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

The Impact of Providing Free HIV Self-testing on Sexual Risk Behaviors Among Men who have Sex with Men in Hunan, China: A Randomized Controlled Trial

HIV self-testing (HIVST) increases testing frequency among men who have sex with men (MSM). However, its impact on sexual risk behaviors is unclear. In a randomized controlled trial conducted in Hunan Province, China, HIV-negative MSM were randomized to receive one of two interventions for one year: (1) facility-based HIV testing, or (2) facility-based HIV testing augmented with free HIVST. From April to June 2018, 230 MSM were enrolled. They self-reported sexual behaviors every 3 months for 12 months. Among 216 MSM with follow-ups (intervention: 110; control: 106), adjusting for potential confounders in Generalized Estimating Equation models, there were no statistically significant differences in consistent condom use with male partners (regular/casual) or female partners, nor on number of male or female sexual partners. Provision of free HIVST kits does not increase risky sex and should be included in comprehensive HIV prevention packages, particularly for sexual minority men in China.

Changes in condom use among males who have sex with males (MSM): Measuring the effect of HIV prevention programme in Dhaka city

Background

A systematic assessment was done to examine the effect of HIV interventions among MSM in Dhaka, Bangladesh. MSM were defined as males having sex with males but did not sell sex in the last year. MSM are hidden, marginalized and stigmatized population groups not only in Bangladesh but also globally. In 2010, HIV interventions for MSM were expanded in 40 districts of Bangladesh through 65 drop-in-centres (DICs) and peer outreach workers.

Methods

Data from two surveys on MSM in Dhaka in 2010 (baseline) and 2013 (midline) were used to analyse the effect of ongoing HIV prevention services. Both surveys used time location sampling to randomly select MSM for risk behaviour interviews. Two outcome variables were considered; condom use in the last anal sex act and consistent condom use during anal sex in the last month. Univariate and multivariate logistic regression methods were used to determine factors associated with condom use.

Results

Condom use significantly increased at the midline than baseline (p<0.001 for both). Multivariate analysis showed that having comprehensive knowledge of HIV and participation in HIV prevention programme were positively associated with both last time and consistent condom use. MSM who had comprehensive knowledge of HIV were 1.9 times (95% CI: 1.3–2.8, p = 0.002) and 2.1 times (95% CI: 1.4–3.2, p<0.001) more likely to use condoms than those who did not have comprehensive knowledge of HIV. The likelihood of using condoms among MSM was more than double at the midline than the baseline (p<0.01 for both). However, odds of condom use was significantly lower among those who perceived themselves to be at risk or were not able to assess their own risk of HIV.

Conclusion

To sustain positive changes in HIV risk behaviours, HIV prevention programmes for MSM need to be continued and strengthened.

"Getting to Zero" Among Men Who Have Sex with Men in China: a Review of the HIV Care Continuum

PURPOSE OF REVIEW

To review the literature on progress towards UNAIDS 90-90-90 targets for HIV prevention and treatment among men who have sex with men (MSM) in China.

RECENT FINDINGS

China has made progress towards UNAIDS 90-90-90 targets among MSM. However, socio-structural barriers, including HIV-related stigma and homophobia, persist at each stage of the HIV care continuum, leading to substantial levels of attrition and high risk of forward HIV transmission. Moreover, access to key prevention tools, such as pre-exposure prophylaxis, is still limited. Multilevel interventions, many using digital intervention, have been shown effective in pragmatic randomized controlled trials in China. Multilevel interventions incorporating digital health have led to significant improvement in engagement of Chinese MSM in the HIV care continuum. However, interventions that address socio-structural determinants, including HIV-related stigma and discrimination, towards Chinese MSM are needed.

Frequent implementation of interventions may increase HIV infections among MSM in China

Intervention measures among men who have sex with men (MSM) are usually designed to reduce the frequency of high risk behaviors (within-community level), but unfortunately may change the contact network and consequently increase the opportunity for them to have sex with new partners (between-community level). A multi-community periodic model on complex network is proposed to study the two-side effects of interventions on HIV transmission among MSM in China, in which the wanning process of the impacts of interventions are modelled. The basic reproduction number for the multi-community periodic system is defined and calculated numerically. Based on the number of annual reported HIV/AIDS cases among MSM in China, the unknown parameters are estimated by using MCMC method and the basic reproduction number is estimated as 3.56 (95%CI [3.556, 3.568]). Our results show that strong randomness of the community-connection networks leads to more new infections and more HIV/AIDS cases. Moreover, main conclusion indicates that implementation of interventions may induce more new infections, depending on relative level of between- and within-community impacts, and the frequency of implementation of interventions. The findings can help to guide the policy maker to choose the appropriate intervention measures, and to implement the interventions with proper frequency.

