Gender minority stress and access to health care services among transgender women and transfeminine people: results from a cross-sectional study in China.

BACKGROUND: Transgender and gender diverse individuals often face structural barriers to health care because of their gender minority status. The aim of this study was to examine the association between gender minority stress and access to specific health care services among transgender women and transfeminine people in China. METHODS: This multicenter cross-sectional study recruited participants between January 1st and June 30th 2020. Eligible participants were 18 years or older, assigned male at birth, not currently identifying as male, and living in China. Gender minority stress was measured using 45 items adapted from validated subscales. We examined access to health care services and interventions relevant to transgender and gender diverse people, including gender affirming interventions (hormones, surgeries), human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Multivariable regression was used to measure correlations between gender minority stress and access to health care service. RESULTS: Three hundred and twenty-four people completed a survey and data from 277 (85.5%) people were analyzed. The mean age was 29 years old (standard deviation [SD] = 8). Participants used hormones (118/277, 42.6%), gender affirming surgery (26/277, 9.4%), HIV testing (220/277, 79.4%), STI testing (132/277, 47.7%), PrEP (24/276, 8.7%), and PEP (29/267, 10.9%). Using gender affirming hormones was associated with higher levels of discrimination (adjusted odds ratio [aOR] 1.41, 95% confidence interval [CI] 1.17-1.70) and internalized transphobia (aOR 1.06, 95%CI 1.00-1.12). STI testing was associated with lower levels of internalized transphobia (aOR 0.91, 95%CI 0.84-0.98). CONCLUSIONS: Our data suggest that gender minority stress is closely related to using health services. Stigma reduction interventions and gender-affirming medical support are needed to improve transgender health.

Building Community in the HIV Online Intervention Space: Lessons From the HealthMPowerment Intervention.

BACKGROUND: Mobile health platforms can facilitate social support and address HIV (human immunodeficiency virus) stigma but pose challenges for intervention design and participant engagement. Giddens's structuration theory, that individuals are shaped by-and shape-their communities through rules and resources that give them power to operate within these environments, provides a useful analytic framework for exploring these dynamic intervention spaces. METHOD: Data were drawn from an online randomized controlled trial intervention (HealthMpowerment) for young Black men who have sex with men to reduce condomless anal intercourse. We applied a conversational analysis informed by structuration theory to 65 user-generated conversations that included stigma content. We aimed to understand how the interdependent relationship between the intervention space and participants' contributions might contribute to behavior change. RESULTS: Thirty five intervention participants contributed to the analyzed conversations. Our analysis identified three types of conversational processes that may underlie behavior change: (1) Through intervention engagement, participants established norms and expectations that shaped their discussions; (2) participants used anecdotes and anonymity to reinforce norms; and (3) intervention staff members sought to improve engagement and build knowledge by initiating discussions and correcting misinformation, thus playing an integral role in the online community. CONCLUSIONS: The lens of structuration theory usefully reveals potential behavior change mechanisms within the social interactions of an online intervention. Future design of these interventions to address HIV stigma should explicitly characterize the context in which individuals (study staff and participants) engage with one another in order to assess whether these processes are associated with improved intervention outcomes.

Mobile Phone Intervention Based on an HIV Risk Prediction Tool for HIV Prevention Among Men Who Have Sex With Men in China: Randomized Controlled Trial.

