Abstract
Background: Monkeypox (Mpox) was declared a public health emergency by World Health Organization (WHO) in 2024. This study aimed to identify subpopulations of men who have sex with men (MSM) in Chongqing, China, who may perceive themselves to be at risk of Mpox infection. Methods: In September 2023, a cross-sectional online survey was conducted with the support of non-governmental organizations (NGOs). A total of 760 MSM were recruited to assess their socio-demographic characteristics, Mpox-related knowledge and awareness, risk perceptions, behavioral risk factors, and willingness to receive Mpox vaccination. Results: Among the participants, 219 (28.8%) were HIV-positive. Significant heterogeneity was observed across HIV statuses in terms of geographic origin, household registration, education level, income, sexual role, and other factors. After adjusting for age, a multivariable linear regression model revealed that Mpox risk perception was positively associated with higher levels of Mpox knowledge (β = -0.64, 95% confidence intervals (CI): -1.01 to -0.27, P < 0.001), experiences of stigma or discrimination (β = -0.20, 95% CI: -0.31 to -0.08, P < 0.001), and willingness to be vaccinated (β = 0.76, 95% CI: 0.64 to 0.88, P < 0.001). It was negatively associated with lower educational attainment and fewer high-risk sexual behaviors (β = 0.30, 95% CI: 0.12-0.48, P = 0.001). Conclusions: HIV-positive MSM, particularly those of lower socioeconomic status and educational attainment, tend to perceive themselves at lower risk of Mpox infection. Future interventions targeting MSM should focus on enhancing disease knowledge, fostering inclusive attitudes, and offering psychological support. Broader societal efforts to promote tolerance and reduce stigma are also essential.
Keywords: Mpox, HIV, perception risk, MSM, cross-sectional study
Introduction
Monkeypox is an endemic zoonotic disease caused by the Monkeypox virus (MPXV), primarily transmitted from animals to humans [1]. Prior to 2022, cases outside of western Africa were rare and typically linked to importation from endemic regions. By December 2023, the World Health Organization (WHO) had reported over 93,689 confirmed cases across 100 countries and territories [2], including 1,611 cases documented in China as of November 30, 2023 [3]. In August 2024, a renewed outbreak of Mpox in African countries prompted the WHO Director-General to declare it a public health emergency of international concern [4].
Transmission of Mpox from animals to humans can occur through direct contact with infected materials, or through bites or scratches from infected animals. Human-to-human transmission has also been reported, primarily by skin-to-skin and sexual contact, particularly among individuals with multiple sexual partners [5]. Accordingly, research has shown that men who have sex with men (MSM) were at higher risk for Mpox infection [6]. This trend was particularly evident during the 2022 global Mpox outbreak, when a high proportion of cases occurred among MSM populations outside traditional endemic regions [7]. WHO has reported that over 90% of recent Mpox infections have occurred within the MSM community, confirming it as the highest-risk population [2].
Previous studies have also shown that MSM were at higher risk of HIV infection compared to the general male population. During the multi-country Mpox outbreak, WHO reported that among 8,200 documented cases, HIV status was available for 3,200 cases, with 52% being HIV-positive, most of whom were MSM [6]. Hospitalization rates were also higher among HIV-positive individuals compared to those without HIV.
Many MSM have limited knowledge about Mpox, engage in casual sex, and have multiple sexual partners. A survey of 2,000 MSM in central China revealed that only 30% consistently used condoms throughout sexual intercourse [5]. Therefore, it is important to understand how MSM subpopulations perceive their own risk of Mpox infection. Unlike prior studies that predominantly focused on epidemiological patterns of monkeypox transmission [5], our research employs a mixed-methods approach to systematically investigate both risk perception and the sociopsychological factors contributing to stigma, including media-driven fear amplification and preexisting societal biases against marginalized communities. This dual-perspective analysis addresses critical gaps in understanding how structural inequities and cognitive heuristics jointly sustain discrimination during emerging zoonotic outbreaks. Accordingly, this study aimed to assess perceived risk of Mpox infection and its related determinants among MSM in Chongqing, China.
Materials and methods
Study sites and sampling
Chongqing, located in southwestern China, is the largest municipality directly governed by the Chinese central government. The city is known for its relatively high tolerance and reduced stigma towards MSM, as evidenced by the fact that Chongqing is one of the major urban centers for the male homosexuality in China [8]. Due to the hidden nature of the MSM population, traditional probability-based sampling methods are not suitable. Therefore, this study employed a cross-sectional design, utilizing an online survey conducted over a one-month period in September 2023. A convenience sample of 760 MSM was recruited through social media advertisements, with support from non-governmental organizations (NGOs) that provide services to the MSM community. The analysis in this study includes only respondents who confirmed residency in three central districts in Chongqing (Figure 1).
Figure 1.
The flowchart of selecting process. Men who have sex with men (MSM), human immunodeficiency virus (HIV).
