Relationship between the use of gay mobile phone applications and HIV infection among men who have sex with men in Ningbo,China: a cross-sectional study

Abstract

In recent years, there has been a significant increase in the use of gay mobile phone applications (gay apps) and HIV prevalence among men who have sex with men (MSM) in China. The aim of this study was to investigate whether there was a relationship between the use of gay apps and HIV infection and provide a targeted intervention to MSM. A cross-sectional study was conducted. Chinese MSM who were over 18 years old and had self-reported homosexual intercourse in the past six months were interviewed in 2016. Proportions were used for categorical variables and determinants of HIV infection were assessed using univariate and multivariate regression. Of the 403 participants, nearly 66.0% reported having used gay apps to seek sexual partners in the past six months. A higher proportion of the gay app users were younger than 19 years old, single, had high school education, were earning less than 115 GBP income per month, and identified themselves as homosexual. Compared to app non-users, a greater proportion of app users reported a higher frequency of male–male sexual contact (≥1 time/week: 57.5% versus 39.4%, p < 0.01), multiple male sex partners (34.2% versus 11.7%, p < 0.001), and unprotected sex with men (51.5% versus 36.5%, p < 0.01) in the past six months. The prevalence of HIV among app users was 7.9%. HIV infection was significantly associated with being an app user (adjusted odds ratio = 5.2, 95% CI = 1.1–24.3). It is suggested that the use of gay apps, especially Blued, is popular among Chinese MSM and is associated with high-risk sexual behaviors and HIV infection. Therefore, there is an urgent need to promote HIV testing and HIV prevention through gay apps to decrease the risk of HIV infection among Chinese MSM.

Keywords

Men who have sex with men gay apps risk behavior HIV China

Introduction

In China, the prevalence of HIV has been rising rapidly among men who have sex with men (MSM), creating a potentially serious and generalized public health problem.¹ MSM accounted for approximately 28.3% of the newly-reported HIV cases; some regions, e.g. Chengdu, reached as high as 80% in 2015.^2,3 Overall prevalence of HIV was 5.0% among MSM, which was much higher than among female sex workers.^4,5

The Chinese Center for Disease Control and Prevention (China CDC) has made many efforts to decrease the rate of new infection of HIV among MSM. Free circumcision, popular opinion leader intervention, intensive HIV counseling, and condom promotion were undertaken by the China CDC and many MSM community-based organizations have given their cooperation for this initiative.^6,7 But these interventions were aimed mainly towards MSM in public bathrooms, bars, clinics, and other public places. Owing to the development of mobile phone and internet technology in recent years, more MSM are able to find sexual partners by using gay mobile phone applications (gay apps) rather than via traditional methods (venues).⁸ Also, HIV interventions aimed at these MSM who use gay apps have been scarce in China.

In recent years, a number of gay apps were developed in China, including Blued, Jack’d, and ZANK. In 2016, Blued reported that it had 27 million users, making it the most popular gay app in China.⁹ These gay apps use a phone's global positioning system to provide a quicker and easier way to find sexual partners who are geographically close. It can be safely assumed that the increasing prevalence of gay apps use is attributed to the wide availability of smart phones. Some studies have indicated that gay apps use was associated with high-risk sexual behaviors and HIV infection,^9,10 but most studies did not include a comparison group (app non-users). It was difficult to ascertain whether app usage was a sexual risk factor or merely a common phenomenon among MSM.

Given the limited research on the relationship between gay app usage and HIV infection among Chinese MSM, more investigation is needed. The purpose of this study was to investigate the prevalence of the use of gay apps among MSM, the characteristics of MSM who use gay apps, and factors associated with HIV infection among MSM in Ningbo, China.

Methods

Study design and setting

A cross-sectional study design was used for this observational study. The study was conducted between 1 April and 30 September 2016 in Ningbo, China. Ningbo is a sub-provincial city in Zhejiang province located on the eastern coast of China, south of Shanghai, with a population of 7.6 million people.

Recruitment and enrollment

Potential participants were recruited to the study by a mixed method that included (a) community-based outreach and peer referral whereby trained project workers distributed study-related information and invitations, and (b) internet advertisement on gay websites and gay Tencent QQ groups (a Chinese instant messaging program). The participants reached the voluntary testing and counseling clinic with the help of the address and phone number provided in the online advertisement. Eligibility criteria were (1) being male, (2) being ≥16 years old, (3) having lived in Ningbo for three months, and (4) having had anal sexual contact with a male partner at least once in the past year. All eligible participants were then required to provide written informed consent as a part of study enrollment.

