Co-Occurring Psychosocial Problems and Multiple Sexual Partners among Men Who Have Sex with Men in Shanghai, China: A Syndemic Approach

Loneliness and depressive symptoms among men who have sex with men in China: A cross-sectional study

Background

While psychosocial problems and their related factors in men who have sex with men (MSM) have been well documented in developed countries, there are still not many studies addressing this issue in China and the results are inconsistent. This study aimed to assess the prevalence of loneliness and depressive symptoms among MSM, examine their associated factors, and investigate potential factors moderating the link between depressive symptoms and loneliness.

Methods

A cross-sectional study was conducted in Taizhou of Zhejiang Province in China between April and November 2021. Loneliness was assessed using the 3-item UCLA Loneliness Scale (UCLA-3), and depressive symptoms were measured using the Patient Health Questionaire-9 (PHQ-9). Data from 655 MSM were eligible for analysis. Logistic regression models were used to examine the associations between independent variables and the outcomes of loneliness and depression. The interaction terms were added in the models to assess the moderating effects.

Results

Of the MSM sample, 13.28 and 7.48% perceived loneliness and reported moderate-to-severe depressive symptoms, respectively. We found that participants who experienced loneliness were more likely to have younger age (OR 0.44, 95% CI 0.21, 0.93, 15-32 years as reference group), low social support (OR 3.60, 95% CI 2.14, 6.04), low self-esteem (OR 3.03, 95% CI 1.45, 6.32) and moderate-to-severe depressive symptoms (OR 5.45, 95% CI 2.66, 11.15). The participants with moderate-to-severe depressive symptoms were more likely to have low self-esteem (OR 6.78, 95% CI 3.08, 14.95) and feelings of loneliness (OR 5.51, 95% CI 2.66, 11.40). Stratified analyzes showed that the magnitude of the associations between depressive symptoms and loneliness varied in MSM with different age, marital status, and self-esteem.

Conclusion

Our study suggests that we need to pay attention to feelings of loneliness and depressive symptoms and their closely associated factors such as social support and self-esteem among MSM in China. The MSM who were young, not married, and had low self-esteem were especially vulnerable to the impact of depressive symptoms on loneliness.

Psychosocial Problems and Condomless Anal Sex among Transgender Women in Two Cities of China: Study Based on the Syndemic Framework

Studies examining the association between psychosocial problems and condomless anal sex (CAS) among transgender women (TGW) are rare. In this study, close attention was paid to the effect of co-occurring psychosocial problems on sexual risk behaviors. A cross-sectional study, including 247 TGW, was conducted in Kunming and Shenyang, China. The prevalence of condomless anal sex among TGW in the previous 6 months was 30.8%. Most of the psychosocial factors were associated with one another in bivariate logistic regression models. Low self-esteem (ORm = 2.99, 95% CI = 1.25-7.18), sexual compulsivity (ORm = 2.13, 95% CI = 1.13-4.00), and intimate partner violence (ORm = 2.21, 95% CI = 1.19-4.11) were discovered to be related to condomless anal sex in the multivariate regression model. No significant interactive effects of the syndemic factors on condomless anal sex were detected. More programmatic and effective HIV prevention interventions targeting psychosocial problems are required to reduce HIV infection within the population.

Prediction Model for the Risk of HIV Infection among MSM in China: Validation and Stability

The impact of psychosocial factors on increasing the risk of HIV infection among men who have sex with men (MSM) has attracted increasing attention. We aimed to develop and validate an integrated prediction model, especially incorporating emerging psychosocial variables, for predicting the risk of HIV infection among MSM. We surveyed and collected sociodemographic, psychosocial, and behavioral information from 547 MSM in China. The participants were split into a training set and a testing set in a 3:1 theoretical ratio. The prediction model was constructed by introducing the important variables selected with the least absolute shrinkage and selection operator (LASSO) regression, applying multivariate logistic regression, and visually assessing the risk of HIV infection through the nomogram. Receiver operating characteristic curves (ROC), Kolmogorov–Smirnov test, calibration plots, Hosmer–Lemeshow test and population stability index (PSI) were performed to test validity and stability of the model. Four of the 15 selected variables—unprotected anal intercourse, multiple sexual partners, involuntary subordination and drug use before sex—were included in the prediction model. The results indicated that the comprehensive prediction model we developed had relatively good predictive performance and stability in identifying MSM at high-risk for HIV infection, thus providing targeted interventions for high-risk MSM.

