amfAR, The Foundation for AIDS Research

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.

Doctor H Liu
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.