Alcohol use, stigmatizing/discriminatory attitudes, and HIV high-risk sexual behaviors among men who have sex with men in China

Characteristics of men who have casual sex with men among Chinese university students: A cross-sectional study

OBJECTIVES

The characteristics of men who have sex with men (either exclusively or with both men and women; MSM) who engaged in casual sex among Chinese male university students have not been compared with the characteristics of men who have sex with only women (MSW). This information is important for tailoring targeted behavioral interventions to prevent human immunodeficiency virus (HIV)/sexually transmitted infection (STI) transmission in this subgroup of MSM.

METHODS

Data were derived from a large cross-sectional electronic questionnaire survey conducted at 13 universities in Zhejiang Province, China, in 2018. Bivariate analyses were used to compare demographic, HIV-related psychosocial, and behavioral characteristics between MSM and MSW students who engaged in casual sex during the previous year. Proportion differences between the two groups and their 95% confidence intervals were analyzed.

RESULTS

Among the 583 sexually active male students who engaged in casual sex during the previous year, 128 and 455 were MSM and MSW, respectively. Compared with MSW students, larger proportions of MSM students reported knowing that male-to-male sexual behavior was the main mode of HIV transmission among Chinese students (62.5% vs. 45.5%), consenting to commercial sex (67.2% vs. 53.4%), wanting to know the HIV serostatus of partners before casual sex (65.8% vs. 51.3%), feeling at risk of HIV infection (40.5% vs. 11.8%), high condom-decision scale scores (55.3% vs. 42.6%), engaging in sex with ≥ 5 casual sex partners (44.6% vs. 25.9%), searching for casual partners online (89.2% vs. 51.3%), consuming alcohol before casual sex (64.8% vs. 45.0%), engaging in sex with regular partners (83.1% vs. 67.0%), engaging in commercial sex (54.2% vs. 26.4%), and visiting a clinic for voluntary counselling and testing (VCT) (16.4% vs. 8.4%). However, compared with MSW students, smaller proportions of MSM students reported knowing that consistent condom use could prevent HIV transmission (80.5% vs. 95.2%) and that VCT should be actively sought after risky sexual behavior (78.9% vs. 93.8%), using condoms sometimes/often (26.4% vs. 44.3%), and consistently using condoms (28.9% vs. 40.1%) while engaging in sex with casual partners.

CONCLUSIONS

MSM students who engaged in casual sex were at a greater risk of HIV/STI transmission, compared with MSW students. Comprehensive interventions to address the risks of unprotected male-to-male sex, searching for casual sex partners online, and non-use of HIV testing services are needed to reduce the burden of HIV/STI transmission among this subgroup of MSM.

Analysis on epidemiological characters and HIV care continuum of HIV-infected students: a retrospective cohort study in Shandong province, China

BACKGROUD

The proportion of HIV-infected students in China showed an increasing trend. This study aimed to identify the epidemiological characteristics and the HIV care continuum for HIV-infected students in Shandong Province, China.

METHODS

Case report and follow-up data of HIV-infected students were obtained from the National HIV/AIDS comprehensive response information management system. Logistic regression analyses were used to analyze the associating factors of HIV-infected students accepting CD4 + T cells (CD4) test and antiviral therapy (ART) in 30 days, and ArcGIS software was used for the spatial anlysis.

RESULTS

From 2017 to 2019, 403 HIV-infected students were reported in Shandong Province. The majority of them were male (99.5%) and transmitted through homosexual sexual activity(92.1%). Most of them lived in Jinan city and Qingdao city. 68.5% (276 cases) accepted CD4 test in 30 days, and 48.6% (196 cases) started ART in 30 days. The heterosexual transmitted cases (AOR = 0.458, 95%CI: 0.210-0.998), patients accepting HIV care in western area (AOR = 0.266,95%CI: 0.147-0.481) were less likely to test CD4 within 30 days; patients aged 23-25 (AOR = 2.316, 95%CI: 1.009-5.316) and patients who had tested CD4 within 30 days (AOR = 4.377; 95%CI: 2.572-7.447) prefered to receive ART within 30 days; patients accepted HIV care in central area (AOR = 0.407; 95%CI: 0.251-0.657) and western area (AOR = 0.508; 95%CI: 0.261-0.989) and patients diagnosed by voluntary blood donation (AOR = 0.352; 95%CI: 0.144-0.864) were less willing to receive ART in 30 days.

