Abstract
Data from 307 young migrant men who have sex with men (MSM) in Beijing were analyzed to examine bisexual behavior and the associated sociodemographic and behavioral factors among Chinese young migrant MSM. More than one-fourth (27%) of the MSM were also concurrently engaged in sexual behavior with women (MSMW). Among MSMW, 8.4% were infected with HIV, and 10.8% with Syphilis, compared to 4.9% and 23.7%, respectively, among men who have sex with men only (MSM-only). Various HIV-related risk behaviors among MSMW were similar to those of MSM-only, such as unprotected anal sex, multiple sexual partners, involvement in commercial sex, and substance use. Compared with MSM-only, MSMW were less likely to have tested for HIV, to participate in HIV prevention activities, and were less knowledgeable about condom use and HIV/AIDS. MSMW also had a higher rate of unprotected sex with female stable sexual partners than with male stable sexual partners (79.5% vs. 59.5%). Results indicated that MSMW were at a very high risk for both HIV infection and transmission. Intervention efforts are needed to target this subgroup of MSM and promote AIDS knowledge and HIV/STD testing among MSMW, and to reduce HIV transmission through MSM’s bisexual behavior.
Keywords: MSM, MSMW, China, bisexual behavior
Introduction
Men who have sex with men (MSM) are among the most-at-risk population in the continuous expansion of the HIV/AIDS epidemic in China, accounting for 32.5% of the newly reported infection cases in 2009 (China Ministry of Health, UNAIDS, World Health Organization, 2009). Many of these MSM are migrants without local residence. As with China’s economic reform and the relaxation of residence registration, there has been an ever increasing the migratory population. In 2009, the number of internal migrants amounted to 211 million, counting for 15% of the nation’s total population (National Population and Family Planning Commission of China [NPFPC], 2010). This growing migratory population has been repeatedly identified as a high-risk population for HIV infection and transmission, as they are young and mobile and have higher rates of HIV/STD infection compared to the general population (He et al., 2009; Yang et al., 2005).
Previous studies have shown that the HIV/STD infection rates among migrant MSM are higher than those among non-migrant MSM (He et al., 2009; Ruan et al., 2009). One study in China found that the HIV infection rate among migrant MSM was 4.3% compared to 1.1% among non-migrant MSM (Ruan et al., 2009). Another study in Guangzhou in China in 2006 revealed that MSM coming from other provinces had higher infection rates of HIV (1.6% vs. 0) and Syphilis (14.5% vs. 7.2%) than local MSM (He et al., 2009). Given the magnitude of migratory population and its high risk for HIV/STD infection and transmission, it is strategically important to develop a better understanding of the MSM subgroup in this migratory population.
One major public health concern with the MSM population is the potential transmission of HIV/STD from this most-at-risk population to the general population (e.g., heterosexual females; Choi, Gibson, Han, & Guo, 2004; Guo, Li, & Stanton, 2011; Lau et al., 2008; Li et al., 2009; Zule, Bobashev, Wechsberg, Costenbader, & Coomes, 2009). Previous studies suggest that men who have sex with men and women (MSMW) may play an important role in HIV transmission because of their bisexual behavior (Aral, 2000; Hightow et al., 2006; Potterat, Rothenberg, & Muth, 1999). By examining sexual network of HIV-infected male college students in North Carolina, Hightow and colleagues found that MSMW occupied “a central position” within the network (Hightow et al., 2006). In the study, MSM-only and heterosexual men formed six discrete sexual networks. However, when MSMW were added to the sample, the previous six sexual networks were all merged into one much larger and denser sexual network with MSMW serving as “nodes” connecting the previously discrete sexual networks.
Many studies using diverse, convenience samples suggest that MSMW engage in fewer sexual risk behaviors than MSM-only, but more than heterosexual men (Doll & Beeker, 1996). A study of 10,295 young MSM in the United States found that MSMW reported fewer unprotected anal intercourses (UAI) with regular and casual sexual partners than MSM-only (Flores, Bakeman, Millett, & Peterson, 2009). Similar results were also found in Thailand (Li et al., 2009) and several African countries (e.g., Malawi, Namibia and Botswana) (Beyer et al., 2010). MSMW were less likely to engage in unprotected receptive anal intercourse than MSM-only based on data between 2005 and 2008 in North Carolina (Zule et al., 2009). Although data regarding sexual risk behaviors among MSMW are limited in China (Ha, Liu, Liu, Cai, & Feng, 2010), existing studies have shown a high prevalence of bisexual behavior among the MSM population (Choi et al., 2004; Jiang et al., 2006). A 2003 survey in Jiangsu province found that among 144 MSM recruited from gay bars, 41.3% of them reported having had sex with both men and women (Jiang et al., 2006). A 2006 study in Harbin, Heilongjiang province, found that 24.8% of the MSM in the community sample and 16.9% in the Internet sample reported having had sex with women in the past six months (Zhang, Bi, Lv, Zhang, & Hiller, 2007). A study in Yunnan province indicated that 59% of the MSM had ever had sex with women, and 31% had done so in the past six months (Lau et al., 2008).
