Abstract
Many men who have sex with men (MSM) in low and middle income countries search for male sexual partners via social media in part due to societal stigma and discrimination, yet little is known about the sexual risk profiles of MSM social media users. This cross-sectional study investigates the prevalence of social media use to find male sex partners in Hanoi, Vietnam and examines associations between social media use and sociodemographic and behavioral characteristics, including levels of internalized, perceived and enacted stigma, high-risk sexual behaviors, and HIV testing. 205 MSM were recruited from public venues where MSM congregate as well as through snowball sampling and completed an anonymous survey. MSM who found their male sexual partners using social media in the last year were more likely to have completed a university or higher degree (aOR 2.6; 95% CI: 1.2–5.7), experience high levels of MSM-related perceived stigma (aOR 3.0; 95% CI: 1.1–8.0), and have more than 10 lifetime male sexual partners (aOR 3.2; 95% CI: 1.3–7.6) compared to those who did not use social media. A niche for social media-based interventions integrating health and stigma-reduction strategies exists in HIV prevention programs for MSM.
Keywords: men who have sex with men, social media, sex partners, HIV, Vietnam
Introduction
The HIV epidemic in Vietnam is primarily concentrated among key populations including people who inject drugs (PWID), female sex workers (FSW), and men who have sex with men (MSM) (1). Although the incidence and prevalence of HIV infection have decreased in recent years among PWID and FSW, the rates among MSM have increased across several regions in Vietnam (2). This increase is prominent in major cities, such as Hanoi and Ho Chi Minh City, where the country’s MSM population is largely concentrated (3). In 2013, the HIV prevalence in the MSM population in Hanoi was approximately 13–16% (4, 5).
MSM face increased vulnerability to HIV infection and challenges in the HIV care continuum due to a combination of biological, behavioral, social and structural factors (6). For instance, stigma, discrimination and societal- and health care-level homophobia are associated with increased sexual risk behaviors, such as unprotected anal intercourse, and poorer access to community social support and health services (7, 8). These factors are in turn associated with higher rates of HIV infection and decreased rates of HIV testing (8, 9). In the last 5 years, more Vietnamese MSM are openly displaying their sexual identities in urban settings due to rapid globalization, spread of LGBT rights movements, and shifting attitudes towards acceptance of homosexuality (8). Despite this progress, stigma and discrimination remain pervasive in Hanoi and public spaces where MSM can congregate and find sexual partners are still limited as compared to Ho Chi Minh City in the southern Vietnam or other cities in Southeast Asia (8, 10). As a result, MSM often hide their sexual identities using more discrete and perhaps riskier methods, such as Internet-based technologies, to engage in sexual activity (10, 11).
Online communities of MSM have historically been “hidden” environments in which MSM are able to freely display their sexual identities without being socially judged or ostracized (10). The Internet and particularly the rapid expansion of Web 2.0 Internet-based websites (sites) and applications (apps) have also transformed the way in which MSM search for and find sexual partners through user-driven social media content. In just the last five years, Vietnam experienced a 22-fold increase in the number of urban social media users (12). Globally, Internet and social media use have been shown to be considerably higher among MSM than in the general population, both for non-sexual social networking and for seeking sex partners (10, 13). Social media platforms include both general sites for social networking, such as Facebook, and apps for mobile-based technology that are specifically designed for MSM to meet sexual partners, such as Grindr. This virtual environment enables MSM to seek sexual partners in quicker, easier and more discrete ways, allows for anonymity of both the seeker and the sexual partner, and provides MSM with the ability to display various versions of personal and sexual preferences (14). In contrast to Western countries, this behavior has not been quantified in Vietnam or elsewhere in Asia.
