception of their risks to be higher [28]. Besides, consistent condom use was associated with elevated risk perception (aOR = 2.004), suggesting that MSM who take protective measures may overestimate risk due to heightened vigilance about their partners’ health status [29, 30]. Even with the protective measure of condom use, they still perceive a high risk of infection. Therefore, it is crucial to conduct HIV testing or inquire about health status before engaging in sexual activities. This aligns with our finding that MSM who do not conduct pre-sex HIV test are more likely to perceive higher HIV infection risk, indicating that the virtual nature of online platforms makes it difficult for MSM to obtain accurate health information about their partners before sex, thereby perceiving higher infection risks. Advocating pre-sex testing can effectively reduce HIV infection risks and is key to promoting informed sexual behaviors [31]. However, the proportion of MSM who conduct HIV testing before online sex (66.6%) still needs improvement. Therefore, future interventions should emphasize self-protection, promote informed sexual behaviors, and raise awareness about HIV testing.

Equally concerning is the underestimation of NPS-related harms, with 10.8% of MSM perceiving minimal health risks—a misperception disproportionately concentrated among youth (age < 25: aOR = 1.649) and provincial residents (aOR = 1.997). This may stem from the recreational rebranding of NPS as “club drugs” or “recreational drugs”, misleading MSM into viewing them merely as tools to facilitate sexual encounters while obscuring their health risks [32]. Even occasional NPS use can induce cumulative toxicity and neurological damage [33], highlighting critical gaps in current prevention campaigns that fail to communicate harms. The underestimation of NPS harm among youth may be related to their higher acceptance of new things, making them more susceptible to the influence of social media and party culture, and less vigilant about the dangers of NPS. The underestimation among provincial residents reflects insufficient publicity efforts and localized interventions targeting NPS, despite their dominance in provincial drug use patterns. These findings underscore the need for targeted interventions, particularly for youth and local residents, leveraging social media, school-based education, and community organizations to disseminate concrete evidence of NPS harms—especially their association with HIV transmission risks. Notably, group sex contexts often involve NPS use, where participants primarily acquire substance-related knowledge through peers [34]. This aligns with our finding that MSM who did not engage in group sex had lower NPS harm awareness, as non-participants lack firsthand exposure to peer-informed risk discussions. Furthermore, non-users of NPS predominantly rely on fragmented media narratives for harm awareness, lacking comprehensive understanding of pharmacological mechanisms. Comparative studies indicate that active users demonstrate 23% higher accuracy in recognizing specific toxic effects [35], which corroborates our observation of lower harm awareness among non-users. The study also find a negative association between HIV knowledge and NPS harm awareness (aOR = 3.765), reflecting the absence of NPS-specific content in traditional HIV education. This highlights a knowledge-behavior gap among MSM, indicating that general health literacy fails to translate into substance-specific harm reduction. This discrepancy likely reflects ineffective, single-modality health education [36]. Interventions must adopt integrated strategies that bridge cognitive understanding and behavioral practice.

The study found that MSM engaged in online dating in Shandong Province have insufficient HIV self-perception risk and NPS harm awareness, compounded by anonymous partnering and cognitive-behavioral dissonance. To enhance risk perception among MSM, the following measures are recommended. First, implement stratified interventions, deploying AI-driven alert systems to deliver targeted information to high-risk subgroups via big data profiling, such as embed real-time risk alerts during partner matching, flag high-risk profiles (e.g., users seeking anonymous/unprotected sex) and deliver tailored prevention messages. Second, enhance warning education by using real-life case studies and visual aids to highlight the dangers, eliminating the lucky mentality among some MSM and awakening their risk perception. Third, promote safe sexual practices and informed dating, emphasizing the importance of pre-sex testing for online-dating MSM, encouraging them to undergo HIV testing and take necessary protective measures before engaging in sexual activities with online partners and mandate pop-up warnings during high-activity hours (10 PM–2 AM). We propose setting mobile testing units in areas with high online-dating activity and establishing partnerships with online platforms to promote regular testing among their users. Additionally, improve publicity about the dangers of NPS, especially among young people in schools. Collaborating with community organizations to organize workshops led by peer educators, which can provide credible information and foster open discussions. To address the dual risks of HIV and NPS, we recommend integrating NPS-related content into existing HIV prevention programs, such as offering joint counseling sessions that highlight the synergistic risks of NPS use and HIV transmission. By integrating online platform regulation with real-world initiatives, Shandong has the potential to transform digital platforms from vectors of transmission to frontiers of prevention.

This study has several limitations that should be acknowledged. First, despite selecting cities across eastern, central, and western Shandong to enhance geographical diversity, the sample was limited to eight urban centers. This may introduce selection bias by oversampling MSM with stronger health-seeking behaviors. Additionally, reliance on snowball sampling and venue-based recruitment likely amplified social network homogeneity, disproportionately including MSM embedded in interconnected communities or active in specific venues. These limitations may restrict the generalizability of findings to rural populations or regions with distinct sociocultural norms. Second, the reliance on self-reported data introduces potential response bias. Participants may underreport stigmatized behaviors (e.g., group sex, NPS use) due to social desirability bias or overestimate protective practices (e.g., condom use) to align with perceived health norms. Although anonymous surveys and trained interviewers were used to mitigate this risk, future studies should incorporate objective measures to validate self-reports. Furthermore, recall bias may affect the accuracy of behaviors reported over the 6-month recall period. Third, the cross-sectional design precludes causal inferences. Longitudinal studies are needed to explore temporal dynamics between risk perception and behavioral changes. Finally, although multiple confounders were adjusted for in the analysis, unmeasured variables (e.g., mental health status, socioeconomic pressures, or platform-specific dynamics) may influence both risk perception and behavioral outcomes. Future research should incorporate these factors to provide a more comprehensive understanding of the mechanisms driving risk-related decision-making among online-dating MSM.

Conclusions

In conclusion, this study highlights the suboptimal risk awareness among online-dating MSM in Shandong Province and calls for implementing multilayered, digitally-integrated interventions to enhance risk perception and promote safer sexual practices in this population.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Abbreviations

MSM

Men Who Have Sex with Men

NPS

New Psychoactive Substances

STI

Sexually Transmitted Infection

P6M

Past 6 Months

ELISA

Enzyme Linked Immunosorbent Assay

TRUST

Toluidine Red Unheated Serum Test

MICE

Multiple imputation by chained equation

VIF

Variance Inflation Factor

OR

Adjusted Odds Ratio

AOR

Adjusted Odds Ratio

95% CI

95% Confidence Interval

Author contributions

YC performed data curation and analysis, wrote the main manuscript. HY, XZ, LL, LW, YZ and NZ conducted field investigations for the study. GW provided research supervision. WM and ML designed the study, supervised research implementation, and revised the manuscript. All authors reviewed the manuscript.

Funding

This work is supported by the National Key Research and Development Program of China (2017YFE0103800, 2022YFC2304905) and Shandong Provincial Medical and Health Science and Technology Development Program (2019WS430, 2019WS427). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Data availability

For the protection of participants’ privacy, the research data in this manuscript cannot be made publicly available. Requests for data access should be directed to the corresponding author.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Institutional Review Board of Shandong Center for Disease Control and Prevention. All procedures involving human participants were conducted in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments. All study participants provided informed consent prior to participation in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.