While researchers have increasingly recognized the potentially important role of MSM’s bisexual behavior in facilitating HIV transmission (Choi et al., 2004, Choi, Ning, Gregorich, & Pan, 2007; Ha et al., 2010; Lau et al., 2008), few studies investigated HIV infection rate and HIV-related risk behaviors among MSMW in China. Less research has examined the bisexual behavior among migrant MSM – a subgroup of MSM most-at-risk for HIV infection and transmission. Accordingly, the current study was designed to examine the association of migrant MSM’s bisexual behavior with the following factors: (1) sociodemographic characteristics; (2) HIV/Syphilis infection rates; (3) HIV-related risk behaviors and other HIV-related knowledge, perceptions, and behaviors (e.g., HIV testing).
Methods
Study site and participants
The current study was conducted in Beijing, China, in 2009. As the capital of China, Beijing had a total population of 17.6 million, including about 5.1 million migrants in 2009 (Beijing Bureau of Statistics, 2010). MSM accounted for 44.11% of the newly reported HIV infected cases in Beijing in 2009 (Xinhua News Agency, 2009). The eligibility criteria of the participants included men who reported having had sex with men, being 18–30 years old, being migrant (without a permanent household registration in Beijing), and willing to provide blood specimens for HIV/Syphilis testing.
Recruitment and survey procedure
The recruitment and consenting procedures have been described in detail elsewhere (Guo, Li, Fang, et al., 2011). Briefly, participants were recruited through peer outreach, informal social network, the Internet, and venue-based sampling. When a potential participant was referred or identified through one of the sampling methods, local research team members verified his eligibility, and explained to the participant the research design and potential risks and benefits of participating in the study.
Each participant completed a self-administered survey privately in either a local Center for Disease Control and Prevention (CDC) or a community medical center in Beijing, with the research staff being present to assure comprehension. All participants were assured of confidentiality of their responses to the survey. The local research staff was faculty members and psychology graduate students at a local university and health workers from a local CDC. Local research staff had received extensive training on research ethics and assessment methodology prior to data collection. Participants received a small monetary incentive (equivalent to US $2) and reimbursement for transportation expenses (up to US $5) on completion of the survey.
Following procedures approved by the Institutional Review Boards at both Wayne State University in the US and Beijing Normal University in China, research staff approached 317 MSM, among whom 311 (98%) agreed to participate and provided written informed consent. We excluded four participants with substantial missing data in their surveys from the dataset, resulting in 307 MSM in the current study.
HIV/STD testing
All participants provided blood specimens for HIV and Syphilis testing. All participants received both pre-test and post-test counseling, following the standard HIV/STD counseling protocol established by the China National Center for AIDS/STD Control and Prevention. For participants who were tested (and confirmed) positive for HIV, the local CDC made appropriate referral arrangements for them to receive government-sponsored free medical treatment. For participants who were tested positive for Syphilis, local CDC provided free appropriate treatment based on the different stages of infection and China CDC’s guidelines on STD treatment.
Measures
Sociodemographic characteristics
Participants were asked about their age, migratory history (i.e., duration of migration, number of cities worked, duration in Beijing), income (in Chinese currency Yuan), ethnicity, education, marital status, types of employment (company/factory, entertainment, others), sexual orientation (homosexual, bisexual, heterosexual, uncertain), and living arrangement (alone, with co-workers, with spouse/lover, others).
Bisexual behavior
Two questions were used to assess bisexual behavior among the participants. One question asked about the gender (female only, male only, both male and female) of their stable sexual partners (e.g., partners with sexual relationship for six months or longer) and the other question on the gender of their casual sexual partners (e.g., partners with sexual relationship for less than six months or with only occasional sexual encounters). MSM who had reported either stable or casual female sexual partners at the time of the interview were considered having bisexual behavior.
