Socio-cultural influences on the transmission of HIV among gay men in rural China

New sexually transmitted HIV infections from 2016 to 2050 in Guangdong Province, China: a study based on a dynamic compartmental model

BACKGROUND

In Guangdong Province, China, there is lack of information on the HIV epidemic among high-risk groups and the general population, particularly in relation to sexual transmission, which is a predominant route. The new HIV infections each year is also uncertain owing to HIV transmission from men who have sex with men (MSM) to women, as a substantial proportion of MSM also have female sexual partnerships to comply with social demands in China.

METHODS

A deterministic compartmental model was developed to predict new HIV infections in four risk groups, including heterosexual men and women and low- and high-risk MSM, in Guangdong Province from 2016 to 2050, considering HIV transmission from MSM to women. The new HIV infections and its 95% credible interval (CrI) were predicted. An adaptive sequential Monte Carlo method for approximate Bayesian computation (ABC-SMC) was used to estimate the unknown parameter, a mixing index. We calibrated our results based on new HIV diagnoses and proportions of late diagnoses. The Morris and Sobol methods were applied in the sensitivity analysis.

RESULTS

New HIV infections increased during and 2 years after the COVID-19 pandemic, then declined until 2050. New infections rose from 8,828 [95% credible interval (CrI): 6,435-10,451] in 2016 to 9,652 (95% CrI: 7,027-11,434) in 2019, peaking at 11,152 (95% CrI: 8,337-13,062) in 2024 before declining to 7,084 (95% CrI: 5,165-8,385) in 2035 and 4,849 (95% CrI: 3,524-5,747) in 2050. Women accounted for approximately 25.0% of new HIV infections, MSM accounted for 40.0% (approximately 55.0% of men), and high-risk MSM accounted for approximately 25.0% of the total. The ABC-SMC mixing index was 0.504 (95% CrI: 0.239-0.894).

CONCLUSIONS

Given that new HIV infections and the proportion of women were relatively high in our calibrated model, to some extent, the HIV epidemic in Guangdong Province remains serious, and services for HIV prevention and control are urgently needed to return to the levels before the COVID-19 epidemic, especially in promoting condom-based safe sex and increasing awareness of HIV prevention to general population.

Parenting Desire Among Sexual Minority Women in China: From the Stigma Perspective

In China, women who are childless or have children outside of heterosexual marriage are generally stigmatized. Consequently, Chinese sexual minority women are challenged for their willingness to have children. This study explored how multiple (structural-interpersonal-individual) levels of sexual minority stigma are related to parenting desire among Chinese sexual minority women. Furthermore, it examined the mediation mechanism of individual stigma and the moderation effect of outness to one's family in the link between structural/interpersonal stigma and parenting desire. Participants (265 lesbian and 193 bisexual women) completed online measures of structural stigma (adherence to Confucianism), interpersonal stigma (discrimination events), individual stigma (internalized homophobia and rejection sensitivity), outness to one's family, and parenting desire. Lesbian women reported lower structural and individual stigma and parenting desire levels than bisexual women. Sexual minority women's high adherence to Confucianism, internalized homophobia, and rejection sensitivity were positively associated with their increased parenting desires. Notably, adherence to Confucianism and discrimination events were associated with parenting desire through internalized homophobia, but not rejection sensitivity; moreover, outness to one's family buffered the direct link between adherence to Confucianism and parenting desire and strengthened the direct link between discrimination events and internalized homophobia and the indirect link between discrimination events and parenting desire. This study contributes to a robust understanding of how sexual minority stigma is connected to parenting desire among sexual minority women in Chinese sociocultural contexts, providing cultural-specific evidence to support theories of stigma and minority stress.

'How can I fix my disrupted life?' Embodied experiences and biocitizenship among men who have sex with men living with HIV in China

Drawing on qualitative data collected from men who have sex with men living with HIV in Fujian and Sichuan provinces in southeast and southwest China, respectively, this study aims to understand their lived experiences in the context of social norms, institutions and roles. We argue that informants encountered biographical disruption as a result of their diagnosed infection. They then painfully experienced different forms of social death on the one hand, while on the other, some also exerted agency/autonomy by strategically fighting for their rights and interests in both private and public domains. By examining these lived experiences, this study discusses the biological citizenship of the respondents so as to deepen understanding of embodied life experiences and trajectories.