Study instruments
The questionnaire was developed based on a WHO fact sheet on Mpox epidemics and existing questionnaires from previously published studies on Mpox awareness and risk perception. A pilot test involving 50 MSM participants was conducted online with the assistance of NGOs. Based on feedback from the pilot, revisions were made to improve the clarity and accessibility of the questionnaire for the target population. Recruitment was facilitated through online platforms, which directed participants to a survey hosted on Wenjuanxing (Ranxing Information Technology, Changsha, China). All data were self-reported. The final questionnaire comprised five modules: socio-demographics (15 items), Mpox knowledge (11 items), perceived and behavioral risks (10 items), Mpox awareness (9 items), and perceptions and willingness to vaccinate (10 items).
Reliability and validity analysis
The questionnaire demonstrated strong reliability and validity. Principal component analysis with varimax rotation was conducted to assess construct validity. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.844, and Bartlett’s Test of Sphericity was statistically significant (P < 0.001), indicating that the data were suitable for factor analysis.
Variables and measurements
Mpox knowledge
Mpox knowledge was assessed using 11 questions covering three domains: sources of infection (5 items), transmission routes (4 items), and susceptible populations (2 items). Correct responses were summed to generate a total score for each participant. A total score greater than 9 was classified as “deep comprehension” of Mpox (Range: 0-12; see Supplementary Table 1). For domain-specific comprehension, scores of ≥ 3 in the infection sources section and > 1 in each of the other two sections were also considered indicative of deep comprehension.
Mpox perception risks
Mpox risk perception was categorized into two dimensions: perceived severity and perceived susceptibility. Perceived severity reflects an individual’s understanding of the consequences of Mpox, while perceived susceptibility refers to perception of individual risk of infection. Perceived severity was measured with 5 questions, and perceived susceptibility was assessed with 4 questions. Each question was rated on a 5-point Likert scale (1 = strongly agree to 5 = strongly disagree). Total scores were aggregated for each dimension, with lower scores indicating higher perceived risk.
Perceptions and willingness to vaccinate
Perceptions of and willingness to vaccinate were evaluated through two constructs: belief in vaccine efficacy and acceptance of vaccination, each assessed by 5 items. Respondents rated each item on a 5-point Likert scale (1 = strongly agree to 5 = strongly disagree). Total scores were summed to estimate participants’ overall perceptions and willingness. (Supplementary Table 2).
Sexually transmitted disease (STD) state
STD status was determined based on participants’ self-reported responses to the relevant questionnaire items.
Statistical analysis
All statistical analyses were performed using R software (version 4.3.1). Continuous variables were analyzed using the Mann-Whitney U test, while categorical variables were analyzed using Pearson’s χ2 test or Fisher’s exact test, as appropriate. Descriptive statistics were used to summarize the distribution of socio-demographic variables, Mpox knowledge, perceived and behavioral risks, Mpox awareness, and perceptions and willingness toward vaccination, stratified by HIV status. Group differences were assessed using a Chi-square test.
A multivariate linear regression model was employed to examine the associations between outcome variables, namely, perceived severity and perceived susceptibility, and selected independent variables, including demographic characteristics, risky sexual behaviors, knowledge level, and attitudes. The model was adjusted for age. Participants were categorized based on self-reported HIV status. Associations were quantified using regression coefficients (β) and 95% confidence intervals (CI). Statistical significance was defined as P < 0.05.
Results
Background information
A total of 838 MSM were initially recruited for the survey. After excluding 78 individuals due to lack of consent or failure to meet predefined inclusion criteria (n = 74), 760 individuals were included in the final analysis. As shown in Table 1, the majority of participants (77.9%) had attained a university degree or higher, and over half (50.3%) reported a monthly income exceeding 5,000 RMB. Among all participants, 219 (28.8%) self-reported as HIV-positive.
Table 1.
Socio-demographic characteristics, sex behaviors, monkeypox-related knowledge, general awareness, and vaccination variables among the MSM population stratified by HIV status in Chongqing, China
| Measure | Total N (%) | HIV positive N = 219 (28.8%) | HIV negative N = 541 (71.2%) | χ2 | P value | ||
|---|---|---|---|---|---|---|---|
| Socio-demographic Characteristic | Region | Yongchuan | 190 (25.0) | 29 (13.2) | 161 (29.8) | 135.10 | < 0.001 |
| Nan’an | 353 (46.4) | 62 (28.3) | 291 (53.8) | ||||
