HIV/AIDS behavioral interventions in China: a literature review and recommendation for future research

Long-Term Changes of HIV/AIDS Incidence Rate in China and the U.S. Population From 1994 to 2019: A Join-Point and Age-Period-Cohort Analysis

Although HIV caused one of the worst epidemics since the late twentieth century, China and the U.S. has made substantial progress to control the spread of HIV/AIDS. However, the trends of HIV/AIDS incidence remain unclear in both countries. Therefore, this study aimed to highlight the long-term trends of HIV/AIDS incidence by gender in China and the U.S. population. The data were retrieved from the Global Burden of Disease (GBD) database since it would be helpful to assess the impact/role of designed policies in the control of HIV/AIDS incidence in both countries. The age-period-cohort (APC) model and join-point regression analysis were employed to estimate the age-period-cohort effect and the average annual percentage change (AAPC) on HIV incidence. Between 1994 and 2019, we observed an oscillating trend of the age-standardized incidence rate (ASIR) in China and an increasing ASIR trend in the U.S. Despite the period effect in China declined for both genders after peaked in 2004, the age effect in China grew among the young (from 15–19 to 25–29) and the old age groups (from 65–69 to 75–79). Similarly, the cohort effect increased among those born in the early (from 1924–1928 to 1934–1938) and the latest birth groups (from 1979–1983 to 2004–2009). In the case of the U.S., the age effect declined after it peaked in the 25–29 age group. People born in recent birth groups had a higher cohort effect than those born in early groups. In both countries, women were less infected by HIV than men. Therefore, besides effective strategies and awareness essential to protect the young age groups from HIV risk factors, the Chinese government should pay attention to the elderly who lacked family support and were exposed to HIV risk factors.

Mediating Effects of Stigma and Depressive Symptoms in a Social Media-Based Intervention to Improve Long-term Quality of Life Among People Living With HIV: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Mobile health (mHealth) interventions have been shown to effectively improve the quality of life (QOL) among people living with HIV. However, little is known about the long-term effects of mHealth interventions.

OBJECTIVE

This study aims to explore the intervention mechanisms of a social media-based intervention, Run4Love, on the QOL of people with HIV over across a 9-month follow-up period.

METHODS

We recruited people living with HIV who were concurrently experiencing elevated depressive symptoms from an HIV outpatient clinic in South China. A total of 300 eligible participants were randomized either to the intervention group or the control group in a 1:1 ratio after they provided informed consent and completed a baseline survey. The intervention group received a 3-month WeChat-based intervention, comprising cognitive-behavioral stress management (CBSM) courses and physical activity promotion. The control group received a printed brochure on nutrition guidelines in addition to the usual care for HIV treatment. Neither participants nor the research staff were blinded to group assignment. All patients were followed at 3, 6, and 9 months. The primary outcome was depressive symptoms. Structural equation model (SEM) with longitudinal data was conducted to examine the sequential mediating effects of HIV-related stigma and depressive symptoms on the long-term intervention effects on participants' QOL.

RESULTS

About 91.3% (274/300), 88.3% (265/300), and 86.7% (260/300) of all participants completed follow-up surveys at 3, 6, and 9 months, respectively. Results showed that the intervention had significantly improved participants' QOL at 9 months, via complete mediating effects of reduced HIV-related stigma at 3 months and decreased depressive symptoms at 6 months. No adverse events were reported.

CONCLUSIONS

These findings underscore the critical roles of HIV-related stigma and depressive symptoms in an mHealth intervention with long-term effects on QOL improvements. We call for targeted mHealth interventions to improve QOL among people living with HIV, especially social media-based interventions that can address HIV-related stigma and alleviate depressive symptoms.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://www.chictr.org.cn/showproj.aspx?proj=21019.

Systematic review and meta-analysis assessing the knowledge and use of the female condom among Nigerians

Background

The female condom (FC) is a critical component in a comprehensive and sustainable approach to prevent HIV, other sexually transmitted infections and unintended pregnancies.

Objectives

This review provides comprehensive information about Nigerian's knowledge and use of FC.

Methods

We screened search output, evaluated study eligibility, and extracted data in duplicate. Data from similar studies were combined in a meta-analysis.

Results

There was a significantly (p < 0.0001) high-level of awareness amongst the respondents. However, the use of the FC was very low at 5.5% among female respondents. There was a significant (p < 0.0001) difference between FC awareness and use. The main reasons for FC use were prevention of unintended pregnancy (55%) and STIs/HIV (31%). We observed a significant difference between reasons of non-use of the FC [F (5, 13) = 5.195, P = 0.0077]. Furthermore, there were significant differences between the sources of information on FC [F (3, 8) = 32.89, P < 0.0001].

Conclusion

Despite the high levels of awareness, especially among the female respondents, the use of the FC has remained extremely low even among the young, educated undergraduate students. There is aneed for robust and consistent advocacy to make the FC available and affordable.

A pilot cultural adaptation of LGB-affirmative CBT for young Chinese sexual minority men's mental and sexual health

Young men who have sex with men (YMSM) represent one of the most at-risk groups for HIV infection and experience sexual minority stress especially in high-stigma settings, which affects their psychological health and increases likelihood of HIV-risk behaviors. The HIV epidemic in China is increasing rapidly among YMSM. However, no evidence-based intervention has specifically targeted Chinese YMSM's minority stress to improve their mental and sexual health. Adaptation of evidence-based interventions to promote the mental and sexual health of YMSM is one promising way to achieve the global target of HIV epidemic control. The current adaptation study followed the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing model. YMSM (n = 41) and key stakeholders (n = 16) in China provided feedback into the selected intervention, a cognitive-behavioral therapy called Effective Skills to Empower Effective Men, originally developed with efficacy in the United States. An open pilot (n = 8) was also then conducted. Qualitative and quantitative data collected from each adaptation phase were analyzed to form the adapted intervention: "Yi Si Tang ()." Adaptations addressed a cultural context prioritizing family needs, limited support from the health system, as well as YMSM delivery preferences. YMSM and key stakeholders deemed the intervention acceptable and preliminarily feasible for the Chinese context. The pre-post comparison of mental and sexual health outcomes indicated improvement in mental health and sexual health of Chinese YMSM. Outcomes of the small initial pilot suggest future promise for this first-of-its-kind intervention for Chinese YMSM. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Changing trends of HIV, syphilis, HCV infections and behavioural factors among female sex workers in Chongqing, China: findings from six serial surveillance surveys

OBJECTIVES

To explore the prevalence and changing trends of HIV, syphilis, hepatitis C virus (HCV) infections and risk behaviours among female sex workers (FSWs) and to provide reference and theoretical basis for formulating targeted interventions.

DESIGN

Six consecutive cross-sectional surveys.

SETTING

Chongqing, China.

PARTICIPANTS

FSWs were included if they (1) were aged ≥16 years, (2) provided commercial sex for money or goods during the previous month and (3) were willing to participate in the survey and could provide verbal informed consent. This study included 16 791 of 16 810 participants recruited between 2013 and 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

The prevalence of HIV/syphilis/HCV infection.

RESULTS

The HIV and HCV prevalence among FSWs in Chongqing was stable during the study period, but the prevalence of syphilis had an increasing trend, particularly among low-tier and middle-tier FSWs. Improvements in HIV-related knowledge, condom use, injecting drug use and participation in HIV-related services were observed. However, no change was found in the prevalence of drug use. HIV infection was correlated with no condom use in the last commercial sex (adjusted OR (aOR) 3.48, 95% CI 1.90 to 6.37) and syphilis infection (aOR 4.88, 95% CI 1.95 to 12.18). Syphilis infection was correlated with inconsistent condom use (aOR 1.30, 95% CI 1.02 to 1.65), HIV infection (aOR 5.88, 95% CI 2.40 to 14.41), HCV infection (aOR 7.68, 95% CI 4.37 to 13.49) and sexually transmitted infection (STI) diagnosis in the past year (aOR 3.81, 95% CI 2.40 to 6.03). HCV infection was associated with injecting drug use (aOR 8.91, 95% CI 4.45 to 17.86) and syphilis infection (aOR 7.88, 95% CI 4.49 to 13.83).

CONCLUSIONS

Comprehensive interventions targeting FSWs, particularly low-tier and middle-tier FSWs, should be increasingly implemented to prevent and control HIV, syphilis and other STIs.