HIV/AIDS and condom use knowledge
HIV/AIDS knowledge was measured using 20 true/false questions (scores ranging 0–20), and condom use knowledge using 16 true/false questions (scores ranging 0–16). The sum scores were calculated based on the number of correct answers, with a higher score indicating more knowledge about condom use or HIV/AIDS. The internal consistency estimates (Cronbach’s α) for HIV/AIDS and condom use knowledge were 0.68 and 0.63, respectively.
Participation in HIV/AIDS prevention activities
Participants were asked whether they had participated in HIV/AIDS prevention activities (e.g., condom distribution, lubricant distribution, peer education, hotline, lecture, AIDS website/chat room/blog, AIDS pamphlet, AIDS testing, and counseling). A score of participation was created by summing the number of activities the respondents had participated, with a higher score indicating a higher level of participation in HIV/AIDS prevention activities. Cronbach’s α for participation in HIV/AIDS prevention activities was 0.85.
HIV-related risk behaviors
Participants were asked about various HIV-related sexual risk behaviors. These behaviors included number of sexual partners in the past week and in lifetime, unprotected oral and anal sex (i.e., not using a condom in every sexual episode), unprotected anal sex in the last three episodes, unprotected sex with male or female stable sexual partner, unprotected sex with stable and casual sexual partners in the last three episodes, and commercial sex involvement. Participants’ substance use (alcohol and drug use) prior to sex was also assessed.
Statistical analysis
First, student’s t-tests (for continuous variables) and χ2 tests (for categorical variables) were employed to assess the differences in sociodemographic characteristics by bisexual behavior. Second, the same tests were employed to assess the association of bisexual behavior with HIV/Syphilis infections, HIV-related risk behaviors, and other HIV-related knowledge and behaviors. Third, multivariate logistic regression was employed to examine the independent association of bisexual behavior with the sociodemographic and behavioral factors. Bisexual behavior was included as a dichotomous dependent variable (yes/no) in the regression. Variables that showed significant association with bisexual behavior at p<0.05 in bivariate analyses were included in the multivariate logistic analysis as independent variables. All the statistical analyses were conducted using SPSS for Windows 15.
Results
Sociodemographic characteristics
As shown in Table 1, 83 (27%) of the participants also reported having sex with women. MSMW were 23 years of age on average; a majority were of Han ethnicity (90%) and single (92%), with at least high school education (76%); they had about 3.5 years of migration experience and a little less than three years in Beijing, had stayed in more than three cities in the past, had worked on two jobs in the last year, and made an average of 2210 Yuan (US $333) per month.
Table 1.
Sociodemographic characteristics by bisexual behavior.
| Characteristics | Total | Bisexual behavior | |
|---|---|---|---|
| Yes | No | ||
| Sample size | 307 (100%) | 83 (27%) | 224 (73%) |
| Age (years) | 23.7 (2.86) | 23.0 (2.57) | 24.0 (2.93)** |
| Duration of migration (months) | 49.3 (30.98) | 43.9 (27.88) | 51.2 (31.89) |
| No. of cities stayed | 2.7 (2.95) | 3.3 (4.41) | 2.5 (2.14)* |
| Duration in Beijing (months) | 36.2 (27.19) | 32.5 (23.64) | 37.5 (28.32) |
| No. of work places (last year) | 1.9 (2.54) | 2.0 (2.08) | 1.9 (2.69) |
| Monthly income (100 Yuan) | 22.1 (16.80) | 20.9 (14.36) | 22.5 (17.63) |
| Han ethnicity | 282 (92%) | 75 (90%) | 207 (92%) |
| Education | * | ||
| ≤ Middle school | 51 (17%) | 20 (24%) | 31 (14%) |
| High School | 121 (39%) | 34 (41%) | 87 (39%) |
| ≥ Associate degree | 135 (44%) | 29 (35%) | 106 (47%) |
| Marital status | |||
| Never married/cohabitation | 287 (93%) | 75 (92%) | 212 (94%) |
| Married | 9 (3%) | 2 (2%) | 7 (3%) |
| Separated/divorced/widowed | 11 (4%) | 5 (6%) | 6 (3%) |
| Employment | |||
| Company/factory | 93 (30%) | 30 (36%) | 63 (28%) |
| Entertainment | 48 (16%) | 13 (16%) | 35 (16%) |
| Others | 166 (54%) | (48%) | 126 (56%) |
| Sexual orientation | *** | ||
| Homosexual | 184 (60%) | 25 (30%) | 159 (71%) |
| Heterosexual | 4 (1%) | 1 (1%) | 3 (1%) |
| Bisexual | 95 (31%) | 43 (52%) | 52 (23%) |
| Uncertain | 24 (8%) | 14 (17%) | 10 (5%) |
| Original residence | |||
| City | 102 (33%) | 28 (34%) | 74 (33%) |
| Town | 107 (35%) | 32 (38%) | 75 (34%) |
| Rural | 98 (32%) | 23 (28%) | 75 (33%) |
| Living arrangement | ** | ||
| Alone | 123 (%) | 46 (56%) | 77 (34%) |
| W/co-workers | 64 (21%) | 11 (13%) | 53 (24%) |
| W/ lover | 59 (19%) | 13 (16%) | 46 (20%) |
| Other | 61 (20%) | 12 (15%) | 49 (22%) |
Note: For continuous variables including age, duration of migration, duration in Beijing, number of cities stayed, number of work places last year, and income, means and standard deviations were reported. For dichotomous or categorical variables, frequencies and percentages were reported.
