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Globally, there were an estimated 350,000 new human immunodeficiency virus (HIV) infections among youth aged 15–24 years in 2022 (1). In China, the majority of young people living with HIV were out-of-school youth, accounting for 77.8% of newly diagnosed HIV cases in the 15–24 age group in 2020 (2). Out-of-school young men who have sex with men (MSM) face a higher risk of HIV infection compared to MSM among college students (3) and encounter barriers when accessing HIV-related services. To address the specific vulnerabilities and health needs of out-of-school young MSM (YMSM), a survey was conducted in 6 cities and Tianjin Municipality to estimate HIV prevalence. A total of 1,407 participants were recruited, with an HIV prevalence of 4.4% (62/1,407). Among the 62 participants living with HIV, 51.6% had been previously diagnosed. Participants who had a history of past or current syphilis infection, inconsistent condom use during anal sex in the last 6 months, and a lack of awareness of post-exposure prophylaxis (PEP) had higher odds of HIV infection. These findings highlight the disproportionately high burden of HIV among out-of-school YMSM and the limited access they have to HIV preventive services. Improving access to HIV testing and care, as well as delivering tailored interventions for out-of-school YMSM, are urgently needed.
The survey was conducted between October 2022 and May 2023 in 7 major cities (Tianjin Municipality; Shenyang City, Liaoning Province; Fuzhou City, Fujian Province; Qingdao City, Shandong Province; Changsha City, Hunan Province; Shenzhen City, Guangdong Province; Haikou City, Hainan Province) with large populations of out-of-school YMSM and well-established community-based organizations (CBOs). Participants were recruited from MSM-visited venues, as well as online platforms such as WeChat and Microblog. To be eligible, YMSM had to have engaged in anal sex with a man in the past 6 months; be between the ages of 16 and 24, and not be currently enrolled as students. With the assistance of CBO staff, eligible participants completed an online, self-administered structured questionnaire that covered sociodemographic information, HIV knowledge, sexual behaviors, sexually transmitted infections (STIs), and utilization of HIV services. HIV knowledge was assessed using 8 questions from the “Chinese AIDS Sentinel Surveillance Implementation Plan”. A score of six or more correct answers was considered comprehensive knowledge of HIV. All consenting participants underwent on-site rapid HIV and syphilis testing using NewScen HIV antibody rapid test kits (NewScen Coast Bio-Pharmaceutical, Tianjin, China) and NewScen syphilis antibody rapid test kits (NewScen Coast Bio-Pharmaceutical, Tianjin, China), respectively, led by qualified staff. For participants who received a positive result on rapid HIV testing and self-reported no prior diagnosis, further confirmatory HIV testing was conducted. As rapid syphilis testing cannot distinguish between past and current infections, participants with a positive result were categorized as having either a past or current syphilis infection.
Categorical variables were analyzed using descriptive statistics, including proportions and 95% confidence intervals (CIs). Univariable logistic regression was conducted to assess the association between biobehavioral factors and HIV infection. Variables with a P-value of ≤0.10 in the univariable model were included in the multivariable logistic regression, along with demographic variables to account for potential confounding factors. To address the potential influence of HIV diagnosis on behavior change among out-of-school YMSM, a separate multivariable logistic regression analysis was conducted excluding previously diagnosed HIV cases. All statistical analyses were performed using R software (version 4.3.1, R Foundation for Statistical Computing, Vienna, Austria).
A total of 1,407 eligible participants were recruited for our study from different cities in China (Table 1): 298 participants from Tianjin, 206 from Shenyang, 192 from Fuzhou, 186 from Changsha, 183 from Qingdao, 179 from Shenzhen, and 163 from Haikou. Among the participants, 692 (49.2%) were between the ages of 23 and 24. Furthermore, 761 (54.1%) had completed vocational college or higher education, and 1,106 (78.6%) were employed full-time. In terms of sexual orientation, 1,287 (91.5%) identified as homosexual, 94 (6.7%) as bisexual, 23 (1.6%) as unsure, and 3 (0.2%) as heterosexual. Additionally, 641 (45.6%) participants reported having disclosed their sexual orientation.
