Effectiveness of instant versus text messaging intervention on antiretroviral therapy adherence among men who have sex with men living with HIV.

Objective: This study aimed to compare the effectiveness of instant versus text messaging intervention (TMI) on antiretroviral therapy (ART) adherence among men who have sex with men (MSM) living with HIV. Methods: This study was conducted in an infectious disease hospital of Jinan, China from October 2020 to June 2021, using non-randomized concurrent controlled design to compare the effectiveness of instant messaging intervention (IMI) versus TMI. The intervention strategies (health messaging, medication reminder, and peer education) and contents were consistent between the two groups, and the difference was service delivery method and type of information. The primary outcome was the proportion of achieving optimal ART adherence, defined as never missing any doses and delayed any doses more than 1 hour. Results: A total of 217 participants (including 72 in TMI group and 145 in IMI group) were included in the study. The proportion of achieving optimal adherence was higher in IMI group than TMI group at the first follow-up (90.2% versus 77.6%, p = 0.021) and second follow-up (86.5% versus 76.6%, p = 0.083). The effect of IMI versus TMI on improving ART adherence was found not to be statistically significant (risk ratio (RR) = 1.93, 95% confidence interval (CI): 0.95-3.94) in complete-case analysis. However, when excluding participants who did not adhere to the interventions, a significant improvement was observed (RR = 2.77, 95%CI: 1.21-6.38). More participants in IMI group expressed highly rated satisfaction to the intervention services than those in TMI group (67.3% versus 50.0%). Conclusions: The IMI demonstrated superior efficacy over TMI in improving ART adherence and satisfaction with intervention services. It is suggested that future digital health interventions targeting ART adherence should prioritize instant messaging with multimedia information in areas with Internet access. Trial registration: The study was registered at the Chinese Clinical Trial Register (ChiCTR), with number [ChiCTR2000041282].

Associations between perceived and actual risk of HIV infection and HIV prevention services uptake among men who have sex with men in Shandong province, China: a cross-sectional study.

BACKGROUND: Associations between perceived and actual risk of HIV infection and HIV prevention services uptake are inconclusive. This study aimed to evaluate the discrepancy between the perceived and actual HIV risk, and quantify the associations between perceived and actual risk of HIV infection and three HIV prevention services utilization among men who have sex with men (MSM) in Shandong province, China. METHODS: A cross-sectional study was conducted in Shandong province in June 2021. Participants were eligible if they were born biologically male, aged 18 years or older, had negative or unknown HIV status, and had sex with men in the past year. Participants were recruited online. The discrepancy between their perceived and actual risk of HIV infection was evaluated by calculating the Kappa value. Bayesian model averaging was used to assess the associations between perceived and actual risk of HIV infection and HIV prevention services uptake. RESULTS: A total of 1136 MSM were recruited, most of them were 30 years old or younger (59.9%), single (79.5%), with at least college education level (74.7%). Most participants (97.4%) perceived that they had low risk of HIV infection, and 14.1% were assessed with high actual risk. The discrepancy between their perceived and actual risk of HIV infection was evaluated with a Kappa value of 0.076 (P < 0.001). HIV testing uptake had a weak association with perceived high HIV prevalence among social networks (aOR = 1.156, post probability = 0.547). The perceived high HIV prevalence among national MSM was positive related to willingness to use PrEP (aOR = 1.903, post probability = 0.943) and PEP (aOR = 1.737, post probability = 0.829). Perceived personal risk (aOR = 4.486, post probability = 0.994) and perceived HIV prevalence among social networks (aOR = 1.280, post probability = 0.572) were related to history of using PrEP. Perceived personal risk (aOR = 3.144, post probability = 0.952), actual risk (aOR = 1.890, post probability = 0.950), and perceived risk among social networks (aOR = 1.502, post probability = 0.786) were related to history of using PEP. CONCLUSIONS: There is discordance between perceived and actual personal risk of HIV infection among MSM in China. HIV risk assessment and education on HIV prevalence among MSM should be strengthened to assist high-risk populations aware their risk accurately and hence access HIV prevention services proactively.

Utilization of post-exposure prophylaxis potentially contributed to the changes of risk behaviors among men who have sex with men in China.