Questionnaire

The survey instrument was developed by interviewing 10 MSM and by a literature search. After development, the revised survey was conducted among 20 MSM prior to the final survey. Once enrolled, all participants were given the survey paper that contained a self-administered questionnaire to fill out. The questionnaire included the following: (1) socio-demographic data including year of birth, marital status, education level, income, and sexual orientation; (2) homosexual behaviors, including frequency of sex, the number of sexual partners, group sex, and unprotected anal intercourse in the past six months; (3) use of gay apps, including apps classification, reasons for use, duration and frequency of use, and login time; and (4) acceptance of intervention by gay apps, including asking whether participants would like to receive information alerts. They were also asked what information they would like to receive and the frequency of receiving information.

HIV testing

Blood samples were collected from all eligible participants after completing the paper survey. Blood specimens were tested for HIV antibodies using enzyme-linked immunosorbent assay (ELISA, Livzon Pharmaceutical Group Inc., China) by trained doctors in Ningbo CDC. Positive HIV-1 ELISAs were confirmed by Western blot (HIV 2.2 WB, Genelabs Diagnostics, Singapore).

Statistical analysis

Categorical variables were presented as number and percent. Chi square tests were used to compare the demographic and sexual behavioral characteristics between gay app users and gay app non-users. Statistically significant variables at the bivariate level and theoretically important covariates were included in the multiple logistic regression models. Adjusted odds ratios (AORs) and 95% CI for risk factors associated with HIV infection were processed, and p < 0.05 was considered statistically significant. Statistical analysis was performed with SPSS version 21.0 (IBM, Armonk, NY, USA).

Ethical considerations

This study was reviewed and approved by the Ethics Board of the Ningbo Center for Disease Control and Prevention. Informed consent was obtained from each participant prior to study commencement. Participants were given a gift after the survey. Those participants who were found to be HIV-positive were referred for treatment.

Results

Participants

A total of 410 individuals were recruited and screened for study inclusion. Of these, seven participants (1.7%) were excluded for the following reasons: did not have sexual contact with a male partner in the past year (1.5%) and diagnosed with HIV two years ago (0.2%). Thus, a total of 403 participants (98.3%) were included in the analysis. The characteristics of the study participants are provided in Table 1. A majority of participants were 20–29 years old (73.4%), single (89.8%), had at least some college-level education (53.6%), and self-identified as homosexual (81.9%), and 178 participants (44.2%) had monthly income of 347 to 577 GBP. In the past six months, the frequency of male–male sexual contact was reported to be at least once a week by approximately half of the participants (51.4%). A majority reported not having multiple male sex partners (73.4%), not having group sex with men (89.8%), and not having unprotected sex with men (53.6%) in the past six months.

Table 1.

Characteristics of study participants and of gay mobile app users and non-users in Ningbo, China, 2016 (n = 403).

Characteristics	All participants	Subgroup comparison
	All participants	App users	App non-users	p^a
	N (%)	N (%)	N (%)	p^a
Overall	403 (100)	266 (100)	137 (100)
Demographics
Age (years)
<19	39 (9.7)	27 (10.2)	12 (8.8)	0.27
20–29	296 (73.4)	201 (75.6)	95 (69.3)
30–39	58 (14.4)	33 (12.4)	25 (18.2)
≥40	10 (2.5)	5 (1.9)	5 (3.6)
Marital status
Single	362 (89.8)	242 (91.0)	120 (87.6)	0.43
Married/cohabitating	37 (9.2)	21 (7.9)	16 (11.7)
Separated/divorced/widowed	4 (1.0)	3 (1.1)	1 (0.7)
Education level
Middle school or less	44 (10.9)	26 (9.8)	18 (13.1)	0.56
High school	143 (35.5)	97 (36.5)	46 (33.6)
College or above	216 (53.6)	143 (53.8)	73 (53.3)
Monthly income (GBP)
<115	87 (21.6)	62 (23.3)	25 (18.2)	0.55
115–346	88 (21.8)	60 (22.6)	28 (20.4)
347–577	178 (44.2)	112 (42.1)	66 (48.2)
≥578	50 (12.4)	32 (12.0)	18 (13.1)
Sexual orientation
Homosexual	330 (81.9)	220 (82.7)	110 (80.3)	0.74
Bisexual	46 (11.4)	28 (10.5)	18 (13.1)
Uncertain	27 (6.7)	18 (6.8)	9 (6.6)
Sexual behavior
Frequency of male–male sexual contact (times/week)^b
<1	196 (48.6)	113 (42.5)	83 (60.6)	<0.01
≥1	207 (51.4)	153 (57.5)	54 (39.4)
Multiple male sex partners^b
No	296 (73.4)	175 (65.8)	121 (88.3)	<0.01
Yes	107 (26.6)	91 (34.2)	16 (11.7)
Group sex with men^b
No	362 (89.8)	235 (88.3)	127 (92.7)	0.17
Yes	41 (10.2)	31 (11.7)	10 (7.3)
Unprotected sex with men^b
No	216 (53.6)	129 (48.5)	87 (63.5)	<0.01
Yes	187 (46.4)	137 (51.5)	50 (36.5)

^aSubgroups were compared using Chi square tests to generate p values.