Characteristics n Percentage (95% CI) Region Tianjin 298 21.2 (19.1, 23.4) Shenyang 206 14.6 (12.9, 16.6) Fuzhou 192 13.6 (11.9, 15.6) Qingdao 183 13.0 (11.3, 14.9) Changsha 186 13.2 (11.5, 15.1) Shenzhen 179 12.7 (11.0, 14.6) Haikou 163 11.6 (10.0, 13.4) Age, years 16–18 79 5.6 (4.5, 7.0) 19–20 183 13.0 (11.3, 14.9) 21–22 453 32.2 (29.8, 34.7) 23–24 692 49.2 (46.5, 51.8) Education ≤Junior high school 234 16.6 (14.7, 18.7) Senior high/vocational/secondary 412 29.3 (26.9, 31.8) ≥Vocational college 761 54.1 (51.4, 56.7) Monthly income (CNY) <1,000 101 7.2 (5.9, 8.7) 1,000–3,000 251 17.8 (15.9, 20.0) 3,001–5,000 615 43.7 (41.1, 46.4) >5,000 440 31.3 (28.9, 33.8) Employment status Employed full time 1,106 78.6 (76.4, 80.7) Employed part time 161 11.4 (9.9, 13.2) Unemployed 140 10.0 (8.5, 11.7) Local living time <1 year 128 9.1 (7.7, 10.8) 1–2 year 184 13.1 (11.4, 15.0) >2 year 1,095 77.8 (75.5, 80.0) Living situation Family 366 26.0 (23.8, 28.4) Alone 597 42.4 (39.8, 45.1) Friends/roommates 239 17.0 (15.1, 19.1) Partner 105 7.5 (6.2, 9.0) Dormitory 100 7.1 (5.8, 8.6) Sexual orientation Homosexual 1,287 91.5 (89.9, 92.9) Bisexual 94 6.7 (5.5, 8.1) Heterosexual 3 0.2 (0.1, 0.7) Not sure 23 1.6 (1.1, 2.5) Disclosure of sexual orientation 641 45.6 (42.9, 48.2) Abbreviation: MSM=men who have sex with men; CI=confidence interval; CNY=Chinese Yuan. Table 1. Sociodemographic characteristics of out-of-school young MSM aged 16–24 years in 6 Cities and Tianjin Municipality, China (N=1,407).
A total of 62 participants (4.4%, 95% CI: 3.4%–5.6%) out of 1,407 were confirmed to have HIV through laboratory testing. Among them, 32 participants (51.6%, 32/62) had previously been diagnosed with HIV (Table 2). The prevalence of current or past syphilis was 4.9% (95% CI: 3.9%–6.2%), and the co-infection rate of syphilis and HIV was 1.1% (15/1,407). Within the past 12 months, 78.4% of participants (1,103/1,407) reported using HIV-related services. These included HIV infection risk assessment (49.6%, 698/1,407), receiving free condoms (52.5%, 738/1,407), pre-exposure prophylaxis (PrEP) (22.5%, 317/1,407), PEP (21.3%, 299/1,407), and HIV counseling and testing (56.2%, 791/1,407). Additionally, 47.5% of participants (669/1,407) reported not having consistent condom use (CCU) during anal sex in the past 6 months. Group sex behavior was reported by 8.7% of participants (123/1,407), which was nearly twice the prevalence of heterosexual behavior during the same period (4.4%, 62/1,407). Drug use within the past 12 months was reported by 59.1% of participants (832/1,407). Furthermore, 5.1% of participants (72/1,407) reported experiencing any symptoms of STIs within the past 12 months, while 5.5% (77/1,407) were diagnosed with an STI during the same period. The overall rate of comprehensive HIV knowledge was 88.3% (1,242/1,407), with 77.8% (1,095/1,407) and 80.8% (1,137/1,407) reporting awareness of PrEP and PEP, respectively.