Background: The HIV infection status among men who have sex with men (MSM) in China is a cause for concern. Post-exposure prophylaxis (PEP) serves as a highly effective biomedical preventive measure against HIV infection. Substantial evidence has established an association between PEP utilization and risk behaviors among MSM, but whether the utilization of PEP has an impact on risk behaviors remains unknown. This study sought to elucidate the impact of PEP usage on risk behaviors among MSM and provide recommendations for developing targeted HIV prevention programs. Methods: A cohort study was conducted in Qingdao, China, from April 2021 to January 2022. Participants were enlisted by volunteers from community-based organizations through a snowball sampling method. Face-to-face interviews were conducted to collect sociodemographic and behavioral information of participants. The study encompassed a retrospective investigation, baseline survey, and follow-up survey, representing periods before, during, and after PEP usage, respectively. Generalized estimating equations, fitting a Poisson regression model, were applied to scrutinize changes in risk behaviors of MSM during and after PEP usage, in comparison to before PEP usage. Results: A total of 341 MSM were recruited in the cohort study, with 179 individuals completing the follow-up survey. In comparison to before PEP usage, there was a significant increase in the proportion of Rush Popper usage (17.6% vs. 23.8% vs. 29.6%) and commercial sexual partners (10.9% vs. 17.6% vs. 21.8%) among MSM during and after PEP usage. Before PEP usage, 88.7% of MSM reported having ≥3 temporary sexual partners in the last 6 months. This proportion exhibited no significant change during PEP usage (91.8%), but it significantly increased to 97.8% after PEP usage (P < 0.05). Notably, there was a significant decrease in group sex during and after PEP usage compared to before PEP usage (30.8% vs. 21.4% vs. 21.2%). Conclusion: The utilization of PEP may impact risk behaviors among MSM, potentially leading to increased Rush Popper usage, temporary sexual partners, and commercial sexual partners after PEP usage, accompanied by a decrease in group sex. Further research is imperative to elucidate the impact of PEP utilization on MSM and develop targeted HIV prevention programs.

The impact of HIV self-testing on risk behaviors among men who have sex with men: a mixed-methods study.

Background: Men who have sex with men (MSM) have a high prevalence of HIV and a low rate of HIV testing in China. HIV self-testing (HIVST) presents a viable strategy for expanding HIV testing among MSM. However, the impact of HIVST on risk behaviors among MSM remains controversial. Our study sought to ascertain this impact. Methods: From April 2021 to January 2022, a mixed-methods study was conducted in Qingdao City, employing both quantitative and qualitative methodologies. The quantitative component entailed a cohort study among MSM who had used HIVST. Generalized estimating equations fitting Poisson regressions were used to analyze the changes in risk behaviors of MSM in short time after HIVST (ST-HIVST) and longer time after HIVST (LT-HIVST) compared to before HIVST. Subsequently, we conducted in-depth interviews with 18 MSM who completed the follow-up to delve deeper into the impact of HIVST on MSM. Results: A total of 410 MSM were recruited in the cohort, of whom 83 were lost to follow-up. Compared to before HIVST, there were no significant changes in risk behaviors in ST-HIVST (p > 0.05), while the proportion of recreational drugs abuse (20.7% vs. 33.3%), commercial sex (14.6% vs. 22.9%), and unprotected anal sex (95.9% vs. 98.5%) increased significantly in LT-HIVST (p < 0.05). Specific changes varied across demographic characteristics. According to qualitative interviews, MSM might have decreased risk perception and increased risk behaviors after HIVST. Conclusion: The use of HIVST may promote MSM to engage in risk behaviors. In the future, customized HIVST promotion programs need to be developed to expand HIV testing among MSM and simultaneously control their risk behaviors.

Digital, Crowdsourced, Multilevel Intervention to Promote HIV Testing Among Men Who Have Sex With Men: Cluster Randomized Controlled Trial.

