Introduction

In China there are currently about 780,000 people living with HIV (PLWH). [1] The percentage of newly reported HIV cases attributed to male homosexual exposure has increased from 0.2% in 2001 [2] to 32.5% in 2009 [3] and HIV prevalence among Chinese men who have sex with men (MSM) reached 5.3%. [4] A high prevalence of unprotected anal intercourse (UAI) among HIV positive MSM has been reported, [5] while another study reported a reduction of sexual risk behaviors among HIV positive MSM as well as other at-risk populations. [6] Predictors of HIV transmission via HIV positive MSM include the use of stimulants and other drugs, low coping self-efficacy, failure to disclose one’s HIV serostatus to all partners, past sexual behaviors and intentionality of condom use. [7] It is further argued that the benefits of highly active antiretroviral therapy (HAART) and earlier diagnosis of the disease have been offset by an increase in risk behaviors. [8] Quantitative psychosocial assessments dominate the studies of sexual risk among HIV positive MSM, emphasizing the prevalence of risk behaviors and the statistical significance of associated factors, such as substance use [9] and a diagnosis of depression. [10] These studies however have underestimated the importance of understanding subjective experience, and therefore provided limited contextual and cultural insight on the occurrence of and meanings behind this behavior. Only a few qualitative studies have explored factors associated with UAI among HIV positive MSM, [11] combined with associated factors such as substance use, mental health, cultural norms and personal responsibility. [12]

There are limited studies to date that undertake a qualitative approach to explain UAI among HIV positive MSM within a Chinese context. In the reported study, a socio-ecological approach [13] was employed to enable a contextualization of the complex relationships and nuances of the interplay of UAI and related socio-ecological factors.

Prior to conducting the main study, the first author conducted a pilot study using a draft semi-structured interview guide in Mandarin Chinese with five HIV-infected MSM and five healthcare workers and volunteers independent from the main study, with modifications made accordingly. The socio-ecological approach, as supported by the pilot study, enabled an exploration of a broad range of personal and socio cultural factors within the context of contemporary Chinese society.

The current study conducted, in China, aimed to explore intrapersonal (e.g. individual characteristics of knowledge, attitudes, self-concept, emotion, behavior, and skills), interpersonal (e.g. significant others and interpersonal relationships), and socio-cultural (e.g. cultural context, social norms and networks) factors shaping the practice of UAI.

Methods

Participants

The inclusion criteria for participation were: 18 years of age or older, diagnosed as HIV positive in the last six months (newly diagnosed), and identified as a MSM. We used purposive sampling based on diverse socioeconomic backgrounds to recruit participants. A total of 31 eligible newly diagnosed HIV positive MSM (Table 1) were interviewed, among which six participants (Table 2) reported UAI after being diagnosed as HIV positive.

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Table 1. Summary of the characteristics of the newly diagnosed HIV positive MSM who took part in repeated in-depth interviews.

https://doi.org/10.1371/journal.pone.0140555.t001

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Table 2. The characteristics of six participants who practiced unprotected anal intercourse after the diagnosis of HIV positive.

https://doi.org/10.1371/journal.pone.0140555.t002

Results

The majority of participants reported practicing safer sex after an initial diagnosis of being HIV positive, while the minority of participants reported UAI that may put their sex partners at risk of acquiring HIV. Some participants reported initially using condoms or practicing oral sex and masturbation, but then resorting to UAI again. We illustrate the practice of UAI underpinned by the socio-ecological factors as follows.

Discussion

In this study, an adapted socio-ecological model was used to underline and explore UAI among newly diagnosed HIV positive MSM in China enabling a multi-level and multi-dimensional analysis. The findings highlight intrapersonal contexts, partner type, the ensuing complexity between anonymous sexual encounters and psychological status, and moral judgments.

Our findings show that the intrapersonal context, such as emotionality, mental health, risk perception, and substance use, is an important domain related to UAI, which is consistent with previous studies. [18, 19] In the current study, some participants initiated safer sex after being newly diagnosed as HIV positive but subsequently reengaged in the practice of UAI when they felt under stress. Men with self-reported poor moods and holding a negative view of themselves or their futures (e.g., nothing to lose after becoming HIV positive) may well have a higher propensity to engage in unsafe sexual practices. This practice could result in increasingly negative views about popularized social models regarding condom use. [20]

Moreover, perceptions of self-rationalized optimism (e.g., “zhuan yin”) also warrants further attention with Chinese MSM populations. The perception of low HIV transmission risk from “0” to “1” accounted for the practice of UAI among some participants. Such findings are consistent with studies in the US, reporting that HAART reduced perception of negative health consequences (e.g., HIV transmission) and provided an added rationale for unsafe sex. [19, 21] Compared with men who reported no engagement with UAI, strategic positioning (serosorting) was associated with an increased risk of sexually transmitted infections, such as urethral gonorrhea and chlamydia. [22] MSM who had UAI with casual partners as well as MSM in serodiscordant relationships could be viewed as independent predictors of HIV seroconversion in Australia. [23]