p<0.5;
p<0.01;
p<0.001.
More than half (52%) of the MSMW self-identified as bisexual, one third (30%) as homosexual, 1% as heterosexual and 17% uncertain of their sexual orientation; one in six worked in entertainment establishments; 28% came from rural areas, 38% from towns, and 34% from cities; more than half of them lived alone, 16% living with spouse or lover, and 13% with co-workers. Compared with MSM-only, MSMW were younger (23 vs. 24 years, p<0.01) and more likely to self-identify as bisexual (52% vs. 23%, p<0.001), had lower education (24% vs. 14% ≤ middle school education, p<0.05), had stayed in more cities (3.3 vs. 2.5, p<0.05), and were more likely to live alone (56% vs. 34%, p<0.01).
Bivariate analysis
Seven (8.4%) of the MSMW were infected with HIV and nine (10.8%) with Syphilis (Table 2). MSMW had 1.7 sexual partners in the last week and 45 in lifetime on average. More than half of the MSMW had unprotected oral sex (54.9%) or unprotected anal sex (51.2%). More than one-fourth (27.2%) of the MSMW had unprotected anal sex in the last three episodes. MSMW had a higher rate of unprotected sex with female stable sexual partner than with male stable sexual partner (79.5% vs. 59.5%). MSMW had a higher rate of unprotected sex with stable sexual partner than with casual sexual partner in the last three episodes (42.3% vs. 35.4%). About one-fourth (23.2%) of the MSMW were engaged in commercial sex. Among MSMW, sex under the influence of alcohol was more common (37.8%) than that under other drugs (3.7%). Compared with MSM-only, MSMW were more likely to be HIV-positive (8.4% vs. 4.9%), although the difference was not statistically significant; they were less likely to have Syphilis (10.8% vs. 23.7%, p<0.05). All the sexual risk and substance use behaviors were similar between the two groups, except that MSMW had a lower rate of unprotected oral sex than MSM-only.
Table 2.
Differences in HIV and Syphilis infection and HIV-related risk behaviors by bisexual behavior.
| Characteristics | Total | Bisexual behavior | |
|---|---|---|---|
| Yes | No | ||
| HIV infection | 18 (5.9%) | 7 (8.4%) | 11 (4.9%) |
| Syphilis infection | 62 (20.2%) | 9 (10.8%) | 53 (23.7%)* |
| Sexual Risk Behaviors | |||
| Total number of sex partners in the last week | 1.5 (1.72) | 1.7 (1.71) | 1.4 (1.72) |
| Total number of sex partners in lifetime | 52 (110.53) | 45 (94.26) | 54 (116.07) |
| Unprotected oral sex in lifetime | 199 (64.8%) | 45 (54.9%) | 154 (68.4%)* |
| Unprotected anal sex in lifetime | 161 (52.4%) | 42 (51.2%) | 119 (52.9%) |
| Unprotected anal sex in the last three episodes | 90 (29.4%) | 22 (27.2%) | 68 (30.2%) |
| Unprotected sex with male stable sex partner lifetime | 113 (62.1%) | 25 (59.5%) | 88 (62.9%) |
| Unprotected sex with female stable sex partner lifetime | – | 31 (79.5%) | – |
| Unprotected sex with stable sex partner in the last three episodes | 78 (39.0%) | 22 (42.3%) | 56 (37.8%) |
| Unprotected sex with casual sex partner in the last three episodes | 92 (30.4%) | 29 (35.4%) | 63 (28.5%) |
| Involvement in commercial sex | 69 (22.5%) | 19 (23.2%) | 50 (22.2%) |
| Substance use before sex | |||
| Alcohol | 120 (39.1%) | 31 (37.8%) | 89 (39.6%) |
| Other drug | 9 (2.9%) | 3 (3.7%) | 6 (2.7%) |
Note: For continuous variables (total number of sex partners in the last week and in lifetime), means and standard deviations were reported; for dichotomous variables (all the others), frequencies and percentages were reported.
p<0.5.