BACKGROUND: eHealth interventions based on risk stratification have not been extensively applied for HIV behavioral interventions among HIV-negative men who have sex with men (MSM). OBJECTIVE: This study aimed to evaluate the efficacy of a mobile phone intervention based on an HIV risk prediction tool in promoting HIV testing and reducing high-risk behavior among HIV-negative MSM in China. METHODS: We performed a mobile phone-based randomized controlled clinical trial for 12 weeks. A comprehensive intervention package deployed on Jinshuju-an online survey platform-was developed and consisted of 4 components: (1) a validated HIV risk prediction tool that provides information on personalized risk reduction interventions; (2) a map of individualized HIV testing facilities based on their geographic location; (3) a QR code for free resources on HIV prevention, including condoms and HIV self-testing kits; and (4) general resources for HIV health education. MSM participants recruited from WeChat/QQ groups were randomly assigned to the intervention or control group at a 1:1 ratio. The staff sent the QR code for the comprehensive intervention package to MSM in the intervention group over WeChat and sent the QR code only for the resources on HIV health education to those in the control group. At baseline and 12-week follow-up, data on HIV-related risk behavior and HIV testing behavior were collected through the Jinshuju online survey platform. RESULTS: In total, 192 MSM were recruited and assigned to the intervention or control group (n=96 each). At week 12, the total clinical trial retention rate was 87.5%. The number of male sexual partners of the MSM in the past 3 months was significantly lower in the intervention group than in the control group (3.51, SD 4.1 vs 6.01, SD 11.4, respectively; mean difference -2.5; 95% CI -5.12 to 0.12; P=.05); the rate of condom use with casual sexual partners was higher in the intervention group than in the control group (87%, n=66/76 vs 70%, n=54/77 respectively; odds ratio 2.81, 95% CI 1.23-6.39; P=.01). The proportion of individuals intending to undergo HIV testing after in the following 30 days was marginally higher in the intervention group than in the control group (90%, n=77/86 vs 79%, n=65/82 respectively; odds ratio 2.20, 95% CI 0.90-5.35; P=.07). The incremental cost-effectiveness ratio of eHealth intervention was US $131.60 on reducing 1 sexual partner and US $19.70 for a 1% increment in condom usage with casual partners. CONCLUSIONS: A comprehensive intervention based on an HIV risk prediction tool can reduce the number of male sexual partners among MSM and increase the rate of condom use with casual partners. Hence, this intervention is a very promising preventive strategy for HIV among MSM, especially in areas with a prominent HIV epidemic. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1800017268; http://www.chictr.org.cn/showprojen.aspx?proj=29271.

Addressing unmet health needs among Chinese transgender individuals.

Chinese transgender individuals encounter significant barriers to accessing health care. In this letter we summarise the main health issues among Chinese transgender individuals and propose several recommendations to address these challenges. These recommendations include, but are not limited to, improving access to HIV prevention services, mental health services, and access to sex reassignment surgery and gender-affirming hormone therapy services. We anticipate that these measures will promote physical and mental health for transgender individuals in China.

Understanding How Gay, Bisexual, and Other Men Who Have Sex With Men in China Cope With HIV Care-Related Stressors.

Understanding how Chinese gay, bisexual, and other men who have sex with men (GBMSM) cope with HIV care-related stressors could improve their care engagement. Qualitative semistructured interviews were conducted with 30 GBMSM living with HIV recruited through clinics and a community-based organization (CBO) in Chengdu, China. Interviews focused on treatment-related stress, coping strategies, social support, and well-being. Half reported symptoms consistent with mild or moderate depression as measured by the PHQ-9 scale. HIV care-related stressors included side effects, difficulty with adherence, and fear of drug resistance. Challenges to coping include navigating contradictory information about HIV and treatment, experiencing stigma and discrimination within medical and nonmedical settings, and managing financial concerns. CBOs, peer groups, and providers were salient sources of social support benefitting coping. To improve sustained HIV care that meets the needs of Chinese GBMSM living with HIV, tailored interventions that address the above-mentioned stressors and coping challenges are likely needed.

The role of space in obstructing clinical sexual health education: A qualitative study on breast cancer patients' perspectives on barriers to expressing sexual concerns.

OBJECTIVE: Breast cancer patients report hoping to receive professional medical advice on sexual health and sexuality, but only few of them actively seek help from medical professionals. This study aims to gain clear understanding about barriers to patients' sexual health education seeking from the patient perspective. METHODS: A qualitative study using in-depth interviews was conducted in an urban hospital in Guangdong Province. China. 20 female breast cancer patients were selected and interviewed. The interview was recorded and transcribed verbatim. Content analysis was used for the data analysis. RESULTS: Four main barriers participants experienced to expressing sexual health education need to medical personnel included: (1) Avoiding discussion of sexuality due to the inappropriate space. (2) Avoiding sexual activity due to the disease treatment. (3) Avoiding sexual activity due to the body related distress. (4) Sexuality as a metaphor. CONCLUSIONS: It is found that breast cancer patients' expression about sexuality was constrained by the hospital, disease, body space and the cultural logic behind the three spaces. Clinical staff should provide an appropriate space for discussing sexual concerns, increase sexual health knowledge, comprehensively evaluate patients' condition and develop a culturally adaptable sexual health education.

Effect of stress and avoidant coping on depression and the moderating role of age among men who have sex with men: Findings from a 6-month prospective cohort study.