BACKGROUND: Despite great efforts in HIV prevention worldwide, HIV testing uptake among men who have sex with men (MSM) remains suboptimal. The effectiveness of digital, crowdsourced, multilevel interventions in improving HIV testing is still unclear. OBJECTIVE: The aim of this study was to evaluate the effect of a digital, crowdsourced, multilevel intervention in improving HIV testing uptake among MSM in China. METHODS: We conducted a 2-arm cluster randomized controlled trial among MSM in 11 cities in Shandong province, China, from August 2019 to April 2020. Participants were men who were HIV seronegative or had unknown serum status, had anal sex with a man in the past 12 months, and had not been tested for HIV in the past 3 months. Participants were recruited through a gay dating app and community-based organizations from preselected cities; these cities were matched into 5 blocks (2 clusters per block) and further randomly assigned (1:1) to receive a digital, crowdsourced, multilevel intervention (intervention arm) or routine intervention (control arm). The digital multilevel intervention was developed through crowdsourced open calls tailored for MSM, consisting of digital intervention images and videos, the strategy of providing HIV self-testing services through digital tools, and peer-moderated discussion within WeChat groups. The primary outcome was self-reported HIV testing uptake in the previous 3 months. An intention-to-treat approach was used to examine the cluster-level effect of the intervention in the 12-month study period using generalized linear mixed models and the individual-level effect using linear mixed models. RESULTS: A total of 935 MSM were enrolled (404 intervention participants and 531 controls); 751 participants (80.3%) completed at least one follow-up survey. Most participants were younger than 30 years (n=601, 64.3%), single (n=681, 72.8%), had a college degree or higher (n=629, 67.3%), and had an HIV testing history (n=785, 84%). Overall, the proportion of testing for HIV in the past 3 months at the 3-, 6-, 9-, and 12-month follow-ups was higher in the intervention arm (139/279, 49.8%; 148/266, 55.6%; 189/263, 71.9%; and 171/266, 64.3%, respectively) than the control arm (183/418, 43.8%; 178/408, 43.6%; 206/403, 51.1%; and 182/397, 48.4%, respectively), with statistically significant differences at the 6-, 9-, and 12-month follow-ups. At the cluster level, the proportion of participants who had tested for HIV increased 11.62% (95% CI 0.74%-22.5%; P=.04) with the intervention. At the individual level, participants in the intervention arm had 69% higher odds for testing for HIV in the past 3 months compared with control participants, but the result was not statistically significant (risk ratio 1.69, 95% CI 0.87-3.27; P=.11). CONCLUSIONS: The intervention effectively improved HIV testing uptake among Chinese MSM. Our findings highlight that digital, crowdsourced, multilevel interventions should be made more widely available for HIV prevention and other public health issues. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1900024350; http://www.chictr.org.cn/showproj.aspx?proj=36718. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-020-04860-8.

HIV Status Disclosure and Associated Characteristics Among HIV-Positive MSM Receiving Antiretroviral Therapy in Jinan, China.

Disclosure of HIV status offers potential benefits to individuals and is also good for public health. Limited studies have been conducted to gain insight into the current situation and associated factors of HIV disclosure among HIV-positive Chinese men who have sex with men (MSM) in the era of "treat all." We carried out a cross-sectional study among MSM receiving antiretroviral therapy from October 2020 to January 2021 at a hospital in Jinan, China. We used univariate and multivariable logistic regression to examine the factors associated with general disclosure and disclosure to family, friends, and sexual partners. Of the 585 participants recruited, 62.2% reported HIV disclosure, among which 25.3% had disclosed their status to family members, 25.3% had disclosed it to friends, and 28.4% had disclosed it to partners. The findings suggest that HIV disclosure is more likely to occur among individuals who are younger, married/cohabiting, and who self-identify as homosexual/bisexual. Participants with higher education levels or personal monthly incomes are less likely to disclose their HIV status. Furthermore, related factors of disclosure vary across the types of disclosure targets. Given the positive outcomes of disclosure, interventions and implementation research to facilitate it are urgently needed for MSM.

HIV infection disclosure, treatment self-efficacy and quality of life in HIV-infected MSM receiving antiretroviral therapy.

