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

Peer- and community-led responses to HIV: A scoping review

INTRODUCTION

In June 2021, United Nations (UN) Member States committed to ambitious targets for scaling up community-led responses by 2025 toward meeting the goals of ending the AIDS epidemic by 2030. These targets build on UN Member States 2016 commitments to ensure that 30% of HIV testing and treatment programmes are community-led by 2030. At its current pace, the world is not likely to meet these nor other global HIV targets, as evidenced by current epidemiologic trends. The COVID-19 pandemic threatens to further slow momentum made to date. The purpose of this paper is to review available evidence on the comparative advantages of community-led HIV responses that can better inform policy making towards getting the world back on track.

METHODS

We conducted a scoping review to gather available evidence on peer- and community-led HIV responses. Using UNAIDS' definition of 'community-led' and following PRISMA guidelines, we searched peer-reviewed literature published from January 1982 through September 2020. We limited our search to articles reporting findings from randomized controlled trials as well as from quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. The overall goals of this scoping review were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to quickly inform policy, practice, and research.

FINDINGS

Our initial search yielded 279 records. After screening for relevance and conducting cross-validation, 48 articles were selected. Most studies took place in the global south (n = 27) and a third (n = 17) involved youth. Sixty-five percent of articles (n = 31) described the comparative advantage of peer- and community-led direct services, e.g., prevention and education (n = 23) testing, care, and treatment programs (n = 8). We identified more than 40 beneficial outcomes linked to a range of peer- and community-led HIV activities. They include improved HIV-related knowledge, attitudes, intentions, self-efficacy, risk behaviours, risk appraisals, health literacy, adherence, and viral suppression. Ten studies reported improvements in HIV service access, quality, linkage, utilization, and retention resulting from peer- or community-led programs or initiatives. Three studies reported structural level changes, including positive influences on clinic wait times, treatment stockouts, service coverage, and exclusionary practices.

CONCLUSIONS AND RECOMMENDATIONS

Findings from our scoping review underscore the comparative advantage of peer- and community-led HIV responses. Specifically, the evidence from the published literature leads us to recommend, where possible, that prevention programs, especially those intended for people living with and disproportionately affected by HIV, be peer- and community-led. In addition, treatment services should strive to integrate specific peer- and community-led components informed by differentiated care models. Future research is needed and should focus on generating additional quantitative evidence on cost effectiveness and on the synergistic effects of bundling two or more peer- and community-led interventions.

Prevalence and correlates of HIV infection among men who have sex with men: a multi-provincial cross-sectional study in the southwest of China

Objective

This study aims to assess the prevalence and correlates of HIV Infection among men who have sex with men (MSM) in two major provinces in southwest of China.

Method

We adopted the method of anonymous survey and HIV blood test on 1,245 MSM >18 years of age from Chongqing and Sichuan Province, China.

Results

The prevalence of HIV infection among MSM was 21.20%. Multiple logistic regression analysis revealed significant independent predictors of HIV infection among MSM as follows: lower level of education, preference to be receptive, lower frequency of condom use, drug usage, higher number of sexual partners in the past 1 month, and people suffering from sexually transmitted diseases. The distribution of HIV infection probability scores among HIV-negative MSM shows a positively skewed distribution, which will help to find persons at higher risk of HIV infection.

Conclusion

HIV prevalence in Chongqing and Sichuan Province is extremely high. We must find a way to identify people at high risk of HIV infection and employ different interventions among different risk levels of HIV infection in order to achieve maximum prevention and treatment benefit. Considering the relative shortage of resources, efforts to prevent HIV might be more effectively employed if they stratify men based on validated risk criteria.

HIV prevalence among female sex workers in Guigang City, Guangxi, China: an 8-year consecutive cross-sectional study

Background

Female sex workers (FSW) are a population that are at high risk for HIV infection, and their HIV/AIDS knowledge levels and sexual behaviors are of concern. This study describes changes in HIV prevalence and factors associated among female sex workers in Guigang City, Guangxi, one of the highest HIV prevalence areas in China.

Methods

Data were derived from an annual cross-sectional venue-based survey, 2008 to 2015, in the form of sentinel surveillance. The participants were recruited using cluster sampling. FSW aged 16 years and above who completed a questionnaire and HIV testing. Both descriptive and multi-level analyses were used to explore factors associated with changes in HIV prevalence.

Results

Seven thousand four hundred ninety-six FSW were recruited in this study. HIV prevalence among FSW in Guigang City fell into two periods, one with an increasing trend (2008–2011) and one with a decline (2012–2015). Differences between these time periods included age, relationship status, HIV knowledge, consistent condom use, lifetime illicit drug use, history of sexually transmitted infection in the past year, HIV testing, receipt of a condom distribution and education program or HIV counseling and testing, and peer education services.