CONCLUSIONS

The HIV care continuum of HIV-infected students in Shandong Province still needed strenghthing. More health education and case management should be done for cases transmitted through heterosexual behavior, accepted HIV care in central and western area, and diagnosed by voluntary blood donation.

Association between depression and HIV infection vulnerable populations in United States adults: a cross-sectional analysis of NHANES from 1999 to 2018

Background

Although the government has made a commitment to advance education on HIV disclosure, depression continues to play a significant role in whether people living with HIV (PLWH) choose to disclose their HIV status to families or friends. Vulnerable populations who are at risk of contracting HIV may also be more susceptible to mental illness. However, there is a limited understanding of the association between depression and vulnerable populations affects by HIV among United States adults. We aimed to explore the incidence of depression in the HIV infection vulnerable populations and assessed the association between the HIV infection vulnerable populations and depression.

Methods

We analyzed the most current statistics from the National Health and Nutrition Examination Survey (NHANES) that included 16,584 participants aged 18 years or older between 1999 and 2018. The Patient Health Questionnaire-9 (PHQ-9) was used to evaluate symptoms of depressive disorder. Demographic characteristics were compared between the HIV infection vulnerable groups and HIV infection low-risk groups. Multivariable logistic regression analysis was also carried out to evaluate the odds rate and association between the HIV infection vulnerable populations and depression.

Results

Based on the most recent statistics from NHANES, HIV infection vulnerable populations were male, younger, less married or living together, non-Hispanic White people, lower income, and lower body mass index (BMI), with higher levels of cigarette smoking, alcohol drinking, a higher prevalence of depression, lower prevalence of hypertension and diabetes mellitus (DM; p < 0.05). Additionally, individuals with severe depression had a higher prevalence of cardiovascular disease (CVD), hypertension, DM, chronic kidney disease (CKD), and a higher proportion of HIV infection vulnerable populations and less married or living together (p < 0.01). Finally, the odds of depression from the logistic regression were significantly increased in HIV infection vulnerable groups (p < 0.01).

Conclusion

Depression might be associated with HIV infection vulnerable populations in the United States adults. More research is needed to evaluate the association between HIV infection vulnerable populations and depression and explore their causal associations. In addition, prevention efforts focusing on HIV disclosure and HIV infection vulnerable populations in the United States should address common co-prevalent depression to reduce new HIV infections.

Methodologies of Stigma-Related Research Amongst Men Who Have Sex With Men (MSM) and Transgender People in Asia and the Pacific Low/Middle Income Countries (LMICs): A Scoping Review

Much stigma-related research focuses on marginalized populations, including men who have sex with men (MSM) and transgender people. The importance of research in this area is widely recognized, however methodologies and measures vary between studies. This scoping review will collate existing information about how stigma-related research has been conducted in low/middle income countries (LMICs) within the Asia Pacific region, and will compare research designs, sampling frameworks, and measures. Strengths and limitations of these studies will inform recommendations for future stigma-related health research. A methodological framework for scoping studies was applied. Searches of Psych INFO, Scopus, ProQuest, Global Health and PubMed were used to identify articles. Stigma-related research amongst MSM and transgender communities, published between 2010 and 2019 in LMICs within the Asia Pacific region were included. A total of 129 articles based on 123 different studies were included. Of the 129 articles 51.19% (n = 66) were quantitative; 44.96% (n = 57) were qualitative and 3.88% (n = 5) were mixed methods studies. The majority of studies (n = 57; 86.36%) implemented a cross sectional survey. In-depth interviews (n = 20, 34.48%) were also common. Only 3.88% of studies utilized mixed-methods design. Non-probabilistic and probabilistic sampling methods were employed in 99.22 and 0.78% of studies respectively. The most common measures used in quantitative studies were the Center for Epidemiological Study on Depression (CES-D) (n = 18) and the Self Stigma Scale (SSS) (n = 6). Strengths and limitations proposed by researchers included in this review are summarized as lesson learnt and best practices in stigma-related research.