Epidemiological risk factors associated with primary infection by Epstein-Barr virus in HIV-1-positive subjects in the Brazilian Amazon region

To identify the prevalence and risk factors for primary Epstein–Barr virus (EBV) infection in human immunodeficiency virus (HIV)-1-positive adult treatment-naïve patients between January 2018 and December 2019 in a state of the Brazilian Amazon region. A total of 268 HIV-1 positive patients and 65 blood donors participated in the study. Epidemiological data were obtained from medical records and through a designed questionnaire. EBV infection was screened by the semiquantitative detection of anti-viral capsid antigen (VCA) EBV IgM and IgG, followed by molecular detection of the EBNA-3C gene. The plasma viral loads of HIV-1 and EBV were quantified using a commercial kit. The prevalence of primary coinfection was 7.12%. The associated risk factors were education level, family income, history of illicit drug use and sexually transmitted infections, homosexual contact and condom nonuse. Approximately 58.5% had late initiation of highly active antiretroviral therapy, which influenced the risk of HIV-EBV 1/2 multiple infection (odds ratio (OR): 4.76; 95% CI 1.51–15.04) and symptom development (p = 0.004). HIV viral load was associated with patient age (OR: 2.04; 95% CI 2.01–2.07; p = 0.026) and duration of illicit drug use (OR: 1.57; 95% CI 1.12–2.22; p = 0.0548). EBV viral load was associated with younger age (OR: 0.82; 95% CI 0.79–1.03; p = 0.0579). The replication of both viruses was associated with symptom development (HIV = OR: 2.06; 95% CI 1.22–3.50; p = 0.0073; EBV = OR: 8.81; 95% CI 1–10; p = 0.0447). The prevalence of HIV/EBV coinfection was lower than that observed in other studies, and social vulnerability and promiscuous sexual behavior were associated risk factors. A long time of HIV-1 infection, without therapy, influenced the risk of coinfection and disease progression. The viral loads of both viruses may be associated with some epidemiological aspects of the population.

Victimization, Substance Use, Depression, and Sexual Risk in Adolescent Males Who Have Sex with Males: A Syndemic Latent Profile Analysis

Adolescent males who have sex with males (AMSM) are at increased risk of HIV/STI acquisition compared to other adolescents, making sexual risk behaviors in this population a priority public health focus. AMSM experience more victimization (including sexual/partner violence), depression, and substance abuse than their heterosexual counterparts; these may form a syndemic associated with risky sexual behavior. We pooled data from the 2015 and 2017 Youth Risk Behavior Survey, restricted to male students who reported a previous male sexual partner (n = 448). Latent profile analysis was used to identify syndemic profiles, with log-binomial and cumulative complementary log-log models used to test associations with substance use at last intercourse, condomless sex at last intercourse, and the number of sexual partners. Nearly all measures of victimization, depression, and substance use had bivariate associations with greater substance use during sex and more sexual partners. We identified three profiles of AMSM: The profile (n = 55) with the greatest risk factors (evident of a syndemic) had substantially higher prevalence of substance use during sex (aPR = 4.74, 95% CI 3.02, 7.43) and more sexual partners (aPR = 2.45, 95% CI 1.39, 4.31) than the profile with the lowest risk factors (n = 326) after adjusting for confounders. This profile was not associated with condomless sex. We identified a syndemic characterized by victimization, depression, and substance use associated with risky sexual behaviors in a nationally representative sample of AMSM. Comprehensive sexual risk reduction interventions incorporating mental health and substance use are critically important in this population.

