Comparison of risk behaviors and socio-cultural profile of men who have sex with men survey respondents recruited via venues and the internet

The prevalence of HIV among men who have sex with men (MSM) has been increasing in different parts of the world [1‐5]. Although venue-based sampling has frequently been used in studies targeting MSM [6‐9], the internet is becoming a potentially useful and cost-effective option [10‐13]. Internet-recruited MSM, as compared to venue-based MSM, were in general more likely to report different socio-demographic profiles and higher levels of risk behaviors such as unprotected anal intercourse (UAI) [14, 15], though mixed results have been reported [14‐16]. Most studies investigating risk factors in association with UAI sampled MSM from gay-venues [e.g., 6,8,9] but it is unknown whether internet-based MSM have different risk factors. There is a dearth of data comparing risk factors among MSM recruited from different sampling spaces [11, 12, 14‐16].

The HIV prevalence among MSM in Hong Kong, China in 2007 was around 4% [17], which is comparable to rates reported in some other Chinese cities [18]. A previous population-based study showed that around 2% of the general adult male population in Hong Kong self-reported having sex with men in the last 6 months and practicing risk behaviors such as UAI [19‐21]. Moreover, a substantial proportion of MSM both in Hong Kong and in mainland China seek their male sex partners via gay venues or via the internet [20, 22] and MSM in Hong Kong are interacting intensively with MSM in other Chinese cities [21, 23].

The present study compared socio-cultural factors and levels of risk behaviors among Hong Kong MSM participants recruited via venue-based and internet-based sampling methods. The variables compared include socio-demographics, prevalence of self-reported sexually transmitted diseases (STD), risk behaviors, service utilization and socio-cultural characteristics. The associations between these factors and UAI were investigated separately for venue-based and internet-based participants and these 2 sets of factors were compared.

Consistent with the results of some previous studies [14, 15, 20], internet-recruited MSM were more likely than their venue-recruited counterparts to have engaged in UAI and commercial sex, and to report having contracted STD in the last 12 months. The level of perceived HIV risk was however lower among internet-recruited MSM than among MSM recruited from venues. Different recruitment methods may therefore provide different results.

Internet-recruited MSM were less likely than venue-recruited MSM to have multiple MSM sex partners. It is possible that venue-goers meet many potential sex partners face-to-face in bars and saunas etc. and may end up having sex with some of them eventually, whilst internet-based sex networks are often constructed in a virtual reality. Sexual networks are important platforms for both HIV transmission [24, 25] and HIV interventions. Network-based interventions might be more feasible for venue-based respondents than for internet-based respondents. The problem of consuming psychoactive substances or alcohol prior to sexual intercourse was also more severe among venue-recruited MSM respondents than among internet-recruited respondents. Alcohol, drugs, and relevant peer pressure are more likely to prevail in venues. The findings of this study are consistent with those reported in other countries [14]. This suggests that venue-based campaigns should strengthen harm reduction of substance use and alcohol misuse.

Stating whether internet-based or venue-based respondents are at higher risk may oversimplify the issue. The two sampling methods may not be accessing a single population. Some but not all MSM can be accessed via both the internet and venues. Our data did not allow us to assess the degree of overlap. Our data, however, informed us that survey results of risk behaviors in MSM depend on the mode of data collection.

This study represents one of few attempts made to discern the socio-cultural profiles of venue-recruited and internet-recruited MSM. It can be seen that as compared to their counterparts recruited from venues, internet-recruited MSM respondents were less likely to disclose their sexual orientation to family members and to accept their own sexual orientation, and more likely to fear disclosing their sexual orientation to others, and to date/marry a woman in order to hide their sexual orientation. Implementation of face-to-face peer education may hence be more difficult and less feasible for internet-based MSM. Instead, internet-based empowerment efforts may be relevant for this group. Empowerment among MSM would increase condom use [26]. This study has also shown that only a minority of the participants, especially internet-based ones, had family or best friends who were supportive of their sexual orientation, possibly reflecting the severity of social stigma against MSM in Hong Kong.

Our findings indicated no significant between-group differences in service utilization rates. However, reservations and fear related to disclosing one's MSM identity might prevent some internet-recruited MSM from visiting gay venues. Since most MSM studies were based on venue-based sampling methods, the results of which were used to design programs targeting MSM in general, these programs may not be the most appropriate for internet-based MSM.

With respect to factors associated with UAI for venue-recruited and internet-recruited MSM respondents, perceived discrimination was significant for the former group but not the latter; the reverse was true for having some or all friends having MSM behaviors. Having best friends supporting one's MSM sexual orientation was significant for both groups. It is therefore seen that the two groups of MSM have both common and different factors associated with UAI. Social networks and social support may lead to both safer and riskier sexual behaviors [8, 24]. Having best friends to support one's sexual orientation was associated with UAI in both groups; the norm among their peers however may not favor condom use. Furthermore, internet-recruited respondents were relatively lacking in social support and may therefore be more affected by peer influences. This may explain partially why the variable related to having more MSM friends was significant in internet-recruited MSM but not the venue-recruited sample. It is however less clear why perceived discrimination matters in the latter group but not in the former group. Further research is required.

The present study has some limitations. Firstly, convenience-sampling was used as random sampling was not feasible. Many published MSM studies have used similar recruitment methods [e.g., 8]. Secondly, data were self-reported and may be subject to reporting bias, though most sex behavior studies are also self-reported [e.g., 8,14,19,21]. Respondents were assured of strict anonymity and privacy of the interviews. Thirdly, we did not ask about HIV status of the individuals. HIV positive individuals may have higher levels of risk behavior as compared to their HIV negative counterparts. An alternate explanation of our results may hence be due to a higher proportion of HIV positive MSM using the internet to seek sex partners or for sero-sorting. We cannot test this hypothesis with our results and further research is warranted. However, the involved website does not have any special contents catering HIV positive MSM and sero-sorting is unpopular in Hong Kong. HIV positive MSM are also not deferred from seeking partners from gay venues. Therefore, the bias should not be too serious. Fourthly, stronger social desirability bias may occur among venue-recruited participants as compared to internet-recruited participants, who did not need to face an interviewer. Fifthly, it is possible that a higher proportion of internet-recruited participants were living with a regular partner, with whom unprotected anal intercourse is usually more common than with casual partners. There also was a possibility of self-selection bias in the internet-recruited respondents. Finally, biological markers were not collected in this study.

The results of this study have implications on research survey methodology. They reinforce the claim that for HIV-related risk behavior studies, results are heavily dependent on the mode of data collection. Most of the published MSM studies are venue-based [e.g., 6,8] and their results should be interpreted with care. The relatively new respondent-driven sampling method (RDS) is meant to give probabilistic sampling estimates and has recently been applied to different MSM populations [e.g., 27]. Comparisons between venue-based, internet-based, and RDS survey results are warranted to understand potential impacts due to different sampling methods.

The study findings remind HIV workers that MSM are not a homogeneous group. According to the social marketing framework, segmentation is required for effective HIV prevention [28]. The "orientation-mix" of the segmented audience has to be sorted out for designing effective HIV intervention. Such does not seem to have been emphasized adequately in existing programs.