Conclusions

Since 2012, a reduction in HIV prevalence among FSW in Guigang City has been observed. The decline of HIV prevalence was associated with coinciding changes in demographic characteristics of FSW, improvement of HIV knowledge and safer sexual behaviors, and a program that promotes condom use, HIV counseling & testing, and peer education.

Peer-Led or Expert-Led Intervention in HIV Prevention Efficacy? A Randomized Control Trial Among Spanish Young People to Evaluate Their Role

HIV new infections still affect young people around the world. In this context, behavioral interventions seem to be effective in promoting safe sex although some conditions are still inconclusive in different regions. For example, there is insufficient evidence about who may be the best facilitator. For this reason, this study evaluates the effectiveness of peer and expert facilitators for HIV prevention aimed at Spanish young people. For this purpose 225 Spanish college students, aged between 18 and 25 (74.20% women and 25.80% men), were involved in an experimental design to evaluate the facilitators' effect in a brief intervention for HIV prevention. Participants' results were measured by three HIV preventive variables (knowledge, beliefs, and protective sex behavior in vaginal sex, anal sex, and sex after drugs consumption). Our findings reveal that both facilitators, experts and peers, have improved the HIV-associated factors and safe sex behaviors. Therefore, facilitators' status would not be so relevant for effectiveness in HIV prevention aimed at Spanish young people. To facilitate decision making in HIV prevention, we should study in depth what other variables make more effective facilitators.

A synthesis of meta-analytic evidence of behavioral interventions to reduce HIV/STIs

To identify the mode of delivery, communicator, and content dimensions that make STI/HIV prevention interventions most successful at increasing condom use/protected sex or reducing STI/HIV incidence. A literature search for published meta-analyses of STI/HIV prevention interventions yielded 37 meta-analyses that had statistically tested the moderating effects of the dimensions. Significant and non-significant moderators from the coded dimensions were extracted from each meta-analysis. The most consistently significant moderators included matching the gender or ethnicity of the communicator to the intervention recipients, group targeting or tailoring of the intervention, use of a theory to underpin intervention design, providing factual information, presenting arguments designed to change attitudes, and providing condom skills and intrapersonal skills training. The absence of significant effects for intervention duration and expert delivery are also notable. The success of HIV/STI prevention interventions may be enhanced not only by providing skills training and information designed to change attitudes, but also by ensuring that the content is tailored to the target group and delivered by individuals of the same gender and ethnicity as the recipients.

Low willingness and actual uptake of pre-exposure prophylaxis for HIV-1 prevention among men who have sex with men in Shanghai, China

Little is known about the acceptance and actual uptake of pre-exposure prophylaxis (PrEP) and associated factors in men who have sex with men (MSM) in China. This study is the baseline survey of an intervention study designed to evaluate the effectiveness of tenofovirdisoproxil fumarate (TDF) on a daily use for human immunodeficiency virus (HIV) prevention among MSM in Shanghai, China. From October 2012 to December 2013, a total of 1,033 MSM in Shanghai were recruited by local district Centers for Disease Control and Prevention (CDC) and a MSM community-based non-governmental organization (NGO). Among them, 197 (19.1%) participants expressed willingness to use the TDF group at baseline survey, but only 26 (2.5%) participated in the TDF group and took TDF one tablet a day. Higher willingness to use PrEP was associated with being 45 years or older, non-local residents, having more male sex partners in the past 6 months and not using condom at last anal sex with man. Acutal uptake of PrEP was associated with having ≥ 11 male sex partners in lifetime and reporting no female sex partners in lifetime. Reasons for not participating in TDF group among those who expressed willingness to use PrEP at baseline survey included loss of contact, ineligiblity because of abnormal results for liver or renal function tests, change of mind, and HIV seroconversion before uptake of PrEP. Our findings suggest that promotion of PrEP in MSM remains challenging at current circumstancein China. Future research is needed to solicit effective education and intervention programs to promote acceptance of PrEP among Chinese MSM.