| Jiangbei | 217 (28.6) | 128 (58.5) | 89 (16.4) | ||||
| Register | Rural | 278 (36.6) | 99 (45.2) | 179 (33.1) | 9.87 | 0.002 | |
| Urban | 482 (63.4) | 120 (54.8) | 362 (66.9) | ||||
| Ethnicity | Han | 727 (95.7) | 208 (95.0) | 519 (95.9) | 0.34 | 0.599 | |
| Others | 33 (4.3) | 11 (5.0) | 22 (4.1) | ||||
| Age | Young age | 741 (97.5) | 211 (96.3) | 530 (98.0) | 1.68 | 0.195 | |
| Middle and old age | 19 (2.5) | 8 (3.7) | 11 (2.0) | ||||
| Education level | Junior school and below | 44 (5.8) | 23 (10.5) | 21 (3.9) | 28.03 | < 0.001 | |
| High school and technical | 124 (16.3) | 52 (23.7) | 72 (13.3) | ||||
| College/university and above | 592 (77.9) | 144 (65.8) | 448 (82.8) | ||||
| Marital status | Never married | 108 (14.2) | 30 (13.7) | 78 (14.4) | 0.07 | 0.797 | |
| Ever married | 652 (85.8) | 189 (86.3) | 463 (85.6) | ||||
| Average monthly income last year | Less than 3500 | 156 (20.5) | 48 (21.9) | 108 (20.0) | 10.58 | 0.005 | |
| 3500 to 5000 | 222 (29.2) | 80 (36.5) | 142 (26.2) | ||||
| More than 5000 | 382 (50.3) | 91 (41.6) | 291 (53.8) | ||||
| Roles in sex | 1 | 225 (29.6) | 37 (16.9) | 188 (34.8) | 24.64 | < 0.001 | |
| 0 | 248 (32.6) | 89 (40.6) | 159 (29.4) | ||||
| 0.5 | 287 (37.8) | 93 (42.5) | 194 (35.8) | ||||
| Chronic disease history | Yes | 252 (33.2) | 167 (76.3) | 85 (15.7) | 257.80 | < 0.001 | |
| No | 508 (66.8) | 52 (23.7) | 456 (84.3) | ||||
| Travel history | Yes | 7 (0.9) | 1 (0.5) | 6 (1.1) | 0.19 | 0.665 | |
| No | 753 (99.1) | 218 (99.5) | 535 (98.9) | ||||
| People living together | 1 | 366 (48.2) | 104 (47.5) | 262 (48.4) | 1.22 | 0.544 | |
| 2 | 213 (28.0) | 67 (30.6) | 146 (27.0) | ||||
| 3 or more | 181 (23.8) | 48 (21.9) | 133 (24.6) | ||||
| Fixed sex partner | Yes | 322 (42.3) | 86 (39.3) | 236 (43.6) | 3.34 | 0.188 | |
| No | 376 (49.5) | 119 (54.3) | 257 (47.5) | ||||
| Inconvenient to tell | 62 (8.2) | 14 (6.4) | 48 (8.9) | ||||
| Occupation state | Work in the district or town in the registration | 204 (26.8) | 48 (21.9) | 156 (28.8) | 3.94 | 0.140 | |
| Work in the city or province in the registration | 325 (42.8) | 98 (44.7) | 227 (42.0) | ||||
| Work out of the registration | 231 (30.4) | 73 (33.4) | 158 (29.2) | ||||
| Sex behavior | Frequency of the anal sex within half a year | Never or once a month | 452 (59.4) | 134 (61.2) | 318 (58.8) | 0.69 | 0.953 |
| Twice/three times a month or 4-6 times a month | 255 (33.6) | 71 (32.4) | 184 (34.0) | ||||
| More than 6 times a month | 53 (7.0) | 14 (6.4) | 39 (7.2) | ||||
| Frequency of the oral sex within half a year | Never or once a month | 434 (57.1) | 139 (63.5) | 295 (54.5) | 6.53 | 0.163 | |
| Twice/three times a month or 4-6 times a month | 256 (33.7) | 60 (27.4) | 196 (36.2) | ||||
| More than 6 times a month | 70 (9.2) | 20 (9.1) | 50 (9.3) | ||||
| Frequency of the business sex within half a year | Never or once a month | 726 (95.5) | 205 (93.6) | 521 (96.4) | 3.43 | 0.488 | |
| More than twice a month | 34 (4.5) | 14 (6.4) | 20 (3.6) | ||||
| Frequency of using condoms during sex within half a year | Never or seldom use condoms | 212 (27.9) | 63 (28.8) | 149 (27.5) | 2.19 | 0.702 | |
| Half of time/Most of the time use condoms | 174 (22.9) | 55 (25.1) | 119 (22.0) | ||||
| Always use condoms | 374 (49.2) | 101 (46.1) | 273 (50.5) | ||||
| Unfixed sex partner within half a year | 0 or 1 to 5 | 714 (94.1) | 213 (97.3) | 502 (92.8) | 2.04 | 0.153 | |
| More than 6 | 45 (5.9) | 6 (2.7) | 39 (7.2) | ||||
| State of STD including syphilis, gonorrhea | Never infected | 601 (79.1) | 151 (68.9) | 450 (83.2) | 41.91 | < 0.001 | |
| Ever infected | 111 (14.6) | 60 (27.4) | 51 (9.4) | ||||
| Not clear | 48 (6.3) | 8 (3.7) | 40 (7.4) | ||||
| Frequency of HIV testing | Never/less than once a year | 263 (34.6) | 98 (44.7) | 165 (30.5) | 13.99 | < 0.001 | |
| Once to twice a year/Once to twice a season/Once to twice a month | 497 (65.4) | 121 (55.3) | 376 (69.5) | ||||
| Frequency of syphilis testing | Never/less than once a year | 391 (51.4) | 126 (57.5) | 265 (49.0) | 4.56 | 0.033 | |
| Once to twice a year/Once to twice a season/Once to twice a month | 369 (48.6) | 93 (42.5) | 276 (51.0) | ||||
| Knowledge | Grades | Less than 9 points (have a shallow comprehension) | 298 (39.2) | 77 (35.2) | 221 (40.8) | 2.12 | 0.146 |
| More than 9 points (have a deep comprehension) | 462 (60.8) | 142 (64.8) | 320 (59.2) | ||||
| Awareness | Have an observation of partners’ genitals before the sex behavior | Yes | 651 (85.7) | 183 (83.6) | 468 (86.5) | 1.10 | 0.294 |
| No | 109 (14.3) | 36 (16.4) | 73 (13.5) | ||||
| Go to hospital when symptoms like the Mpox appear | Yes | 727 (95.7) | 212 (99.1) | 515 (95.2) | 0.97 | 0.324 | |
| No | 33 (4.3) | 7 (0.9) | 26 (4.8) | ||||
| Pay attention to the Mpox within last 6 months | Yes | 601 (79.1) | 177 (80.8) | 424 (78.4) | 0.57 | 0.452 | |
| No | 159 (20.9) | 42 (19.2) | 117 (21.6) | ||||
| Vaccine | Be willing to get vaccination | Yes | 687 (90.4) | 205 (93.6) | 482 (89.1) | 3.66 | 0.056 |
| No | 73 (9.6) | 14 (6.4) | 59 (10.9) | ||||
Men who have sex with men (MSM), human immunodeficiency virus (HIV).