The impact that this pattern of sexual networking has on high-risk sexual behaviors remains controversial. MSM who find sex partners using social media sites or apps tend to have greater numbers of sexual partners overall, increased levels of unprotected anal intercourse, and higher likelihood of having sexual intercourse with anonymous as well as HIV-positive individuals (15–17), but in some studies, online sexual networking is only associated with sexual partner number and not high-risk sexual behaviors (18–20). Directionality is a particular challenge: whether using the Internet increases risky behaviors in MSM and subsequent HIV risk or if MSM who practice risky sexual behaviors are more likely to use the Internet to seek sex partners is unclear.
Given the popularity of social media sites and apps and the rapid rise of HIV infection rates among MSM in Vietnam, research exploring the extent to which MSM use social media to find sexual partners and understanding the association between the use of social media to find sexual partners and HIV risk is essential. In this paper, we describe the prevalence of social media use to find male sexual partners among MSM and the sociodemographic and behavioral characteristics among MSM who use social media for sexual networking. To our knowledge, our study is the first to address this issue in Vietnam.
Methods
Study Setting, Design, Population, and Recruitment:
We conducted a cross-sectional anonymous survey at the Sexual Health Promotion (SHP) Clinic at Hanoi Medical University (HMU) from February to May 2016. Social workers and outreach staff from the Center for Research and Training on HIV/AIDS (CREATA) at HMU recruited participants from 25 known social congregating areas for MSM and through snowball sampling. To enroll in the study, participants had to be at least 18 years old and male, have had sexual intercourse with one or more men in the past three months, have lived in Hanoi for at least three months, be willing to undergo HIV/STI testing and drug screening, and complete written informed consent forms. Participants were paid 200,000 Vietnamese Dong (VND; $10.00 USD) as compensation for their time. For each referred participant who completed the study, the referring participant was compensated an additional 100,000 VND.
The study was approved by the Institutional Review Boards at the University of North Carolina at Chapel Hill and Hanoi Medical University.
Measures:
Participants completed a 174-item questionnaire administered by trained SHP social workers and sexual health counselors.
Basic Demographics:
Demographic questions included age, education level, employment status, marital status, current roommates, years lived in Hanoi, gender identity, sexual preference, and disclosure of having sex with men.
In Vietnam, MSM identify their gender using terms such as “female” and “male” as well as the terms “gay” and “bisexual,” although the last two terms are primarily used in Western culture to describe sexual orientation. Vietnamese MSM view gender based on appearance, mannerisms, and self-perceived levels of masculinity and feminism, with “male” and “female” falling on two ends of the spectrum and “gay” and “bisexual” in between (9, 21). “Male” includes men who are masculine in appearance and often hide the fact that they have sex with other men. “Female” includes men who dress as females publicly and are usually open about having sex with men. “Bisexual” includes men who identify partly as female and partly as male, while “gay” refers to men who are openly homosexual and may appear or behave effeminately. Although sexual preference is separate from gender identity, openness about one’s sexual preference influences one’s gender identity (9, 21).
Stigma:
We measured enacted, perceived, and internalized stigma using the MSM-related stigma scale developed and piloted in Hanoi, Vietnam (22). Each item used a 4-point Likert scale and composite scores were calculated for each dimension of stigma. Based on the distribution of responses, measures of internalized and perceived stigma were dichotomized as “high” or “low,” with “high” levels of stigma representing those scoring at the 75th percentile or higher. Enacted stigma was dichotomized as “any” or “none” with “none” representing participants who reported “never” on the Likert scale for all questions on enacted stigma.
Violence:
Questions on violence were derived from the CDC’s Bio-Behavioral Surveys Questionnaires Modules Team and included lifetime history of physical abuse and sexual coercion, assault or rape (23).
Sexual behaviors:
To assess sexual behaviors, we included questions on lifetime number of male sexual partners, multiple male sexual partners in the past 3 months, condom use during the last sexual intercourse with a male, alcohol consumption during or within 3 hours prior to sexual intercourse with a male in the past 3 months, anonymous male sexual partners in the past 3 months, and ever had sex with a woman. We also asked if participants ever exchanged anal sex with a male for drugs, money, food, items, or a place to live.
