Strategies for promoting HIV testing uptake: willingness to receive couple-based and collective HIV testing among a cross-sectional online sample of men who have sex with men in China

HIV Testing Strategies, Types of Tests, and Uptake by Men Who have Sex with Men and Transgender Women: A Systematic Review and Meta-analysis

This systematic review and meta-analysis investigated the effectiveness of strategies and types of tests on HIV testing uptake by men who have sex with men (MSM) and transgender women (TGW), and in reaching PLWH. Articles published up to July 2020 were identified from major electronic databases and grey literature. Data were extracted and assessed for risk of bias. Estimates were pooled using random-effect meta-analysis while heterogeneity was evaluated by Cochran's Q test and I². This study is registered with PROSPERO (CRD42020192740). Of 6820 titles, 263 studies (n = 67,288 participants) were included. The testing strategies reported in most studies were community- (71.2%) and facility-based (28.8%). Highest uptake, with facility-based testing, occurred and reached more PLWH while with standard laboratory tests, it occurred with the highest HIV prevalence among MSM. However, urine test showed a highest rate of new HIV infection. Multiple test combinations had the highest uptake and reached more PLWH among TGW. Various testing strategies, considering barriers and regional differences, and different test types, need be considered, to increase uptake among MSM and TGW.

Syphilis Self-testing: A Nationwide Pragmatic Study Among Men Who Have Sex With Men in China

BACKGROUND

Syphilis self-testing may help expand syphilis testing among men who have sex with men (MSM). China has rapidly scaled up human immunodeficiency virus (HIV) self-testing, creating an opportunity for integrated syphilis self-testing. However, there is a limited literature on implementing syphilis self-testing.

METHODS

A cross-sectional online survey was conducted among Chinese MSM in 2018. Participants completed a survey instrument including sociodemographic characteristics, sexual behaviors, syphilis self-testing, and HIV self-testing history. Multivariable logistic regression was conducted to identify correlates of syphilis self-testing. We also recorded potential harms associated with syphilis self-testing.

RESULTS

Six hundred ninety-nine MSM from 89 cities in 21 provinces in China completed the study. A total of 361/699 (51.7%) men tested for syphilis, of whom 174/699 (24.9%) men used syphilis self-testing. Among 174 who had self-tested, 90 (51.7%) reported that the self-test was their first syphilis test and 161 (92.5%) reported that they undertook syphilis self-testing together with HIV self-testing. After adjusting for covariates, syphilis self-testing was correlated with disclosure of sexual orientation to family or friends (adjusted odds ratio [aOR], 1.90; 95% confidence interval [CI], 1.32-2.73), reporting 2-5 male sexual partners (aOR, 1.81; 95% CI, 1.04-3.16), HIV self-testing (aOR, 39.90; 95% CI, 17.00-93.61), and never tested for syphilis in the hospital (aOR, 2.96; 95% CI, 1.86-4.72). Self-reported harms associated with syphilis self-testing were minimal.

CONCLUSIONS

Scaling up syphilis self-testing could complement facility-based testing in China among MSM. Self-testing may increase first-time testing and has limited harms. Our findings suggest that syphilis self-testing could be integrated into HIV self-testing services.

HIV testing uptake and yield among sexual partners of HIV-positive men who have sex with men in Zhejiang Province, China, 2014-2016: A cross-sectional pilot study of a choice-based partner tracing and testing package

Background

Measures to effectively expand tracing and testing to identify undiagnosed HIV infections are significant for the control of HIV/AIDS epidemic among men who have sex with men (MSM). We piloted a choice-based tracing and testing package aimed at improving partner tracing, uptake, and yield of HIV testing for sexual partners of newly diagnosed HIV-positive MSM.

Methods

This package was piloted in the cities of Hangzhou and Ningbo, Zhejiang province, China from June 2014 to June 2016. The package adopted four modes: couples’ HIV counseling and testing (CHCT), information assisted partner notification (IAPN), assisted HIV self-testing (HIVST) and patient referral. Data regarding sociodemographic factors and sexual behaviors between HIV-positive MSM and their sexual partners, as well as tracing and testing outcomes of each mode, were collected.

Results

Among 2,495 newly diagnosed HIV-positive MSM, 446(18%) were enrolled as index cases (ICs) through two rounds of contact tracing. The ICs disclosed a total of 4,716 sexual partners, of whom 548 (12%) were reachable. The pilot study resulted in a testing uptake of 87% (478/548), and a yield of 16% (74/478) among sexual partners. The generalized linear mixed model showed that the odds of a reachable sexual partner enrolled via IAPN taking an HIV test were 290% greater than that of a partner traced via CHCT (95% CI: 1.6, 9.3).