Characteristics n Percentage (95% CI) HIV and STI prevalence HIV positive 62 4.4 (3.4, 5.6) Previously diagnosed 32 2.3 (1.6, 3.2) Newly diagnosed 30 2.1 (1.5, 3.1) Past or current syphilis 69 4.9 (3.9, 6.2) HIV service engagement in the past 12 months HIV infection risk assessment 698 49.6 (47.0, 52.3) Received free condoms 738 52.5 (49.8, 55.1) PrEP 317 22.5 (20.4, 24.8) PEP 299 21.3 (19.2, 23.5) HIV counseling and testing 791 56.2 (53.6, 58.8) Individual-level HIV risks Number of anal sex partners in the past 6 months 1 456 32.4 (30.0, 34.9) 2–5 691 49.1 (46.5, 51.8) ≥6 260 18.5 (16.5, 20.6) Condom use during anal sex in the past 6 months CCU 738 52.5 (49.8, 55.1) Not CCU 669 47.5 (44.9, 50.2) Group sex behavior in the past 6 months 123 8.7 (7.3, 10.4) Condom use during group sex in the past 6 months (n=123) CCU* 71 57.7 (48.5, 66.5) Not CCU 52 42.3 (33.5, 51.5) Heterosexual behavior in past 6 months 62 4.4 (3.4, 5.6) Number of heterosexual partners in past 6 months (n=62) 1 30 48.4 (35.7, 61.3) 2–5 28 45.2 (32.7, 58.2) ≥6 4 6.5 (2.1, 16.5) Condom use during heterosexual behavior (n=62) CCU 20 32.3 (21.3, 45.5) Not CCU 42 67.7 (54.5, 78.7) Any drug use in the past 12 months 832 59.1 (56.5, 61.7) Suffered any STI symptoms in the past 12 months 72 5.1 (4.1, 6.4) Diagnosed any STI in the past 12 months 77 5.5 (4.4, 6.8) HIV knowledge Comprehensive knowledge of HIV 1,242 88.3 (86.4, 89.9) PrEP awareness 1,095 77.8 (75.5, 80.0) PEP awareness 1,137 80.8 (78.6, 82.8) Abbreviation: HIV=human immunodeficiency virus; MSM=men who have sex with men; CI=confidence interval; STI=sexually transmitted infection; PEP=post-exposure prophylaxis; PrEP=pre-exposure prophylaxis; CCU=consistent condom use.
* Consistent condom use and changing condoms between people.Table 2. HIV, syphilis, service engagement, individual level risks, and HIV knowledge of out-of-school young MSM aged 16–24 years in 6 Cities and Tianjin Municipality, China (N=1,407).
In the multivariable analysis, we found that out-of-school YMSM with current or past syphilis infection had higher odds of HIV infection [adjusted odds ratio (aOR)=9.90, 95% CI: 3.86–24.86]. Additionally, YMSM who reported inconsistent condom use during anal sex within the past 6 months also had higher odds of HIV infection (aOR=3.06, 95% CI: 1.61–6.01). On the other hand, YMSM who were aware of PEP had lower odds of HIV infection (aOR=0.27, 95% CI: 0.12–0.62) (Table 3). A sensitivity analysis, excluding data from previously diagnosed HIV cases, revealed no significant difference in the identified risk factors.
Characteristics HIV infection vs. HIV negative (N=1,407) Undiagnosed HIV infection vs. HIV negative (N=1,375) HIV infection
n (%)aOR (95% CI)* P value Undiagnosed HIV infection
n (%)aOR (95% CI)* P value Past or current syphilis No 47/1,338 (3.5%) 1 (ref) − 21/1,312 (1.6%) 1 (ref) − Yes 15/69 (21.7%) 9.90 (3.86, 24.86) <0.001 9/63 (14.3%) 19.70 (5.00, 80.08) <0.001 HIV infection risk assessment in the past 12 months No 43/709 (6.1%) 1 (ref) − 20/686 (2.9%) 1 (ref) − Yes 19/698 (2.7%) 0.54 (0.27, 1.06) 0.078 10/689 (1.5%) 0.63 (0.22, 1.71) 0.365 Received free condoms in the past 12 months No 43/669 (6.4%) 1 (ref) − 19/645 (2.9%) 1 (ref) − Yes 19/738 (2.6%) 0.51 (0.25, 1.02) 0.062 11/730 (1.5%) 0.66 (0.23, 1.84) 0.425 PrEP in the past 12 months No 54/1,090 (5.0%) 1 (ref) − 28/1,064 (2.6%) 1 (ref) − Yes 8/317 (2.5%) 1.03 (0.38, 2.53) 0.946 2/311 (0.6%) 0.37 (0.05, 1.71) 0.254 HIV counseling and testing in the past 12 months No 35/616 (5.7%) 1 (ref) − 18/599 (3.0%) 1 (ref) − Yes 27/791 (3.4%) 0.94 (0.49, 1.80) 0.844 12/776 (1.5%) 1.77 (0.63, 5.10) 0.278 Condom use during anal sex in the past 6 months CCU 17/738 (2.3%) 1 (ref) − 3/724 (0.4%) 1 (ref) − Not CCU 45/669 (6.7%) 3.06 (1.61, 6.01) <0.001 27/651 (4.1%) 10.98 (3.08, 54.07) <0.001 Group sex behavior in the past 6 months No 52/1,284 (4.0%) 1 (ref) − 26/1,258 (2.1%) 1 (ref) − Yes 10/123 (8.1%) 1.66 (0.70, 3.63) 0.223 4/117 (3.4%) 1.21 (0.28, 4.10) 0.776 Suffered any STI symptoms in the past 12 months No 54/1,335 (4.0%) 1 (ref) − 29/1,310 (2.2%) 1 (ref) − Yes 8/72 (11.1%) 1.78 (0.61, 4.70) 0.264 1/65 (1.5%) 0.51 (0.02, 4.10) 0.594 Diagnosed any STI in the past 12 months No 52/1,330 (3.9%) 1 (ref) − 26/1,304 (2.0%) 1 (ref) − Yes 10/77 (13.0%) 0.66 (0.21, 1.96) 0.468 4/71 (5.6%) 0.48 (0.07, 2.60) 0.416 PrEP awareness No 20/312 (6.4%) 1 (ref) − 15/307 (4.9%) 1 (ref) − Yes 42/1,095 (3.8%) 1.43 (0.64, 3.34) 0.397 15/1,068 (1.4%) 1.47 (0.41, 5.35) 0.554 PEP awareness No 24/270 (8.9%) 1 (ref) − 18/264 (6.8%) 1 (ref) − Yes 38/1,137 (3.3%) 0.27 (0.12, 0.62) 0.002 12/1,111 (1.1%) 0.07 (0.02, 0.26) <0.001 Abbreviation: HIV=human immunodeficiency virus; MSM=menwho have sex with men; aOR=adjusted odds ratio; CI=confidence interval; CCU=consistent condom use; STI=sexually transmitted infection; PEP=post-exposure prophylaxis; PrEP=pre-exposure prophylaxis.
