AIDS Prevention among MSM in Hong Kong:

Review of Research and Prevention Activities

Executive Summary

1. Introduction

Although the incidence of HIV transmission among MSM in Hong Kong is not as great as in many Western countries, the potential for a serious problem among this population exists. This purpose of this report is to review what we know and what we do not know about HIV related risk behavior among MSM in Hong Kong and what efforts have been made so far to promote HIV prevention in this population. This review will later be supplemented with information gathered from formal and informal individual and group interviews with a cross-section of the MSM community to form a ‘Situation Report’ which will help the Hong Kong HIV/AIDS Community Planning Committee in planning suitable prevention and research activities for MSM.

2. Epidemiological Situation

As of June 2000, of the 1446 reported cases of HIV transmission and the 475 reported cases of AIDS in Hong Kong, 286 HIV infections and 91 AIDS cases were attributed to ‘homosexual’ transmission and 74 HIV infections and 26 AIDS cases were attributed to ‘bisexual’ transmission.

The number of cases attributed to ‘homosexual’ or ‘bisexual’ transmission per year has been showing a clear though erratic increase since the first reported case in 1984 (see table 1).

Annual cases attributed to ‘homosexual’ or ‘bisexual’ transmission routes

Year	Total cum. HIV/AIDS cases in HK	“homosexual” or “bisexual” cases
Year	Total cum. HIV/AIDS cases in HK	HIV*	AIDS	Cum. No
1984	7	1	0	1
1985	53	11	2	12
1986	106	8	0	20
1987	134	19	3	39
1988	172	14	6	53
1989	206	21	11	74
1990	266	13	5	87
1991	337	26	8	113
1992	416	29	10	142
1993	520	22	8	164
1994	642	26	18	190
1995	776	30	12	220
1996	957	23	7	243
1997	1146	43	13	286
1998	1359	22	7	308
1999	1399	43	9	351
June 2000	1446	9	1	360

* The number of HIV cases has included AIDS cases.

Table 1 (Hong Kong SAR Government Department of Health)

There are several reasons why it is difficult to estimate actual cases of HIV infection from reported cases of infection:

1) Little is known about the extent of HIV testing among MSM, but one study (Lau and Wong 2000) suggests that the rate of testing among MSM in Hong Kong is lower than in other places.

2) Social stigmatization of MSM and cultural norms against disclosure suggest that the number of men admitting to homosexual or bisexual behavior in the context of HIV testing may be smaller than those who have actually engaged in this type of behavior.

3) The epidemiological categories used (homosexual/bisexual) may not reflect the way actual MSM conceptualize their sexual identity or sexual activities.

3. Overview of Research

The number of research projects exploring the risk behavior of MSM in Hong Kong is small, and most of the studies done thus far are of limited validity and reliability due to small sample sizes, problems with sampling and methodological limitations. Table 2 summarizes the major research that has been done on MSM in Hong Kong.