Substance use:
Participants reported on history of injection and non-injection drug use and completed the AUDIT-C brief alcohol screen.
Testing behaviors:
We asked participants if they were ever tested for HIV or other STIs, including gonorrhea, chlamydia, syphilis, herpes, HPV, or HBV.
Social media use:
We asked participants if they had used a social media website or mobile-based application to find male sexual partners in the past year and to report specific social media sites and apps used for sexual networking.
Statistical Analyses:
All analyses were conducted in Stata version 14 (College Station, TX, USA). Our main outcome was using social media at least once to search for a male sexual partner in the last year. Associations between the outcome and socio-demographic variables, sexual behaviors, substance use, stigma, physical and sexual violence, and history of HIV and STI testing were assessed using bivariable logistic regressions. Factors associated with the main outcome with p-value less than 0.20 and those hypothesized to be associated based on our literature review were assessed for collinearity and entered into a multivariable logistic regression model.
Results
Sociodemographic characteristics:
A total of 205 MSM participants completed questionnaires. The mean age of participants was 24.7 years; most participants were 20–29 years of age (Table 1). Over half (56.1%) had completed a university degree or higher, more than 80% of the sample had either a full-time or part-time job and about one-third were students at the time of the study.
Table 1:
Sociodemographic characteristics by use of social media for sexual networking
| Overall (N=205) | MSM who used social media for sexual networking in the last year (N=157) | MSM who did not use social media for sexual networking in the last year (N=48) | |
|---|---|---|---|
|
| |||
| N (%) | N (%) | N (%) | |
|
| |||
| Age | |||
| 18–19 years | 15 (7.3) | 10 (6.4) | 5 (10.4) |
| 20–24 years | 104 (50.7) | 78 (49.7) | 26 (54.2) |
| 25–29 years | 62 (30.2) | 52 (33.1) | 10 (20.8) |
| 30–39 years | 20 (9.8) | 14 (8.9) | 6 (12.5) |
| ≥40 years | 4 (1.5) | 3 (1.9) | 1 (2.1) |
| Highest Education | |||
| Primary school | 2 (1.0) | 1 (0.6) | 1 (2.1) |
| Secondary school | 12 (5.8) | 7 (4.5) | 5 (10.4) |
| High school | 76 (37.1) | 53 (33.8) | 23 (47.9) |
| University or higher | 115 (56.1) | 96 (61.1) | 19 (39.6) |
| Employmenta | |||
| Full-time | 89 (45.4) | 72 (48) | 17 (37) |
| Part-time | 70 (35.7) | 51 (34) | 19 (41.3) |
| Unemployed | 37 (18.9) | 27 (18) | 10 (21.7) |
| Current student | |||
| Yes | 76 (37.1) | 59 (37.6) | 17 (35.4) |
| No | 129 (62.9) | 98 (62.4) | 31 (64.6) |
| Marital Status | |||
| Single | 189 (92.2) | 145 (92.4) | 44 (91.7) |
| Married | 15 (7.3) | 11 (7.0) | 4 (8.3) |
| Separated/Divorced | 1 (0.5) | 1 (0.6) | 0 (0) |
| Currently living withb | |||
| Relatives | 79 (38.5) | 64 (40.8) | 15 (31.2) |
| Friends | 72 (35.1) | 50 (31.8) | 22 (45.8) |
| Spouse | 9 (4.4) | 6 (3.8) | 3 (6.2) |
| Sex partner | 20 (9.8) | 15 (9.6) | 5 (10.4) |
| Alone | 35 (17.1) | 26 (16.6) | 9 (18.8) |