The Holistic Health Status of Chinese Homosexual and Bisexual Adults: A Scoping Review

Background: Same-sex marriage is currently not legalized in China, despite the considerably large number of homosexual and bisexual Chinese populations. At the same time, their holistic health status remains unclear. This is the first scoping review conducted to comprehensively examine all the available literature and map existing evidence on the holistic health of homosexual and bisexual Chinese. Methods: This scoping review used the framework of Arksey and O'Malley and followed the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews (PRISMA-ScR). A comprehensive search strategy was carried out across 20 English (EN) and Chinese (both traditional and simplified) electronic databases from January 1, 2001, to May 31, 2020. Two reviewers conducted the reference screening and study selection independently and consulted a third senior reviewer whenever a consensus must be achieved. Data extraction was conducted using a structured data form based on the Cochrane template, after which a narrative synthesis of the findings was performed. Results: A total of 2,879 references were included in the final analysis, with 2,478 research articles, 167 reviews, and 234 theses. Regarding the study populations, the vast majority of studies centered on men only (96.46%), especially men who have sex with men (MSM). Only 1.32% of the studies targeted female sexual minorities. The geographical distribution of all research sites was uneven, with most of them being conducted in mainland China (95.96%), followed by Hong Kong (2.05%), Taiwan (2.02%), and Macau (0.06%). Regarding the specific study focus in terms of the health domain, around half of the studies (45.93%) focused on sexual health only, and an additional quarter of the studies (24.15%) investigated both sexual health and social well-being. Meanwhile, the studies focusing on mental health only accounted for approximately 15% of the total. Conclusions: This scoping review revealed that previous research focused more on male than female sexual minorities, on disease-centered surveys than person-centered interventions, and investigations on negative health conditions than positive health promotion. Therefore, investigations centered on the female sexual minorities and corresponding person-centered interventions are highly needed. Review Registration: The protocol of this review has been registered within Open Science Framework (https://osf.io/82r7z) on April 27, 2020.

Current heterosexual marriage is associated with significantly decreased levels of anxiety symptoms among Chinese men who have sex with men

BACKGROUND

The high heterosexual marriage rate could be a 'double-edge' sword for the emotional health of Chinese men who have sex with men (MSM). The aim of this study was to determine if current marriage and breakdown of marriage (divorce) have different effects on the mental health of Chinese MSM.

METHODS

Eight hundred seven MSM were recruited using respondent-driven sampling from four cities in northeastern China. Gay-related stressful events (GRSE) were measured using the Gay Related Stressful Life Events Scale; social support was measured by the Social Support Rating Scale (SSRS); and depressive and anxiety symptoms were assessed using the Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS), respectively.

RESULTS

Of the study participants, 13.4% were married to women and 4.5% were divorced. The rates of marriage or divorce were 35.3 and 75.8% for participants 30-39 and > 40 years of age, respectively. The current married MSM had the highest SDS (50.0 ± 10.9) and SSRS (35.8 ± 8.6) levels, but the lowest SAS (38.7 ± 12.1) levels. Divorced MSM had the highest SAS (44.4 ± 9.6) and lowest SSRS (30.8 ± 8.1) levels. Age, GESE number, and HIV infection were predictors for SDS and SAS, and current marriage was associated with significantly decreased level of SAS (β = - 0.136, P = 0.001) based on multiple linear analysis.

CONCLUSIONS

Current marriage is associated with significantly decreased levels of anxiety symptoms among Chinese MSM. More studies are needed to understand the mechanisms underlying the effects of different marriage status on the emotional distress of Chinese MSM.