As shown in Table 3, compared with MSM-only, MSMW were less likely to have tested for HIV (75.6% vs. 63.4%, p<0.05), or less likely to obtain or know the result even if they had tested (78.4% vs. 89.2%, p<0.05). MSMW were less likely than MSM-only to participate in AIDS prevention activities (3.4 vs. 4.5, p<0.01), less knowledgeable about AIDS (15.7 vs. 16.9, p<0.001) and condom use (11.2 vs. 12.4, p<0.001).
Table 3.
HIV testing, AIDS prevention activities participation, and knowledge of condom use and AIDS.
| Characteristics | Total | Bisexual behavior | |
|---|---|---|---|
| Yes | No | ||
| Had HIV test | 222 (72.3%) | 52 (63.4%) | 170 (75.6%)* |
| Result of the last HIV-test | * | ||
| Had known the result | 188 (86.5%) | (78.4%) | 148 (89.2%) |
| Result had not come out yet | 14 (6.5%) | 3 (5.9%) | 11 (6.6%) |
| Did not go and get the result | 14 (6.5%) | 7 (13.7%) | 7 (4.2%) |
| Did not understand the result | 1 (0.5%) | 1 (2.0%) | 0 (0.0%) |
| Participation in AIDS prevention activities | 4.2 (2.90) | 3.4 (3.11) | 4.5 (2.77)** |
| AIDS knowledge score | 16.6 (2.71) | 15.7 (3.14) | 16.9 (2.46)*** |
| Condom use knowledge score | 12.1 (2.58) | 11.2 (2.59) | 12.4 (2.51)*** |
p<0.5;
p<0.01;
p<0.001.
Multivariate analysis
Results of multivariate analysis (Table 4) showed that number of cities stayed was positively associated with bisexual behavior, whereas living with other people, Syphilis infection, participation in AIDS prevention activities, and AIDS knowledge were negatively associated with bisexual behavior. Specifically, those who had stayed in more cities were more likely to engage in bisexual behavior, while those who lived with other people (i.e., co-workers, lover, family members or others), who had Syphilis, who had participated in AIDS prevention activities, and who were more knowledgeable about AIDS were less likely to engage in bisexual behavior.
Table 4.
Factors associated with bisexual behavior among Chinese MSM (Logistic regression model).
| Background characteristics | aOR | 95%CI |
|---|---|---|
| Age (exact year) | 0.93 | (0.84, 1.03) |
| Number of cities stayed | 1.14 | (1.02, 1.28)* |
| Education | ||
| ≤ Middle school | 1.00 | |
| High school | 0.61 | (0.28, 1.37) |
| ≥ 3 yr college | 0.59 | (0.25, 1.39) |
| Living arrangement | ||
| Alone | 1.00 | |
| With co-workers | 0.21 | (0.09, 0.50)*** |
| With lover | 0.38 | (0.17, 0.78)* |
| With family members or others | 0.31 | (0.15, 0.79)** |
| Syphilis infection | 0.35 | (0.14, 0.85)* |
| Whether had HIV test | 1.51 | (0.78, 2.90) |
| Participation in AIDS prevention activities | 0.88 | (0.79, 0.98)* |
| AIDS knowledge | 0.87 | (0.79, 0.97)** |
| Condom use knowledge | 0.63 | (0.18, 2.23) |
p<0.5;
p<0.01;
p<0.001.
Discussion
Our study found that more than one-quarter (27%) of the MSM in the study sample were engaged in bisexual behavior in the past six months. Although global literature has shown a lower HIV prevalence among MSMW than MSM-only (Li et al., 2009; Zule et al., 2009), MSMW in the current study had an alarmingly high rate of HIV infection (8.4%). Although it is unclear why the MSMW in the current study had a lower rate of Syphilis infection but a higher rate of HIV infection than MSM-only, it is nevertheless evident in the current study that this subgroup of MSM was at a very high risk of HIV/STD infection and transmission. Results in the current study also indicated that MSMW engaged in high sexual risk behaviors similar to those of MSM-only, contrary to previous studies that reported lower sexual risk among MSMW than MSM-only (Beyer et al., 2010; Flores et al., 2009; Li et al., 2009; Zule et al., 2009).