BACKGROUND: Men who have sex with men (MSM) are at increased risk of mental health problems. Few studies have examined the risk factors for mental health problems of Chinese MSM and identified potential moderators using a longitudinal design. OBJECTIVES: The present study examined the effect of stress and avoidant coping on depression among MSM, and the moderating role of age on such relationship. METHODOLOGY: A 6-month observational prospective cohort study was conducted among Chinese MSM. Respectively 592 and 402 MSM completed a survey at baseline and 6-month follow-up. RESULTS: The prevalence of probable depression was 36.1% at baseline and 34.1% at 6-month follow-up. After adjusting for background characteristics and baseline depression score, both stress (ß = .22, p<.05) and avoidant coping (ß = .14, p<.05) showed significant positive relationship with depression at 6-month follow-up. The interaction effect of age and stress / avoidant coping was also significant. The effect of stress on depression was stronger among younger MSM, and the effect of avoidant coping on depression was significant among younger MSM but non-significant among older MSM. CONCLUSIONS: Mental health promotion for MSM should reduce stress and avoidant coping, and specific intervention should be designed for younger MSM.

The use of inappropriate anal douching tool associates with increased HIV infection among men who have sex with men: a cross-sectional study in Shenyang, China.

BACKGROUND: Rectal douching (RD) is widely practiced by men who have sex with men (MSM), and is associated with increased risk of HIV infection. However, the mechanism of how RD increases the risk of HIV infection is not well understood, and there is limited data on RD behavior in MSM practicing anal sex in China. We examine the purpose of RD, its timing in relation to anal sex, the types of RD products used, and risky sexual behaviors among MSM reporting anal sex. METHODS: Between August 2017 and December 2018, a cross-sectional study was conducted among adult MSM in Shenyang, China. Data were collected on demographics, sexual behaviors, and RD for the most recent sexual intercourse by means of interviewer-administered face-to-face questionnaires. Blood samples were collected to test for antibodies to HIV and syphilis. Multivariable logistic regression models were used to assess the risk factors associated with HIV infection. RESULTS: A total of 515 eligible MSM participated in this survey (median age: 31 years). During the most recent anal intercourse, 28.3% (146/515) had condomless receptive anal intercourse (CRAI), 21.4% (110/515) practiced serosorting, and more than half (61.6%, 317/515) reported RD before or after anal sex. Of those practicing RD, 96.8% (307/317) conducted RD before sex, while 62.5% (198/317) conducted RD after sex. The douching devices used were primarily shower hoses (85.3%, 262/307), and relatively few MSM used commercial RD products (8.1%, 25/307) before sex. The prevalence of HIV-1 and syphilis was 11.7% and 13.2%, respectively. HIV infection was positively associated with RD, practicing RD before sex, the interaction between RD and CRAI using a shower hose for RD and other risk factors, practicing RD after sex, CRAI, using nitrite inhalants, main sexual role with males as bottom and syphilis infection. CONCLUSIONS: RD is popular among Chinese MSM. Improper noncommercial RD tools use (such as shower hose), the interaction effect between RD and CRAI associated with HIV infection. Public health workers and the MSM community should publicize scientific knowledge and prevention approaches relating to RD and HIV transmission to MSM. We recommend that further studies should be conducted to understand the detailed mechanism between RD and increased HIV prevalence.

Illness representations on pneumonia and pneumococcal vaccination uptake among community-living Chinese people with high-risk conditions aged ≥65 years --- a population-based study.

This study investigated the associations between illness representations of pneumonia and pneumococcal vaccination (PV) uptake among a group of community-living aging adults having at least one high-risk condition for severe invasive pneumococcal diseases (IPD). A total of 750 community-living Chinese-speaking individuals aged ≥65 y completed a random telephone survey. This study was based on 483 participants having at least one high-risk condition for severe IPD. The Illness Representation Questionnaire-Revised (IPQ-R) measured four dimensions of illness representations. These dimensions included timeline (whether pneumonia is believed to be acute/chronic), consequences (severity of pneumonia), treatment control (whether pneumonia is under volitional control), and emotional response (anger, guilty, or shame). Using PV uptake (among all participants) and behavioral intention to take up PV (among unvaccinated participants) as the dependent variables, logistic regression models were fitted. Among all participants (n = 483), 17.8% reported PV uptake; 18.6% of unvaccinated participants (n = 397) intended to take up two doses of free PV in the next year. After adjustment for significant background variables, participants who perceived more severe consequences of pneumonia (adjusted odds ratios, AOR: 1.18, 95%CI: 1.01, 1.40) and belief that treatment can control pneumonia (AOR: 1.41, 95%CI: 1.25, 1.58) reported higher PV uptake. Perceived pneumonia to be chronic (AOR: 1.44, 95%CI: 1.16, 1.78), belief that treatment can control pneumonia (AOR: 1.25, 95%CI: 1.12, 1.40) and having negative emotions related to pneumonia (AOR: 1.17, 95%CI: 1.09, 1.25) were positively associated with behavioral intention to take up PV. Results confirmed that illness representations were associated with PV-related behaviors.