Addressing Minority Stress and Mental Health among Men Who Have Sex with Men (MSM) in China

PURPOSE OF REVIEW

Men who have sex with men (MSM) in China experience elevated risks of mental health issues in comparison to the general population in China, which contribute to vulnerability to HIV/STI risks and can comprise the effectiveness of HIV prevention efforts. A conceptual framework for understanding this mental health disparity is minority stress theory, which posits that experiences of external prejudice events (i.e., distal stressors) and internal stress processes such as internalized homophobia and concealment (i.e., proximal stressors) contribute to sexual minorities' elevated risk of psychological distress. To deepen the understanding of mental health among Chinese MSM and explore the potential utility of minority stress theory in this population, this paper synthesizes research evidence regarding prevalent mental health issues as well as how minority stress may be linked to psychological health in Chinese MSM.

RECENT FINDINGS

Results indicate that Chinese MSM experience a high prevalence of several mental health issues including depression, anxiety, suicidal behaviors, and alcohol dependence. This review further reveals minority stress to be an important determinant of psychological distress among Chinese MSM, though evidence is mixed regarding the relationship between proximal minority stress and psychological health. Nonetheless, there is a lack of mental health services and interventions focusing on MSM in China. Culturally relevant, competent, and LGBT-affirmative mental health interventions are needed for Chinese MSM. To guide future intervention research, we provide considerations for reducing minority stress and promoting psychological health among Chinese MSM.

Syndemic Factors and HIV Risk Among Men Who Have Sex with Men in Guangzhou, China: Evidence from Synergy and Moderated Analyses

Syndemic factors tend to co-occur and increase the risks of condomless anal intercourse (CAI), multiple sexual partners (MSP) and HIV vulnerability among men who have sex with men (MSM). This study aimed to test the synergistic effects of syndemic factors on HIV risk and to further explore the moderators between syndemics and HIV risk among Chinese MSM. A cross-sectional study was conducted to recruit MSM in Guangzhou to collect data on syndemic factors (depression, intimate partner violence, childhood sexual abuse [CSA], alcohol, and rush popper use before anal sex). The relative excess risk due to interactions (RERIs) was calculated to test the synergy in adjusted regression models. A moderated analysis was conducted to test the buffer effects of potential resilience factors (education and income). Among the 976 included MSM, individuals experiencing more syndemic factors were more likely to have CAI (odds ratio [OR]= 1.26, 95% confidence interval [CI] 1.11-1.44), MSP (OR= 1.33, 95% CI 1.16-1.52), and HIV infection (OR= 1.46, 95% CI 1.12-1.90). RERIs showed a synergy of depression and rush popper use prior to sex for MSP (1.17, 95% CI 0.03-2.03) and CSA and rush popper use prior to sex for HIV infection (1.72, 95% CI 0.05-3.43). However, no significant association was found for the interaction between the number of syndemic factors and education or income. Our findings support the synergy approach in syndemic studies and highlight the need for comprehensive and multifactorial intervention strategies on sexual health of MSM. Future studies are needed to identify potential resilience factors among Chinese MSM.

How involuntary subordination and social support influence the association between self-esteem and depression: a moderated mediation model

BACKGROUND

In China, young migrants are at elevated risk of mental health problems, such as depression. The influence of self-esteem on depression is well acknowledged. We examined correlates of depression and their mediating and moderating role in the association between self-esteem and depression to promote a better understanding of depression prevention among young migrants.

METHODS

We conducted a cross-sectional study among young Chinese migrants. A moderated mediation model was used to test the combined effect of involuntary subordination and social support on the association between self-esteem and depression. The Johnson-Neyman method was used to identify the range of scores for which social support acted as a moderator.

RESULTS

A total of 572 participants completed questionnaires. The median depression score was 19 (interquartile range: 14). Self-esteem had a negative effect on involuntary subordination (β = - 2.1440, p < 0.001). Involuntary subordination (β = 0.2406, p < 0.001), self-esteem (β = - 0.3870, p < 0.01), and social support (β = - 0.1221, p < 0.01) all had significant effects on depression. The effect of involuntary subordination on depression was moderated by social support (β = - 0.0041, p < 0.05), and the effect decreased as social support scores increased.