The Use of Intervention Mapping to Develop a Tailored Web-Based Intervention, Condom-HIM

Background

Many HIV (human immunodeficiency virus) prevention interventions are currently being implemented and evaluated, with little information published on their development. A framework highlighting the method of development of an intervention can be used by others wanting to replicate interventions or develop similar interventions to suit other contexts and settings. It provides researchers with a comprehensive development process of the intervention.

Objective

The objective of this paper was to describe how a systematic approach, intervention mapping, was used to develop a tailored Web-based intervention to increase condom use among HIV-positive men who have sex with men.

Methods

The intervention was developed in consultation with a multidisciplinary team composed of academic researchers, community members, Web designers, and the target population. Intervention mapping involved a systematic process of 6 steps: (1) needs assessment; (2) identification of proximal intervention objectives; (3) selection of theory-based intervention methods and practical strategies; (4) development of intervention components and materials; (5) adoption, implementation, and maintenance; and (6) evaluation planning.

Results

The application of intervention mapping resulted in the development of a tailored Web-based intervention for HIV-positive men who have sex with men, called Condom-HIM.

Conclusions

Using intervention mapping as a systematic process to develop interventions is a feasible approach that specifically integrates the use of theory and empirical findings. Outlining the process used to develop a particular intervention provides clarification on the conceptual use of experimental interventions in addition to potentially identifying reasons for intervention failures.

Clinical challenges in HIV/AIDS: Hints for advancing prevention and patient management strategies

Acquired immune deficiency syndrome has been one of the most devastating epidemics of the last century. The current estimate for people living with the HIV is 36.9 million. Today, despite availability of potent and safe drugs for effective treatment, lifelong therapy is required for preventing HIV re-emergence from a pool of latently infected cells. However, recent evidence show the importance to expand HIV testing, to offer antiretroviral treatment to all infected individuals, and to ensure retention through all the cascade of care. In addition, circumcision, pre-exposure prophylaxis, and other biomedical tools are now available for included in a comprehensive preventive package. Use of all the available tools might allow cutting the HIV transmission in 2030. In this article, we review the status of the epidemic, the latest advances in prevention and treatment, the concept of treatment as prevention and the challenges and opportunities for the HIV cure agenda.

Behavioral interventions to reduce HIV risk behavior for MSM and transwomen in Southeast Asia: a systematic review

This systematic review aims to gain insights from existing literature from Southeast Asian countries to improve future HIV prevention programs for men who have sex with men (MSM) and transgender women (transwomen). We conducted a systematic search in six international databases for literature published prior to 1 January 2015. We included studies describing behavioral interventions targeting MSM and/or transwomen, and conducted in at least one Southeast Asian country. Five out of 575 screened studies met the inclusion criteria and reported a significant intervention effect on at least one outcome measure, that is, condom use (with casual or commercial partner), water-based lubricant use, number of sex partners, HIV prevention knowledge, or willingness to use pre-exposure prophylaxis. Peer education/outreach was the most commonly employed type of intervention in the five included studies and was usually delivered as an element of a larger intervention package, together with condom distribution and the provision of drop-in centers. Motivational interviewing was effective, while internet-based interventions appeared to be a viable platform for intervention delivery. Nevertheless, research on behavioral interventions among MSM and transwomen in Southeast Asia is limited. Future interventions should be culturally appropriate, theoretically grounded, and rigorously evaluated. Only then can we best address the HIV epidemic among MSM and transwomen in this region.