Most MSM reported engaging in sexual behaviors at a moderate frequency over the past six months. Notably, fewer than 6% (5.9%) reported having more than six casual sex partners during the same period. The majority of HIV-negative MSM demonstrated a deep understanding of Mpox (Figure 2).
Figure 2.
Understanding of different knowledge modules on monkeypox for different HIV statuses. Men who have sex with men (MSM), human immunodeficiency virus (HIV).
The mean scores for belief in vaccine efficacy and willingness to be vaccinated were 2.07 and 1.59, respectively, indicating a moderately high level of trust in, and acceptance of, Mpox vaccination among the MSM population.
Mpox risk perception
For perceived severity, the mean score was 1.53. HIV-positive individuals exhibited a higher mean score (1.89) compared to HIV-negative individuals (1.57). Among the participants, 205 HIV-positive MSM (93.6%) and 494 HIV-negative MSM (91.3%) reported strong agreement with concerns about skin symptoms caused by Mpox. Additionally, 88.6% of HIV-positive respondents (n = 195) and 85.2% of HIV-negative respondents (n = 461) expressed concern about the potential effect of Mpox on their interactions within the MSM community. In contrast, fewer MSM (78.5% of HIV-positive (n = 172) and 72.8% of HIV-negative (n = 394)) expressed strong concerns about others discovering their sexual orientation or behaviors.
For perceived susceptibility, the overall mean score was 2.21, with HIV-negative and HIV-positive participants reporting mean scores of 2.29 and 2.51, respectively. A total of 57.6% (n = 126) of HIV-positive MSM and 53.4% (n = 289) of HIV-negative MSM expressed high levels of fear regarding the likelihood of Mpox transmission through interactions with other MSM. Conversely, 45.2% (n = 99) of HIV-positive and 49.2% (n = 266) of HIV-negative participants believed that Mpox was not a major concern due to their lack of engagement in high-risk sexual behaviors. However, a significant proportion of respondents expressed concern over increased infection risk in the context of rising case numbers: 67.6% of HIV-positive (n = 148) and 70.3% of HIV-negative respondents (n = 380) reported heightened concern as more cases were reported. Details are shown in Table 2.
Table 2.
Mpox risk perceptions among MSM (n = 760)
| Perceived severity | HIV positive N (%) | HIV negative N (%) |
|
| ||
| Mpox infection-related skin symptoms are a severe problem for me | ||
| Strongly agree | 162 (74.0) | 363 (67.1) |
| Agree | 43 (19.5) | 131 (24.1) |
| Neutral | 10 (4.6) | 29 (5.4) |
| Disagree | 1 (0.5) | 10 (1.9) |
| Strongly disagree | 3 (1.4) | 8 (1.5) |
| The severe symptoms and complications of the Mpox infection frighten me | ||
| Strongly agree | 148 (67.6) | 344 (63.5) |
| Agree | 59 (26.8) | 147 (27.2) |
| Neutral | 8 (3.7) | 35 (6.5) |
| Disagree | 1 (0.5) | 9 (1.7) |
| Strongly disagree | 3 (1.4) | 6 (1.1) |
| Mpox infection would affect my interactions with other gay men | ||
| Strongly agree | 139 (63.5) | 310 (57.3) |
| Agree | 55 (25.1) | 151 (27.9) |
| Neutral | 14 (6.4) | 51 (9.4) |
| Disagree | 7 (3.2) | 20 (3.7) |
| Strongly disagree | 4 (1.8) | 9 (1.7) |
| Mpox infection may reveal my sexual activity to colleagues and non-gay individuals | ||
| Strongly agree | 128 (58.4) | 268 (49.5) |
| Agree | 44 (20.1) | 126 (23.3) |
| Neutral | 22 (10.0) | 92 (17.0) |
| Disagree | 15 (6.9) | 33 (6.1) |
| Strongly disagree | 10 (4.6) | 22 (4.1) |
| Mpox infection would make it difficult for me to face my family | ||
| Strongly agree | 133 (60.7) | 298 (55.1) |
| Agree | 49 (22.4) | 128 (23.7) |