| Time living in Hanoi | |||
| 3–6 months | 20 (9.8) | 12 (7.6) | 8 (16.7) |
| 6–12 months | 10 (4.9) | 7 (4.5) | 3 (6.3) |
| 1–2 years | 23 (11.2) | 16 (10.2) | 7 (14.6) |
| 2–5 years | 40 (19.5) | 30 (19.1) | 10 (20.8) |
| Greater than 5 years | 112 (54.6) | 92 (58.6) | 20 (41.6) |
| Sexual Identity | |||
| Female | 5 (2.4) | 4 (2.5) | 1 (2.1) |
| Male | 135 (65.9) | 100 (63.7) | 35 (72.9) |
| Bisexual | 7 (3.4) | 5 (3.2) | 2 (4.2) |
| Gay | 56 (27.3) | 46 (29.3) | 10 (20.8) |
| Don’t know | 2 (1) | 2 (1.3) | 0 (0) |
| Self-reported sexual preference | |||
| Men only | 123 (60.3) | 100 (64.1) | 23 (47.9) |
| Both men and women | 65 (31.9) | 49 (31.4) | 16 (33.3) |
| Women only | 16 (7.8) | 7 (4.5) | 9 (18.8) |
| Disclosure of being MSM | |||
| Wife or female sex partner | 2 (1) | 1 (0.6) | 1 (2.1) |
| Parents | 19 (9.3) | 18 (11.5) | 1 (2.1) |
| Other relatives | 31 (15.1) | 26 (16.6) | 5 (10.4) |
| Non-MSM friends | 77 (37.6) | 62 (39.5) | 15 (31.2) |
| Other MSM | 154 (75.1) | 123 (78.3) | 31 (64.6) |
| Colleagues | 5 (2.4) | 3 (1.9) | 2 (4.2) |
| Healthcare providers | 6 (2.9) | 6 (3.8) | 0 (0) |
| MSM-related stigmac | |||
| Internalized stigmac | |||
| High | 60 (29.3) | 45 (28.7) | 15 (31.2) |
| Low | 145 (70.7) | 112 (71.3) | 33 (68.8) |
| Perceived stigmac | |||
| High | 52 (25.4) | 45 (28.7) | 7 (14.6) |
| Low | 153 (74.6) | 112 (71.3) | 41 (85.4) |
| Enacted stigma | |||
| Any | 166 (81) | 134 (85.4) | 32 (66.7) |
| None | 39 (19) | 23 (14.6) | 16 (33.3) |
| Ever been physically abused | |||
| Yes | 40 (19.5) | 31 (19.7) | 9 (18.8) |
| No | 165 (80.5) | 126 (80.3) | 39 (81.2) |
| Ever been sexually abused | |||
| Yes | 58 (28.3) | 44 (28) | 14 (29.2) |
| No | 147 (71.7) | 113 (72) | 34 (70.8) |
For Employment, N=196
For Current Roommates, reported values are not mutually exclusive
High defined as >/= 75 th percentile
Participants mostly identified their gender as male (65.9%) or gay (27.3%) and mostly preferred only male sexual partners (60.3%). Seventy-five percent of MSM disclosed their same-sex sexual desires and behaviors to other MSM whereas less than one-third of the sample did so to individuals outside of the MSM community. About 25% reported high levels of MSM-related internalized (29.3%) and perceived (25.4%) stigma, and the majority of participants (81%) reported experiencing any form of MSM-related enacted stigma at least once in their lifetime.
Sexual behaviors, substance use and testing history:
The mean number of lifetime male sexual partners was 29.4 (median=8; range 1–500). Two-thirds of MSM reported unprotected anal intercourse at the last sexual intercourse, almost half reported having multiple or anonymous male sexual partners, and about one-third had consumed alcohol within temporal proximity to sexual intercourse in the last 3 months (Table 2). One-third of participants reported a lifetime history of male sex work. Sixty-three percent reported hazardous alcohol consumption, while 28.3% reported a history of illicit drug use. Just over two-thirds of the sample reported having tested at least once for HIV in their lifetime.