Factors associated with self-reported unprotected anal intercourse among men who have sex with men in Changsha city of Hunan province, China

Men who have sex with men (MSM) in China are highly susceptible to HIV infection and HIV prevalence among Chinese MSM is rapidly increasing in recent years. Unprotected anal intercourse (UAI) is a major contributing factor of HIV transmission. This study aims to identify factors associated with UAI among MSM in Changsha city, China. A cross-sectional survey was conducted among 642 MSM in Changsha city from July 2009 to June 2011 via a venue-based sampling method. Data on socio-demographic characteristics, sexual behaviours and utilisation of HIV/AIDS services were collected to determine the associates of UAI in MSM. Among the 642 MSM, 184 (28.7%) reported having UAI with male partners at the last sexual episode. UAI was associated with the venues where MSM met other MSM, and having unprotected sex with female partners at last the sexual episode and in the past six months. In addition, UAI was significant associated with not being exposed to HIV interventions, including free condom, lubricant, HIV testing and counselling, and peer education. MSM who have UAI practice are more likely to have unprotected sex with female; hence, potentially bridging HIV to the general female population. Specific harm-reduction programmes are shown to have significant impacts in reducing UAI and should be scaled up among MSM in China.

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 and syphilis testing preferences among men who have sex with men in South China: a qualitative analysis to inform sexual health services

Background

Health services for men who have sex with men (MSM) are inadequate in many areas around the world. HIV and syphilis test uptake remain suboptimal among MSM in China and many other regions. To inform the development of more comprehensive sexually transmitted disease (STD) testing programs among MSM, we collected descriptive data on MSM testing practices and preferences.

Methods

MSM in two large urban Chinese cities were recruited through community-based organizations and clinics to participate in semi-structured interviews. We purposively sampled MSM across a range of sociodemographic characteristics and testing history, and assessed preferences for HIV and syphilis testing in the context of facilitators and barriers to testing and previous testing experiences. Each interview transcript was coded and thematically analyzed using Atlas.ti 7.0.

Results

35 MSM were interviewed. Confidentiality and privacy were the most important factors influencing participants’ decisions about whether and where to get tested. Men preferred rapid testing (results available within 30 minutes) compared to conventional tests where results take several hours or days to return. Participants described concerns about quality and accuracy of rapid tests offered in non-clinical settings such as community-based organizations. Men preferred testing service providers who were MSM-friendly, non-discriminatory, and medically trained. Preferred service center environments included: convenient but discrete location, MSM-friendly atmosphere, and clean/standard medical facilities.

Conclusion

Our data highlight the need for HIV/syphilis testing services that are confidential and inclusive of MSM. Rapid testing in decentralized (i.e. peripheral health facilities and community-level, non-clinical venues) settings provides an opportunity to reach individuals who have not been tested before, but must be accompanied by quality assurance systems and technical competence. Implementation research could further evaluate HIV/syphilis testing programs responsive to MSM preferences.

Short Summary

A qualitative study of MSM in South China found that men preferred rapid STD testing at MSM-focused test centers, but were concerned about test quality assurance and confidentiality.

Sexual Practices and the Prevalence of HIV and Syphilis among Men Who Have Sex with Men in Lanzhou, China

We aimed to assess the risk of infections caused by sexual practices and determine the factors affecting the prevalence of human immunodeficiency virus (HIV) and syphilis among men who have sex with men (MSM) in Lanzhou, China. A survey including 600 MSM was conducted from March 2008 to December 2009. Demographic and sexual behavior data were collected using the snowball sampling technology, and blood samples were obtained. Multivariate logistic regression models were used to determine the predictors of HIV and syphilis infection. The seroprevalence of HIV, syphilis, HCV, and co-infection of HIV with syphilis was 6.0%, 18.0%, 1.3%, and 2.5%, respectively. Use of condoms was more inconsistent in vaginal sex than that in anal sex, buying sex or selling sex. Multivariate analysis showed that MSM with syphilis infection, MSM from other provinces, and MSM of Han ethnicity were more likely to have HIV infection. Further, MSM with HIV infection, inconsistent condom use, and less knowledge about AIDS prevention were more likely to have syphilis infection. Their social background, habit of condom use, and infection status may affect the prevalence of HIV or syphilis. These findings may have important implications for further behavioral interventions among this population.

Relationship between exposure to the Avahan intervention and levels of reported condom use among men who have sex with men in southern India

BACKGROUND

The Avahan intervention promotes consistent (100%) condom use amongst men who have sex with men in southern India. We assessed how condom use varies with intervention exposure for men who have sex with men in Bangalore.