Association between rectal douching and HIV acquisition: the mediating role of condom use and rectal bleeding in a national online sample of Chinese men who have sex with men.

OBJECTIVES: Previous studies have demonstrated that rectal douching (RD) is associated with HIV acquisition among men who have sex with men (MSM). However, the precise mechanism underlying the association between RD and HIV remains unclear. METHODS: We recruited participants over WeChat from October 2017 to October 2018. Respondents received mailed HIV self-testing kits, uploaded images of HIV self-test results and completed an online electronic questionnaire simultaneously. The questionnaire assessed sociodemographic characteristics, RD practices and sexual risk behaviours. HIV status was measured as the result of the HIV self-testing. The Baron and Kenny statistical method was used to assess the association between RD and HIV, controlling for condomless anal intercourse (CAI) and rectal bleeding. RESULTS: Of 1365 participants, 39.93% (545/1365) reported RD in the past 6 months, 60.07% had multiple male sexual partners and 43.08% had CAI in the past 6 months. The prevalence of HIV, based on self-testing, was 3.37% (46/1365). Multivariable logistic analysis showed RD was significantly associated with bottom sexual role (adjusted OR (aOR) 14.0; 95% CI 9.8 to 20.2), having multiple male sexual partners (aOR 1.8; 95% CI 1.4 to 2.2), CAI (aOR 1.3; 95% CI 1.0 to 1.6), rectal bleeding (aOR 2.0; 95% CI 1.6 to 2.6) and HIV infection (aOR 1.9; 95% CI 1.0 to 3.4). Baron and Kenny analysis found both CAI (aOR 2.2; 95% CI 1.2 to 4.1) and rectal bleeding (aOR 1.9; 95% CI 1.0 to 3.4) play a mediating role in the association between RD and HIV. CONCLUSIONS: Our study results confirmed the relationship between RD and HIV, and found CAI and rectal bleeding mediated HIV infection in Chinese MSM who douched. Strategies should be encouraged to strengthen health education and reduce high-risk sexual behaviour in order to reduce the risk of HIV in MSM who use enemas. Rectal microbicides may represent an efficient means of providing HIV prophylaxis among MSM.

Moral practices shaping HIV disclosure among young gay and bisexual men living with HIV in the context of biomedical advance.

Biomedical advances in diagnostics, treatment and prevention increase the means available to reduce HIV transmission risk. Subsequent shifts in HIV status disclosure obligation and ethics may impact how those living with HIV view, enact and experience disclosure. We analysed focus group and interview data to explore how these changes are reflected in disclosure decision-making to sexual partners among young gay and bisexual men living with HIV in the USA. Three interrelated themes were identified: engaging with partners' varying HIV knowledge; attribution of blame; and negotiating disclosure-related harms. Participants experienced blame from partners that questioned the timing of HIV testing, status disclosure and sex events without regards for viral suppression or use of pre-exposure prophylaxis. Substantial HIV stigma was described in response to disclosure, mitigated in some cases by partners' higher HIV knowledge. Overall, an uneven diffusion of HIV treatment and prevention knowledge and continuing HIV stigma seemed to limit the translation of biomedical advances into improved disclosure experiences. Our findings suggest that young gay and bisexual men living with HIV may continue to perform much of the moral labour involved in disclosure by managing others' reactions, correcting inaccurate sexual health information, and negotiating the risks of disclosure-related harm.

Correction: Risk-Taking Behaviors and Adherence to HIV Pre-Exposure Prophylaxis in Users of Geosocial Networking Apps: Real-World, Multicenter Study.