Our study found that different partner typologies were differentially linked to the practices of UAI. For those HIV positive MSM with lovers or stable partners, fear of losing partners in a context of non-serostatus disclosure provided an important explanation for practicing UAI. Such a rationale is likely embedded in a social and cultural context with these Chinese HIV positive MSM finding it considerably more difficult to look for lovers or stable partners within MSM circles. This may be because in contemporary China homosexuals are excluded from cultural legitimacy. [24] Homosexuality in China has long been regarded as sick, abnormal or perverted, interwoven by traditional values of family, marriage, gender roles, and contemporary ideology of reformation and neo-liberalism. [25] A diagnosis of HIV may have further exacerbated these men’s suffering and sense of inequality.

In Shenzhen, it has been reported that 52.6% of MSM are not in steady relationships. [26] After being diagnosed with HIV, the MSM interviewed testified to needing emotional and social support, which was commonly associated with the fear of losing their partners. Moreover, non-disclosure of HIV status to sexual partners often coincided with the establishment of a new relationship. Internationally, it has been reported that a high percentage of HIV positive MSM who practiced unprotected sex did not disclose their HIV status to prospective sex partners before having unprotected sex. [27] An ethnography in the US indicated that few newly diagnosed HIV positive MSM had a consistent pattern of HIV disclosure since it is related to multiple and often competing emotional, situational, and legal factors. [28]

The fear of losing partners was reported to be an important reason for the practices of UAI among lovers or stable partners. In contrast, anonymous sexual encounters (e.g., tongzhi sauna) and the practice of moral judgment (e.g., equity) appeared to be closely related to UAI among casual partners. Anonymous sexual encounters have been repeatedly reported to promote unsafe sex. [12] Our analysis further emphasize that, for some newly diagnosed HIV positive Chinese MSM, anonymous sexual encounters coupled with the self-perceived psychological status was related to intrapersonal emotions, risk perception, and substance use. Our findings are consistent with an ethnographic study contending that experiencing negative emotions served to prompt unsafe sex in saunas. [29] A similar contention is applicable in tongzhi saunas in China, where unprotected sex was regarded by some MSM as a norm in this specific sexual space and as a way to satisfy certain emotional needs. For our participants who reported regularly visiting saunas and practicing unprotected sex, sexual gratification was testified to be a motivator justified by a lack of partners, loneliness, emptiness, boredom, or other social and psychological concerns.

For casual partners, the moral judgments of others within the domain of collectivistic and utilitarian Chinese morality was seen to be influential in the decision to practice UAI. Chinese society has been reported to be relatively more likely to punish people who practiced undesirable behaviors and to offer duty-based justifications than do their counterparts in the US. [30] Therefore, protecting oneself against HIV may be publically regarded as a personal duty, and anyone who violates this duty could be seen as deviating from this norm of equity, an underlying basis for many Chinese moral and ethical social dilemmas. [31] Our participants referred to equity and fairness as rationales for UAI with sex partners, who they regarded as deserving punishment. This finding is consistent with the equity theory in that individuals will become distressed when they find themselves participating in inequitable relationships subsequently leading to attempts to eliminate their distress through restoring equity. [32] A study in the US argued that HIV positive men who believe that other persons have intentionally tried to infect them are at especially high risk of engaging in UAI, due to attempting to restore a sense of equity. [33]

The current study is subject to limitations. Firstly, the use of digital recorders may have prohibited participants from openly talking about their stories of unsafe sex. Secondly, the sample size was small and sampling was limited to social networks of local MSM/PLWH groups mainly confined to the author’s ethnographic field. Thirdly, this manuscript has focused on the socio-ecological understanding of UAI, which was an element of the larger study. However, most of the participants reported practicing safer sex. Despite these limitations, we would contend that the current study has highlighted a Chinese socio-ecological context that may be related to UAI among newly diagnosed HIV positive MSM in a partner-specific manner. We contend that UAI among these HIV positive MSM was embedded in the Chinese socio-cultural environment, personalized belief systems, and experiences in notions of comparative moral judgment, tongzhi saunas, psychological status, partner types and negative intrapersonal contexts. It is important that prevention and intervention strategies for secondary HIV transmission among newly diagnosed HIV positive MSM in China take into account these specifics.

Acknowledgments

Disclaimer: The publication’s contents are solely the responsibility of the authors and do not necessary represent the official view of the center or the school.

Authors wish to thank all participants who shared their life histories and experiences, Shenzhen 258 Rainbow Workgroup and Shenzhen CDC who helped significantly in the fieldwork and access to the populations.