| Neutral | 18 (8.2) | 73 (13.5) |
| Disagree | 11 (5.0) | 31 (5.7) |
| Strongly disagree | 8 (3.7) | 11 (2.0) |
|
| ||
| Perceived susceptibility | ||
|
| ||
| During the interactions with gay men, I am afraid of being more likely to be infected by the Mpox | ||
| Strongly agree | 65 (29.7) | 156 (28.8) |
| Agree | 61 (27.9) | 133 (24.6) |
| Neutral | 48 (21.9) | 139 (25.7) |
| Disagree | 23 (10.5) | 61 (11.3) |
| Strongly disagree | 22 (10.0) | 52 (9.6) |
| With an increasing number of cases being reported, my possibility of infecting Mpox is rising | ||
| Strongly agree | 79 (36.1) | 188 (34.8) |
| Agree | 69 (31.4) | 192 (35.5) |
| Neutral | 46 (21.0) | 98 (18.1) |
| Disagree | 15 (6.9) | 39 (7.2) |
| Strongly disagree | 10 (4.6) | 24 (4.4) |
| I don’t have high-risk sex behavior. Therefore, there is no need for me to worry about the Mpox infection | ||
| Strongly agree | 55 (25.1) | 145 (26.8) |
| Agree | 44 (20.1) | 121 (22.5) |
| Neutral | 79 (36.1) | 142 (26.2) |
| Disagree | 23 (10.5) | 83 (15.3) |
| Strongly disagree | 18 (8.2) | 50 (9.2) |
| I pay more attention to the hygiene in gay contacts. People in the social network have higher risks to get the Mpox | ||
| Strongly agree | 86 (39.2) | 207 (38.3) |
| Agree | 63 (28.8) | 169 (31.2) |
| Neutral | 51 (23.3) | 121 (22.4) |
| Disagree | 15 (6.9) | 27 (5.0) |
| Strongly disagree | 4 (1.8) | 17 (3.1) |
Men who have sex with men (MSM), human immunodeficiency virus (HIV).
Factors associated with Mpox risk perception (Table 3)
Table 3.
Factors associated with perceived severity and susceptibility among MSM with different HIV status
| Characteristic | Perceived severity* | Perceived susceptibility* | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||||
| HIV positive | HIV negative | Total | HIV positive | HIV negative | Total | |||||||
|
|
|
|
|
|
|
|||||||
| β (95% CI) | P | β (95% CI) | P | β (95% CI) | P | β (95% CI) | P | β (95% CI) | P | β (95% CI) | P | |
| Demographic characteristics | ||||||||||||
| Register | ||||||||||||
| Urban | Ref | Ref | Ref | Ref | Ref | Ref | ||||||
| Rural | -0.07 (-0.34-0.20) | 0.603 | -0.05 (-0.20-0.09) | 0.471 | -0.05 (-0.17-0.07) | 0.400 | -0.10 (-0.37-0.17) | 0.473 | -0.13 (-0.29-0.03) | 0.115 | -0.11 (-0.25-0.03) | 0.114 |
| Education level | ||||||||||||
| University and above | Ref | Ref | Ref | Ref | Ref | Ref | ||||||
| High school and technical | -0.16 (-0.50-0.19) | 0.371 | -0.07 (-0.26-0.12) | 0.475 | -0.04 (-0.20-0.11) | 0.602 | -0.13 (-0.46-0.22) | 0.472 | -0.04 (-0.26-0.17) | 0.708 | -0.09 (-0.27-0.09) | 0.329 |
| Junior school and below | 0.35 (-0.11-0.80) | 0.138 | 0.21 (-0.07-0.49) | 0.143 | 0.26 (0.01-0.50) | 0.040 | 0.33 (-0.13-0.78) | 0.162 | 0.04 (-0.27-0.36) | 0.782 | 0.07 (-0.22-0.36) | 0.627 |
| Average monthly income last year | ||||||||||||
| More than 5000 | Ref | Ref | Ref | Ref | Ref | Ref | ||||||
| 3500 to 5000 | -0.01 (-0.32-0.30) | 0.949 | -0.10 (-0.27-0.06) | 0.219 | -0.07 (-0.21-0.06) | 0.275 | -0.04 (-0.35-0.27) | 0.805 | -0.10 (-0.28-0.09) | 0.311 | -0.06 (-0.21-0.10) | 0.464 |
| Less than 3500 | -0.20 (-0.52-0.12) | 0.217 | -0.12 (-0.30-0.05) | 0.172 | -0.07 (-0.22-0.08) | 0.381 | 0.01 (-0.31-0.33) | 0.963 | -0.04 (-0.23-0.16) | 0.705 | -0.01 (-0.18-0.17) | 0.935 |
| Unfixed sex partner within half a year | ||||||||||||
| More than 6 | Ref | Ref | Ref | Ref | Ref | Ref | ||||||
| 0 or 1 to 5 | -0.82 (-1.94-0.30) | 0.152 | -0.58 (-1.52-0.36) | 0.226 | -0.53 (-1.43-0.38) | 0.225 | -1.48 (-2.58- -0.37) | 0.009 | -1.30 (-2.35- -0.25) | 0.020 | -1.22 (-2.28- -1.52) | 0.030 |
| Knowledge | ||||||||||||