Health related behaviors among HIV-infected people who are successfully linked to care: an institutional-based cross-sectional study

BACKGROUND

By the end of October 2019, there were 958 thousand people were reported living with HIV/AIDS in China. Unhealthy lifestyle factors, such as smoking, drinking alcohol, using illicit drugs and no physical activity have been found to mitigate the positive impact of antiretroviral therapy (ART) on viral load and HIV-related quality of life. Moreover, risky sexual behavior among HIV-positive persons places their partners at risk for HIV transmission and other sexually transmitted infections. The aim of the study is to determine the prevalence of unhealthy behavior of people living with HIV/AIDS and related influencing factors, particularly those that are closely connected with HIV infection and ART effects.

METHODS

An institutional based cross-sectional study design was used to collect data from people living with HIV/AIDS (PLWHA) in Beijing and Yunnan Province. The following information was included in the questionnaire survey: social-demographic characteristics, health behavior information, sexual risk behaviors. Binary logistic regression model was conducted to analyze the influencing factors of unhealthy general health behaviors and risky sexual behaviors.

RESULTS

In total, 2575 PLWHA were included in the study and 78.3% (2017/2575) were male. For the general health behaviors, 34.2% (987/2544) smoke; 33.8% (870/2575) drank alcohol and 2.3% (49/2134) reported the use of illicit drugs in the previous 6 months. From the sexual behaviors perspective, 59.0% (1519/2575) had sex in the previous 6 months. Among people who had sex, 92.0% (1398/1519) had fixed sexual partners. Among those with no fixed sexual partner, 38.0% (46/121) had more than three partners. Among men who had sex, 34.7% (448/1292) reported having sex with men in the previous 6 months and 16.7% (75/448) of these had group sexual activity. Among participants, 72.2% (1053/1458) used condoms every time they had sex while 6.4% (94/1458) of people never used condom. Male people living with HIV/AIDS were more likely to have sexual risk behaviors (adjusted odds ratio [OR] = 2.208, 95% confidence interval [CI]: 1.147-4.252) and unhealthy general health behaviors (adjusted OR = 2.029, 95% CI: 1.480-2.783). The odds of higher risk sexual behaviors was 1.546 times (95% CI: 1.302-1.827, P = 0.001) greater among participants who drank alcohol compared with their non-drinking counterparts.

CONCLUSIONS

PLWHA is a group that is vulnerable to problematic health behaviors, especially for men who were more likely to drink alcohol, have more sexual partners, more sexual risk behaviors including group sexual activity, not using condoms and using drugs. Therefore, interventions focusing on gender-specific risk behaviors reduction for people living with HIV/AIDS are now necessary to control the spread of HIV infection and improve the efficacy of antiviral treatment.

Effects of cognitive-behavioural therapy on anxiety, depression and condom use in people with HIV in Mexico City: a pilot study

Anxiety and depression in people living with HIV (PLWH) are negatively associated with healthy sexual behaviours. We pilot-tested a Cognitive-Behavioural Therapy (CBT)-based intervention to reduce anxiety and depression, aimed to increase serostatus disclosure to sexual partners, quality of sexual life (QoSL) and condom use. The study had a single-case experimental design (AB) with follow-up measures. Eleven PLWH with moderate/severe anxiety/depression received six-module CBT intervention delivered in ten one-hour individual weekly sessions. Anxiety, depression, consistent/correct condom use and QoSL were measured. Depression and anxiety decreased after the intervention (depression baseline [BL] Mdn = 21, final [F] Mdn = 3, z = -2.934, p = .003; anxiety BL Mdn = 30, F Mdn = 4, z = -2.941, p = .003). QoSL improved (BL Mdn = 28, F Mdn = 13, z = -2.625, p = .009), along with participants' ability to use condoms (57.14 vs.100, z = -2.937, p = .003). Effect size was large, changes were maintained at follow-up measurements. The CBT intervention had positive effects in reducing anxiety and depression, which could facilitate the acquisition of healthy sexual behaviours. Further studies are important to clarify the benefits of targeting emotional variables to improve wellbeing and prevention behaviours in PLWH.

A randomized controlled trial to enhance coping and posttraumatic growth and decrease posttraumatic stress disorder in HIV-Infected men who have sex with men in Beijing, China

Although HIV-infected men who have sex with men (MSM) constitute a newly emerged high-risk group in China, little research outside Western countries is available on effective intervention programs to enhance their well-being. The purpose of this randomized controlled trial was to evaluate the efficacy of a group intervention program designed to improve the well-being and adaptive coping strategies of 60 HIV-infected MSM in Beijing, China, randomly assigned either to the intervention group for participation in four weekly sessions or to the control group for placement on a waiting list. They all completed measurements at pre- and postintervention. Compared with the control group, the intervention group reported significantly increased problem-focused coping strategies and levels of posttraumatic growth (PTG) as well as decreased symptoms of posttraumatic stress disorder (PTSD) at the completion of the intervention. In addition, mediation analysis showed that changes in problem-focused coping strategies mediated the intervention effect on increases in PTG; however, the mediating effect of coping strategies on the association of intervention and PTSD was not significant. This study provides empirical evidence for conducting psychological intervention to promote the well-being of HIV-infected MSM. The findings also elucidate the mechanism through which intervention improved PTG.

Effectiveness of needle and syringe Programmes in people who inject drugs - An overview of systematic reviews

BACKGROUND

Needle and syringe programmes (NSP) are a critical component of harm reduction interventions among people who inject drugs (PWID). Our primary objective was to summarize the evidence on the effectiveness of NSP for PWID in reducing blood-borne infection transmission and injecting risk behaviours (IRB).

METHODS

We conducted an overview of systematic reviews that included PWID (excluding prisons and consumption rooms), addressed community-based NSP, and provided estimates of the effect regarding incidence/prevalence of Human Immunodeficiency Virus (HIV), Hepatitis C virus (HCV), Hepatitis B virus (HBV) and bacteremia/sepsis, and/or measures of IRB. Systematic literature searches were undertaken on relevant databases, including EMBASE, MEDLINE, and PsychINFO (up to May 2015). For each review we identified relevant studies and extracted data on methods, and findings, including risk of bias and quality of evidence assessed by review authors. We evaluated the risk of bias of each systematic review using the ROBIS tool. We categorized reviews by reported outcomes and use of meta-analysis; no additional statistical analysis was performed.

RESULTS

We included thirteen systematic reviews with 133 relevant unique studies published between 1989 and 2012. Reported outcomes related to HIV (n = 9), HCV (n = 8) and IRB (n = 6). Methods used varied at all levels of design and conduct, with four reviews performing meta-analysis. Only two reviews were considered to have low risk of bias using the ROBIS tool, and most included studies were evaluated as having low methodological quality by review authors. We found that NSP was effective in reducing HIV transmission and IRB among PWID, while there were mixed results regarding a reduction of HCV infection. Full harm reduction interventions provided at structural level and in multi-component programmes, as well as high level of coverage, were more beneficial.

CONCLUSIONS

The heterogeneity and the overall low quality of evidence highlights the need for future community-level studies of adequate design to support these results.

TRIAL REGISTRATION

The protocol of this systematic review was registered in Prospective Register of Systematic Reviews (PROSPERO 2015: CRD42015026145 ).

HIV prevention among street-based sex workers (SSWs) in Chongqing, China: interviews with SSWs, clients and healthcare providers

Street-based female sex workers (SSWs) are subjected to a relatively high risk of HIV transmission, even higher than establishment-based female sex workers in China. However, very few HIV intervention programmes have targeted this particular group to date. Based in Southwest China, this study aims to identify perceived barriers, demands and suggestions on HIV prevention from the perspectives of SSWs, clients and healthcare providers in Chongqing. Face-to-face, in-depth interviews were conducted in July 2008 with 23 participants. They were recruited by purposive, convenience sampling and included 12 SSWs, 5 male clients, 4 government healthcare providers and 2 outreach workers from a community-based non-governmental organisation. Thematic analysis was used. SSWs were largely rural-to-urban migrants with a low socioeconomic status. Most of their clients shared a similar background. Both SSWs and their clients demonstrated a low awareness of HIV infection and a lack of understanding of effective preventive strategies. Financial hardships, lack of family support, fear of police arrest and stigma in relation to sex work were identified as SSWs' major barriers for accessing healthcare services. Both SSWs and their clients indicated an urgent demand for accessing adequate HIV prevention and care programmes. On the other hand, government organisations trying to provide services to this group have also encountered obstacles, specifically their limited ability to establish mutual trust. Programmes provided by community-based non-governmental organisation, however, were perceived to be more attractive. In conclusion, there remains a substantial gap between the need of adequate HIV prevention services for SSWs and their clients and what is currently available. Strengthening inter-sectoral collaboration, providing specifically tailored health services, actively involving SSW peers and their clients, and reducing stigma in the society are keys to meet this urgent demand by SSWs in China.