METHODS

Self-reported condom use and intervention exposure data were derived from a cross-sectional survey. Consistent condom use and condom use at last sex act with all, main, and casual male sex partners were assessed. Binary and continuous variables reflecting intervention exposure (including contact(s) with intervention staff, receiving condoms and seeing condom demonstrations) were used. Multivariable logistic regression was employed to assess the relationship between condom use with each type of partner and each exposure variable independently, controlling for socio-demographic and behavioural factors associated with condom use or intervention exposure.

RESULTS

Condom use with all partners was higher among those who had ever been contacted by, received condoms from, or seen a condom demonstration by intervention staff (adjusted odds ratio >2, p < 0.02 for all). Consistent condom use with all types of partner increased with the number of condom demonstrations seen in the last month (adjusted odds ratio = 2.1 per demonstration, p < 0.025), while condom use at last sex act with a casual (but not main) partner increased with the number of condoms received from the intervention (adjusted odds ratio = 1.4 per condom, p = 0.04).

CONCLUSIONS

Direct contact with Avahan program staff is associated with increased reported condom use among men who have sex with men in Bangalore. Reported consistent condom use and condom use at last sex act are associated with contacts involving demonstrations of correct condom use, and with receiving condoms, respectively.

Event-specific risk factors predicting episodes of unprotected anal intercourse with male nonregular partners among men who have sex with men using case-crossover study design

This study investigated event-specific factors that determine episodes of unprotected and protected anal intercourse (UAI and PAI) among 215 men who have sex with men (MSM), who used condoms inconsistently with nonregular partners (NRP) in the last six months, in Hong Kong. A case-crossover study design was used. Lower likelihood of episodes involving UAI with NRP was associated with (1) five partner attributes (NRP were <35 years old, at least three previous anal sex experiences with the NRP, perception that participant and the NRP had asymmetrical sexual experience, perception that the NRP was feminine, and liking toward the NRP; OR = 0.16-0.52), (2) six situational variables (the participant having had UAI with another man in the last week, having discussed condom use, perception that the NRP liked to use condom, partner's suggestion to have PAI, participant's suggestion to have PAI, and participant's plan to use condoms; OR = 0.11-0.39), and (3) four environmental/setting variables (condoms already placed at the venue, display of condom use promotion materials, participant's possession of a condom, and the NRP possessed a condom; OR = 0.27-0.45). HIV prevention targeting MSM should focus on event-specific protective factors, which may be different from those obtained from studies distinguishing condom users versus nonusers.

Prevalence of unprotected anal intercourse among men who have sex with men in China: an updated meta-analysis

OBJECTIVE

The purpose of this review was to assess the prevalence of unprotected anal intercourse (UAI) among men who have sex with men (MSM) in China.

METHODS

A comprehensive search was conducted including online databases like "Wanfang", Chinese National Knowledge Infrastructure, PubMed and manual searches. Analyses using random-effects models were performed to estimate the prevalence of UAI among MSM in China.

RESULTS

Sixty-two articles reporting eighty-two studies were selected. The pooled prevalence rates of UAI with any male partner, with regular male partners, with non-regular male partners, with casual male partners, and with commercial male partners among MSM were 53%(95%CI: 51-56%), 45%(95%CI: 39-51%), 34%(95%CI: 24-45%), 33%(95%CI: 30-36%), 12% (95%CI: 5-26%), respectively. A cumulative meta-analysis found that the pooled UAI prevalence decreased over time.

CONCLUSIONS

Although the prevalence of UAI with male partners among MSM in China presents a decreasing trend over the past decade, the concomitant rise in HIV prevalence and incidence indicates that current prevention intervention efforts are insufficient to effectively contain the spread of HIV. Therefore, the persistently high prevalence of risky sexual behaviors underscores the need for innovative and effective prevention strategies among MSM.