BACKGROUND: Research on the relationship between disclosure of HIV status to male sexual partners (HIV disclosure) and quality of life (QOL) revealed complex and even contradictory results. The impact of HIV disclosure on various domains of QOL and the mediation effect between them are unclear. The purposes of this study were to explore the impact of HIV disclosure on QOL among men who have sex with men (MSM), and whether HIV treatment self-efficacy mediated these relationships. METHODS: The data came from a baseline survey on the design of a randomized control trial conducted in Shandong, China. A total of 579 MSM patients were included. SPSS 24.0 was used to conduct independent samples t test, one-way analysis of variance and nonparametric tests and the PROCESS macro was used to conduct mediation analysis. RESULTS: Among 579 participants, 16.06% disclosed their HIV infection status to their male sexual partners. The effect of HIV disclosure on QOL was mediated by treatment self-efficacy. Self-efficacy played partial mediating role in social relationships, meaning that HIV disclosure had both direct and indirect effects on this factor. In the overall QOL and domains of physical, psychological, independence, and environment, HIV disclosure had an indirect effect only through self-efficacy and no significant effect on the spirituality domain. CONCLUSIONS: The results emphasize the importance of HIV disclosure and self-efficacy on the QOL of MSM patients and suggest that health care providers should assist MSM patients in deciding whether to disclose their HIV status during daily medical services.

Impact of antiretroviral therapy (ART) duration on ART adherence among men who have sex with men (MSM) living with HIV in Jinan of China.

BACKGROUND: Consistent and complete adherence is considered an essential requirement for patients on antiretroviral therapy (ART). This study aimed to evaluate the impact of ART duration on ART adherence, identify the trend of complete adherence, and compare the factors associated with ART adherence between short-term and long-term ART group among men who have sex with men (MSM) living with HIV in Jinan of China. METHODS: MSM living with HIV aged 18 or above and currently on ART were recruited from October to December 2020 using convenience sampling. Univariate and multivariable logistic regressions were used to evaluate the impact of ART duration on adherence and compare factors associated with ART adherence between subgroups. The Mann-Kendall test was used to identify the trend of complete adherence. RESULTS: A total of 585 participants were included in analysis, consisting of 352 on short-term ART (ART initiation ≤ 3 years) and 233 on long-term ART (ART initiation > 3 years). Significant difference of complete ART adherence between short-term and long-term ART group was detected (79.8% vs. 69.1%, P = 0.003). Multivariable analysis showed that men with longer ART duration were less likely to report complete ART adherence (AOR = 0.88, 95% CI 0.81-0.95). A descending trend of complete adherence was identified (Z = 1.787, P = 0.037). Alcohol use and lack of medication reminders were barriers to complete adherence for both of the subgroups. CONCLUSIONS: Sustained efforts to encourage maintaining adherence for a lifetime are necessary, especially for those on long-term ART. Future interventions should be tailored to subgroups with different ART duration and individuals with specific characteristics.

A differentiated digital intervention to improve antiretroviral therapy adherence among men who have sex with men living with HIV in China: a randomized controlled trial.

BACKGROUND: Antiretroviral therapy (ART) adherence is still suboptimal among some key populations, highlighting the need for innovative tailored strategies. This randomized controlled trial (RCT) aimed to evaluate the effect of a differentiated digital intervention on ART adherence among men who have sex with men (MSM) living with HIV in China. METHODS: The two-armed parallel RCT was conducted at one HIV clinic in Jinan of China from October 19, 2020, to June 31, 2021. Men were referred by health providers to join the study and then choose one of three digital strategies-text message, only instant message, or instant message plus social media. They were assigned in a 1:1 ratio to the intervention arm or control arm using block randomization, and inside each arm, there were three groups depending on the type of delivering the message. The groups were divided according to participants' preferred digital strategies. The intervention arm received ART medication messages, medication reminders, peer education, and involved in online discussion. The control arm received messages on health behavior and nutrition. The primary outcome was self-reported optimal ART adherence, defined as not missing any doses and not having any delayed doses within a one-month period. Secondary outcomes included CD4 T cell counts, viral suppression, HIV treatment adherence self-efficacy, and quality of life. Intention-to-treat analysis with generalized linear mixed models was used to evaluate the intervention's effect. RESULTS: A total of 576 participants were enrolled, including 288 participants assigned in the intervention arm and 288 assigned in the control arm. Most were ≤ 40 years old (79.9%) and initiated ART ≤ 3 years (60.4%). After intervention, the proportion of participants achieving optimal ART adherence in the intervention arm was higher than in the control arm (82.9% vs 71.1%). The differentiated digital intervention significantly improved ART adherence (RR = 1.74, 95%CI 1.21-2.50). Subgroup analysis showed one-to-one instant message-based intervention significantly improved ART adherence (RR = 2.40, 95% CI 1.39-4.17). CONCLUSIONS: The differentiated digital intervention improved ART adherence among MSM living with HIV in China, which could be integrated into people living with HIV (PLWH) management and further promoted in areas where PLWH can access text messaging and instant messaging services. TRIAL REGISTRATION: ChiCTR2000041282. Retrospectively registered on 23 December 2020.