A Framework for Sexual Decision-Making Among Female Sex Workers in Jamaica

The Jamaican government has provided targeted HIV and sexually transmitted infection prevention, treatment, and other services for female sex workers (FSW) since 1989. HIV prevalence among FSW declined from 20 to 12% between 1989 and 1994, then to 9% in 2005, 5% in 2008, and 4.1% in 2011. This article distills the literature and two decades of experience working with FSW in Jamaica. Drawing on the constant comparative method, we put forward an innovative conceptual framework for explaining sexual decision-making and risk behaviors within both transactional and relational sexual situations. This framework helps fill the gaps in existing models that focus on individual behaviors. The model identifies interactions between environmental and structural elements of sex work, and three individual-level factors: risk perception, perceived relationship intimacy, and perceived control, as the four primary mediating factors influencing sexual decision-making among FSW. We propose that other factors such as violence, socioeconomic vulnerability, and policy/legal frameworks influence sexual decision-making through these primary mediating factors. This conceptual model may offer a useful framework for planning and evaluating prevention interventions among sex workers. However, it remains to be tested in order to establish its value.

Human immunodeficiency virus, syphilis and hepatitis C virus prevalence trends among cross-border migrant Vietnamese female sex workers in Guangxi, China

Background

Global literature indicates the burden of human immunodeficiency virus (HIV), syphilis and hepatitis C virus (HCV) has disproportionately affected cross-border migrant female sex workers (FSW). However, few studies reported the HIV risk among Vietnamese FSW at borderline areas in China. We examined five consecutive years of HIV, syphilis, and HCV prevalence and corresponding risk factors among this group in Guangxi Province of China in the current study.

Method

Demographic and behavioral data as well as test results of blood samples for HIV/syphilis/HCV testing were collected from the annual National Sentinel Surveillance (NSS) from the year of 2010 to 2014. The prevalence trends were first examined by stratified demographic and behavioral status. Predictive models with logistic regression were further employed to identify risk predictors for HIV, syphilis and HCV combined with multiple imputation for missing data as well as restricted cubic splines for key continuous covariates. Moreover, weighted prevalence using the distribution of venue types among all FSW from the NSS survey as the standardized population was also reported.

Results

The overall prevalence of HIV, syphilis and HCV across the five year period was 3.2 % (95 % CI = 2.1 %,4.3 %), 6.9 % (95 % CI = 5.3 %,8. %), and 2.6 % (95 % CI = 1.6 %,3.6 %), respectively. HIV prevalence changed from 8.2 % (95 % CI = 0.5 %,15.9 %) in 2010 to 1.7 % (95 % CI = 0.4 %,3.0 %) in 2014, and the prevalence decreased notably among FSW who were younger than 25 years old, stayed less than six months, and who participated in the HIV prevention services (P < 0.05). The syphilis prevalence also ranged from 8.2 % (95 % CI = 0.5 %,15.9 %) in 2010 to 3.9 % (95 % CI = 1.9 %,5.9 %) in 2014, and the prevalence remained relatively stable among FSW who reported inconsistent condom use with clients in the past month, those who did not participate in HIV prevention services, and had lower HIV knowledge (P > 0.05). HCV prevalence increased from 0 % in 2010 to 2.2 % (95 % CI = 0.7 %, 3.7 %) in 2014. Multivariable analyses revealed that infection with HCV increased the odds of HIV and syphilis infection. Drug use (aOR = 44.0, 95C % = 16.3,129.5) increased the odds of HCV infection.

Conclusions

The relatively higher HIV, syphilis and HCV prevalence among Vietnamese FSW compared to their Chinese counterparts sets a challenge for health officials at both sides. To curb the epidemic among the cross-border FSW, preventive action requires bilateral cooperation and action by health authorities of China and Vietnam. A national-level response system should be launched in order to tackle the urgently ever-increasing epidemic.

Behavioral Interventions Improve Condom Use and HIV Testing Uptake Among Female Sex Workers in China: A Systematic Review and Meta-Analysis

Condomless commercial sex work is a common mode of HIV transmission in China. This study systematically reviews the impacts of behavioral interventions on condom use and HIV testing uptake among female sex workers (FSW) in China. Chinese and English language peer-reviewed articles published between January 2000 and December 2013 were searched in five electronic databases. Odds ratios (OR) were calculated by comparing the levels of improvements in condom use and HIV testing uptake by various intervention strategies. Study quality was assessed for included studies. This review followed the PRISMA guidelines and was registered in PROSPERO. One hundred and twenty-eight studies met inclusion criteria. Meta-analyses indicated that FSW in the post-intervention period were 2.3-5.0 times more likely to use condoms with male clients in their last sexual act and 2.3-3.4 times more likely to use condoms consistently in the last month than in the pre-intervention period. In particular, multiple session intervention were more effective in improving condom use among FSW with male clients (OR=5.6, [4.0-7.8]) than a single session intervention (OR=3.3, [2.8-3.8]). Behavioral interventions also improved past-12-month HIV testing uptake 4.6-fold (95% CI, 2.9-7.4). Comprehensive intervention programs were more effective (OR=8.1, [4.0-16.7]) in improving HIV testing uptake compared with health education only programs (OR=2.7, [1.6-4.5]). Longer intervention duration (>12 months) did not increase effectiveness in improving condom use or HIV testing rate among Chinese FSWs. Behavioral interventions are effective in improving condom use and HIV testing uptake among Chinese FSW. This review highlights both the potentials and limitations of condom promotion interventions targeting female sex workers.

HIV risk and sexual health among female migrants in China

Sexual behavior is the dominant mode of HIV transmission in China, and young female migrants are among the populations at highest risk. This article examines how HIV-related risk behaviors among female migrants might vary according to workplace settings. Participants were young female migrants recruited from three workplace settings-factories, restaurants and entertainment venues. In a cross-sectional survey, we assessed 457 participants' sociodemographic characteristics, HIV/AIDS-related knowledge, condom use knowledge, sexual behaviors, condom use behavior and reproductive health factors. Participants working in entertainment venues were significantly more likely than those working in factories and restaurants to report sexual behavior, unprotected sex, multiple pregnancy terminations and sexually transmitted infections (STI). However, participants working in factories and restaurants reported significantly lower levels of HIV/AIDS knowledge, condom use knowledge, condom use self-efficacy and history of HIV/AIDS counseling and testing. Independent correlates of unprotected sex included employment in an entertainment venue, abortion history and sexual self-efficacy. Independent correlates of STI or genitourinary tract infection included employment in an entertainment venue, abortion history, recent migration and recent unprotected sex. These findings indicate a need for sexual and reproductive health interventions prioritizing young female migrants, and call for programs that can be incorporated into different workplace settings.

Prevalence and associated factors of HIV infection among men who have sex with men in Hefei, China, 2013-2014: a cross-sectional study

The objective of this study was to investigate the prevalence and influencing factors of HIV infection among men who have sex with men (MSM) in Hefei, China. A total of 578 MSM were recruited, with a mean age of 28.13 ± 6.91; 70.7% were under 30. The awareness rate was 95.4% (560/587) in the cross-sectional study. Of all the respondents, 73 (12.44%) were seropositive for HIV and 56 (9.54%) for syphilis. Multivariate analysis showed that self-reported sexually transmitted infections (STIs) (AOR = 8.02, 95% CI: 2.58-24.98, P < 0.001), received HIV testing in the past year (AOR = 0.33, 95% CI: 0.19-0.60, P < 0.001) and syphilis (AOR = 3.40, 95% CI: 1.69- 6.85, P = 0.001) were independently associated with HIV infection. It is necessary for post-test counselling to address risk among those who engage in sexual risk behaviours. More efforts are needed to enhance HIV/STI testing and treatment services in China.