A study of the factors influencing HIV-preventive intentions among "hookup" application users

"Hooking up" refers to the act of experiencing sexual intimacy with strangers without committing to a romantic relationship. Social media provide more convenient conditions for hooking up; however, it also poses a greater risk for HIV infection. Therefore, it is necessary to study the factors influencing the HIV-preventive intentions of those who engage in online dating to devise effective strategies for preventing the spread of HIV. This study consisted of a questionnaire that was distributed to 520 users of the Hello Group application. The survey results revealed that structural equation modeling is a useful framework for understanding the risk of HIV transmission in casual hookup encounters. In addition, combining the health belief model with the theory of planned behavior can provide recommendations for enhancing HIV-preventive intentions among users of dating applications. The results showed that mindfulness, the Chinese cultural context, perceived benefits, and self-efficacy were the main predictors of users' HIV-preventive intentions when using online dating applications. Among the perceived HIV risks, only perceived barriers had a negative effect on users' HIV-preventive intentions. In addition, attitude, subjective norms, and behavior control served as mediating variables between independent variables and HIV-preventive intentions; however, the mediating effect of attitude on perceived benefits and intentions was not significant. According to our study, some users misunderstand the risks and make incorrect assessments of the cultural risks of hooking up. Therefore, it is necessary to pay attention to the research on the psychological tendencies of users and risk intervention when studying the concept of hooking up.

What triggers depressive symptoms among gay and bisexual men? A sequential mediation model of sexual minority-related stigma and self-criticism

A growing number of studies has shown that gay and bisexual men are more likely to experience adverse mental health status than their heterosexual counterparts. Stigma-related stress and self-criticism are believed likely to exacerbate depressive symptoms among gay and bisexual men. This research used cross-sectional findings to illustrate the mediating role of internalized self-stigma and self-criticism in the association between perceived public stigma and depressive symptoms. A total of 317 Chinese gay and bisexual men (267 gays and 50 bisexuals with a mean age of 25.29) were invited to participate in this study from October to November 2021. Sociodemographic characteristics, perceived public stigma, internalized self-stigma, self-criticism and depressive symptoms were measured through self-reported online questionnaires. The results indicated that the association between perceived public stigma and depressive symptoms was sequentially mediated by internalized self-stigma and self-criticism. The findings indicated that public stigma, as a distal stressor, was perceived and internalized as self-stigma by gay and bisexual men. This self-stigma may pose a risk for depressive symptoms via self-criticism (a maladaptive consequence of their attempts to reduce cognitive dissonance). These results highlight the necessity of reducing sexual minority-related stigma and self-criticism to reduce depressive symptoms. Our findings appeal to society to further decrease prejudice and stigma, increase tolerance, and focus on the negative mental health status of gay and bisexual men.

Heterosexual Marital Intention: The Influences of Confucianism and Stigma Among Chinese Sexual Minority Women and Men

In traditional Confucianist culture in China, marriage and offspring are highly valued, placing sexual minority adults under tremendous pressure to marry an opposite sex partner. This study explored how Confucianism and stigma were associated with the intention to pursue a heterosexual marriage among Chinese sexual minority individuals as well as the moderating mechanisms of gender and age. Cross-sectional data were collected from 747 participants via online social networks from March to June 2020. Items assessed Confucianism values (communalism, filial piety, traditional gender roles); stigma (rejection sensitivity, social discrimination); and heterosexual marital intention (HMI). A total of 1.7% (n = 12) participants had ever been married, 11.6% (n = 87) planned to marry a different-sex partner, 60.4% (n = 451) had no intention to pursue a heterosexual marriage, and 26.4% (n = 197) had no specific marital plan. Bisexual participants scored significantly higher than homosexual individuals in HMI. Sexual minority adults with high levels of Confucianism and stigma were more likely to intend to marry. Importantly, both individual stigma (rejection sensitivity) and interpersonal stigma (social discrimination) partially mediated the relationship between Confucianism and HMI. Confucianism had a stronger impact on HMI for men than women, and age moderated the influence of Confucianism (including communalism and filial piety) on HMI, with a stronger impact for younger than older generations. This study contributes to a better understanding of how Confucianism and stigma may be connected to the intention to pursue a heterosexual marriage, suggesting culture-modified theories of stigma and sexual minority stress are needed to explain the experiences of sexual minority people in contemporary China.