| Infection sources | -0.25 (-0.67-0.18) | 0.251 | -0.49 (-0.70- -0.28) | <0.001 | -0.48 (-0.65- -0.31) | <0.001 | 0.04 (-0.39-0.46) | 0.857 | -0.26 (-0.50- -0.02) | 0.031 | -0.40 (-0.60- -0.20) | <0.001 |
| Transmission routes | -0.28 (-0.78-0.22) | 0.268 | -0.50 (-0.76- -0.25) | <0.001 | -0.49 (-0.70- -0.28) | <0.001 | 0.14 (-0.36-0.64) | 0.580 | -0.21 (-0.49-0.08) | 0.157 | -0.31 (-0.56- -0.05) | 0.020 |
| Susceptible populations | -0.64 (-1.01- -0.27) | <0.001 | -0.63 (-0.81- -0.46) | <0.001 | -0.61 (-0.76- -0.46) | <0.001 | -0.37 (-0.74-0.003) | 0.052 | -0.38 (-0.58- -0.18) | <0.001 | -0.45 (-0.64- -0.27) | <0.001 |
| Sex behavior | ||||||||||||
| The frequency of using condoms during sex within half a year | ||||||||||||
| Most of the time/Always | Ref | Ref | Ref | Ref | Ref | Ref | ||||||
| Seldom/Half of time | -0.20 (-0.57-0.16) | 0.271 | 0.30 (0.11-0.49) | 0.002 | 0.33 (0.17-0.49) | <0.001 | 0.21 (-0.16-0.57) | 0.270 | -0.16 (-0.37-0.06) | 0.155 | 0.24 (0.06-0.43) | 0.010 |
| Never | 0.35 (0.03-0.67) | 0.033 | 0.30 (0.12-0.48) | 0.001 | 0.16 (0.01-0.31) | 0.040 | -0.13 (-0.45-0.20) | 0.444 | 0.21 (0.004-0.41) | 0.045 | 0.29 (0.12-0.47) | 0.001 |
| State of STD including syphilis, gonorrhea | ||||||||||||
| Never infected/Not clear | Ref | Ref | Ref | Ref | Ref | Ref | ||||||
| Infected but healed | -0.10 (-0.57-0.37) | 0.673 | 0.51 (0.28-0.75) | <0.001 | -0.48 (-0.66- -0.29) | 0.001 | -0.51 (-0.97- -0.05) | 0.031 | 0.19 (-0.08-0.45) | 0.175 | -0.53 (-0.74- -0.31) | <0.001 |
| Ever infected | 0.90 (0.34-1.46) | 0.002 | 0.49 (0.17-0.82) | 0.003 | 0.01 (-0.28-0.29) | 0.967 | 0.80 (0.24-1.35) | 0.005 | 0.15 (-0.22-0.53) | 0.417 | 0.38 (0.04-0.71) | 0.027 |
| The frequency to test HIV | ||||||||||||
| Once to twice a year/Once to twice a season/Once to twice a month | Ref | Ref | Ref | Ref | Ref | Ref | ||||||
| Never/less than once a year | 0.33 (0.07-0.59) | 0.014 | 0.31 (0.17-0.45) | <0.001 | 0.06 (-0.06-0.18) | 0.300 | 0.04 (-0.23-0.30) | 0.786 | 0.19 (0.02- 0.35) | 0.025 | 0.06 (-0.09-0.20) | 0.445 |
| Attitude | ||||||||||||
| Pay attention to the Mpox within last 6 months VS not | -0.17 (-0.44-0.09) | 0.205 | -0.23 (-0.39- -0.07) | 0.006 | -0.24 (-0.37- -0.10) | <0.001 | -0.01 (-0.27-0.26) | 0.960 | -0.20 (-0.38- -0.02) | 0.030 | -0.23 (-0.40- -0.07) | 0.006 |
| Conceal the disease if getting the Mpox VS not | -0.23 (-0.49-0.03) | 0.086 | -0.23 (-0.37- -0.09) | 0.001 | -0.20 (-0.31- -0.08) | <0.001 | -0.33 (-0.59- -0.07) | 0.012 | -0.20 (-0.36- -0.04) | 0.012 | -0.17 (-0.31- -0.04) | 0.012 |
| Actively stay away from the gay who are suspected Mpox infected VS not | -0.67 (-0.98- -0.37) | <0.001 | -0.73 (-0.91- -0.54) | <0.001 | -0.61 (-0.77- -0.45) | <0.001 | -0.27 (-0.58-0.05) | 0.090 | -0.39 (-0.61- -0.18) | <0.001 | -0.35 (-0.54- -0.15) | <0.001 |
| Perceived susceptibility/Perceived severity | 0.65 (0.55-0.75) | <0.001 | 0.45 (0.38-0.51) | <0.001 | 0.40 (0.34-0.45) | <0.001 | 0.65 (0.55-0.75) | <0.001 | 0.45 (0.38-0.51) | <0.001 | 0.40 (0.34-0.45) | <0.001 |
| Vaccine | ||||||||||||
| Concern the effect of the vaccine VS not | -0.52 (-1.18-0.14) | 0.120 | -0.06 (-0.50-0.38) | 0.787 | -0.11 (-0.47-0.26) | 0.567 | -0.28 (-0.94-0.38) | 0.410 | -0.13 (-0.63-0.36) | 0.604 | -0.24 (-0.67-0.19) | 0.270 |
| Reaction efficacy | 0.47 (0.35-0.59) | <0.001 | 0.37 (0.29-0.44) | <0.001 | 0.35 (0.29-0.41) | <0.001 | 0.59 (0.48-0.71) | <0.001 | 0.49 (0.41-0.57) | <0.001 | 0.49 (0.42-0.56) | <0.001 |
| Self-efficacy | 0.76 (0.64-0.88) | <0.001 | 0.67 (0.59-0.75) | <0.001 | 0.66 (0.59-0.73) | <0.001 | 0.46 (0.32-0.61) | <0.001 | 0.45 (0.34-0.55) | <0.001 | 0.47 (0.37-0.56) | <0.001 |
Adjusted by ages.