Researcher(s)/ Year	Type of Study	Source of Respondents	n=	Focus
Ho, P.S.K. (1995)	Qualitative (case study)	Personal network	1	Gay identity
Chou, W.S. (1996)	qualitative (interviews) and quantitative (questionnaire survey)	Tongji organizations	300	Gay identity, sexual practices,
Hong Kong Government (1996)	Quantitative (telephone survey)	Random (‘general public’)	1535	Discrimination, Attitudes towards homosexuality
Smith, G. (1998a)	Discussion paper	na	na	HIV prevention experience among MSM
Smith, G. (1998b)	Report of prevention project	Saunas	na	HIV prevention experience among MSM
Choi, T. (1998)	Literature Review	na	na	HIV prevention
Li M. C. (1998)	Quantitative (questionnaire survey)	Tongji organizations	100	Sexual behavior and attitudes towards safer sex and HIV
Lulla, R. (1997)	Quantitative (questionnaire survey)	Tongji organizations/ bars/ toilets/ internet/personal network	110	Sexual and social behavior
Jones, R. (2000)	Qualitative (Text analysis)	Personal advertisements	1040	Gay identity, self-presentation
Jones, R., Yu, K.K. and Candlin, C. (2000)	Qualitative (diary study)/ Quantitative (questionnaire survey)	Tongji organizations/ bars/saunas/toilets/ personal network	16/ 203	Sexual behavior, risk behavior, attititudes, patterns of interaction
Ho, P.S.K. and Tsang, A.K.T. (2000)	Qualitative (Interviews)	Tongji organizations/ Personal network	12	Anal sex in interracial relationships
‘Gei Lo’ (nd)	Qualitative (participant observation)	Saunas	na	‘Sexual culture’
Lau, J.T.F. and Wong, W.S. (2000)	Quantitative (telephone survey)	Random (‘general male population’, MSM, clients of sex workers)	2074	HIV testing and risk behavior
AIDS Scenario Surveillance Research Project (2000)	Quantitative (survey)	Clinic based		Risk history/ behavior of MSM visiting Government HIV testing clinics

4. Research Findings: Sexual Behavior

Table 3 broadly sums up the research findings regarding sexual behavior. It should remembered that sue to the small sample size and methodological limitations of the studies, none of these findings can be regarded as conclusive.

Area of Study	Findings
Number of sexual partners	Probable average of 3-4 sexual partners a year 15%-25% respondents in studies reported more than 10 partners a year There is a difficulty with definition of ‘sexual partners’ in stidies The kind of practices engaged in rather than number of partners is a better indication of HIV vulnerability (Lulla 1997, Li 1998, Chou 1996)
Relationships	Relationships among MSM take a variety of forms from strict monogamy to ‘open relationships’ Unprotected oral and anal sex appear much more likely to occur in those that are perceived as ‘steady relationships’ Relationship with or perception of partner is a major determinant of risk behavior Issues like love and trust interfere with safer sex Fears of not finding or not ‘keeping’ a lover can contribute to unsafer sex ‘Steady relationships’ (and even ‘monogamy’ are liable to be defined in very different ways by different men. (Jones et al. 2000, Lulla 1997)
Sexual Practices	Oral sex appears to be the most popular sexual practice among MSM (about 90%) Ejaculation in mouth appears common The prevalence of anal sex is unclear (probably around 50%) Probably around 20%-30% of anal intercourse is unprotected (Chou 1996, Jones et al. 2000, Li 1998, Lulla 1997)
Safer Sex Practices	Condom use appears to be most popular risk reduction strategy for anal sex (about 50%) Other popular strategies for anal sex include withdrawal, being selective about partners and avoiding it altogether Condom is use much less common in oral sex The most common risk reduction strategies for oral sex include withdrawal (not getting ejaculate in mouth) and being selective about partners Reasons for not using condoms include love for/trust in partner, perceptions of partner as not promiscuous, lack of enjoyment associated with condoms and condoms not being readily available (Jones et al. 2000, Li 1998, Lulla 1997)

Table 3: Research Findings: Sexual Behavior

5. Research Findings: Social Factors

Table 4 summarizes research findings regarding the social factors involved in HIV related risk behavior among MSM:

Area of Study	Research Findings
Tongji social scene	Common places when MSM socialize and meet sexual partners are bars, karaoke lounges, saunas, public toilets, beaches, swimming pools, shopping centers, internet chat rooms and activities of tongji organizations Relative popularity of different venues is difficult to determine from current studies due to sampling bias (e.g. questionnaires distributed in bars and saunas) There are currently about 20 tongji organizations in Hong Kong (for men) Media like magazines, internet chat rooms. ICQ, internet radio stations play an increasing role in the formation of social and sexual networks A large number of tongji live with their families (Chou 1996, Jones et al. 2000, Lulla 1997, Spodick 2000, Smith 1999)
Places people have sex: Public toilets	About a third of those surveyed in studies reported visiting public toilets to meet sexual partners Practices most commonly engaged in in toilets include exhibitionism/voyeurism mutual masturbation and oral sex Anal sex is rare in toilets Negotiation of sex in toilets is mostly silent Different toilets have different ‘cultures’ (Different kinds of MSM visit them and engage in different kinds of activities) Risk of arrest, robbery or blackmail sometimes overshadows risk of HIV infection Toilets are important sites of socialization for young tongji, often where their first same sex sexual encounter takes place Toilets also appear to be popular with married tongji ( Jones et al. 2000, Li 1998, Lulla 1997)
Places people have sex: Saunas	There are about 20 saunas catering to MSM in Hong Kong In studies about half of respondents reported visiting saunas regularly Currently about eighteen saunas are making condoms available to users Saunas appear to be associated with a high degree of unsafer oral and anal sex, but no data is available on the prevalence Saunas provide more opportunities for non-sexual contact between MSM than other public sex venues. Clients at saunas may engage in multiple sexual episodes in a single visit and use different safer sex practices with different partners There are logistical problems with customers dealing with condoms when they are not immediately available in the places where sex takes place Saunas also appear to be popular with married MSM (Gei Lou nd, Jones et al. 2000, Lulla 1997, Smith 1998b)
Places people have sex: Other	Other places men seek sexual partners are beaches, swimming pools, shopping centers, and over the internet No data is available on social/sexual behavior in these venues (Jones et al. 2000, Lulla 1997)
Age	About half the men surveyed in studies had their first sexual encounter before the legal age of consent (21) Many MSM appear to be more willing to engage in unsafer sex with younger men, believing them to be less ‘risky’ Younger men are sometimes expected to take the passive role in anal intercourse Younger men are less equipped to negotiate safer sex with older partners The most popular venues for younger MSM to seek sexual partners appear to be toilets and over the internet (Chou 1996, Jones et al. 2000, Li 1998, Lulla 1997)
Culture and race	Cultural factors which may be important in HIV risk behavior are norms against disclosure (particularly to family members) and concerns regarding ‘face’ in the negotiation of safer sex Some research has suggested that inter-racial or inter-cultural relationships may involve special dynamics in the negotiation of safer sex (Ho and Tsang 2000, Jones et al. 2000)
Discrimination	Public acceptance of homosexuality and bisexuality is low, but appears to be higher among the younger and those with more formal education Discrimination reported by tongji includes self-rejection and self-stigmatization, the need to conceal sexual orientation, public misconceptions about homosexuality; and discrimination in certain areas like housing and employment. Discrimination makes MSM less likely to seek medical care and testing, lowers motivation for safer sex through lowering self-esteem and forces men to plan their sexual activities around the need to conceal them from friends and family members (HK SAR Government 1996, Jones et. al 2000)
Community affiliation	A sense of ‘community’ is still relatively new among MSM in Hong Kong There appear to be a large number of MSM who do not identify with the tongji community Many men appear to have negative views of the community and of other MSM (Jones et al. 2000)
Other factors	Other factors mentioned in studies that seem to have an impact on HIV risk related behavior include boredom, curiosity, low self-esteem, depression, frustration, communication problems in relationships and difficulties negotiating safer sex in ‘casual’ encounters. Drug and alcohol use have been associated with unsafer sex in foreign studies, but no data is available in Hong Kong. This seems particularly important due to the apparent increase in the use of recreational drugs like ‘ecstasy’ by MSM (and young people in general) (Jones et al. 2000)

Table 4: Research Findings: Social Factors

5.7/8 HIV Prevention and Testing

Table 5 provides a summary of research findings regarding attitudes towards HIV/AIDS and HIV antibody testing:

Area of Study

Research Findings

Attitudes towards HIV

About of third of those surveyed in studies reported low concern about HIV infection, about a third reported moderate concern, and about a third reported high concern
High concern about HIV does not necessarily lead to safer sex; anxiety about infection can sometimes contribute to unsafer sex
A ‘fatalistic’ attitude towards HIV appears to be common
Lack of exposure to peers with HIV infection lessens feelings of concern