Conclusions

A choice-based tracing and testing package can feasibly expand HIV testing uptake and case finding among sexual partners of HIV-positive MSM. IAPN may be an acceptable option to reach sexual partners for whom limited contact information is available.

Pay-it-forward gonorrhoea and chlamydia testing among men who have sex with men in China: a randomised controlled trial

BACKGROUND

WHO recommends that men who have sex with men (MSM) receive gonorrhoea and chlamydia testing, but many evidence-based preventive services are unaffordable. The pay-it-forward strategy offers an individual a gift (eg, a test for sexually transmitted diseases) and then asks whether they would like to give a gift (eg, a future test) to another person. This study examined the effectiveness of a pay-it-forward programme to increase gonorrhoea and chlamydia testing among MSM in China.

METHODS

We did a randomised controlled superiority trial at three HIV testing sites run by MSM community-based organisations in Guangzhou and Beijing, China. We included MSM aged 16 years or older who were seeking HIV testing and met indications for gonorrhoea and chlamydia testing. Restricted randomisation was done using computer-generated permuted blocks. 30 groups were randomised into three arms (1:1:1): a pay-it-forward arm in which men were offered free gonorrhoea and chlamydia testing and then asked whether they would like to donate for testing of prospective participants, a pay-what-you-want arm in which men were offered free testing and given the option to pay any desired amount for the test, and a standard-of-care arm in which testing was offered at ¥150 (US$22). There was no masking to arm assignment. The primary outcome was gonorrhoea and chlamydia test uptake ascertained by administrative records. We used generalised estimating equations to estimate intervention effects with one-sided 95% CIs and a prespecified superiority margin of 20%. The trial is registered with ClinicalTrials.gov, NCT03741725.

FINDINGS

Between Dec 8, 2018, and Jan 19, 2019, 301 men were recruited and included in the analysis. 101 were randomly assigned to the pay-it-forward group, 100 to the pay-what-you-want group, and 100 to the standard-of-care group. Test uptake for gonorrhoea and chlamydia was 56% (57 of 101 participants) in the pay-it-forward arm, 46% (46 of 100 participants) in the pay-what-you-want arm, and 18% (18 of 100 participants) in the standard-of-care arm. The estimated difference in test uptake between the pay-it-forward and standard-of-care group was 38·4% (95% CI lower bound 28·4%). Among men in the pay-it-forward arm, 54 of 57 (95%) chose to donate to support testing for others.

INTERPRETATION

The pay-it-forward strategy can increase gonorrhoea and chlamydia testing uptake among Chinese MSM and could be a useful tool for scaling up preventive services that carry a mandatory fee.

FUNDING

US National Institute of Health; Special Programme for Research and Training in Tropical Diseases, sponsored by UNICEF, UNDP, World Bank, and WHO; the National Key Research and Development Program of China; Doris Duke Charitable Foundation; and Social Entrepreneurship to Spur Health.

HIV self-testing among men who have sex with men in China: a qualitative implementation research study

BACKGROUND

HIV self-testing (HIVST) may expand HIV testing, but there have been few pilot programmes among men who have sex with men (MSM). This purpose of this study was to evaluate HIVST implementation among MSM in China using qualitative methods.

METHODS

We undertook semistructured interviews among MSM and those organising HIVST programmes for MSM. Purposive sampling method was used to ensure men with different HIV serostatuses, ages and HIVST frequencies were included. Men were recruited from MSM community-based organisations and a local HIV clinic. An implementation science framework was used to interpret the findings. Two individuals used a standard code-based methodology to identify themes.

RESULTS

Forty-two MSM and six stakeholders were interviewed. Our data showed many MSM and stakeholders preferred HIVST to facility-based testing. Most men reported that HIVST empowered MSM and informed sexual decision making. Many men noted that decreasing the HIVST price may increase demand. Some men noted that HIVST could be scaled up through social media and by modifying bulky packaging. Minimal adverse events were reported.

CONCLUSIONS

HIVST may expand HIV testing and promote empowerment of MSM. Minimal adverse outcomes were noted, but further implementation research is needed.

Prevalence and Correlates of Point-of-sex Human Immunodeficiency Virus Self-testing Among Human Immunodeficiency Virus-negative Men Who Have Sex With Men in China

BACKGROUND

Human immunodeficiency virus (HIV) self-testing (HIVST) provides a promising tool to screen sex partners for men who have sex with men (MSM) who engage in condomless sex and want to avoid HIV infection. Although previous studies have demonstrated HIVST acceptability and increased testing uptake, limited data exist on its use between sex partners for point-of-sex HIV testing. This study examined prevalence and correlates of point-of-sex HIVST among Chinese MSM.