CONCLUSIONS

Our results indicated a mediating role of involuntary subordination and a moderating role of social support in the association between self-esteem and depression among young Chinese migrants. Future intervention strategies should focus on these factors to reduce depressive symptoms.

Assessing consistent condom use among migrant men who have sex with men in Shanghai, China: validation of an information-motivation-behavioural skills model

BACKGROUND

In China, high prevalence of risky sexual behaviours and inequity in health services lead to situations in which migrant men who have sex with men face higher risk of contracting the human immunodeficiency virus. Consistent condom use is a primary means of preventing HIV infection during anal sex among MSM. This study aimed to apply the information-motivation-behavioural skills model to examine the predictors of consistent condom use among migrant MSM in Shanghai, and tested the associations between model constructs.

METHODS

A cross-sectional study was conducted among 412 migrant MSM in Shanghai. Data on HIV-related information, motivation, behavioural skills, and behaviours were collected via structured questionnaires. A structural equation model was used to assess the IMB model.

RESULTS

Of the 412 participants, 4.4% reported HIV-positive status, and prevalence of consistent condom use in the previous 6 months was 44.9%. A restricted IMB model provided an acceptable fit to the data. Behavioural skills were found to directly predict consistent condom use (β = 0.629, P < 0.01). Neither information nor motivation could directly predict consistent condom use (P > 0.05), but motivation predicted it indirectly and was mediated by behavioural skills.

CONCLUSION

The prevalence of consistent condom use was found to be relatively low among migrant MSM in Shanghai. The restricted IMB model was found to be a good predictor of consistent condom use among them. The results of this study indicate that intervention strategies for safer sexual behaviour should not only include information dissemination, but also emphasize motivation and behavioural skills among this population.

Prospective Predictors of Multiple Sexual Partners Among African American Men Who Have Sex with Men

Studies show that having sex with multiple partners increases the risk of acquiring and transmitting sexually transmitted diseases, including HIV. The present article reports prospective predictors of having multiple sexual partners among 505 African American men in Philadelphia who have sex with men (MSM) who participated in an intervention trial and attended a 6-month follow-up. Participants completed audio computer-assisted surveys of demographics, sexual behavior, and Reasoned Action Approach and Social Cognitive Theory mediators concerning multiple partners. We analyzed the incidence of self-reported multiple partners at the 6-month follow-up, controlling for treatment condition and baseline levels of the theoretical variables. The odds of having multiple partners decreased with increasing age (p < .03). Participants who said they were HIV positive had lower odds of having multiple partners (p < .009). The more pride participants reported in their identities as black or African American men, the lower the odds that they reported having multiple partners (p < .02). Adverse outcome expectancies accruing to multiple partners fully mediated the effect of black pride and partially mediated the effects of age on the odds of having multiple partners. Modifiable factors such as perceived negative outcome expectancies regarding having multiple sex partners should be addressed in designing interventions and prevention programs with the goal of decreasing the number of sexual partners among African American MSM.

Syndemics: A theory in search of data or data in search of a theory?

The concept of a syndemic was proposed more than two decades ago to explain how large-scale social forces might give rise to co-occurring epidemics that synergistically interact to undermine health in vulnerable populations. This conceptual instrument has the potential to help policymakers and program implementers in their endeavors to improve population health. Accordingly, it has become an increasingly popular heuristic for advocacy, most notably in the field of HIV treatment and prevention. However, most empirical studies purporting to validate the theory of syndemics actually do no such thing. Tomori et al. (2018) provide a novel case study from India illustrating how the dominant empirical approach fails to promote deeper understanding about how hazardous alcohol use, illicit drug use, depression, childhood sexual abuse, and intimate partner violence interact to worsen HIV risk among men who have sex with men. In this commentary, I relate the theory of syndemics to other established social science and public health theories of disease distribution, identify possible sources of conceptual and empirical confusion, and provide concrete suggestions for how to validate the theory using a mixed-methods approach. The hope is that more evidence can be mobilized -- whether informed by the theory of syndemics or not -- to improve health and psychosocial wellbeing among vulnerable populations worldwide.