^bIn the past six months.

A total of 266 participants (66.0%) reported having used gay apps in the past six months, whereas 137 (34%) reported no use of gay apps in that timeframe. Compared to app non-users users, a greater proportion of app users reported having higher frequency of male–male sexual contact (≥1 time/week; 57.5% versus 39.4%, p < 0.01), having multiple male sex partners (34.2% versus 11.7%, p < 0.001), and having unprotected sex with men (51.5% versus 36.5%, p < 0.01) in the past six months.Table 1 presents a comparison of the characteristics of participants in these two groups.

The gay app most commonly used by app users was Blued (97.0%), followed by ZANK (26.3%), Jack’d (7.5%), and HORNET (1.1%). Among app users, a majority reported the reason for use as being to find friends (65.0%), while only a small proportion reported using gay apps to find sex partners (13.5%). A majority had used gay apps for at least two years (41.7%), used them between one and four times a day (44.4%), and most commonly used them in the evenings (59.4%, Table 2).

Table 2.

Gay mobile app use of study participants in Ningbo, China, 2016 (n = 403).

Apps use	N	%
Gay mobile apps used
Blued	258	97.0
ZANK	70	26.3
Jack’d	20	7.5
HORNET	3	1.1
Reason for using gay mobile apps
To find friends	173	65.0
To “kill” time	56	21.1
To find sex partners	36	13.5
To get news about gay issues	1	0.4
History of gay mobile app use (months)
<3	20	7.5
3–6	27	10.2
7–11	34	12.8
12–23	74	27.8
≥24	111	41.7
Frequency of use (times/day)^a
<1	106	39.8
1–4	118	44.4
≥5	42	15.8
Time of day used^a
Morning	22	8.3
Afternoon	37	13.9
Evening	158	59.4
Night	35	13.2
Only on holiday	14	5.3
Acceptance of interventions by apps
Periodic HIV testing auto-reminder	189	56.6
Risk assessment	162	48.5
HIV/AIDS counselling	124	37.1
Desired frequency to receive interventions (times per month)
1	261	77.0
2	40	11.8
4	23	6.8
8	15	4.4

^aIn the past six months.

Of the 403 MSM surveyed, 82.9% wanted to receive health information through gay apps, including periodic HIV testing auto-reminders (56.6%), risk assessments about sexual behavior (48.5%), and HIV counseling (37.1%). Moreover, 78.1% wanted to receive this information once a month (Table 2).

Among all participants, 23 were found to be HIV-positive, with an overall prevalence of HIV of 5.7%. Among app users, HIV prevalence was 7.9% compared to 1.5% among app non-users. As shown in Table 3, after controlling for confounding in a multivariable analysis, higher educational attainment was found to be a protective factor against HIV infection (high school: AOR = 0.3, CI = 0.1–0.9; college or above: AOR = 0.2, CI = 0.1–0.7). Risk factors for HIV infection were having multiple male sex partners (AOR = 3.1, CI = 1.2–7.8), having group sex with men (AOR = 3.4, CI = 1.2–9.7), having unprotected sex with men (AOR = 3.9, CI = 1.5–9.7), and using gay apps (AOR = 5.2, CI = 1.1–24.3).

Table 3.

Factors associated with HIV infection among study participants in Ningbo, China, 2016 (n = 403).

Factor	All participants	HIV-positive participants	Unadjusted	Adjusted
Factor	N (%)	N (%)	OR (CI)^a	OR (CI)^a
Overall	403	23 (100)
Education level
Middle school or less	44	7 (15.9)	1.0	1.0
High school	143	7 (4.9)	0.3 (0.1–0.8)	0.3 (0.1–0.9)
College or above	216	9 (4.2)	0.2 (0.1–0.7)	0.2 (0.1–0.7)
Multiple male sex partners^b
No	296	9 (3.0)	1.0	1.0
Yes	107	14 (13.1)	4.8 (2.0–11.5)	3.1 (1.2–7.8)
Group sex with men^b
No	362	16 (4.4)	1.0	1.0
Yes	41	7 (17.1)	4.5 (1.7–11.6)	3.4 (1.2–9.7)
Unprotected sex with men^b
No	295	11 (3.7)	1.0	1.0
Yes	108	12 (11.1)	3.2 (1.4–7.6)	3.9 (1.5–9.7)
Gay mobile apps use^b
App non-user	137	2 (1.5)	1.0	1.0
App user	266	21 (7.9)	5.8 (1.3–25.1)	5.2 (1.1–24.3)

^aUnivariate and multivariate regression analyses were used to generate odds ratios (ORs) and 95% CIs.