The Impact of Peer Education on HIV Testing for Chinese Men Who Have Sex With Men: The Mediation Effect of Accompanying Friends for Testing.

This study aims to explore how peer education influences men who have sex with men (MSM) to accompany friends to test and then affects their own testing, and to reveal the internal mechanism of peer education influencing HIV testing. A cross-sectional study among MSM in 11 cities in Shandong province, China was conducted to collect information on demographic characteristics, behavior, HIV-related knowledge, HIV testing history, and use of prevention services. Blood samples were tested for HIV status. Logistic regression was used for univariate and multivariate analyses, and R Mediation package was used for mediating effect analysis. Of 4,005 participants, 66.8% (2,674/4,005) had HIV testing in the last year, 50.6% (2,026/4,004) accompanied a friend for HIV testing, and 65.3% (2,614/4,005) received peer education in the last year. In multivariate logistic regression analysis, MSM who had anal sex with men in the past six months (adjusted odds ratio [AOR] = 1.772, 95% confidence interval [CI] = [1.438, 2.182]), had used drugs (AOR = 2.762, 95% CI = [2.264, 3.368]), received peer education in the past year (AOR = 2.412, 95% CI = [2.081, 2.796]), and accompanied a friend for testing in the past year (AOR = 3.077, 95% CI = [2.653, 3.569]) were more likely to take HIV testing. Receiving peer education in the past year could influence their own HIV testing in the past year by affecting their accompanying one's friends to take the test in the past year (a*b = 0.889, 95% CI = [0.733, 1.053]). Peer education not only had a direct effect on HIV testing but also had an indirect effect on HIV testing by influencing accompanying friends for testing.

Digital crowdsourced intervention to promote HIV testing among MSM in China: study protocol for a cluster randomized controlled trial.

BACKGROUND: Men who have sex with men (MSM) are an important HIV key population in China. However, HIV testing rates among MSM remain suboptimal. Digital crowdsourced media interventions may be a useful tool to reach this marginalized population. We define digital crowdsourced media as using social media, mobile phone applications, Internet, or other digital approaches to disseminate messages developed from crowdsourcing contests. The proposed cluster randomized controlled trial (RCT) study aims to assess the effectiveness of a digital crowdsourced intervention to increase HIV testing uptake and decrease risky sexual behaviors among Chinese MSM. METHODS: A two-arm, cluster-randomized controlled trial will be implemented in eleven cities (ten clusters) in Shandong Province, China. Targeted study participants will be 250 MSM per arm and 50 participants per cluster. MSM who are 18 years old or above, live in the study city, have not been tested for HIV in the past 3 months, are not living with HIV or have never been tested for HIV, and are willing to provide informed consent will be enrolled. Participants will be recruited through banner advertisements on Blued, the largest gay dating app in China, and in-person at community-based organizations (CBOs). The intervention includes a series of crowdsourced intervention materials (24 images and four short videos about HIV testing and safe sexual behaviors) and HIV self-test services provided by the study team. The intervention was developed through a series of participatory crowdsourcing contests before this study. The self-test kits will be sent to the participants in the intervention group at the 2nd and 3rd follow-ups. Participants will be followed up quarterly during the 12-month period. The primary outcome will be self-reported HIV testing uptake at 12 months. Secondary outcomes will include changes in condomless sex, self-test efficacy, social network engagement, HIV testing social norms, and testing stigma. DISCUSSION: Innovative approaches to HIV testing among marginalized population are urgently needed. Through this cluster randomized controlled trial, we will evaluate the effectiveness of a digital crowdsourced intervention, improving HIV testing uptake among MSM and providing a resource in related public health fields. TRIAL REGISTRATION: ChiCTR1900024350 . Registered on 6 July 2019.

Mediation Analysis of Peer Norms, Self-Efficacy, and Condom Use Among Chinese Men Who Have Sex with Men: A Parallel Process Latent Growth Curve Model.