[This corrects the article DOI: 10.2196/22388.].

Risk-Taking Behaviors and Adherence to HIV Pre-Exposure Prophylaxis in Users of Geosocial Networking Apps: Real-World, Multicenter Study.

BACKGROUND: Over half of men who have sex with men (MSM) use geosocial networking (GSN) apps to encounter sex partners. GSN apps' users have become a unique large subpopulation among MSM for interventions concerning HIV prevention and control. Pre-exposure prophylaxis (PrEP) is a promising measure for HIV prevention, especially for MSM, but its effectiveness largely depends on medication adherence. However, little is known about PrEP adherence among GSN apps' users, which is critical to addressing the overall optimization of PrEP compliance outside of clinical trials in the context of large-scale implementation. OBJECTIVE: The objective of this study is to understand the correlation between GSN apps' use and medication adherence among MSM receiving PrEP, with the aim to increase their awareness about PrEP use in order to increase adherence. METHODS: This study based on the China Real-world Oral intake of PrEP (CROPrEP) project, a multicenter, real-world study of Chinese MSM on daily and event-driven PrEP. Eligible participants completed a detailed computer-assisted self-interview on sociodemographic, GSN apps' use, and sexual behavior. Then participants were followed up for 12 months and assessed for various characteristics (eg, PrEP delivery, adherence assessment, PrEP coverage of sexual activities, and regimens switch). A generalized estimation equation was used to analyze the predictors of medication adherence and regimen conversion among GSN apps' users and nonusers. RESULTS: At baseline, 756 of the 1023 eligible participants (73.90%) reported primarily using GSN apps to seek sexual partners, and GSN apps' users are more likely to have high-risk behaviors such as multiple sex partners and condomless anal intercourse than other nonusers (all P<.05). During follow-up, GSN apps' users had a significantly low level of pill-counting adherence than nonusers (adjusted odds ratio [aOR] 0.8, 95% CI 0.6-1.0, P=.038). In the event-driven group, GSN apps' users had marginally lower levels of self-reported adherence (aOR 0.7, 95% CI 0.4-1.0, P=.060) and lower PrEP coverage of sexual practices (aOR 0.6, 95% CI 0.4-1.0, P=.038). Additionally, GSN apps' users seemed more likely to switch from event-driven to daily regimen (aOR 1.8, 95% CI 0.9-3.3, P=.084). CONCLUSIONS: GSN apps' users are highly prevalent among MSM, despite their higher sexual risk and lower adherence levels, suggesting that eHealth needs to be introduced to the GSN platform to promote PrEP adherence. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR-IIN-17013762; https://tinyurl.com/yy2mhrv4. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12879-019-4355-y.

Associations of Mental Health and Personal Preventive Measure Compliance With Exposure to COVID-19 Information During Work Resumption Following the COVID-19 Outbreak in China: Cross-Sectional Survey Study.

BACKGROUND: Risk and crisis communication plays an essential role in public health emergency responses. The COVID-19 pandemic has triggered spontaneous and intensive media attention, which has affected people's adoption of personal preventive measures and their mental health. OBJECTIVE: The aim of this study was to investigate the associations between exposure to COVID-19-specific information and mental health (depression and sleep quality) and self-reported compliance with personal preventive measures (face mask wearing and hand sanitizing). We also tested whether these associations were moderated by thoughtful consideration of the veracity of the information to which people were exposed. METHODS: A cross-sectional, closed web-based survey was conducted among a sample of 3035 factory workers at the beginning of work resumption following the COVID-19 outbreak in Shenzhen, China. A stratified two-stage cluster sampling design was used for recruitment. Multivariate linear and logistic regression models were used for the analyses. RESULTS: The prevalence of probable moderate-to-severe depression was 170/3035 (5.6%), while that of good or excellent sleep quality was 2110/3035 (69.5%). The prevalence of self-reported consistent face mask wearing in public places was 2903/3035 (95.7%), while that of sanitizing hands every time after returning from public spaces or touching public installations was 2151/3035 (70.9%). Of the 3035 respondents, 1013 to 1638 (33.3% to 54.0%) reported >1 hour of daily exposure to COVID-19-specific information through web-based media and television. After controlling for significant background variables, higher information exposure via television and via newspapers and magazines was associated with better sleep quality and higher compliance with hand sanitizing. Higher exposure via unofficial web-based media was associated with higher compliance with hand sanitizing but was also associated with higher depressive symptoms. In contrast, higher exposure through face-to-face communication was associated with higher depressive symptoms, worse sleep quality, and lower compliance with hand sanitizing. Exposure to information about positive outcomes for patients with COVID-19, development of vaccines and effective treatments, and heroic stories about frontline health care workers were associated with both better mental health and higher compliance with preventive measures. Higher overall information exposure was associated with higher depressive symptoms among participants who were less likely to carefully consider the veracity of the information to which they were exposed; it was also associated with better sleep quality among people who reported more thoughtful consideration of information veracity. CONCLUSIONS: This study provides empirical evidence of how the amount, sources, and contents of information to which people were exposed influenced their mental health and compliance with personal preventive measures at the initial phase of work resumption in China. Thoughtful consideration of information quality was found to play an important moderating role. Our findings may inform strategic risk communication by government and public health authorities during the COVID-19 pandemic.