Table 2:
Sexual risk factors, substance use and testing behaviors by use of social media for sexual networking
| Overall (N=205) | MSM who used social media for sexual networking in the last year (N=157) | MSM who did not use social media for sexual networking in the last year (N=48) | |
|---|---|---|---|
|
|
|||
| N (%) | N (%) | N (%) | |
|
| |||
| Lifetime number of male sex partnersa | |||
| Median | 8 | 10 | 5.5 |
| Range | 1–500 | 1–500 | 1–90 |
| Had CAIb at last sexual intercoursec | |||
| Yes | 116 (63) | 93 (66.4) | 23 (52.3) |
| No | 68 (37) | 47 (33.6) | 21 (47.7) |
| Had multiple anal sexual partners, last 3 monthsd | |||
| Yes | 110 (53.9) | 88 (56.4) | 22 (45.8) |
| No | 94 (46.1) | 68 (43.6) | 26 (54.2) |
| Had anonymous anal sexual partners, last 3 months | |||
| Yes | 101 (49.3) | 80 (51) | 21 (43.8) |
| No | 104 (50.7) | 77 (49) | 27 (56.2) |
| Used alcohol before or during anal sex, last 3 months | |||
| Yes | 56 (27.3) | 43 (27.4) | 13 (27.1) |
| No | 149 (72.7) | 114 (72.6) | 35 (72.9) |
| Ever exchanged anal sex for money or goods | |||
| Yes | 67 (32.7) | 45 (28.7) | 22 (45.8) |
| No | 138 (67.3) | 112 (71.3) | 26 (54.2) |
| Ever had sex with a woman | |||
| Yes | 81 (39.5) | 57 (36.3) | 24 (50) |
| No | 124 (60.5) | 100 (63.7) | 24 (50) |
| Current hazardous alcohol consumption (AUDIT-C score >=4) | |||
| Yes | 130 (63.4) | 96 (61.1) | 34 (70.8) |
| No | 75 (36.6) | 61 (38.9) | 14 (29.2) |
| Ever used illicit drugs (injection and non-injection) | |||
| Yes | 58 (28.3) | 45 (28.7) | 13 (27.1) |
| No | 147 (71.7) | 112 (71.3) | 35 (72.9) |
| Ever tested for HIV | |||
| Yes | 141 (68.8) | 114 (72.6) | 27 (56.2) |
| No | 64 (31.2) | 43 (27.4) | 21 (43.8) |
| Ever tested for other STIe | |||
| Yes | 96 (46.8) | 77 (49) | 19 (39.6) |
| No | 109 (53.2) | 80 (51) | 29 (60.4) |
For lifetime number of male sex partners, N=201
CAI: condomless anal intercourse
For CAI at last sexual intercourse, N=184
For multiple anal sexual partners, last 3 months, N=204
other STI includes: syphilis, gonorrhea, chlamydia, herpes, HPV, HBV, HCV
Use of social media for sexual networking:
Overall, 76.6% of MSM participants reported using social media at least once in the last year to find a male sexual partner. The most common social media platforms used for sexual networking were Facebook (67.3%), Jack’d (63.4%) and Zalo (62.9%). Comparatively, 21.5% of MSM sought male sexual partners at saunas or massage parlors, 13.7% at parks, and 9.8% at bars or clubs at least once in the last year.
Factors associated with using social media to find male sex partners:
In bivariate analysis, MSM who completed a university or higher education (OR=2.4; 95% CI: 1.2–4.6), had a sexual preference for only men (OR=5.6; 95% CI: 1.9–16.6), had a sexual preference for both men and women (OR=3.9; 95% CI: 1.3–12.3), lived in Hanoi for 5 or more years (OR=2.0; 95% CI: 1.1–3.8), experienced any form of MSM-related enacted stigma in their lifetime (OR=2.9; 95% CI: 1.4–6.1), had more than 10 male sexual partners in their lifetime (OR=2.2; 95% CI: 1.1–4.3), and ever tested for HIV (OR=2.1; 95% CI: 1.1–4.0) were significantly more likely to use social media to find male sex partners in the last year compared to MSM without a university degree, with a sexual preference for only women, who had lived in Hanoi for less than 5 years, and who reported never experiencing enacted stigma or testing for HIV, respectively (Table 3). MSM who had exchanged anal sex for money or goods at least once in their lifetime were less likely to find sex partners using social media than those who did not (OR=0.5; 95% CI: 0.2–0.9).