Unpacking the 'structural' in a structural approach for HIV prevention among female sex workers: a case study from China

Interventions for HIV prevention among female sex workers (FSWs) in China focus on HIV/sexually transmitted infection (STI) and individual behaviour change. An occupational health framework facilitates intervention across an array of health issues FSWs face including HIV/STI, violence, reproductive health, stigma and substance use. Through a case study of a community-based Jiaozhou (JZ) FSW programme, we developed a conceptual framework incorporating global discussions of structural approaches to HIV prevention with the specific social and structural contexts identified among FSWs in China. Based on ethnographic fieldwork between August 2010 and May 2013, we describe the evolution of this programme to its current occupational health focus and unpack the intervention strategies. We describe the critical features of the programme that have fostered success among FSWs including high-quality clinical services provided within a welcoming setting, responsive outreach work through staff and trained FSW peers, interpersonal and community-level engagement aimed at changing the local social and structural environments of sex work and tailored health education materials. This intervention differs from other projects in China by adopting a more holistic approach to FSW health that incorporates social issues. It also demonstrates the feasibility of structural interventions among FSWs even within an environment that has strong anti-prostitution policies.

Exploring HIV prevention strategies among street-based female sex workers in Chongqing, China

Background: Commercial sex plays an increasingly important role in China’s growing HIV and sexually transmitted infection (STI) epidemics. In China, street-based sex workers (SSWs) are a subgroup of female sex workers with a particularly high risk of HIV/STI infections but are neglected in responses to HIV. This study assesses changes in HIV voluntary counseling and testing (VCT) utilization and high-risk sexual behaviors following a three-month HIV preventive intervention among SSWs in Chongqing, China. Methods: A three-month intervention was conducted by a team of peer educators, outreach workers from community-based organizations and health professionals. It mainly included distribution of free pamphlets and condoms and delivery of onsite and clinic-based VCT. Cross-sectional surveys were conducted prior to (n = 100) and immediately following (n = 112) the intervention to assess its impact. In-depth interviews were conducted among 12 SSWs after the intervention to further explore potential barriers to HIV prevention. Results: The intervention significantly increased SSWs’ participation in VCT (from 2.0%–15.2%, P < 0.001). Despite participants’ improved HIV-related knowledge level (from 24.0%–73.2%, P < 0.001), there were minimal changes in the levels of condom use with clients. Qualitative research revealed that fear of police arrest and stigma were the main barriers to VCT utilization. Low condom use was associated with family financial constraints, inadequate power in condom negotiation, low awareness and misconceptions of HIV infection risks. Conclusion: HIV intervention improved VCT utilization and knowledge but we did not observe an increase in condom use after this short intervention. SSWs faced substantial economic, social and environmental barriers to VCT utilization and condom use.

Preventing HIV transmission in Chinese internal migrants: a behavioral approach

This study is a step towards a behavioral intervention to prevent HIV transmission among Chinese internal migrants. To explore important and changeable determinants of condom use and inspect effective and feasible methods to increase condom use for the target population, we conducted a three-round web-based Delphi study among a panel of 62 experts between October 2012 and March 2013. The panelists were purposely selected using a stepwise procedure to represent topic-related areas of expertise. The response rate per round ranges from 21% to 81%. The panelists identified 19 possible determinants of condom use and reported 16 intervention methods they considered successful. They agreed that attitude towards condom use was the most important and changeable determinant, while applying behavioral theory, increasing sexual education and condom access, performing worksite health promotion, detecting risk factors, and working closely with relevant organizations and the government were effective and feasible methods to increase condom use among internal migrants in China. In conclusion, results of this study highlight the importance of attitude in changing condom use and underscore the need to apply behavior theory and integrate multiple educational approaches for developing behavioral HIV prevention interventions targeting internal migrants in China.

HIV risk among female sex workers with different patterns of drug use behaviors in Southwest China: a cross-sectional study

Although many researchers found that drug use behaviors significantly increased HIV risk, few of them investigated the association between HIV risk and different drug use behaviors among female sex workers (FSWs) in China. The current study examines demographic and behavioral risk factors as well as the infections of HIV, syphilis, and among a subgroup of FSWs who are injection drug users (IDU) or noninjection drug users (NIDU) in comparison to Hepatitis C Virus (HCV) nondrug users (non-DU). We conducted secondary analysis of the 2010 National Sentinel Surveillance (NSS) data from Guangxi China. A self-administered, standard behavioral surveillance survey was completed by a total of 12,622 FSWs recruited from Guangxi, China. The Guangxi 2010 NSS sample included 2.6% NIDU and 0.5% IDU. Compared to non-DU, IDU were more likely to report no condom use in the last sex act (aOR = 3.25, 95%CI = 1.65, 6.40), inconsistent condom use in the past month (aOR = 4.88, 95%CI = 2.66, 8.96), having an HIV testing (aOR = 2.48, 95%CI = 1.34, 4.58), infections of HIV (aOR = 42.60, 95%CI = 9.45, 192.06), syphilis (aOR = 4.13, 95%CI = 1.86, 9.16), and HCV (aOR = 74.54, 95%CI = 30.26, 183.61). NIDU had 2.89 times higher than non-DU to report a history of sexually transmitted disease and 26% less likely to report inconsistent condom use in the past month (p < 0.05). We called for tailored, accessible, and nonjudgmental drug treatments coupled with effective sexual risk reduction interventions to help FSWs with various drug use problems to reduce their vulnerability and susceptibility of HIV risk in China as well as other cultural settings.

Female sex workers and their gatekeepers in China: implications for HIV/STI prevention

Female sex workers (FSWs) play a key role in HIV/AIDS transmission and their gatekeepers play a crucial role in shaping their behaviors. Limited studies are available on the relationship between FSWs and gatekeepers. In the current study we used an ethnographic approach to examine the dynamic and multidimensional relationship of FSWs and their gatekeepers from the perspectives of both parties. We recruited 38 FSWs and 16 gatekeepers from different types of commercial sex venues in Guangxi, China, and conducted in-depth individual interviews. Our data suggest that FSWs and gatekeepers maintain an interdependent and reciprocal relationship during their business practice, but gatekeepers exert significant influence and control over FSWs. Designing culturally appropriate HIV/STI-prevention programs requires us to take advantage of the unique and crucial roles of gatekeepers. We conclude with a call for structural interventions to protect FSWs' occupational health and safety.

Behavioral and psychosocial interventions for HIV prevention in floating populations in China over the past decade: a systematic literature review and meta-analysis

BACKGROUND

Floating populations have been repeatedly characterized as "the tipping point" for the HIV epidemic in China. This study aims to systematically summarize and assess the effectiveness of HIV prevention interventions in floating populations in China over the past decade.

METHODS

We conducted a systematic search in three international databases for literature published between 2005 and 2012 with condom use as the primary outcome, and knowledge about HIV transmission and prevention and stigma towards HIV-infected individuals as secondary outcomes. The impact of interventions on changing the primary and secondary outcomes was calculated by risk difference (RD). We also performed subgroup analyses and meta-regression based on different study characteristics, using Stata 12.0, for the primary outcome.

RESULTS

Sixteen studies (out of 149) involved 19 different programs and a total of 10,864 participants at entry from 11 provinces in China. The pooled effect estimate of all studies indicated that people participating in HIV-related interventions were 13% more likely to use condoms (95%CI: 0.07, 0.18), however, the effects on increasing condom use exhibited significant heterogeneity across programs (P<0.01, I2 = 0.93). The meta-regression results suggest that interventions have been significantly less successful in changing condom use in more recent studies (β, 0.14; 95%CI: 0.01, 0.27), adjusted for sexual relationship, study design and follow-up period. Regarding the secondary outcomes, HIV-related interventions were successful at improving knowledge about HIV transmission and prevention (RD, -0.26; 95%CI: -0.36, -0.16 and RD, -0.25; 95%CI: -0.33, -0.16, respectively), and decreasing stigma (RD, 0.18; 95%CI: 0.09, 0.27).

CONCLUSIONS

The included studies between 2005 and 2012 indicate that HIV prevention interventions among Chinese floating populations in the past decade were only marginally effective at increasing condom use, but relatively successful at increasing HIV knowledge and decreasing stigma. To avert new infections, novel sexual risk-reduction interventions taking into account the changing socio-economic and cultural situation of Chinese floating populations are urgently needed.

Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis

BACKGROUND

Needle and syringe programmes (NSP) aim to reduce the risk of HIV by providing people who inject drugs (PWID) with sterile injecting equipment. A recent review of reviews (ROR) concluded that there was only tentative evidence to support the effectiveness of NSP in reducing HIV. We carried out a systematic review and meta-analysis to assess the association between NSP and HIV transmission.

METHODS

Relevant primary articles presenting data on the risk of HIV transmission associated with NSP were identified in two stages: (i) from reviews identified in two published RORs (covering the period 1980-2008); and (ii) a literature search of CINAHL, Cochrane Library, EMBASE, MEDLINE and PsychINFO for primary articles published since the most recent high quality review (covering the period 2008-12). Study results were synthesized using random-effects meta-analysis.