Self-Reported Compliance With Personal Preventive Measures Among Chinese Factory Workers at the Beginning of Work Resumption Following the COVID-19 Outbreak: Cross-Sectional Survey Study.

BACKGROUND: Maintaining compliance with personal preventive measures is important to achieve a balance of COVID-19 pandemic control and work resumption. OBJECTIVE: The aim of this study was to investigate self-reported compliance with four personal measures to prevent COVID-19 among a sample of factory workers in Shenzhen, China, at the beginning of work resumption in China following the COVID-19 outbreak. These preventive measures included consistent wearing of face masks in public spaces (the workplace and other public settings); sanitizing hands using soap, liquid soap, or alcohol-based hand sanitizer after returning from public spaces or touching public installations and equipment; avoiding social and meal gatherings; and avoiding crowded places. METHODS: The participants were adult factory workers who had resumed work in Shenzhen, China. A stratified two-stage cluster sampling design was used. We randomly selected 14 factories that had resumed work. All full-time employees aged ≥18 years who had resumed work in these factories were invited to complete a web-based survey. Out of 4158 workers who had resumed work in these factories, 3035 (73.0%) completed the web-based survey from March 1 to 14, 2020. Multilevel logistic regression models were fitted. RESULTS: Among the 3035 participants, 2938 (96.8%) and 2996 (98.7%) reported always wearing a face mask in the workplace and in other public settings, respectively, in the past month. However, frequencies of self-reported sanitizing hands (2152/3035, 70.9%), avoiding social and meal gatherings (2225/3035, 73.3%), and avoiding crowded places (1997/3035, 65.8%) were relatively low. At the individual level, knowledge about COVID-19 (adjusted odds ratios [AORs] from 1.16, CI 1.10-1.24, to 1.29, CI 1.21-1.37), perceived risk (AORs from 0.58, CI 0.50-0.68, to 0.85, CI 0.72-0.99) and severity (AOR 1.05, CI 1.01-1.09, and AOR 1.07, CI 1.03-1.11) of COVID-19, perceived effectiveness of preventive measures by the individual (AORs from 1.05, CI 1.00-1.10, to 1.09, CI 1.04-1.13), organization (AOR 1.30, CI 1.20-1.41), and government (AORs from 1.14, CI 1.04-1.25, to 1.21, CI 1.02-1.42), perceived preparedness for a potential outbreak after work resumption (AORs from 1.10, CI 1.00-1.21, to 1.50, CI 1.36-1.64), and depressive symptoms (AORs from 0.93, CI 0.91-0.94, to 0.96, CI 0.92-0.99) were associated with self-reported compliance with at least one personal preventive measure. At the interpersonal level, exposure to COVID-19-specific information through official media channels (AOR 1.08, CI 1.04-1.11) and face-to-face communication (AOR 0.90, CI 0.83-0.98) were associated with self-reported sanitizing of hands. The number of preventive measures implemented in the workplace was positively associated with self-reported compliance with all four preventive measures (AORs from 1.30, CI 1.08-1.57, to 1.63, CI 1.45-1.84). CONCLUSIONS: Measures are needed to strengthen hand hygiene and physical distancing among factory workers to reduce transmission following work resumption. Future programs in workplaces should address these factors at multiple levels.

HIV Self-Testing Programs to Men Who Have Sex With Men Delivered by Social Media Key Opinion Leaders and Community-Based Organizations are Both Effective and Complementary: A National Pragmatic Study in China.