Perceived severity
Among HIV-positive individuals, several factors were significantly associated with lower perceived severity of Mpox. These included: limited knowledge of susceptible populations (β = 0.64, 95% CI: 0.27-1.01), no condom use in the past six months (β = 0.35, 95% CI: 0.03-0.67), infrequent HIV testing (β = 0.33, 95% CI: 0.07-0.59), a history of other STDs (β = 0.90, 95% CI: 0.34-1.46), intimacy with potentially infected individuals (β = 0.67, 95% CI: 0.37-0.98).
For HIV-negative individuals, factors associated with reduced perceived severity included: low Mpox knowledge scores, rare condom use (β = 0.30, 95% CI: 0.11-0.49), infection with other STD (β = 0.49, 95% CI: 0.17-0.82), infrequent HIV testing (β = 0.31, 95% CI: 0.17-0.45), low attention to Mpox (β = 0.23, 95% CI: 0.07-0.39), lack of concealment regarding infection (β = 0.23, 95% CI: 0.09-0.37), intimacy with potentially infected MSM (β = 0.73, 95% CI: 0.54-0.91).
Overall, individuals who were less concerned with concealing infection status and those maintaining intimate contact with potentially infected MSM were less likely to perceive Mpox as a serious health threat.
Factors associated with perceived susceptibility
Among HIV-positive individuals, the following factors were significantly associated with higher perceived susceptibility to Mpox infection: fewer than six casual sexual partners (β = -1.48, 95% CI: -2.58 to -0.37), a history of recovery from STDs (β = -0.51, 95% CI: -0.97 to -0.05), greater belief in vaccine efficacy (β = -0.59, 95% CI: -0.71 to -0.48), higher self-efficacy (β = -0.46, 95% CI: -0.61 to -0.32). Conversely, current STD infection was linked to lower perceived susceptibility (β = 0.80, 95% CI: 0.24-1.35).
Among HIV-negative individuals, higher perceived susceptibility was associated with: fewer than 6 casual sex partners (β = -1.30, 95% CI, -2.35 to -0.25), deep understanding of Mpox infection sources and susceptible populations (β = -0.26, 95% CI, -0.50 to -0.02), greater awareness of Mpox (β = -0.20, 95% CI, -0.38 to -0.02), willingness to conceal infection (β = -0.20, 95% CI, -0.36 to -0.04), avoidance of contact with potentially infected MSM (β = -0.39, 95% CI, -0.61 to -0.18). In contrast, infrequent HIV testing was a negative predictor of perceived susceptibility (β = 0.19, 95% CI: 0.02-0.35).
Across the full sample, concealment of infection and avoidance of contact with potentially infected MSM were associated with higher perceived susceptibility to Mpox.
Discussion
Since the Mpox outbreak in 2022, there has been growing concern about its transmission mode, associated risks, and distinct clinical manifestations [7].
In this large-scale cross-sectional study of Mpox awareness and risk perception among HIV-positive and HIV-negative MSM in Chongqing, we identified that HIV-positive MSM demonstrated lower levels of Mpox risk perception. This finding contrasts with previous research. For instance, Yang et al. reported a positive association between HIV status and Mpox risk perception [8]. Similarly, another research suggested that HIV-positive individuals were more likely to perceive themselves at risk of Mpox, possibly due to heightened awareness of their compromised immune systems [9]. This discrepancy may be attributed to differences in health behaviors: HIV-positive individuals in our research may exhibit lower health awareness and reduced perceived vulnerability, possibly leading to underestimation of Mpox-related risks. Interestingly, we also observed that HIV-negative MSM who had recovered from previous STDs demonstrated lower perceptions of Mpox severity. However, their HIV-positive counterparts perceived themselves as high risk. Likely, one paper [10] gave an understandable reason: Most HIV-positive individuals who recover from certain STD, considering themselves fragile, will be more cautious about their Mpox risk perception.
Our study revealed that HIV-positive individuals who engaged in risky sexual behaviors and demonstrated limited attention to their HIV status were less likely to perceive themselves as being at risk of Mpox infection. This finding may be explained by the lower socioeconomic status observed among many participants in our study, which is often associated with limited access to health information and lower health literacy regarding Mpox [11]. Consequently, these men were less likely to perceive Mpox as a high-risk threat and adopt protective behaviors [12]. This finding is different from findings in other studies, which reported a positive association between risky sexual behaviors and higher Mpox risk perception [13,14]. In those studies, participants with higher socioeconomic status tended to be more aware of the risks associated with high-risk sexual behavior and therefore perceived themselves as more vulnerable to infection. Our results suggest that the relationship between socioeconomic status and risk perception among MSM may be context-specific.