RESULTS

There were 12 studies comprising at least 12 000 person-years of follow-up. Exposure to NSP was associated with a reduction in HIV transmission: pooled effect size 0·66 [95% confidence interval (CI) 0·43, 1·01] across all studies, and 0·42 (95% CI 0·22, 0·81) across six higher quality studies (according to the Newcastle-Ottawa tool).

CONCLUSIONS

There is evidence to support the effectiveness of NSP in reducing the transmission of HIV among PWID, although it is likely that other harm reduction interventions have also contributed to the observed reduction in HIV risk. NSP should be considered as just one component of a programme of interventions to reduce both injecting risk and other types of HIV risk behaviour.

Testing the efficacy of an HIV stigma reduction intervention with medical students in Puerto Rico: the SPACES project

Introduction

Stigma associated with HIV has been documented as a barrier for accessing quality health‐related services. When the stigma manifests in the healthcare setting, people living with HIV receive substandard services or even be denied care altogether. Although the consequences of HIV stigma have been documented extensively, efforts to reduce these negative attitudes have been scarce. Interventions to reduce HIV stigma should be implemented as part of the formal training of future healthcare professionals. The interventions that have been tested with healthcare professionals and published have several limitations that must be surpassed (i.e., lack of comparison groups in research designs and longitudinal follow‐up data). Furthermore, Latino healthcare professionals have been absent from these intervention efforts even though the epidemic has affected this population disproportionately.

Methods

In this article, we describe an intervention developed to reduce HIV stigma among medical students in Puerto Rico. A total of 507 medical students were randomly introduced into our intervention and control conditions.

Results

The results show statistically significant differences between the intervention and control groups; intervention group participants had lower HIV stigma levels than control participants after the intervention. In addition, differences in HIV stigma levels between the groups were sustained for a 12‐month period.

Conclusions

The results of our study demonstrate the efficacy of the modes of intervention developed by us and serve as a new training tool for future healthcare professionals with regard to stigma reduction.

Sexual communication, safer sex self-efficacy, and condom use among young Chinese migrants in Beijing, China

Mediation effect of sexual communication on the relationship between safer sex self-efficacy and condom use was tested among 307 homosexually active migrant men, 376 heterosexually active migrant men, and 265 heterosexually active migrant women. The study found certain aspects of sexual communication mediated the effect of self-efficacy on condom use among the three samples. The findings underscored the importance of including components that promote safer sex self-efficacy and sexual communication in HIV prevention interventions for Chinese migrants.

Testing the efficacy of an HIV stigma reduction intervention with medical students in Puerto Rico: the SPACES project

INTRODUCTION

Stigma associated with HIV has been documented as a barrier for accessing quality health-related services. When the stigma manifests in the health care setting, people living with HIV receive substandard services or even be denied care altogether. Although the consequences of HIV stigma have been documented extensively, efforts to reduce these negative attitudes have been scarce. Interventions to reduce HIV stigma should be implemented as part of the formal training of future health care professionals. The interventions that have been tested with health care professionals and published have several limitations that must be surpassed (i.e. lack of comparison groups in research designs and longitudinal follow-up data). Furthermore, Latino health care professionals have been absent from these intervention efforts even though the epidemic has affected this population disproportionately.

METHODS

In this article, we describe an intervention developed to reduce HIV stigma among medical students in Puerto Rico. A total of 507 medical students were randomly introduced into our intervention and control conditions.

RESULTS

The results show statistically significant differences between the intervention and control groups; intervention group participants had lower HIV stigma levels than control participants after the intervention. In addition, differences in HIV stigma levels between the groups were sustained for a 12-month period.

CONCLUSION

The results of our study demonstrate the efficacy of the modes of intervention developed by us and serve as a new training tool for future health care professionals with regard to stigma reduction.

Predictors of HIV testing among men who have sex with men in a large Chinese city

BACKGROUND

HIV testing is the gateway for prevention and care. We explored factors associated with HIV testing among Chinese men who have sex with men (MSM).

METHODS

In Chongqing City, we recruited 492 MSM in 2010 using respondent-driven sampling in a cross-sectional study. Computer-assisted self-interviews were conducted to collect information on history of HIV testing.

RESULTS

Only 58% of participants reported ever having taken an HIV test. Men who have sex with men who had a college degree (adjusted odds ratio [AOR], 1.7; 95% confidence interval (CI), 1.2-2.6; P = 0.008) were more likely to take a test; those who preferred a receptive role in anal sex were less likely to do so than those with insertive sex preference (AOR, 0.6; 95% CI, 0.35-0.94; P = 0.03); and those who used condoms with the recent male partner during the past 6 months were more likely to get tested (AOR, 2.87; 95% CI, 1.25-6.62; P = 0.01). Principal perceived barriers to testing included the following: fear of knowing a positive result, fear of discrimination if tested positive, low perceived risk of HIV infection, and not knowing where to take a test. Factors reported to facilitate testing were sympathetic attitudes from health staff and guaranteed confidentiality. Prevalence was high: 11.7% HIV positive and 4.7% syphilis positive.

CONCLUSIONS

The HIV testing rate among MSM in Chongqing is still low, although MSM prevalence is high compared with other Chinese cities. Men who have sex with men preferring receptive anal sex are less likely to get testing and perceive having lower HIV risk. Along with expanded education and social marketing, a welcoming and nonjudgmental environment for HIV testing is needed.

Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness

BACKGROUND

Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.

METHODS

A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.

RESULTS

Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission.

CONCLUSION

Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.

The study of KBP of road construction workers of highway AIDS prevention project before and after intervention

OBJECTIVE

To get scientific basis for further health education through the research of the road construction workers' KBP before and after the interventions of highway AIDS prevention project.

METHODS

Multi-stage random sampling method was employeed to select workers of 8 sites from 14 sites along highway to investigate their AIDS knowledge, belief and performance (KBP) before and after highway AIDS prevention project.

RESULTS

Over 90% of the investigated workers had ever heard about AIDS, and the non-skilled workers of lower educational level improved more after intervention. The correct answer rate of the three transmitting ways of AIDS of drivers which is the focused group of highway before and after intervention had the obvious statistical significance (P<0.05), and the other group's correct answer rates also had improved after intervention. Most people's understanding of preventing AIDS through correct use of condoms when having sex had a statistically significant difference(P<0.05) after prevention. The rates of using condoms of foremen and skilled workers when having sex with commercial sex worker/casual partner increased after intervention.

CONCLUSIONS

The health education of HIV among the road construction workers is effective and further health education of HIV prevention should be carried out among the road construction workers to improve their knowledge and awareness of avoiding the high-risk behaviors.

Effect of an educational intervention on knowledge, attitudes and preventive behaviours related to HIV and sexually transmitted infections in female sex workers in southern Iran: a quasi-experimental study

This quasi-experimental, before–after study was designed to assess the effect of an educational intervention on knowledge and attitudes about sexually transmitted infections, HIV and preventive behaviours among female sex workers in Shiraz, Iran. A single-group pre–post test design was used and the study was done between August and December 2009. The participants were 80 female sex workers recruited from three drop-in centers in Shiraz, with stratified random sampling. Pre-intervention knowledge was assessed by interview with a standard questionnaire. The educational intervention consisted of a lecture, face-to-face education, printed information, an educational movie, role playing and a contest. After 2 months, the effect of the intervention was evaluated (post-test). The average age of the participants was 32.6 ± 9.1 years. After the intervention, the mean score for general knowledge about HIV and sexually transmitted infections increased from 13.7 ± 0.95 (pre-test) to 19.47 ± 11.62 (post-test, p < 0.001). There were significant improvements in attitude and the number of participants who self-reported preventive behaviours such as using a condom consistently (from 45 to 63) ( p < 0.001). The results show that the educational programme was successful in increasing the participants’ HIV- and AIDS-related knowledge and attitudes, and in decreasing their risk behaviours.

A health promotion logic model to review progress in HIV prevention in China

Using the theory and concepts of health promotion, this paper proposes a logic model for HIV/AIDS prevention and control which provides a structure for describing planned actions and predicted impacts/outcomes from comprehensive HIV prevention interventions. The potential usefulness of the model is examined by reviewing the evolution of HIV prevention and management in China, drawing on evidence from interventions reported from a mixture of study designs and formats. It reports that HIV interventions in China can be considered in two distinctive phases, before and after 2003 when China commenced its 'official' response to the HIV epidemic. The logic model was useful in comparing actions taken over these two periods highlighting the importance of political leadership in distinguishing between the two phases, and the continuing importance of systematic and broadly based public education and communication. We conclude that the logic model can not only be used as a planning model, but can also be applied retrospectively to assess successes and failures in national and local responses to HIV in complex social settings.