Table 3:
Factors associated with using social media for sexual networkinga
| Bivariable logistic regression | Multivariable logistic regressionb | |
|---|---|---|
|
| ||
| cOR (95% CI) | aOR (95% CI) | |
|
| ||
| Education | ||
| University or higher | 2.4** (1.2, 4.6) | 2.6** (1.2, 5.7) |
| High school or less | 1.0 | 1.0 |
|
| ||
| Time living in Hanoi | ||
| Greater than 5 years | 2.0* (1.1, 3.8) | 1.4 (0.6, 2.9) |
| Less than 5 years | 1.0 | 1.0 |
|
| ||
| Self-reported sexual preference | ||
| Men only | 5.6*** (1.9, 16.6) | 6.0*** (1.1, 16.1) |
| Both men and women | 3.9* (1.3, 12.3) | 3.9* (1.2, 13.4) |
| Women only | 1.0 | 1.0 |
|
| ||
| MSM-related perceived stigma | ||
| High | 2.4 (1.0, 5.6) | 3.0* (1.1, 8.0) |
| Low | 1.0 | 1.0 |
|
| ||
| MSM-related enacted stigma | ||
| Any | 2.9** (1.4, 6.1) | 1.8 (0.7, 4.4) |
| None | 1.0 | 1.0 |
|
| ||
| Lifetime number of male sex partners | ||
| ≥10 | 2.2* (1.1, 4.3) | 3.2** (1.3, 7.6) |
| <10 | 1.0 | 1.0 |
|
| ||
| Ever exchanged anal sex for money or goods | ||
| Yes | 0.5* (0.2, 0.9) | 0.6 (0.2, 1.5) |
| No | 1.0 | 1.0 |
|
| ||
| Ever tested for HIV | ||
| Yes | 2.1* (1.1, 4.0) | 1.5 (0.7, 3.3) |
| No | 1.0 | 1.0 |
cOR: crude odds ratio; aOR: adjusted odds ratio; CI: confidence interval
All variables significant at either the bivariate or multivariate level are displayed in the table
Model adjusted for age
p<0.05
p<0.01
p<0.005
In the age-adjusted multivariable model, a university or higher education (aOR 2.6; 95% CI: 1.2–5.7), a sexual preference for only men (aOR 6.0; 95% CI: 1.1–16.1), a sexual preference for both men and women (aOR 3.9; 95% CI 1.2–13.4), high levels of MSM-related perceived stigma (aOR 3.0; 95% CI: 1.1–8.0), and more than 10 lifetime male sexual partners (aOR 3.2; 95% CI: 1.3–7.6) remained significantly associated with social media use.
Discussion
Social media use has rapidly increased among the MSM community in Hanoi in the last decade, with more than 75% of MSM using social media sites or apps to find a male sexual partner compared to only 35% reported in 2008 (24). While the prevalence of social media use in Hanoi is consistent with that among Taiwanese and Chinese MSM (19, 25), it is much higher than that reported in several Western countries (17, 26). We also observed that social media use is replacing traditional methods of finding male sexual partners in what are known as MSM “hot spots”. These “hot spots” include public places such as parks and lakes, bars, saunas and massage parlors. Although MSM were recruited from these various MSM-specific physical locations and through participant referral, our study may miss MSM who are uncomfortable with approaching the research center, disclosing their sexual orientation or reporting personal sexual behaviors. Thus, we cannot comment on the demographic profiles of the MSM who may be unaccounted for in our study and whether their social media usage is higher or lower than what we measured. Regardless, how this increasing trend to use social media to find sex partners continues or changes over the next several years will influence the design and success of sexual health interventions aimed at HIV prevention.