METHODS

A cross-sectional survey was conducted among 400 HIV-negative Chinese MSM in 2017. Participants were recruited through a multifaceted sampling approach and self-administered an electronic questionnaire. Point-of-sex HIVST was measured by asking participants if they had ever conducted HIVST with a sex partner before sex to ensure that they both knew their HIV statuses. Multivariable logistic regression was used to identify correlates of point-of-sex HIVST after controlling for age, education and sexual orientation.

RESULTS

Overall, 19.2% (77/400) men reported point-of-sex HIVST (51.3% among self-testers). Participants who had four or more HIV self-tests before had 7.57-fold greater odds (95% confidence interval, 3.75, 15.28) of reporting point-of-sex HIVST compared to those who had fewer HIVST experiences. Point-of-sex HIVST was otherwise not associated with most other socio-demographic or behavioral practices, suggesting that it may be broadly acceptable.

CONCLUSIONS

A substantial proportion of Chinese MSM had utilized HIVST with their partners before sex, especially among those who were more experienced with HIVST. Scale up and routine implementation of HIVST programs are further warranted to facilitate point-of-sex HIV testing.

Acceptability of Peer-Delivered HIV Testing and Counselling Among Men Who Have Sex with Men (MSM) and Transgender Women (TW) in Myanmar

Men who have sex with men (MSM) and transgender women (TW) are a priority population for HIV prevention in Myanmar but report sub-optimal HIV testing frequency. Previous studies have shown that peer involvement in HIV testing can normalize stigmatized sexualities and reduce barriers to testing. We explored the acceptability of peer-delivered HIV testing among 425 undiagnosed MSM and TW in Yangon and Mandalay. An overwhelming majority of participants (86%) reported being 'comfortable/very comfortable' with peer-delivered HIV testing. Logistic regression identified reporting sexual identity as Apone [adjusted odds ratio (aOR) 3.8; 95% CI 1.2-11.7], recent HIV testing (aOR 3.1; 95% CI 1.4-6.5), reporting a high likelihood of HIV acquisition (aOR 3.6; 95% CI 1.7-7.6), and reporting ≥ 5 casual partners in the past 3 months (aOR 0.2; 95% CI 0.1-0.6) as associated with peer-delivered HIV testing acceptability. Given ongoing HIV vulnerability among MSM and TW in Myanmar, peer-delivered testing may offer prevention benefits by increasing testing rates and identifying undiagnosed infection earlier.

Qualitative Assessment of Barriers and Facilitators of Access to HIV Testing Among Men Who Have Sex with Men in China

Diagnosis of HIV is the entry point into the continuum of HIV care; a well-recognized necessary condition for the ultimate prevention of onward transmission. In China, HIV testing rates among men who have sex with men (MSM) are low compared to other high risk subgroups, yet experiences with HIV testing among MSM in China are not well understood. To address this gap and prepare for intervention development to promote HIV testing and rapid linkage to treatment, six focus groups (FGs) were conducted with MSM in Beijing (40 HIV-positive MSM participated in one of four FGs and 20 HIV-negative or status unknown MSM participated in one of two FGs). Major themes reported as challenges to HIV testing included stigma and discrimination related to HIV and homosexuality, limited HIV knowledge, inconvenient clinic times, not knowing where to get a free test, fear of positive diagnosis or nosocomial infection, perceived low service quality, and concerns/doubts about HIV services. Key facilitators included compensation, peer support, professionalism, comfortable testing locations, rapid testing, referral and support after diagnosis, heightened sense of risk through engagement in high-risk behaviors, sense of responsibility to protect self, family and partner support, and publicity via social media. Themes and recommendations were generally consistent across HIV-positive and negative/status unknown groups, although examples of enacted stigma were more prevalent in the HIV-positive groups. Findings from our study provide policy suggestions for how to bolster current HIV prevention intervention efforts to enhance 'test-and-treat' strategies for Chinese MSM.

Advances in HIV prevention for serodiscordant couples

Serodiscordant couples play an important role in maintaining the global HIV epidemic. This review summarizes biobehavioral and biomedical HIV prevention options for serodiscordant couples focusing on advances in 2013 and 2014, including World Health Organization guidelines and best evidence for couples counseling, couple-based interventions, and the use of antiviral agents for prevention. In the past few years, marked advances have been made in HIV prevention for serodiscordant couples and numerous ongoing studies are continuously expanding HIV prevention tools, especially in the area of pre-exposure prophylaxis. Uptake and adherence to antiviral therapy remains a key challenge. Additional research is needed to develop evidence-based interventions for couples, and especially for male-male couples. Randomized trials have demonstrated the prevention benefits of antiretroviral-based approaches among serodiscordant couples; however, residual transmission observed in recognized serodiscordant couples represents an important and resolvable challenge in HIV prevention.

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.

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.