Systematic review of HIV prevention interventions in China: a health communication perspective

OBJECTIVES

To examine whether communication strategies and principles have been utilized in the HIV prevention intervention programs conducted in China.

METHODS

Comprehensive literature searches were conducted using PsycINFO, Medline, and Academic Search Complete with combinations of a number of keywords. Studies were included if they (1) were conducted in China and published prior to October 2011; (2) tested interventions promoting HIV/sexual risk reduction; and (3) reported empirical outcome evaluations on HIV knowledge, condom use and other condom-related variables. Data on 11 dimensions were extracted and analyzed, including formative research, theory, message targeting, messenger and channels, process evaluation, evaluation design, outcome measures.

RESULTS

The majority of the 45 intervention studies were not theory-based, did not report conducting formative research or process evaluation, used pretest-posttest control group designs, combined nonmedia channels, printed and visual materials, and employed HIV knowledge and condom use as outcome measures.

CONCLUSIONS

Many HIV prevention interventions in China have been successful in reducing HIV risk-related outcomes. This literature has its weaknesses; however, the current review illuminates gaps in the literature and points to important future directions for research.

Factors associated with HIV infection among men who have sex with men in Henan Province, China: a cross-sectional study

Background

HIV prevalence among men who have sex with men (MSM) has increased rapidly in China. Behavioral and biological interventions are key to controlling the spread of HIV in the MSM population and the primary strategy for reducing the spread of AIDS in China. The purpose of this study is to investigate the prevalence of HIV among MSM in Henan province and to assess their knowledge levels and risk behaviors related to HIV/AIDS.

Method

A cross-sectional survey was conducted among 388 MSM in 2010 in Zhengzhou City, Henan province, China.

Results

Of the 388 respondents, 13.1% were infected with HIV and 10.3% were infected with syphilis. The results of multivariate analysis showed that participants who had a history of being infected by syphilis were more than 4 times more likely to be HIV positive (AOR=4.91; 95% CI: 1.70 to 12.02). For those who were residents from other provinces, the risk of HIV infection was 5.53 times higher (OR=5.53, 95% CI: 1.14, 6.25). Receipt of condoms (AOR = 0.15; 95% CI: 0.02 to 0.87), consistent condom use during last intercourse with a male (AOR=0.35; 95% CI: 0.14 to 0.87), and consistent condom use during last intercourse with a female (AOR=0.16; 95% CI: 0.08 to 0.90) were associated with a lower risk of HIV infection.

Conclusion

The study suggests that some intervention strategies, including education intervention, condom promotion and distribution, and HIV counseling and testing are necessary to control HIV infection among MSM.

Prevalence and related risk behaviors of HIV, syphilis, and anal HPV infection among men who have sex with men from Beijing, China

Specific risk behaviors related to different sexually transmitted infections have not been widely evaluated among men who have sex with men in China. In the present study, a total of 302 MSM were recruited from Beijing with a prevalence of HIV, syphilis, and anal HPV infection as 9.9, 19.2 and 71.4%, respectively. Lower education level was observed to be related to higher infection rate of HIV and syphilis. "Ever found sexual partners in gay venues" was significantly associated with HIV infection as well. "Taking anilinction as regular sexual behavior" was observed to be a significant predictor for anal HPV infection.

Intervention to increase condom use and HIV testing among men who have sex with men in China: a meta-analysis

Behavioral interventions have been shown to both promote and change many health-related behaviors and issues. This meta-analysis was performed to assess whether behavioral interventions have the potential to increase condom use and HIV testing uptake among men who have sex with men (MSM) in China. PubMed, Elsevier Science Direct, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang (Chinese) were searched to June 2011 to identify relevant articles. Data of eligible citations were extracted by two reviewers. Sixteen studies were identified. Aggregated findings indicated that interventions were associated with a significant increase in condom use between MSM and male sex partners in the last anal sex act (RR=1.17, 95% CI=1.05-1.29) and consistent condom use between MSM and male sex partners in the past 6 months (RR=1.36, 95% CI=1.15-1.60) and HIV testing (RR=2.22, 95% CI=1.72-2.88). However, no significant increase was detected in condom use over the course of the intervention among MSM engaging in sex with women. In the subgroup analyses, the positive effects were not detected in some subgroups such as anal sex with casual partners and intervention interval less than or equal to 6 months. The sensitivity analysis showed that these estimates were unchanged after removal of the study that had the biggest sample or the studies that had the most rigorous study design. This meta-analysis can inform future intervention design and implementation in terms of sample size, target populations, settings, goals for process measures, and intervention interval.

Efficacy of human immunodeficiency virus prevention interventions among men who have sex with men in China: a meta-analysis

OBJECTIVES

This study aimed to determine the efficacy of HIV prevention interventions among men who have sex with men (MSM) in China. Human immunodeficiency virus (HIV) knowledge, HIV testing, condom use, sexual risk activity, incidence of sexually transmitted diseases, and HIV incidence were used as outcomes.

METHODS

Meta-analytic techniques were used to compute and aggregate effect sizes for 22 studies, published between 2004 and 2011, which met inclusion criteria. Variables with the potential to moderate intervention efficacy were also tested.

RESULTS

The overall mean weighted effect size was d = 0.627 (95% confidence interval [CI], 0.460-0.793; Z = 7.38; P < 0.001) for HIV knowledge, d = 0.394 (95% CI, 0.274-0.514; Z = 6.44; P < 0.001) for condom use with men, and d = 0.590 (95% CI, 0.420-0.761; Z = 6.80; P < 0.001) for HIV testing, which indicates a statistically significant impact through intervention. Statistically significant effect sizes were also found for condom use with women and for number of sexual partners. Interventions for condom use conducted in Southwest China (the region in China with the highest prevalence of HIV) were significantly less efficacious. Interventions for condom use were significantly more efficacious when the respondent-driven sampling recruitment method and popular opinion leader intervention strategy were used.

CONCLUSIONS

Human immunodeficiency virus prevention interventions were efficacious among MSM in China. Additional efforts are needed to control the growing HIV/acquired immunodeficiency syndrome infection among MSM in China. Future interventions need to use more rigorous intervention methodologies (e.g., respondent-driven sampling method, and popular opinion leader intervention strategy).

The Global HIV Archive: Facilitating the Transition from Science to Practice of Efficacious HIV Prevention Interventions

This paper describes the development, content, and capabilities of the online Global HIV Archive (GHA). With the goal of facilitating widespread adaptation and appropriate use of efficacious HIV prevention programs throughout the globe, GHA has: first, expanded and updated the search for HIV prevention programs originating in low-resource countries; second, identified those meritorious HIV prevention programs meeting established efficacy criteria of technical merit, replicability, and positive outcomes; third, prepared both implementation and evaluation materials from the efficacious programs for public use; fourth, developed interactive wizards or capacity-building tools to facilitate appropriate program selection, implementation, and adaptation; and, fifth, made the efficacious programs and accompanying wizards available to health practitioners throughout the globe in both printed and online formats.

Alcohol use and sexual risks: use of the Alcohol Use Disorders Identification Test (AUDIT) among female sex workers in China

The association between alcohol use and sexual risks among female sex workers (FSWs) has been insufficiently studied. This article reports a cross-sectional study of the relationship between alcohol use risk, measured by the Alcohol Use Disorders Identification Test (AUDIT), and sexual risk behaviors among 1,022 FSWs in Guangxi, China. Bivariate analysis showed that FSWs at higher AUDIT levels tended to have earlier sexual initiation, became involved in the sex trade at a younger age, and were more vulnerable to sex under the influence of alcohol. Multivariate analysis revealed an independent association of problem drinking with both unprotected sex and a history of sexually transmitted diseases (STDs). Alcohol use in commercial sex shall be considered as an occupational hazard that requires immediate intervention. Future longitudinal studies are needed to confirm the association between alcohol use and sexual risks among this most-at-risk population.

Older HIV-positive adults in Xiangxi, China: infection modes and associated risk factors

OBJECTIVE

An unusual increase in HIV/AIDS cases among rural older adults was reported between 2005 and 2008 in Xiangxi Prefecture, Hunan Province. We explored the reasons for this increase and suggested preventive measures for the future control of HIV infection in this population.