Behavioral Interventions to Reduce Sexual Risk Behavior in Adults with HIV/AIDS Receiving HIV Care: A Systematic Review

Regular interactions with people living with HIV/AIDS (PLWHA) who are receiving care provide caregivers opportunities to deliver interventions to reduce HIV-related risks. We conducted a systematic review of behavioral interventions for PLWHA (provided at individual level by caregivers at HIV care settings) to determine their efficacy in reducing sexual risk behavior. Conference websites and biomedical literature databases were searched for studies from 1981 to 2013. Randomized and quasi-randomized controlled trials (with standard-of-care control groups), considering at least one of a list of HIV-related behavioral or biological outcomes in PLWHA aged ≥18 receiving HIV care with at least 3-month follow-up were included. No language or publication status restrictions were set. Standardized search, data abstraction, and evaluation methods were used. Five randomized controlled trials were included in the review. We found limited evidence that sexual risk reduction interventions increase condom use consistency in HIV transmission risk acts, and reduce the number of (casual) sexual partners. We still believe that regular interactions between HIV care providers and PLWHA provide valuable opportunities for theory-based sexual risk reduction interventions to restrain the spread of HIV.

Efficacy of theory-based HIV behavioral prevention among rural-to-urban migrants in China: a randomized controlled trial

Our objective was to evaluate the efficacy of a cultural adaptation of a social cognitive theory-based HIV behavioral prevention program among young rural-to-urban migrants in China. The intervention design and assessment were guided by the Protection Motivation Theory (PMT). The intervention was evaluated through a randomized controlled trial with 6-month and 12-month follow-ups. The primary behavioral outcome was the use of condoms. Other outcome measures include HIV knowledge, condom use knowledge, HIV-related perceptions (PMT constructs), and intention to use condom. The mixed-effects regression models for condom use with regular partners indicated that overall frequency of condom use, condom use in last three sexual acts and proper condom use increased over time for the participants but the increases were significantly greater among the intervention group than the control group at 6-month and 12-month follow-ups. The mixed-effects models for HIV-related perceptions indicated that extrinsic rewards, intrinsic rewards, and response costs decreased while vulnerability, severity, response efficacy, and self-efficacy increased over time for the intervention group. The increases in HIV knowledge, condom use knowledge, and intention to use condom were also significantly greater among the intervention group than the control group. The data in the current study suggested efficacy of a social cognitive theory-based behavioral intervention in increasing condom use among young migrants in China. The intervention also increased protective perceptions and decreased risk perception posited by the theory (i.e., PMT).

Attitudes toward HIV pre-exposure prophylaxis among men who have sex with men in western China

Pre-exposure prophylaxis (PrEP), as demonstrated in recently published clinical trials, is one promising approach for controlling the emerging epidemic among men who have sex with men (MSM). We evaluated the attitudes towards use of PrEP among MSM in western China. A total of 1402 participants completed a self-administered questionnaire. Overall, 22% of the participants reported that they had heard of PrEP, <1% had ever used medicine to prevent HIV, and 64% reported that they were absolutely willing to use PrEP if it were proven to be safe and effective. The predictors of willingness to use PrEP included lower education, moderate income compared with the lowest income, never or rarely finding sexual partners through the Internet in the past 6 months, sexually transmitted infection (STI) history, more knowledge of AIDS, worrying about HIV as a threat to themselves and their family, having previously heard of PrEP, and believing that PrEP was effective in preventing HIV. This study demonstrates that Chinese MSM have moderate awareness of PrEP and a high interest in using it.

Highly active antiretroviral therapy is associated with decreased incidence of sexually transmitted diseases in a Taiwanese HIV-positive population

There are reports of increased sexual risk behaviors in the HIV-positive population since the introduction of highly active antiretroviral therapy (HAART). Little is known about the effects of the case management (CM) program and HAART on sexually transmitted diseases (STDs) in Taiwan. HIV-positive subjects, who visited the outpatient clinics of Taoyuan General Hospital between 2007 and 2010, were enrolled. A total of 574 subjects and 14,462 person-months were reviewed. Incident STDs occurred in 104 (18.1%) subjects, and the incidence rate was 8.6 (95% confidence interval [CI], 7.1-10.5) per 100 person-years (PY). For men who have sex with men (MSM), heterosexual men and women, and injection drug users (IDU), 19.4 per 100 PY(95% CI, 15.7-24.0), 3.5 per 100 PY (95% CI, 1.4-7.3), and 1.1 per 100 PY (95% CI, 0.4-2.4) of STDs were noted, respectively; (MSM versus IDU and MSM versus heterosexual subjects, p<0.000001; heterosexual subjects versus IDU, p=0.061). Syphilis (59.6%) was the most common STD. Regular CM and no HAART (hazard ratio, 2.58; 95% CI, 1.14-5.84; p=0.02) was significantly associated with STDs in MSM. Though this retrospective study might underestimate the incidence of STDs and not draw the conclusion of causality, we concluded that the CM program and HAART are associated with lower acquisition of STDs in the Taiwanese HIV-positive population.