Boundless China and Backward Asians: Hegemonic Confucianism as Epistemological Violence in Queer Psychology

The formation of queer psychology has been a critical intervention in breaking apart the psychological tendency of reifying categories of gender and sexuality. Nonetheless, latent Orientalism and white-centered epistemologies in psychology have continued to produce culturally essentialist depictions of a repressive "Chinese sexuality" and "backward Asian culture." In this article, I present three main problems in psychological representations of Sinophone queers: (a) "cultural colorblindness" resulting from the conflation of race and culture, (b) the problematic analytical category of "Chineseness," and (c) race and culture being theorized as a burden for Sinophone and Asian queers. In order for psychology and queer studies scholars to destabilize these epistemologically violent interpretations, this article argues that we must engage with Sinophone critique and shift away from a framework of culture to one of "concerns" in order to capture the heterogeneity of queer Sinophone subjectivities.

Money boys in Chengdu, China: migration, entrepreneurial precarity and health service access

This qualitative study highlights the complex interplay between the social and structural conditions in Chengdu, China that shape the possibilities and vulnerabilities of money boys' sexual health. Within the context of China's liberalised market economy, we explore (1) how money boys' enter the sex trade market and navigate their sexual networks; (2) how their lives are enmeshed in fields of sexual desire, stigma and coercion; and (3) how the illicit and stigmatising nature of their work poses barriers to health service access. Findings reveal how the sex trade market and clinic are precarious spaces in which entrepreneurial ethics of the self and stigma-related coercive relations simultaneously enable and constrain money boys' sexual freedom and safer sex practices. By understanding this entrepreneurial precarity through the co-articulation of clinical and organisational work spaces, public health and social service providers can have a stronger sense of how various vulnerabilities configure to affect safer sex practices.

HIV risk behavior and HIV testing among rural and urban men who have sex with men in Zhejiang Province, China: A respondent-driven sampling study

BACKGROUND

Currently, human immunodeficiency virus (HIV) sentinel surveillance among men who have sex with men (MSM) in China conducted in large and medium-sized cities, and no HIV sentinel surveillance conducted in rural areas. HIV testing and intervention is predominantly conducted in urban areas, there have been a limited number of studies in rural areas MSM, it is necessary to conduct the investigation of HIV risk sexual behavior, HIV testing among rural and urban MSM.

METHOD

Between December 2013 and August 2015, a cross-sectional study was conducted in rural and urban areas in Zhejiang Province using respondent-driven sampling (RDS). Participants completed face-to-face interviewer-administered questionnaire surveys and were tested for HIV.

RESULTS

A total of 710 MSM participants were recruited, of whom 36.1% were from rural areas. The overall HIV prevalence was 16.6%, and was considerably lower among MSM living in rural areas (3.9%) than those living in urban areas (24.2%). 61.1% participants had not condom use with male sexual behavior in the past 6 months (86.7% in rural areas and 46.7% in urban areas). The social demographic and behavioral characteristics had significance difference among rural and urban MSM. Multivariate logistic regression revealed that, compared to men living in urban areas, MSM living in rural areas MSM were more likely to use dating apps to find sexual partners, were more likely to engage in bisexual behavior, and had lower condom use. 43.0% participants had been tested for HIV in the past year (41.8% in rural areas and 43.6% in urban areas). Multivariate logistic regression also revealed that among participants living in rural areas, having rural health insurance and not accepting HIV intervention were associated with lower HIV testing rates, while a higher monthly income and through use of internet to find sexual partner were associated with higher rates of HIV testing.

CONCLUSION

High risk behavior was prevalent, and HIV testing rates were low among MSM living in rural areas compare to urban areas in Zhejiang Province, therefore, preventative intervention measures should be immediately among rural MSM urgently to reduce HIV transmission and to promote HIV testing.

'I loved him all my life': love, duty and homosexuality in post-liberation China

This article is born out of an oral history study of 31 elderly homosexual men in four cities in China. It shows the ways in which major events of Chinese history since the birth of the People's Republic in 1949 intervene in personal lives and, in turn, how personal lives are drawn into larger historical events. One of the major themes running through these life narratives is that of love and duty. The interrelationship, as well as the tensions, between duty and love is a central part of the experiences of elderly Chinese homosexual men; their lives have been beset by hardships and duty, as well as by the joys of love, and these have an impact on their health and wellbeing. The experience of one individual, Mr Peng, illustrates the important yet shifting ways in which love and duty have been twinned throughout key life events. His narrative indicates an intricate interweaving of love for family, love for Deng, his male partner of 20 years, and love for his wife, as well as duty to family and to a patron. The inseparable couplet of love and duty served as the source of hardship and pain, but also of protection and great joy.