BACKGROUND: Social media key opinion leaders (SMKOLs) and community-based organizations (CBOs) are 2 leading delivery strategies for HIV self-testing (HIVST). This study compared respondent characteristics, linkage to care, antiretroviral treatment, and cost of HIVST among men who have sex with men (MSM) recruited via SMKOLs and CBOs in China. METHODS: Between January and December 2018, SMKOLs distributed HIVST advertisements to MSM through WeChat public platforms; simultaneously, CBOs distributed HIVST program messages to local MSM. All participants were required to pay a deposit to apply for the HIVST kit and had their deposit refunded after completing an online survey and uploading HIVST results. Trained staff provided HIV referral services by telephone and WeChat. RESULTS: One thousand seven hundred forty-three [63.0% (1743/2766)] and 1023 [37.0% (1023/2766)] individuals met criteria via SMKOLs and CBOs, respectively. MSM reached by SMKOLs had a lower HIV seropositive rate [2.1% (33/1561) vs. 12.5% (100/803)] and higher proportion received antiretroviral treatment [94.4% (31/33) vs. 29.0% (29/100)] compared with CBO-recruited MSM (all P < 0.05). The average number of HIVST respondents recruited by each investigator in SMKOL-strategy was higher than that of CBO-strategy (290 vs. 49). The SMKOLs had lower cost of per person tested (USD 13.18 vs. USD 101.21) and per newly identified HIV infection case (USD 632.66 vs. USD 812.70). CONCLUSIONS: SMKOLs have lower cost of per person tested, whereas CBOs can reach MSM subpopulations with higher HIV seropositive rates. Both recruitment methods are efficient and should be used as complementary HIVST delivery strategies to address low HIV testing coverage among Chinese MSM.

HIV Self-Testing to Promote Serostatus Disclosure Among Men Who Have Sex With Men in China: Protocol for a Stepped Wedge Randomized Controlled Trial.

BACKGROUND: Disclosure of HIV serostatus is important for the prevention of HIV infection among men who have sex with men (MSM). However, knowledge of sexual partners' HIV status among MSM in China is low. As a complement to HIV testing services, HIV self-testing (HIVST) has considerable potential to promote serostatus disclosure. OBJECTIVE: The primary objective of our trial is to evaluate the effect of HIVST on improving serostatus disclosure to sexual partners. We hypothesize that MSM in an intervention condition will have a higher awareness of the HIV status of their sexual partners compared with MSM in the control condition. The secondary aims are to evaluate (i) changes in sexual behaviors after disclosure of HIV status by sexual partners, (ii) promotion of the frequency of HIV and syphilis testing on participants and their sexual partners, and (iii) factors that restrict the disclosure of HIV infection to sexual partners. We hypothesize that MSM in the intervention condition will exhibit safer sexual decision making and a higher rate of HIV testing uptake compared with MSM in the control condition. METHODS: A stepped wedge randomized controlled trial will be conducted throughout China. Study recruitment of 800 MSM will be promoted through advertisements released on WeChat public accounts. Individuals who are born biologically male, aged ≥18 years, HIV negative, and who have not undergone HIV testing in the past 3 months will be recruited. Eligible men will be randomly divided (1:1:1:1) into four groups and randomized. The group cluster will initiate the intervention so that participants will be provided with 2-4 free finger prick-based HIVST kits until trial completion. The intervention period for participants in each of the four groups will be initiated at 3-month intervals. Men in both groups will be required to complete a baseline and four follow-up surveys every 3 months. The primary intervention outcome will evaluate the effect of the distribution of HIVST kits on improvement in the disclosure of sexual partners' HIV status. The secondary outcomes will be changes in sexual behaviors after disclosure of HIV status from sexual partners, the promotion of the frequency of HIVST on participants and their sexual partners, and the factors that restrict disclosure of HIV status to sexual partners. RESULTS: Subject recruitment began in August 2018. The first round of follow-up surveys post intervention is complete, with three rounds remaining to be done. Data analysis was scheduled for April 2020 and the results will be disseminated through conferences and peer-reviewed publications. CONCLUSIONS: Few studies have evaluated interventions to increase knowledge of sexual partners' HIV status among MSM. Our trial will provide information on the link between HIVST and HIV serostatus disclosure. The findings of this trial will facilitate the implementation of HIVST services to help control the spread of HIV among MSM in China. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1800019453; http://www.chictr.org.cn/showproj.aspx?proj=30158. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17788.