METHODS

A cross-sectional study was conducted using an HIV/AIDS registry in Hunan Province, China, to explore the likely transmission mode and risk factors of HIV/AIDS among older adults. The data were collected by face-to-face interview.

RESULTS

A total of 80 participants including 5 couples were interviewed. Among them, 46 (57.5%) participants were male and 34 (42.5%) were female. Of 46 male HIV-positive participants, 45 (97.8%) reported to have sexual intercourse with commercial sex workers. None of the female HIV-positive participants reported to have engaged in commercial sex activities. Among 46 male participants' spouses, 71.7% of them had received HIV testing and 48.5% were HIV-positive. Among 34 female participants' spouses, 92.2% of them had received HIV testing and 87.1% were HIV-positive. Ninety-seven percent of the participants reported never using condoms during sexual intercourse with their marital partners or commercial sex workers before knowing their HIV status. Eighty-two percent of participants did not know that condoms could prevent HIV/AIDS/STIs.

CONCLUSION

Chinese older adults are an underappreciated at-risk population for HIV/AIDS. The likely transmission mode of HIV/AIDS among rural older adults was unprotected sex. The HIV/AIDS/STIs knowledge among this population is very limited.

Factors associated with unprotected anal intercourse among men who have sex with men in Liaoning Province, China

Background

HIV prevalence among men who have sex with men (MSM) has increased rapidly. MSM may play a bridging role in the spread of HIV and other STDs from the high-risk population to the general population. Interventions to reduce high-risk behavior are the key to controlling the spreading of HIV in the MSM population and the primary strategy for reducing the spread of AIDS in China. The purpose of the study was to examine the demographic characteristics of MSM, evaluate the HIV-related knowledge of MSM, and identify factors associated with unprotected anal intercourse (UAI) among MSM to make recommendations for future research.

Methodology/Principal Finding

A cross-sectional survey was conducted among 293 MSM in Fushun and Huludao City, China. A total of 91 participants (34.0%) reported engagement in UAI with a male partner during the previous six months. The results of univariate analysis showed that UAI was associated with older age, lower levels of education, less knowledge about HIV, and not receiving condoms, lubricant, peer education, AIDS counseling, STD checks, and informational materials (p<0.05). In a multivariate logistic regression model, awareness of the major HIV transmission routes (OR = 2.191; 95% CI: 0.869 to 5.524), receiving condoms (OR = 2.164; 95% CI: 1.149 to 4.076), receiving peer education (OR = 2.632; 95% CI: 1.566 to 4.426), and AIDS counseling (OR = 2.347; 95% CI: 1.260 to 4.372) were independently associated with a lower risk of UAI.

Conclusions/Significance

The study suggested that UAI could be decreased by improving education about AIDS, increasing the promotion of voluntary counseling and testing (VCT), and improving the accessibility and convenience of service.

Impact evaluation of a sexually transmitted disease preventive intervention among female sex workers in Hohhot, China

OBJECTIVES

The aim of this study was to evaluate the impact of HIV and sexually transmitted disease (STD) prevention interventions among female sex workers (FSWs) in the city of Hohhot in northern China.

METHODS

Three serial cross-sectional surveys were conducted in 2006, 2007, and 2008 among FSWs. A questionnaire was administered to the FSWs, and HIV and syphilis tests were performed for all participants. Intervention activities including condom promotion and provision, increased condom availability and accessibility, and voluntary HIV counseling and testing (VCT) were carried out among FSWs.

RESULTS

There were 624 participants in the 2006 survey, 444 in the 2007 survey, and 451 in the 2008 survey. The United Nations General Assembly Special Session (UNGASS) indicators for FSWs increased from 13.9% in 2006 to 37.7% in 2008 (p<0.001). The average rate of consistent condom use with commercial clients in the month preceding the interview increased significantly from 39.8% in 2006 to 59.6% in 2008 (p<0.001). Not a single HIV-positive case was found among the FSWs over these 3 years, and the prevalence of syphilis decreased remarkably from 9.5% in 2006 to 1.3% in 2008. Logistic regression analysis showed that sauna or hair salon work venues, receiving services from intervention programs, and accepting HIV tests were factors associated with consistent condom use.

CONCLUSIONS

The findings suggest that consistent condom use and awareness of HIV/AIDS prevention-related knowledge among FSWs have been improved by the intervention. Further prioritized and combined prevention programs aimed at FSWs are needed in order to prevent the HIV/AIDS epidemic spreading in the general population in China.

Unprotected sex with their clients among low-paying female sex workers in southwest China

China has been experiencing a rapid increase in the HIV epidemic for decades. Commercial sex plays a critical role in heterosexual transmission of HIV. Limited studies suggested that low-paying female sex workers (FSWs) faced a higher risk of HIV infection. Low-paying FSWs are women who usually encounter their clients on the street or small establishments in rural or less-developed areas, or who charge low fees for each sexual service. A total of 720 low-paying FSWs from 130 commercial sex venues/locations in southwest China were included in the data analysis. Multivariate regression models were employed to examine the associations of unprotected sex with a number of exploratory variables among the study sample. About 33.9 and 61.5% of low-paying FSWs reported unprotected sex with clients in the last sex act and in the last month, respectively. After controlling for confounders, women's HIV knowledge, risk perception, experience of police arrest, and venue types were significantly associated with unprotected sex among low-paying FSWs. Low-paying FSWs are at an alarmingly high risk of HIV infection. HIV prevention programs are urgently needed to address risk factors posit in both individual and contextual levels among this most-at-risk population in order to curb the HIV epidemic in China.

Participation of HIV prevention programs among men who have sex with men in two cities of China--a mixed method study

Background

Although various HIV prevention programs targeting men who have sex with men (MSM) are operating in China, whether and how these programs are being utilized is unclear. This study explores participation of HIV prevention programs and influencing factors among MSM in two cities in China.

Methods

This is a mixed-method study conducted in Beijing and Chongqing. A qualitative study consisting of in-depth interviews with 54 MSM, 11 key informants, and 8 focus group discussions, a cross-sectional survey using respondent-driven sampling among 998 MSM were conducted in 2009 and 2010 respectively to elicit information on MSM’s perception and utilization of HIV prevention programs. Qualitative findings were integrated with quantitative multivariate factors to explain the quantitative findings.

Results

Fifty-six percent of MSM in Chongqing and 75.1% in Beijing ever participated in at least one type of HIV prevention program (P=0.001). Factors related to participation in HIV prevention programs included age, ethnicity, income, HIV risk perception, living with boyfriend, living in urban area, size of MSM social network, having talked about HIV status with partners, and knowing someone who is HIV positive. Reasons why MSM did not participate in HIV prevention programs included logistical concerns like limited time for participation and distance to services; program content and delivery issues such as perceived low quality services and distrust of providers; and, cultural issues like HIV-related stigma and low risk perception.

Conclusions

The study shows that there is much room for improvement in reaching MSM in China. HIV prevention programs targeting MSM in China may need to be more comprehensive and incorporate the cultural, logistic and HIV-related needs of the population in order to effectively reach and affect this population’s risk for HIV.

HIV/sexual risk reduction interventions in China: a meta-analysis

The current study was a meta-analysis of the efficacy of educational, psychosocial or behavioral interventions that were conducted in China to promote HIV/sexual risk reduction. A total of 26 intervention studies qualified for the meta-analysis. Outcome variables for which effect sizes were calculated included condom use with different types of sexual partners, HIV/AIDS knowledge, condom use knowledge, intentions of condom use, condom use self-efficacy, and others. Mean weighted effect sizes were calculated for each outcome measure across reviewed studies; effect size for each outcome measure was weighted by their inverse variance; fixed effects and random effects meta-analytic procedures were used. The Q statistic was used to examine whether the effect sizes were homogeneous in nature and moderating analysis (i.e., the Q(b) statistic) was used to compare the effect sizes of intervention studies that were different in a number of categorical variables. The reviewed interventions were successful in improving HIV knowledge (d=0.706), condom use knowledge (d=0.620), attitudes toward people living with HIV/AIDS (PLWHA; d=0.625) and in increasing condom use with regular partners (d=0.477), condom use with casual partners (d=0.444), general condom use (d=0.408), and condom use self-efficacy (d=0.584) among target audiences. In addition, moderating analyses on three most examined variables, including HIV knowledge, condom use, and attitudes toward PLWHA, demonstrated that interventions that reported the conduction of formative research and process evaluation, that were peer-led, and that included only one follow-up were more likely to report a positive impact on condom use behavior among target audiences (p<0.001), HIV knowledge (p<0.001), or attitudes toward PLWHA (p<0.001).