Stigma against patients with HIV/AIDS in the rapid expansion of antiretroviral treatment in large drug injection-driven HIV epidemics of Vietnam

Background

Despite existing efforts to provide antiretroviral treatment (ART) for all HIV-diagnosed people, stigma deprives them of the highest attainable health status and challenges the effectiveness of ART program in Vietnam. This study aimed to assess five dimensions of HIV-related stigma and explore its associated factors among ART patients in a multisite survey. Implications of this study support the development of HIV policies to improve patients’ access, utilization, and outcomes of ART program toward the 90-90-90 goal in Vietnam.

Methods

A total of 1133 ART patients who were recruited by convenience sampling method from 8 ART clinics in Hanoi and Nam Dinh in a cross-sectional study from January to August 2013. Multivariate logistic regression was employed to identify factors associated with stigmatization.

Results

The majority of participants reported experiencing stigmatization due to shame (36.9%), blame/judge (21.6%), and discrimination (23.4%). Further, 91.5% of participants disclosed their HIV status with others. The likelihood of experiencing stigmatization did not only associate with the patients’ socioeconomic status (e.g., age, occupation, education) and HIV status disclosure, but also their health problems. Those with anxiety or depression and perceived lower quality of life were more likely to experience stigma.

Conclusions

To maximize the efficiency of the ART program, it is essential to develop interventions that reduce stigma involving individuals, families, and communities, and recognize and address complex health problems especially those patients showing depressive symptoms. Increasing quality of life of HIV-positive patients by providing vocational training, financial, family, and peer support will reduce the likelihood of experiencing stigma.

"You Have to Keep Yourself Hidden": Perspectives From Malaysian Malay-Muslim Men Who Have Sex With Men on Policy, Network, Community, and Individual Influences on HIV Risk

Malay-Muslim men who have sex with men (MSM) are marginalized and hidden in Malaysia, a predominantly Muslim country in southeast Asia. We explored the policy, network, community, and individual factors related to HIV infection among Malay-Muslim MSM through 26 in-depth interviews and one focus group discussion (n = 5) conducted in Kuala Lumpur and Kota Bharu between October 2013 and January 2014. As religion plays an important role in their lives, participants viewed homosexuality as a sin. Low risk perception and misconceptions about HIV/AIDS were common, and most participants expressed reluctance to consult a doctor unless they had symptoms. Additionally, buying condoms was embarrassing and anxiety-producing. Fear of discrimination by health care providers and community hindered participants from disclosing sexual behaviors and accessing health services. Homophobic comments and policies by the government and religious leaders were concerns of participants. A safe and enabling environment is needed to reduce HIV risks among Malay-Muslim MSM.

The Ethical Sensitivity of Health Care Professionals Who Care For Patients Living With HIV Infection in Hunan, China: A Qualitative Study

The level of ethical sensitivity of health care professionals who care for patients with HIV may shed light on ethical behaviors in HIV care. However, little research has determined how such professionals view ethical issues in clinical practice in China. The purpose of our qualitative descriptive study was to explore the ethical sensitivity of health care professionals in Hunan Province, China, and to discuss the existing deficiencies. We used purposive sampling to recruit 17 health care professionals who provided direct care to patients with HIV and conducted interviews with them. Interview transcripts were analyzed by thematic analysis. Informants showed certain sensitivities to ethical issues, but the majority also held stigmatizing attitudes toward patients with HIV, and exhibited ethics driven by HIV-related laws and regulations rather than ethical principles. There is room to improve the ethical sensitivity of health care professionals who care for patients with HIV in China.

Look into the HIV Epidemic of Gay Community with a Socio-Cultural Perspective: A Qualitative Study in China, 2015-2016

BACKGROUND

Current Chinese studies continue to view male homosexuality through a disease focused lens which pays limited attention to socio-cultural aspects of sexual behavior and HIV transmission. This qualitative study aimed to investigate how socio-cultural factors influence gay men's sexual beliefs and behaviors in contemporary China, and their implications for HIV epidemic.

METHODS AND FINDINGS

Qualitative methodology was used in this study. During 2015-2016, in-depth interviews were conducted with 61 self identified gay men in Jiangxi, Henan, Heilongjiang, Guangdong, Jiangsu provinces and Chongqing municipality of China. Our study revealed that: 1) influenced by Chinese traditional culture, gay men have conflicts on self-identity, which led to low self-acceptance and negative attitude on sex, and huge socio-psychological stress; 2) a generational differences within gay community was observed, reflected in varied sexual attitudes and practices as well as way for approaching new friends, both of which have implications and challenges on HIV control and prevention; 3) socio-cultural barriers, including open minds towards casual sex and nonmonogamous relationship, and low priority of health demands were widely observed and led to negative coping with AIDS among gay community.