Factors associated with HIV and syphilis co-infection among men who have sex with men in seven Chinese cities

HIV-syphilis co-infection is often cited as a major reason behind recent resurgence in syphilis prevalence among men who have sex with men in China. Most published literatures explore factors associated with either HIV or syphilis, but not their co-infection. We analysed data from a cross-sectional survey on men who have sex with men in seven Chinese cities. Snowball sampling was used to recruit participants for the survey. Socio-demographic and behavioural predictors for HIV-syphilis mono/co-infection were examined using ordinal logistic regression. Factor scores were used to summarise (1) HIV-related knowledge and (2) access to HIV preventive services. Prevalence of HIV, syphilis, and their co-infection, among 2936 self-identified men who have sex with men, were 7.7%, 14.3%, and 2.6%, respectively. In the adjusted analysis, the significant positive correlates of poorer diagnoses (co-infection vs mono- and no infection or co- and mono-infection vs no infection) were: 30 to 39 years and ≥40 years age, education up to senior high school, unprotected anal intercourse, recent sexually transmitted infection symptoms, incorrect knowledge about routes of transmission, and access to preventive or counselling/testing services for HIV. For effective control of this dual epidemic, integrated HIV and syphilis surveillance and targeted intervention strategies for Chinese men who have sex with men are needed urgently.

Pattern of HIV testing and multiple sexual partnerships among men who have sex with men in China

Background

Men who have sex with men (MSM) are a hidden but emerging population susceptible to HIV infection against a background of rapidly increasing HIV prevalence in China. Low HIV testing levels and multiple partnerships among MSM are two major contributing factors to HIV transmission.

Methods

We conducted a cross-sectional survey among 447 Chinese MSM in Changsha and Tianjin cities from November to December 2011 using an anonymous questionnaire. We aim to investigate (1) the trend of HIV testing rates among Chinese MSM during 2009 to 2011; and (2) the patterns of multiple sexual relationships with male, female and commercial partners.

Results

The self-reported past-12-months HIV testing level among Chinese MSM increased from 16.6% in 2009 to 46.3% in 2010 and 58.6% in 2011 (χ² = 173.49, p < 0.001). Compared with men who have tested for HIV, the never-tested MSM were generally younger, never married, students, and more likely to have unprotected anal intercourse with non-commercial male partners. Furthermore, 21.3% (56/263) MSM reported having multiple regular male and female sexual partnerships and 6.2% (16/257) reported having commercial male partners in the past six months. However, individuals who were never-tested for HIV are consistently less likely to engage in multiple sexual relationships.

Conclusions

HIV testing rates have increased substantially among Chinese MSM in the period 2009–2011, although significant barriers to testing remain. Multiple sexual partnerships, and especially bisexual behaviours, are common among Chinese MSM.

Effectiveness of HIV risk reduction interventions among men who have sex with men in China: a systematic review and meta-analysis

Objective

To evaluate the effect of risk reduction interventions on HIV knowledge, attitudes and behaviors among men who have sex with men (MSM) in China.

Methods

We performed a systematic review and meta-analysis of HIV risk reduction intervention studies among Chinese MSM. The summary difference of standardized mean differences (SMD) between both study arms or between pre- and post-intervention assessments were defined as the effect size (ES); ES was calculated using standard meta-analysis in random effects models.

Results

Thirty-four eligible studies were included in the analysis, including two randomized clinical trials (RCT), six quasi-experimental studies, six pre-and-post intervention studies, and twenty serial cross-sectional intervention studies. These studies showed an increase in consistent condom use with any male sexual partners (mean ES, 0.46; 95% confidence interval [CI], 0.35–0.56), with regular sexual partners (mean ES, 0.41; 95% CI, 0.18–0.63), and casual sexual partners (mean ES, 0.52; 95% CI, 0.24–0.79). The analysis of ten studies that measured the impact on uptake of HIV testing also showed a positive result (mean ES, 0.55; 95% CI, 0.38–0.71). The risk reduction interventions also improved HIV/AIDS-related knowledge (mean ES, 0.77; 95% CI, 0.60–0.94) and attitudes (mean ES, 1.35; 95% CI, 0.91–1.79), but did not reduce prevalence of HIV (mean ES, 0.23; 95% CI, 0.02–0.45) and syphilis infections (mean ES, −0.01; 95% CI, −0.19–0.17). There was significant heterogeneity among these studies.

Conclusions

On aggregate, HIV risk reduction interventions were effective in reducing risky behaviors and improving knowledge and attitudes among Chinese MSM, but were not associated with a change in the prevalence of HIV and syphilis. Future studies should use incidence as definitive study outcome.