The objective of this study was to examine direct and indirect relationships among peer norms, self-efficacy, and condom use among Chinese men who have sex with men (MSM). A longitudinal study determined the effectiveness of a condom use video promotion among Chinese MSM in 2015. In this analysis, 804 Chinese MSM were recruited at baseline and then followed at 3 weeks and 3 months after the intervention. Parallel process latent growth curve modeling (LGM) with multiple indicators and bootstrapping was conducted using Mplus 7.4. The LGM model fit indexes were good with RMSEA = 0.046, 90% CI (0.044, 0.048), CFI = 0.956, TLI = 0.955. Our results showed that the initial measure of peer norms affected the initial measure of condom use indirectly through the initial measure of self-efficacy (αß = 0.414, 95% CI 0.260-0.759). The rate of change in peer norms over time also significantly affected the rate of change in condom use through the rate of change in self-efficacy (αß = 0.101, 95% CI 0.014-0.262). Self-efficacy mediated the association between peer norms and condom use, indicating a strong potential of causal relationship between peer norms and self-efficacy among Chinese MSM.

Growth Trajectories of Peer Norms, Self-efficacy and Condom Use Behavior Among Sexually Active Chinese Men Who Have Sex with Men: Latent Class Analysis and Growth Mixture Modeling.

Data from a randomized controlled trial in 2015 were used to estimate the growth trajectories of peer norms, self-efficacy, and condom use behavior, and to identify associated sociodemographic and behavioral factors among a sample of 804 Chinese men who have sex with men (MSM). Latent class analysis and growth mixture modeling were conducted using Mplus. Two growth trajectories were estimated for each outcome variable with good model fit. The growth trajectories of peer norms were related to age (ß = - 0.066, p < 0.05). The growth trajectories of self-efficacy were related to age (ß = 0.057, p < 0.01) and using a condom during first sexual encounter with another man (ß = 0.777, p < 0.001). The growth trajectories of condom use behavior were related to income (ß = 0.366, p < 0.01) and having casual male partners (ß = - 1.016, p < 0.001). Predictors for the growth factors within each latent class were also estimated. For subsets of MSM who are older, richer, used a condom during their first sexual encounter with another man, and do not have a casual male partner, condom videos may not have sufficient efficacy and other interventions may be necessary.

HIV and syphilis and sexual risk behaviours among men who have sex with men attending university in China: a systematic review and meta-analysis.

Background This study was conducted to summarise the HIV epidemic, sexual behaviours and HIV testing among men who have sex with men (MSM) attending university in China. METHODS: Five databases were searched for student MSM information in English and Chinese language publications. Meta-analyses were performed to calculate the pooled prevalence of HIV and syphilis, pooled mean age at first anal intercourse (AFAI) and the rate of other HIV-related behaviours among MSM attending university in China. Univariate meta-regression and subgroup analysis were conducted to explore potential sources of heterogeneity. Publication bias was measured using Egger's test. RESULTS: Thirty-three articles representing 31 studies were included in the analysis. The pooled HIV prevalence was 4.1% (95% CI 3.1-5.0%). The estimated AFAI was 18.7 years, but 37.5% of students had their first anal intercourse before 18 years of age. Most (88.2%) had their first sexual intercourse with a male partner. Of the MSM attending university, 4.2% of MSM engaged in commercial sex (either selling or buying sex), 10.3% had ever engaged in group sex, 13.1% had had sex with a female partner in the past month and 10.1% had ever used drugs. Most (77.7%) sought sex partners via geosocial networking gay apps or the Internet, and 42.9% had ever tested for HIV. There was a tendency for an increase in lifetime HIV testing rate from 32% in 2005-07 to 53% in 2014-16. CONCLUSIONS: This review found high HIV prevalence, early AFAI and a high prevalence of sexual risk behaviours among MSM attending university in China. Interventions aimed at increasing HIV testing and reducing sexual risk behaviours are urgently needed among this young population.

Acceptability and willingness of HIV pre-exposure prophylaxis amongst female sex workers in China.

HIV pre-exposure prophylaxis (PrEP) is a highly effective prevention method. It is an attractive self-initiated approach to reduce the spread of HIV amongst female sex workers (FSW). PrEP, however, has not yet achieved its potential to reduce HIV infections partially due to a general lack of awareness from women who may benefit. Aims of this cross-sectional study of 1,466 FSW in China were to understand: levels of awareness of and willingness to use PrEP among female sex workers (FSW) in China, and factors contributing to willingness to use PrEP. We found that awareness (10.2%) and willingness (35.5%) to use PrEP were low in our survey areas. Low PrEP willingness is likely reflective of the overall poor knowledge and understanding of HIV risk and prevention. FSW that demonstrated greater HIV knowledge through having been tested or having greater decision-making involvement in condom use were more willing to use PrEP. Study findings may be used to inform future HIV prevention activities, including possible use of PrEP among FSW at higher risk of incident HIV infection in China.