MSM who found sexual partners through social media were more educated and have lived in Hanoi for a longer period of time compared to those who did not find sexual partners through social media. These findings have been described in the literature previously (27, 28) and likely represent the impact of urbanization, social influence and greater access to higher education in cities, all of which facilitate exposure to media and technology. In contrast to several other studies (13, 16–17), we did not observe an association between age and social media use. One possible explanation for this is the skewed demographics of our sample population, with 88% of participants under 30 years. It is important to consider age when interpreting these results as younger MSM tend to congregate in large, metropolitan areas in Vietnam (29), and younger individuals globally are also more aware of Internet- and social media-based technologies (30). Nonetheless, public health professionals should be aware that social media-based health promotion interventions for the MSM community might not appropriately target individuals with lower education, who may be less connected to community and health services (31, 32). Traditional approaches to sociobehavioral interventions, such as community outreach, community-based public events, and mass media, should not be abandoned in light of increased use of technology. Furthermore, future research should also seek to investigate the acceptability of social-media based interventions among higher-educated Vietnamese MSM in order for successful implementation.
Our study supported the fact that MSM who use social media to find sexual partners have same-sex sexual preferences, either exclusively or to some degree. MSM with same-sex sexual preferences have reported several motivations to use social media, such as the ease of finding male sexual partners, more personal safety permitted by anonymity and avoiding negative interpersonal contact in social settings, such as bars or clubs (33, 34). MSM with male sexual preferences may also be more likely to find male partners on social media with similar sexual preferences as themselves and thus, able to enter into long-term relationships. In environments that are less accepting of same-sex intimate relationships, these MSM may be particularly likely to utilize social media to find long-term sexual relationships.
MSM who used social media to find sex partners report significantly higher levels of perceived and enacted forms of MSM-related stigma. In the United States, higher levels of HIV/AIDS-related stigma were associated with greater time spent on social networking sites (35). Fear of inadvertent disclosure of sexual orientation to the local community and wanting to avoid in-person stigma can strongly influence MSM to use social media for sexual purposes (6, 28, 35). Our findings are one of the first to suggest that stigma and discrimination originating from an external source, such as family, health care professionals or the general community, are associated with sexual networking on social media. Moreover, we found that perceived stigma is more strongly associated with social media use to find sex partners than enacted stigma. Experiencing stigma often causes increased distress in people, which results in heightened anticipation of stigma as well as modified behaviors and coping mechanisms to avoid enactments of stigma (36). Online communities are known to provide less visible forums and sources of support for stigmatized communities (35, 37); however, our study reveals that online sexual networking may actually be directly associated with the fear and anticipation of stigma rather than the actual enactments of stigma. More importantly, if MSM who experience increased levels of perceived stigma are more likely to use discrete methods to find sexual partners, these MSM may also be at risk for avoiding healthcare services, including sexual health and HIV testing services. Social media-based HIV interventions for MSM should integrate stigma reduction programs in order to raise awareness about HIV transmission, how stigmatizing practices can impact the health of MSM including HIV testing, and engage discussions among online communities of MSM that inform risk assessment and safe sex decision making.
Social media use for sexual networking was associated with greater than 10 lifetime male sexual partners but with no other high-risk sexual behaviors, consistent with findings in Asia and the United States (18–20, 24, 38–39). As the data are cross-sectional, it is unclear whether MSM who have more sexual partners tend to use social media as an efficient means to find sexual partners, or whether the use of social media allows individuals to find sexual partners more efficiently, thereby driving the behavior, or if there is a synergistic effect. A greater proportion of MSM who found sexual partners using social media compared to those who did not, reported unprotected anal intercourse at their last sexual intercourse and had multiple anal sexual partners and anonymous anal sexual partners in the last 3 months in our study, although these estimates may be imprecise. These behaviors may possibly be underreported due to social desirability bias, as participants self-reported their sexual and testing behaviors. Social media can facilitate these high-risk behaviors by encouraging frequent, quick, anonymous sexual encounters that do not create a space for safe-sex discussions and preventive measures (40). Another explanation can be that increasing familiarity and comfort with social media sites and apps and their users over time may lower one’s perceived susceptibility to HIV and other STI’s. Among social media users, the length of time spent on a single social media app and the number of partners attained using that one app were positively correlated with unprotected anal intercourse with the last partner met on that specific app (41). One explanation is that usage patterns such as number of social media platforms used and length of time spent on each site and app, content of profiles and communication on social media platforms, and the purpose of partner-seeking, whether casual or romantic, may be related to one’s perception of risk of acquiring HIV. Although no studies have explored these relationships, these factors may ultimately be important determinants of the relationship between using social media, high-risk sexual behaviors and awareness about HIV risk and transmission among its users.