Rapid increase of gonorrhoea cases in Guangdong Province, China, 2014-2017: a review of surveillance data.

OBJECTIVES: An increased trend in the number of reported gonorrhoea cases has been observed between 2014 and 2017 in China. This study aims to describe the reported epidemic of gonorrhoea and potential driving forces in Guangdong Province, China. DESIGN: A review of surveillance data. PARTICIPANTS: Three different sources of data from Guangdong Province were analysed: gonorrhoea cases reported to the Chinese sexually transmitted infections (STI) case report system (CRS); a clinic-based retrospective study conducted to collect information on annual gonorrhoea screening coverage and data from the Guangdong governmental sentinel surveillance network (SSN) to examine the gonorrhoea prevalence among males attending STI clinics. OUTCOME MEASURES: Reported incidence of gonorrhoea, number of reported gonorrhoea cases, number of screening tests for gonorrhoea and gonorrhoea prevalence. RESULTS: The STI CRS data showed that the reported incidence of gonorrhoea has increased rapidly from 15.7 cases per 100 000 population in 2014 to 27.3 cases per 100 000 in 2017 in Guangdong (p<0.001). Regions with a reported incidence of gonorrhoea cases of more than 10 cases per 100 000 expanded from 7 cities in 2014 to 13 cities in 2017. The SSN data showed that the gonorrhoea prevalence among males attending STI clinics increased from 2.7% in 2015 to 3.6% in 2017 (p=0.14). The retrospective study showed that the increased rate of screening for gonorrhoea between 2014 and 2017 was 35.0%, which was much lower than the increased rate of the number of reported gonorrhoea cases (123.3%). CONCLUSIONS: The number of gonococcal infections is rapidly rising in Guangdong, China. Expanded screening coverage, use of more sensitive diagnostics and increase of gonorrhoea prevalence are three potential contributors to the epidemic. Additional targeted intervention strategies are necessary in the future to control the epidemic.

HIV-positive clients of female sex workers in Hunan Province, China: a mixed methods study assessing sexual relationships and risk behavior by type of partner.

BACKGROUND: In China, clients of female sex workers (CFSWs) have a low rate of condom use and a high prevalence of human immunodeficiency virus (HIV). However, little is known about the high-risk sexual behaviors of HIV-positive CFSWs. METHODS: In 2014, 327 CFSWs diagnosed with HIV for 6 months or longer completed a face-to-face questionnaire for a quantitative survey. In addition, 32 HIV-positive CFSWs were recruited to participate in in-depth interviews (18 participated in both, 14 participated in-depth interviews only) to explore reasons for extramarital sexual behaviors and inconsistent condom use. The quantitative data on sexual risk behaviors were analyzed using chi-square tests. Interviews were coded inductively for emerging themes. RESULTS: Among the participants of the quantitative survey, 41.6% (136/327) had sex with regular sexual partners only in the past 6 months, of whom 64.0% (87/136) had consistent condom use; 27.5% (90/327) of the participants had sex with irregular sexual partners in the past 6 months, of which, 46.7% (42/90) had consistent condom use. The qualitative study suggested that HIV positive sero-status, willingness to protect their spouses or regular sexual partners, and lacking a sense of responsibility to protect their commercial and casual sexual partners, influence CFSWs' sexual behaviors. CONCLUSIONS: HIV-positive CFSWs continue to practice unsafe sexual behaviors with regular and irregular partners after HIV diagnosis, but were more willing to protect their regular partners. Future interventions targeting HIV-positive CFSWs should not only be confined to sero-discordant couples, but also need to instill a sense of responsibility to protect the commercial and casual partners and reduce the number of concurrent partners.

Women's Assessments of Gender Equality.

Women's assessments of gender equality do not consistently match global indices of gender inequality. In surveys covering 150 countries, women in societies rated gender-unequal according to global metrics such as education, health, labor-force participation, and political representation did not consistently assess their lives as less in their control or less satisfying than men did. Women in these societies were as likely as women in index-equal societies to say they had equal rights with men. Their attitudes toward gender issues did not reflect the same latent construct as in index-equal societies, although attitudes may have begun to converge in recent years. These findings reflect a longstanding tension between universal criteria of gender equality and an emphasis on subjective understandings of women's priorities.