Our findings indicate that individuals with lower educational attainment (junior school or below) are less likely to perceive the risk of Mpox infection. Lower education levels are directly associated with limited knowledge about Mpox, which poses a significant barrier to adopting preventive actions [15]. Our findings also underscore the importance of enhancing awareness of Mpox susceptibility among HIV-positive MSM. Specifically, HIV-positive MSM demonstrated lower levels of Mpox knowledge compared to HIV-nagetive participants. Tailored educational interventions are urgently needed for these high-risk populations to enhance disease salience, encourage behavior change, and promote preventative actions [16].
Both HIV-positive and HIV-negative MSM with higher perceived infection risk were more likely to remain alert to Mpox-related information, conceal their disease status, and avoid contact with potentially infected individuals. Notably, stigma and prejudice are critical factors influencing risk perception [17]. In China, where homosexuality remains socially stigmatized, MSM are often perceived as “dangerous” or “immoral”, which further marginalizes these individuals and limits their access to equitable health resources, increasing their vulnerability to infectious diseases [18]. Prolonged social discrimination can lead to mental health issues, including depression and shame [19], which may impair affected individuals’ ability to manage Mpox and other health conditions effectively [20]. Therefore, psychological counseling and supportive services may help alleviate the mental burden faced by MSM. Interviewees also reported heightened concern over visible skin symptoms of Mpox, such as pustules, rashes, and lesions, which may negatively affect their social interactions [21]. These symptoms not only draw public attention but also contribute to intensified stigma and social isolation, leading to exaggerated perceptions of risk. In this context, Mpox risk perception is shaped not only by scientific knowledge or epidemiological data but also by social stigma and structural discrimination [22].
Several limitations of this study should be acknowledged. First, reliance on self-reported data through online questionnaires may have introduced measurement biases. Social desirability bias may have led participants to underreport stigmatized behaviors or overreport compliance with preventive measures, weakening the observed associations between risk perception and actual sexual practices. Additionally, recall bias could further distort the accuracy of retrospective data, particularly in reporting the number of sexual partners and STD history over the past six months. Second, the study’s regional focus on urban Chongqing limits the generalizability of findings to broader MSM populations in China. Socioeconomic disparities and cultural heterogeneity between Chongqing and other Chinese provinces may differentially shape MSM awareness and risk perception of Mpox. For instance, provinces like Guangdong and Zhejiang (reporting 115 and 40 cases, respectively) have shown higher condom use rates among MSM, which may reflect greater awareness and different behavioral responses compared to those observed in Chongqing. Therefore, larger, multiple-center studies are needed. Third, while the study identified individual-level factors, structural determinants, such as public health campaigns and stigma-reduction policies that may influence risk perception, were not examined. For example, government-led Mpox vaccination initiatives implemented during the study period could have influenced participants’ perceived susceptibility and adoption of protective behaviors, thereby acting as unmeasured confounders.
In the future, targeted health interventions should be prioritized to for HIV-positive MSM, given their heightened susceptibility and reduced risk perception of Mpox. This includes integrating mpox prevention into routine HIV care and delivering community-based education to emphasize early screening and behavioral modifications. Concurrently, inclusive societal measures are critical for all MSM populations: stigma reduction by media campaigns and policy advocacy can mitigate discrimination, thereby fostering engagement in health services, while peer-led initiatives and mental health support empower communities to adopt protective practices. These dual strategies - individual-level clinical interventions for HIV-positive individuals and structural-level approaches promoting inclusivity - are individual-level clinical interventions for HIV-positive individuals and structural-level approaches promoting inclusivity.
Conclusion
HIV-positive MSM, particularly those with lower socioeconomic and educational status, often lack fundamental knowledge about Mpox and are less likely to perceive themselves as at risk. Factors associated with Mpox risk perception include educational degree, knowledge of Mpox, engagement in risky sex behaviors, general awareness, and attitudes toward vaccination. Future interventions should focus on enhancing Mpox-related knowledge, fostering non-stigmatizing, inclusive beliefs, and providing psychological support for MSM. A broader societal transformation - toward increased tolerance, reduced stigma, and equitable healthcare access - is imperative to foster more effective prevention and control of Mpox within MSM communities.
Acknowledgements
We would like to thank the NGOs of Sunshine Health Service Center in Chongqing for their kind assistance and coordination throughout the present study. And We thank Liwen Bianji (Edanz) (www.liwenbianji.cn) for editing the English text of a draft of this manuscript. The project was supported by the 2024 Nan’an District Science and Health Joint Medical Research Project (2024-32), Chongqing’s first batch of key public health disciplines (specialties) construction projects (Yuwei Office ([2022] No. 172) - infectious disease prevention and control, and Chongqing Nan’an District’s first batch of district-level public health key disciplines (Nanwei Jianwen [2022] No. 45) - Health emergency.
Disclosure of conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Supporting Information
References
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