Bridging the HIV-syphilis testing gap: dual testing among men who have sex with men living in China.

OBJECTIVES: The WHO recommends dual testing for HIV and syphilis among key populations, including men who have sex with men (MSM). We assessed the proportion of men who had dual tested and reasons for not dual testing. METHODS: In 2017, an online survey of MSM was conducted in eight cities from two provinces in China. Data on sociodemographics and sexual behaviours were collected. Descriptive analysis was used to examine the experience of dual testing. Multivariable logistic regression identified characteristics associated with men who had dual tested. RESULTS: Among 802 men who had ever tested for HIV, 297 dual tested (37%, 95% CI 34 to 40). Men dual tested in a variety of settings: public hospital (35%), voluntary counselling and testing sites (28%), self-testing at home (18%), community-based organisation (8%), community health centre (7%), other (3%) or private hospital (1%). Greater odds for dual testing was found in men who had disclosed their sexuality to a healthcare provider (adjusted OR (AOR) 1.81, 95% CI 1.27 to 2.59, p=0.001), and who had substantial (AOR 2.71, 95% CI 1.67 to 4.41, p<0.001) or moderate community engagement in sexual health (AOR 2.30, 95% CI 1.49 to 3.57, p<0.001), compared with those with no community engagement. The most common reasons for not dual testing were no knowledge that they could be dual tested (34%), did not ask the doctor to be dual tested (25%) and did not believe they were at risk for syphilis (19%). CONCLUSIONS: Chinese MSM are dual testing through a variety of test sites, including home self-testing. However, the overall dual testing rate remains low despite recent efforts to integrate HIV and syphilis testing.

Crowdsourcing to expand HIV testing among men who have sex with men in China: A closed cohort stepped wedge cluster randomized controlled trial.

BACKGROUND: HIV testing rates are suboptimal among at-risk men. Crowdsourcing may be a useful tool for designing innovative, community-based HIV testing strategies to increase HIV testing. The purpose of this study was to use a stepped wedge cluster randomized controlled trial (RCT) to evaluate the effect of a crowdsourced HIV intervention on HIV testing uptake among men who have sex with men (MSM) in eight Chinese cities. METHODS AND FINDINGS: An HIV testing intervention was developed through a national image contest, a regional strategy designathon, and local message contests. The final intervention included a multimedia HIV testing campaign, an online HIV testing service, and local testing promotion campaigns tailored for MSM. This intervention was evaluated using a closed cohort stepped wedge cluster RCT in eight Chinese cities (Guangzhou, Shenzhen, Zhuhai, and Jiangmen in Guangdong province; Jinan, Qingdao, Yantai, and Jining in Shandong province) from August 2016 to August 2017. MSM were recruited through Blued, a social networking mobile application for MSM, from July 29 to August 21 of 2016. The primary outcome was self-reported HIV testing in the past 3 months. Secondary outcomes included HIV self-testing, facility-based HIV testing, condom use, and syphilis testing. Generalized linear mixed models (GLMMs) were used to analyze primary and secondary outcomes. We enrolled a total of 1,381 MSM. Most were ≤30 years old (82%), unmarried (86%), and had a college degree or higher (65%). The proportion of individuals receiving an HIV test during the intervention periods within a city was 8.9% (95% confidence interval [CI] 2.2-15.5) greater than during the control periods. In addition, the intention-to-treat analysis showed a higher probability of receiving an HIV test during the intervention periods as compared to the control periods (estimated risk ratio [RR] = 1.43, 95% CI 1.19-1.73). The intervention also increased HIV self-testing (RR = 1.89, 95% CI 1.50-2.38). There was no effect on facility-based HIV testing (RR = 1.00, 95% CI 0.79-1.26), condom use (RR = 1.00, 95% CI 0.86-1.17), or syphilis testing (RR = 0.92, 95% CI 0.70-1.21). A total of 48.6% (593/1,219) of participants reported that they received HIV self-testing. Among men who received two HIV tests, 32 individuals seroconverted during the 1-year study period. Study limitations include the use of self-reported HIV testing data among a subset of men and non-completion of the final survey by 23% of participants. Our study population was a young online group in urban China and the relevance of our findings to other populations will require further investigation. CONCLUSIONS: In this setting, crowdsourcing was effective for developing and strengthening community-based HIV testing services for MSM. Crowdsourced interventions may be an important tool for the scale-up of HIV testing services among MSM in low- and middle-income countries (LMIC). TRIAL REGISTRATION: ClinicalTrials.gov NCT02796963.