(Jones et al. 2000, Lulla 1997

HIV antibody testing

The prevalence of HIV testing among MSM in Hong Kong appears to be much lower than in many Western countries and could be as low as 15%
There appears to be a weak correlation between perceptions of risk and testing behavior
Most MSM appear to get tested fro HIV at private doctors rather than public clinics
Reasons given for not testing were fear about a possible positive result, perceptions that it is not necessary and inconvenience

(Jones et al. 2000, Lau and Wong 2000, Li 1998)

Table 5: HIV Prevention and Testing

6. Recommendations from Past Research

The following recommendations have come out of past research on MSM:

More research on MSM is needed
Research should, as much as possible, be community based
Earlier intervention and a greater focus on younger tongji is necessary
More promotion of safer sex in commercial venues like bars is necessary
Wider availability of condoms and lubricant in public and semi-public sex venues like saunas and toilets should be ensured
More emphasis should be placed on MSM issues in school-based sex education programs
More emphasis should be placed on addressing social discrimination and stigmatization
Access to care should be improved through better training of medical staff and the formation of dedicated clinics or clinic hours for MSM
Prevention programs should provide tongji with training and counseling on sexual negotiation skills
More attention should be focused on MSM who do not identify as gay or tongji

7. AIDS Prevention Efforts

Table 6 gives a summary of the major AIDS prevention activities undertaken by various organizations for MSM. It does not include smaller, unfounded activities.

Organization	Activity
AIDS Concern	Educational Materials A set of three leaflets on safer sex, oral sex and anal sex. (First printed in 1995, over 60,000 distributed) A set of 12 cards on HIV transmission through oral sex, anal sex, kissing/masturbation, STDs, regular partners, and drug use. (First printed in 1996, over 90,000 cards distributed.) A set of three posters to encourage people to collect all 12 cards. (50 copies produced in 1997) A sticker promoting condom use for use in public toilets. A booklet on STD an AIDS. (First Printed in 1997, over 3,000 distributed.) A cartoon booklet on AIDS and safer sex (4,000 printed in 1998. Distribution began April 1998.) A coaster promoting condoms and lube (10,000 produced in 1998. Distribution began in October 1998) A safer sex kit (key chain with a small plastic bag) A safer sex kit (tissue pack) (30,000 produced in 2000. Distribution began in March 2000) Outreach Programs Sauna outreach program (started in 1997), currently serving at least eighteen saunas with visits from outreach workers and the provision of safer sex materials, condoms and lubricant Toilet outreach program (started Sauna testing service (Pilot program started to two saunas in August 2000) Other Events Workshops on MSM issues for staff at social hygiene clinics and hosting a number of social events promoting AIDS awareness like it’s ‘Rubber Love’ parties, seminars/discussions on safer sex during events like the Gay and Lesbian Film Festival
Ten Percent Club	First AIDS prevention pamphlet produced for MSM (early 1990s) Video on safer sex
Rainbow of Hong Kong	Training Program for MSM & AIDS Hotline Volunteers (2000) Peer Education Program ‘Gay Positive/HIV Negative) (2000)

8. Gaps in Knowledge

More research is needed on the sexual behavior of MSM and the social conditions surrounding it. The direction of current prevention programs seems to be consistent with research findings, but they are too limited and data on their effectiveness is scarce.

The things we need to know more about are:

The effect of relationships on MSM risk behavior
The different kinds of risk behavior associated with different venues in which sex takes place
The effect of culture and the construction of MSM identity on risk behavior
The affect of psychological factors like self-esteem on risk behavior
The extent of HIV antibody testing and the extent of actual infection among MSM
The risk behavior of MSM who do not identify themselves as ‘gay’ or tongji
Other factors not yet uncovered by researchers which might play a role in HIV related risk behavior
The effectiveness of current prevention programs

References

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