Money Boys and the Spread of HIV in China
Jeffrey Laurence, M.D., and Rowena Johnston, Ph.D.
September 14, 2009—Many people recognize that men
who have sex with men (MSM) remain at high risk for HIV infection in
the U.S. and other resource-rich countries, but they believe
heterosexual sex to be the predominant mode of transmission in most of
the developing world, including Asia. However, during the past several
years, researchers have been re-evaluating that assumption.
Dr. Hongjie Liu |
Epidemiologic detective work, including several amfAR-funded
initiatives in Asia, supports a link between HIV-positive MSM and
the spread of the virus among their female partners. In many Asian
countries, this accounts for a substantial fraction of cases spread
through heterosexual contact. Writing in the August issue of the
journal AIDS and Behavior, amfAR-funded researcher Dr.
Hongjie Liu provided details of this transmission network in Shenzhen,
China, and offered some novel prevention strategies.
Dr. Liu, a professor of epidemiology at Virginia Commonwealth School
of Medicine, acknowledged that his work was “supported in whole by a
research grant from amfAR.” He conducted his study in a region along
the southern coast of China, bordering Hong Kong, which was China’s
first and most successful Special Economic Zone. He noted that Chinese
society has long viewed sex between men with disapproval, despite the
fact that nearly every emperor in many prior dynasties had at least one
male sexual partner. This view has led the country’s MSM to hide their
sexuality; indeed, many Chinese MSM marry women while continuing secret
sexual relationships with men. A triad of forces— stigma against
homosexuality and pressure to conform with societal norms; clandestine,
high-risk sex; and a reluctance among MSM to practice safer sex with
their wives or other female partners—creates fertile ground for the
spread of HIV and other sexually transmitted infections.
“Money boys,” or men who sell sex to MSM, appear to be a core HIV
transmitter group for MSM and the general population in China because
of multiple contacts with male and female sexual partners. As an
“invisible,” hard-to-reach population, they are difficult to study. To
reach them, Dr. Liu employed a technique relatively new to social
science known as respondent driven sampling (RDS). Through RDS, initial
participants or “seeds” refer other people to the study, and these
people in turn refer their peers. Dr. Liu and his colleagues recruited
twelve seeds—including three money boys—from saunas, bars, and public
parks, and these men ultimately found 351 MSM who agreed to participate
in the study.
In terms of HIV risks, 54 percent of money boys in the study had had
six or more anal sex partners in the past six months, compared with 22
percent of the non-money boys. During the same time period, 43 percent
of the money boys had had female sex partners, compared with only 26
percent of men who were not money boys. Only nine percent of
money boys had partners who insisted on condom use, and fewer than 30
percent of all the men in the study had sex partners who encouraged
condom use.
Dr. Liu’s study doesn’t simply document the bad news about the
extent of those risks, however. More hopefully, he also found that if
money boys and other MSM perceived that the majority of their peers
used condoms to prevent HIV, they were more likely to use condoms
themselves. This is called a “descriptive norm.” In addition,
“subjective norms”—beliefs about what significant others think one
should do—had a significant influence on the rate of condom use. These
and other findings from the study could aid in the design of targeted
intervention programs not only for MSM, but also for the general
population. Indeed, based on these initial findings, Dr. Liu is
currently using a subsequent amfAR grant to test an HIV prevention
intervention among MSM in Shenzhen using cell phone technology.
Dr. Laurence is amfAR’s senior scientific consultant and Dr. Johnston is vice president and director of research.