Consistent with studies in China (Choi et al., 2004; Folch et al., 2006; Zhang et al., 2007) and other countries (Boulton & Hart, 1992; Li et al., 2009), the current study found that MSMW engaged in a much higher level of unprotected sex with female stable sexual partners than with male stable sexual partners (79.5% vs. 59.5%). This finding may reflect MSMW’s perceptions of low HIV infection risks with female sexual partners (Boulton & Hart, 1992; Lau et al., 2008; Li et al., 2009). In addition, research has shown that MSM’s relationship with women tends to be of longer duration than with men (Choi, Hudes, & Steward, 2008). Therefore a high prevalence of unprotected sex, coupled with a prolonged duration of sexual relationship, may expose MSMW’s female sexual partners to a high risk of HIV infection.
Migrants in China are usually young, mostly from rural areas or small towns or cities where traditional social and familial norms are more deeply rooted than large metropolitan areas such as Beijing. Because of China’s one-child policy since late 1970s, many young migrant MSM may be the only son in their family and may therefore face increased pressure from their family and society to get married and have children. Previous research has shown that Chinese MSM are more likely to get married than their counterparts in western countries and the marriage rate increases with age (Choi et al., 2004; Jiang et al., 2006; Lau et al., 2008). In addition, many migrants are circulative migrants as they often go home and stay with their families during Chinese New Year or other traditional Chinese holidays (NPFPC, 2010). These migrants might also be a bridge population for HIV transmission between large cities and more remote rural areas. Therefore, the social norms and contextual factors should be taken into account in studying the phenomenon of bisexual behavior in China and in designing future interventions targeting specifically this high-risk population (MSMW) to prevent or reduce HIV transmission to both of their female and male sexual partners.
Data in the current study indicated that MSMW were less likely to test for HIV and when tested, less likely to obtain the test result; they were also less likely to participate in HIV/AIDS prevention activities and less knowledgeable about AIDS and condom use. Previous studies suggested that MSM who had tested for HIV were likely to reduce UAI (Choi et al., 2004; Choi, Liu, Guo, Han, & Mandel, 2006). Implications of these findings for future interventions include the needs to target specifically the MSMW population, to reach and encourage them to participate in HIV/AIDS prevention activities, to improve their AIDS and condom use knowledge, and to promote HIV/STD testing.
The current study is subject to several limitations. First, the sample employed was a convenience sample. The participants were young migrant MSM from one major city; they may not be representative of other MSM populations in China (e.g., older MSM, MSM in rural areas or small towns or cities, MSM who are not migrants). Second, data in the current study may be subject to self-reporting bias as participants might provide socially desirable responses. The bias might lead to underestimation of the sexual risk. Third, the current study was based on cross-sectional data that prevent us from establishing a causal relationship. Longitudinal analysis is needed in the future to understand the causal relationships between bisexual behavior and HIV/STD risks among the MSM population. Fourth, data were not available regarding participants’ condom use with commercial sex partners. Although the current study did not find a difference in commercial sex involvement between MSMW and MSM-only, it is possible that MSMW might be less integrated into MSM community and might be more involved in unprotected sex with commercial partners. Finally, measures of HIV and condom use knowledge had relatively low internal consistency estimates (i.e., Cronbach α < 0.70). While these estimates were in line with those obtained in other studies in China and other countries (e.g., Chen et al., 2007; Reynolds, 2010), future study is needed to improve the psychometric properties of these measures in Chinese settings.
Despite these limitations, findings in the current study warrant the public health concern with MSM’s bisexual behavior as a linkage between high risk and low risk populations in the HIV/AIDS epidemic in China. Considering the potential role of MSMW in the HIV/AIDS epidemic in China, future intervention efforts are needed to develop culturally and socially appropriate strategies to reach this subgroup of MSM for HIV prevention and intervention. Public education in reducing stigma and discrimination against homosexuality should also be implemented so that MSMW could feel more comfortable to increase their disclosure of bisexual behavior and reduce both homosexual and heterosexual transmission of HIV among this most-at-risk population.
Acknowledgements
The study described in this report was supported by NIH Research Grant R01NR10498 by the National Institute of Nursing Research and National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research and National Institute of Mental Health. The authors want to thank Xiaoyi Fang, Xiuyun Lin, and other faculty and graduate students at Beijing Normal University School of Psychology for their participation in instrument development and field data collection and thank Joanne Zwemer for help in preparing the manuscript.
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