MSM who had ever exchanged sex for money or goods, also known as male sex workers (MSW), were less likely to use social media to find their sex partners. This observation may indicate that these men are using public spaces, such as parks, tea stalls, saunas, and massage parlors, as the primary method of finding sex partners. Furthermore, MSW in our sample were significantly less likely to own any technologic device, including a smartphone, computer or tablet compared to MSM who did not sell sex (data not shown). Reasons for this are unclear, but socioeconomic factors may be affecting this sub-group of MSM as most MSW in Hanoi report selling sex to other men primarily for economic survival (42). Specifically, resource constraints may limit the use of technology-based methods of social and sexual networking among MSW. Additionally, perhaps greater supply and demand and ease of transaction create a more profitable environment for MSW in physical venues compared to virtual environments, which can be slower paced as individuals search for “matches” based on preferences. The implications of these findings are important as several studies have shown that MSW have higher rates of HIV infection than the rest of the MSM population (42–44). Our study suggests that social media-based interventions may not be as effective with MSW compared to health promotion interventions that are aimed through more traditional channels, such as community- and clinic-based settings. In fact, these methods of engagement with MSW have been met with high levels of acceptability and have had a positive impact on HIV testing and health-seeking intentions in this subgroup of MSM (44).
MSM who found sex partners through social media were more than twice as likely to have been tested for HIV at least one in their life, consistent with studies in China (15, 39). Social media users may have greater access to HIV services or may be more aware of HIV services. It is unclear whether MSM who use social media to find sex partners tend to be more aware of their risk behaviors and therefore get tested for HIV more frequently, are more likely to be high-frequency users of the Internet which provides information on HIV testing services, or whether these social media sites and apps actually provide health resources directly, either through HIV-related content, community outreach activities or HIV-related conversations taking place among MSM. We know that a majority of MSM in Vietnam is willing to use the Internet to seek information on HIV prevention and care, and almost 75% of MSM indicate they would use social networking sites to do so (45). Furthermore, Vietnamese MSM who sought male sexual partners through the Internet were also 3.6 times more likely to be willing to use the Internet for HIV care information than those who did not (45). Thus, Internet-based health promotion interventions may have a unique niche within social media platforms and a greater impact for MSM who utilize these e-resources to find their sex partners.
Conclusion:
Social media use among MSM to find male sexual partners in Hanoi is rapidly evolving to replace traditional methods of sexual networking. At the same time, there are groups of MSM, such as MSW, who may still prefer or are confined to finding sexual partners in public and semi-public venues. A deeper understanding of how the local social and cultural environment shapes online sex-seeking preferences, content and behaviors is required to identify MSM with potential high-risk behaviors and risk of HIV. Moreover, evaluating the conditions under which online sexual networking takes places, while keeping in mind that technology should not necessarily replace in-person services based on the needs of the target population, will provide insight into the development of acceptable and successful social media-based HIV prevention interventions and community engagement strategies for MSM.
Funding:
This study was funded by the Centers for Aids Research, University of North Carolina at Chapel Hill (grant number: UNC CFAR P30 AI50410).
Footnotes
Compliance with Ethical Standards:
Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed consent: Informed consent was obtained from all individual participants included in the study.
Conflict of Interest: The authors declare that they have no conflict of interest.
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