Pressured HIV testing "in the name of love": a mixed methods analysis of pressured HIV testing among men who have sex with men in China.

INTRODUCTION: HIV testing has rapidly expanded into diverse, decentralized settings. While increasing accessibility to HIV testing is beneficial, it may lead to unintended consequences such as being pressured to test. We examined the frequency, correlates and contexts of pressured HIV testing among Chinese men who have sex with men (MSM) using mixed methods. METHODS: We conducted an online survey of MSM (N = 1044) in May 2017. Pressured HIV testing was defined as being forced to test for HIV. We conducted logistic regression analysis to determine the associations between pressured HIV testing and socio-demographic and sexual behavioural factors. Follow-up interviews (n = 17) were conducted with men who reported pressured testing and we analysed qualitative data using a thematic analysis approach. RESULTS: Ninety-six men (9.2%) reported experiencing pressure to test for HIV. Regular male sex partners were the most common source of pressure (61%, 59/96), and the most common form of pressure was a threat to end a relationship with the one who was being pressured (39%, 37/96). We found a higher risk of pressured testing in men who had only used HIV self-testing compared to men who had never self-tested (AOR 2.39 (95%CI: 1.38 to 4.14)). However, this relationship was only significant among men with low education (AOR 5.88 (95% CI: 1.92 to 17.99)) and not among men with high education (AOR 1.62 (95% CI: 0.85 to 3.10)). After pressured testing, about half of men subsequently tested for HIV (55%, 53/96) without pressure - none reported being diagnosed with HIV. Consistent with this finding, qualitative data suggest that perceptions of pressure existed on a continuum and depended on the relationship status of the one who pressured them. Although being pressured to test was accompanied by negative feelings, men who were pressured into testing often changed their attitude towards HIV testing, testing behaviours, sexual behaviours and relationship with the one who pressured them to test. CONCLUSION: Pressured HIV testing was reported among Chinese MSM, especially from men with low education levels and men who received HIV self-testing. However, in some circumstances, pressure to test helped MSM in several ways, challenging our understanding of the role of agency in the setting of HIV testing.

Condom use peer norms and self-efficacy as mediators between community engagement and condom use among Chinese men who have sex with men.

BACKGROUND: Community engagement strategies are often integrated in public health interventions designed to promote condom use among men who have sex with men (MSM), a key population for HIV prevention. However, the ways in which condom use peer norms and self-efficacy play a role in the association between community engagement and condom use is unclear. This study examines the potential mediating roles of peer norms and self-efficacy in this association. METHODS: A nationwide cross-sectional online survey was conducted among Chinese MSM in 2015. Recruitment criteria included being born biologically male, being older than 16 years, having had anal sex with a man at least once during their lifetime, and having had condomless anal or vaginal sex in the past three months. Mplus 6.11 was used to conduct confirmatory factor analysis and path modeling analysis to examine the structural relationships between HIV/sexual health community engagement (e.g., joining social media and community events related to HIV and sexual health services), condom use peer norms, condom use self-efficacy, and frequency of condom use. RESULTS: The study found that HIV/sexual health community engagement, condom use peer norms, condom use self-efficacy, and frequency of condom use were mutually correlated. A good data model was achieved with fit index: CFI = 0.988, TLI = 0.987, RMSEA = 0.032, 90% CI (0.028, 0.036). HIV/sexual health community engagement was associated with frequency of condom use, which was directly mediated by condom use peer norms and indirectly through self-efficacy. CONCLUSION: The study suggests that condom use peer norms and self-efficacy may be mediators in the pathway between community engagement and condom use, and suggests the importance of peer-based interventions to improve condom use.