^bIn the past six months.

Discussion

This study revealed that 66.0% of MSM had used gay apps in the past six months, similar to a study conducted in Los Angeles.¹¹ It indicated that gay apps have become popular social networking media for seeking sex partners.¹² Among Ningbo MSM, Blued (64.0%) was the most commonly used gay app in 2016, which was higher than a study conducted in southern China (1.8%) in 2013,¹³ showing that Blued, which was launched in 2012, has become a popular app among Chinese MSM. In addition, the recent development of 4G smartphones might have increased the usage of apps.¹⁴

Although we did not find any demographic differences among app users and app non-users, gay app users were more likely to be younger than 19 years old, single, with a high school education, were earning less than 115 GBP income per month, and identified themselves as homosexual. Compared to other studies pertaining to the demographic characteristics of HIV-positive MSM, these subgroups of app users should be targeted in HIV prevention studies and interventions.^15–17 The results also revealed patterns of usage of gay apps, including having used for at least two years, logging onto apps between one and four times a day, and most commonly using them in the evening. Therefore, more targeted interventions might need to take into consideration the duration, frequency, and login time of app use.

We found that app users were more likely to engage in sexual behavior more than once a week, have multiple sexual partners and have unprotected anal intercourse in the past six months. These findings are consistent with research from Los Angeles¹⁸ and New York City.¹⁹ These sexual behaviors may increase the risk of HIV transmission. This study also found that the prevalence of HIV among gay app users was significantly higher than among app non-users. Gay app users were five times more likely to be infected with HIV compared with app non-users. One explanation may be that HIV-positive MSM do not find it easy to disclose their HIV status while seeking sexual partners on gay apps because of persistent stigma.²⁰ Another explanation may be that gay apps increase the risk of HIV acquisition. Many studies have confirmed that serosorting can reduce the risk of acquiring or transmitting HIV, which is the practice of using HIV status as a decision-making factor in choosing sexual behavior.^21,22 Therefore, serosorting could be popularized for gay app users by developing a HIV status query system on apps. This intervention could increase coverage of HIV testing to close the testing gap and achieve the UN’s 90–90-90 and 2030 global goals.²³

This study also demonstrated the acceptability of using gay apps. About four-fifths (82.9%) of surveyed MSM would like to receive health information via gay apps. It is necessary to undertake targeted interventions in these hidden populations who use gay apps to seek sexual partners. Fortunately, some gay app companies such as Blued have developed a public platform to engage with mental health services, including HIV prevention and referrals to a local HIV testing site,²⁴ but there were some barriers to using gay apps for HIV prevention. Most companies that launch gay apps are only peripherally interested in HIV testing and control, with their main goal being revenue generation. Therefore, intervention programmes could be improved by app companies cooperating with professional institutions. Heath information such as periodic HIV testing auto-reminders and risk assessments for sexual behavior can be sent to app users once a month. In addition, health counselling can be provided to answer user questions on gay apps.

Limitations

This study had several limitations. First, participants were recruited by the convenience sampling method, and may not be representative of the MSM population in Ningbo or the population in general. Second, the current study design is prone to recall and social desirability bias. In order to minimize these biases, questions about sexual behaviors and use of gay apps were limited to the past six months or most recent sexual behavior. In addition, all questionnaires were anonymised and all interviewers were highly trained. Finally, since this was a cross-sectional study, we were not able to make inferences about causality. Future longitudinal studies are needed to establish causation between the use of gay apps and HIV infection.

Conclusions

The prevalence of the use of gay apps, especially Blued, for seeking sexual partners was widespread in the Chinese MSM population. The use of gay apps was related to high-risk sexual behaviors and HIV infection. The majority of app users had been using them for more than two years, logging on between one and four times a day, and mainly using the apps in the evening in the past six months. We also found that the majority of surveyed MSM would like to receive health information by gay apps. Therefore, there is an urgent need to promote HIV testing and HIV prevention through gay apps to decrease the risk of HIV infection among MSM.

Footnotes

Acknowledgement

The authors thank the project staff of the Ningbo Blue Air Working Group for the survey. The funding organizations (as mentioned in the Funding section) had no role in the design and conduct of this study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the China AIDS Fund for Non-Governmental Organizations (2016–2017330203PY DMSM 001998–2016) and The Medical Key Discipline of Zhejiang Province (07–013).

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