* Adjusted for region, age, education, monthly income, employment status, local living time, living situation, and disclosure of sexual orientation.Table 3. Adjusted logistic regression model of biobehavioral factors associated with HIV Infection and undiagnosed HIV infection among out-of-school young MSM aged 16–24 Years in 6 Cities and Tianjin Municipality, China.
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This study aims to provide a comprehensive analysis of HIV knowledge, risky behaviors, engagement with HIV services, and the prevalence of HIV among out-of-school YMSM in China. The study found that the HIV prevalence among participants was 4.4%. Higher odds of HIV infection were observed among participants who were infected with syphilis, reported inconsistent condom use during anal sex, and lacked awareness of PEP. The study also identified significant gaps in HIV detection and coverage of prevention services. Therefore, addressing the needs of out-of-school YMSM and removing barriers to HIV services should be a priority to control HIV transmission.
In a previous study that utilized meta-analysis, the pooled HIV prevalence among high school and college student MSM in China was calculated to be 3.8% (4). This prevalence was slightly lower than the 4.4% prevalence observed in this current study among out-of-school YMSM. Furthermore, only half of the participants living with HIV had previously been diagnosed, indicating a big gap compared to the first target of the 95-95-95 testing and treatment strategy (51.6% vs. 95%). The low detection rate may be attributed to limited engagement in HIV services, as only 56.2% (791/1,407) of participants reported undergoing HIV counseling and testing in the past 12 months. Consistent with other research studies (5–6), our findings suggest the use of a dual HIV and syphilis testing strategy, as participants infected with syphilis are more likely to be infected with HIV. Furthermore, participants who were aware of PEP exhibited lower odds of HIV infection, underscoring the importance of HIV prevention knowledge education. The proportion of participants with comprehensive knowledge of HIV was 88.3%, slightly below the 90% target for key populations (7). Given that a significant number of out-of-school youth do not continue their education beyond middle school, it is crucial to initiate curriculum-based HIV education no later than middle school.
This study has several limitations. First, there may be selection bias present in this survey. Our participants were recruited through on-site and online platforms of CBOs, which means that out-of-school YMSM that were not affiliated with CBOs were not included in the study. Second, the design of the study was cross-sectional, which means that we cannot infer causality from the results. Third, due to the limited availability of syphilis testing in CBOs, we were unable to conduct additional tests to determine the prevalence of past or current syphilis infection.
This study highlights the disparity in HIV services for out-of-school YMSM and emphasizes the significance of the HIV prevention cascade. Urgent action is required to implement innovative testing strategies to meet the first of the three 95 targets (8). Additionally, priority should be given to interventions that target this marginalized population to address risky behaviors. It is crucial to develop and implement evidence-based HIV programs that cater to their complex needs.
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We would like to express our gratitude to our partner organizations: Shenlan (Tianjin), Weilan (Shenyang), Fuzhou CDC (Fuzhou), Qingtong (Qingdao), the Hunan Association of STD and AIDS Prevention and Control (Changsha), 258 (Shenzhen), Hainan CDC (Haikou), and Haikou Red Ribbon Volunteer Association (Haikou). We would also like to acknowledge Mr. Jacob Wood and all the study participants.
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No conflicts of interest.
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