CONCLUSIONS

It is essential to take a holistic view into gay men's HIV epidemic in China. Socio-cultural barriers for HIV control and prevention found in this study call for serious and imperative consideration on integrated measures, including targeted efforts towards effective sex education and further inclusion of socio-cultural perspectives in HIV/AIDS interventions for gay men.

Chinese attitudes towards sexual minorities in Hong Kong: Implications for mental health

Intolerant attitudes and sexual prejudice against sexual minorities (lesbian, gay, bisexual, and questioning/queer-LGBQ) has been a long-standing global concern. In this article, Chinese attitudes towards sexual minorities are examined with reference to the cultural context in Hong Kong, a place where the East has intermingled with the West for over a century. Chinese sexuality manifested in Hong Kong is a mix of Confucian ideology and Christian thought. Traditional Confucian values of xiao (filial piety) and conventional religious thoughts of Christianity together influence Chinese attitudes towards sexual minorities. Though many governmental policies have been put in place and numerous laws have been enacted to protect the human rights of underprivileged and disadvantaged groups over the past few decades, sexual minorities are frequently being excluded from most of these protections. In Hong Kong, sexual prejudice exists not only among the general public, but also among educators and mental health professionals. Thus, Chinese sexual minorities experience sexual prejudice and minority stress in Hong Kong under unique cultural circumstances. This calls for inclusive policies and an embracing attitude towards sexual minorities so their mental health will not suffer.

Hidden and Mobile: A Web-based Study of Migration Patterns of Men Who Have Sex With Men in China

BACKGROUND

Men who have sex with men (MSM) are highly vulnerable to human immunodeficiency virus (HIV) infection and more likely to migrate due to widespread stigma and discrimination in China. Their mobility complicates estimation of local MSM population sizes and the provision of HIV services, and may also contribute to the spread of HIV.

METHODS

Between 1 January 2008 and 31 December 2012, the visits of all individuals to the largest Chinese MSM dating website were recorded. After a predesigned de-identification procedure by the website, we analyzed Internet Protocol addresses for migration patterns. Migrants were defined as individuals who were away from their registered residence for >6 months in the last 12 months.

RESULTS

The website contained data on 794 912 MSM eligible for the study, of which 34.5% were migrants. The median age was 26 years (range, 18-61 years), and 85.5% were unmarried. Compared with nonmigrant MSM, migrants were less likely to be married to a woman (8.6% vs 13.5%; P < .001). The 5 provinces with the highest migrant inflow ratios were Guangdong, Shanghai, Beijing, Tianjin, and Zhejiang. Eastern coastal cities were the primary destination of MSM from southwestern China.

CONCLUSIONS

Preferential MSM migration may influence MSM population sizes in both originating and destination provinces, particularly for provinces with uneven inflow and outflow. MSM migration from southwestern China, which has the highest HIV prevalence in this population, to coastal cities with lower prevalence may have implications for the spread of the HIV epidemic as well as HIV care services.

Shifting Patterns of the HIV Epidemic in Southwest China: A Case Study Based on Sentinel Surveillance, 1995-2012

The HIV epidemic is experiencing a rapid shift in transmission profile in China. This study aims to examine the changes in magnitude, transmission pattern, and trend of the HIV epidemic in a typical Southwest Chinese prefecture over the period of 1995-2012. HIV surveillance data from the web-based reporting system were analyzed during this period. We investigated the temporal trends in the changing characteristics of HIV transmission, the HIV disease burden in key affected populations, and assessed the impacts on HIV disease progression due to scale-up of antiretroviral treatment. A total of 3556 HIV/AIDS cases were reported in Yuxi prefecture, Yunnan, over the study period. The number of HIV tests conducted has dramatically increased from 1041 in 1995 to 247,859 in 2012, resulting in a substantial increase in HIV diagnoses from 11 cases to 327 cases over the same period. Since 2005, cumulatively 1250 eligible people living with HIV (PLHIV) have received combination antiretroviral therapy which reduced AIDS disease progression from 9.0% (95% CI: 6.7-11.4%) in 1995 to 0.1% (0-0.3%) in 2012 (ptrend=0.0002). The primary mode of HIV transmission has been shifted from injection sharing (71.9% diagnoses in 1995-2004) to unsafe sexual contacts (82.6% diagnoses in 2012). Yuxi prefecture is experiencing a concentrated but shifting HIV epidemic. Scale-up of HIV testing is essential to effective sentinel surveillance and enhancing early diagnosis and treatment in PLHIV.