Racial and ethnic disparities and implications for the prevention of HIV among persons who inject drugs

PURPOSE OF REVIEW

There are now an estimated 16 million people who inject drugs (PWID) throughout the world, 3 million of whom are estimated to be infected with HIV. In many countries, substantial proportions of PWID belong to racial/ethnic/nationality minority groups, and are at increased likelihood of being infected with HIV. This article reviews current evidence on ethnic disparities in HIV infection among PWID and assesses the issues that would need to be addressed to reduce these disparities.

RECENT FINDINGS

An ongoing systematic review of ethnic disparities has found that, in a pooled weighted odds ratio, ethnic minority PWID are twice as likely to be HIV seropositive than ethnic majority, PWID from the same geographic area. If implemented with sufficient quality and coverage, current HIV prevention programs probably have the capability of ending HIV transmission among both ethnic majority and minority PWID. Large-scale, evidence-based prevention programs need to be implemented in the contexts of patterns of injecting drug use that continue to evolve-with injecting practices spreading to new areas, changes in drugs injected, and some transitions from injecting to noninjecting drug use. Lack of financial resources and policies against evidence-based programming are increasingly important problems that are likely to have particularly adverse effects on ethnic minority PWID.

SUMMARY

Racial/ethnic/nationality disparities in HIV infection are quite common among PWID. Addressing these disparities will be a fundamental challenge within a human rights approach to public health.

Penicillium marneffei infection: an emerging disease in mainland China

Penicillium marneffei is an emerging pathogenic fungus that can cause a life-threatening systemic mycosis in immunocompromised hosts, especially in patients with AIDS. This infection is endemic in Southeast Asia. With the prevalence of AIDS in this area, the number of patients with systemic penicilliosis marneffei is found to be increasing rapidly in mainland China in recent years. We recently reviewed 668 cases of penicilliosis marneffei in mainland China from January 1984 to December 2009 in cnki, cqvip, CBMdisc and PubMed. We analyzed epidemiological and clinical features, laboratory findings, reaction to therapy and prognosis of the disease. We found that 99.4% of the cases were reported in the southern part of China; among these cases, 42.8% were from Guangxi (286 cases) and 40.6% were from Guangdong province (271 cases). Five hundred and eighty-six cases (87.7%) of penicilliosis marneffei were reported with infection by the human immunodeficiency virus, 25 cases (3.8%) with other immunocompromised diseases, and 57 cases (8.5%) without any documented underlying diseases. Fever, weight loss, anemia, lymphadenopathy, hepatosplenomegaly, respiratory signs and skin lesions were the common clinical manifestations of P. marneffei infections. The 569 cases received antifungal therapy with a mortality of 24.3% (138 cases), 99 cases who had not received antifungal therapy had a mortality of 50.6%. P. marneffei was an emerging pathogenic fungus and become a medical and public health importance in mainland China. The immunocompromised patients should pay more attention to P. marneffei infection in the endemic areas.

Lack of health risk awareness in low-income Chinese youth migrants: assessment and associated factors

OBJECTIVE

To analyze and assess health risk awareness of youth migrants in China and the factors that influence it, and to provide evidence for making health promotion interventions and decreasing health risks among Chinese youth migrants.

METHOD

This was a cross-sectional survey conducted in 2009 among rural-to-urban migrants aged 15-24 years in Tianjin and Xi'an, China. A total of 1,838 youth migrants were enrolled by the stratified cluster sampling method. An anonymous questionnaire was self-administered to investigate health risk awareness. The t test and χ(2) test were used to analyze differences between different groups. Logistic regression analysis was used to test the influence of various sociodemographic, living condition, and occupational factors.

RESULTS

The smoking rate of men (66.8%) was higher than that of women (6.8%; P < 0.05), the rate of sexual intercourse in men was higher than in women (56.8 vs 27.7%; P < 0.05), and 75.7% of participants had written into medical care systems with 40.4% of them having undergone a physical examination during the last year. Only 438 of the participants (26% of 1,647) were considered to have a satisfactory level of health risk awareness [273 (32.4% of 958) from Tianjin and 165 (28.8% of 689) from Xi'an]. No significant difference was found between the youth migrant populations of the two cities. The percentage of youth migrants with a satisfactory level of health risk awareness who thought they had a good health status was higher than that with an unsatisfactory health risk awareness who thought they had a good health status (P < 0.05). Logistic regression analysis showed that gender, age, education, reading the newspaper, and occupation significantly influenced on health risk awareness.

CONCLUSION

Youth migrants in China have a low health risk awareness. Combined and targeted health education interventions should be promoted to increase their health risk awareness.

The effect of a structural intervention for syphilis control among 3597 female sex workers: a demonstration study in South China

BACKGROUND

Syphilis has made a rapid resurgence in China, especially among high-risk groups including female sex workers (FSWs).

METHODS

Two cities in each of 3 provinces in South China were chosen and allocated to intervention or control arms. The intervention consisted of enhancing community-based syphilis screening outreach intervention with comprehensive sexually transmitted infection services at designated clinics while the control maintained routine intervention activities. Generalized linear modeling was used to examine effect of the intervention on incident syphilis infection.

RESULTS

A total of 8275 women were eligible, and 3597 women enrolled (n = 2011 in control arm, n = 1586 in intervention arm) in the study. The median follow-up duration was 375 days (interquartile range, 267–475). Syphilis incidence density in the intervention group was reduced by 70% (95% confidence interval, 53%–81%) compared with the incidence in the control arm. The syphilis prevention intervention benefits were robust among FSWs at low-tier venues, individuals with less than high school education, migrants, and women who did not report condom use during the last episode of sex.

CONCLUSIONS

Integrated sexually transmitted infection and human immunodeficiency virus prevention strategies substantially reduce syphilis incidence among FSWs, especially among those at low-tier venues. This intervention suggests the need for scaling up comprehensive FSW programs in China.

Prevalence and trend of HIV infection among voluntary blood donors in China since implementation of the Blood Donation Law: a systematic review and meta-analysis

OBJECTIVE

In 1998, the Blood Donation Law was enacted in China in response to the outbreak of HIV endemic in central rural China as a result of unhygienic and commercial blood collection. This study aims to provide a first comprehensive review of available data on the prevalence, trend and other epidemiological characteristics of HIV infection among voluntary blood donors since 1998.

METHODS

Major English and Chinese databases were searched and a systematic review was constructed. Pooled infection rates by province and year were calculated using random-effect or fixed-effect models.

RESULTS

A total of 87 studies met our inclusion criteria. A total of 2573 HIV-positive cases were identified among voluntary blood donors in the past 10 years; the pooled prevalence was 13.22/100,000, with a range of 0.74-125.97 per 100,000. Among the 24 provinces that reported yearly data, the prevalence of HIV increased from 5.62/100,000 to 28.90/100,000. The male-to-female ratio was 2.8; about 60% were below the age of 30 years.

CONCLUSIONS

The prevalence of HIV in voluntary blood donors has risen steadily and fast. Efficient measures need to be taken urgently to prevent HIV test-seeking through blood donor programmes, to promote voluntary blood donation in low-risk groups and to enforce the Blood Donation Law strictly.

Occupational safety and HIV risk among female sex workers in China: a mixed-methods analysis of sex-work harms and mommies

Female sex workers (FSWs) in China are exposed to multiple work-related harms that increase HIV vulnerability. Using mixed-methods, we explored the social-ecological aspects of sexual risk among 348 FSWs in Beijing. Sex-work harms were assessed by property stolen, being underpaid or not paid at all, verbal and sexual abuse, forced drinking; and forced sex more than once. The majority (90%) reported at least one type of harm, 38% received harm protection from 'mommies' (i.e., managers) and 32% reported unprotected sex with clients. In multivariate models, unprotected sex was significantly associated with longer involvement in sex work, greater exposure to harms, and no protection from mommies. Mommies' protection moderated the effect of sex-work harms on unprotected sex with clients. Our ethnography indicated that mommies played a core role in sex-work networks. Such networks provide a basis for social capital; they are not only profitable economically, but also protect FSWs from sex-work harms. Effective HIV prevention interventions for FSWs in China must address the occupational safety and health of FSWs by facilitating social capital and protection agency (e.g., mommies) in the sex-work industry.