Patterns of alcohol use and associated characteristics and HIV-related outcomes among a sample of African-American women living with HIV

BACKGROUND

Alcohol use is common among people living with HIV and negatively impacts care and outcomes. African-American women living with HIV are subject to vulnerabilities that may increase risk for alcohol use and associated HIV-related outcomes.

METHODS

We used baseline data from a randomized controlled trial of an HIV-related stigma-reduction intervention among African-American women living with HIV in Chicago and Birmingham (2013-2015). Patterns of alcohol use [any use, unhealthy alcohol use (UAU), heavy episodic drinking (HED)] were measured using the AUDIT-C. We assessed demographic, social, and clinical characteristics which may influence alcohol use and HIV-related outcomes which may be influenced by patterns of alcohol use in bivariate and multivariable analyses.

RESULTS

Among 220 African-American women living with HIV, 54 % reported any alcohol use, 24 % reported UAU, and 27 % reported HED. In bivariate analysis, greater depressive symptoms, lower religiosity, lower social support, marijuana, and crack/cocaine use were associated with patterns of alcohol use (p < 0.05). Marijuana and cocaine/crack use were associated with patterns of alcohol use in adjusted analysis (p < 0.05). In adjusted analysis, any alcohol use and HED were associated with lower likelihood of ART adherence (ARR = 0.72, 95 % CI: 0.53-0.97 and ARR = 0.65, 95 % CI: 0.44-0.96, respectively), and UAU was associated with lack of viral suppression (ARR = 0.78, 95 % CI: 0.63-0.96).

CONCLUSIONS

Findings suggest any and unhealthy alcohol use is common and associated with poor HIV-related outcomes in this population. Regular alcohol screening and intervention should be offered, potentially targeted to subgroups (e.g., those with other substance use).

A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries

BACKGROUND

Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions.

METHODS

We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations.

RESULTS

Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes.

CONCLUSIONS

Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs.

Risk Prediction Score for HIV Infection: Development and Internal Validation with Cross-Sectional Data from Men Who Have Sex with Men in China

Receptive anal intercourse, multiple partners, condomless sex, sexually transmitted infections (STIs), and drug/alcohol addiction are familiar factors that correlate with increased human immunodeficiency virus (HIV) risk among men who have sex with men (MSM). To improve estimation to HIV acquisition, we created a composite score using questions from routine survey of 3588 MSM in Beijing, China. The HIV prevalence was 13.4%. A risk scoring tool using penalized maximum likelihood multivariable logistic regression modeling was developed, deploying backward step-down variable selection to obtain a reduced-form model. The full penalized model included 19 sexual predictors, while the reduced-form model had 12 predictors. Both models calibrated well; bootstrap-corrected c-indices were 0.70 (full model) and 0.71 (reduced-form model). Non-Beijing residence, short-term living in Beijing, illegal drug use, multiple male sexual partners, receptive anal sex, inconsistent condom use, alcohol consumption before sex, and syphilis infection were the strongest predictors of HIV infection. Discriminating higher-risk MSM for targeted HIV prevention programming using a validated risk score could improve the efficiency of resource deployment for educational and risk reduction programs. A valid risk score can also identify higher risk persons into prevention and vaccine clinical trials, which would improve trial cost-efficiency.

The psychological health and associated factors of men who have sex with men in China: A cross-sectional survey

Objectives

The psychological health of men who have sex with men (MSM) has received increased attention in recent years. We thus investigated the psychological status and associated factors among MSM in China.

Methods

A cross-sectional survey of 248 MSM was conducted from April to September 2015 using Symptom Checklist 90 (SCL-90) in Huludao and Zhengzhou, China. Statistical analyses utilized SPSS version 19.0 for Windows.

Results

All Cronbach’s α coefficients of the SCL-90 subscales exceeded 0.7, suggesting acceptable reliability. The coefficient range of the collective validity for all the subscales was >0.4. For the divisional validity, each item correlated better with the hypothetical subscale than with other subscales. Collective validity and divisional validity were both acceptable. The four most frequent types of psychological distress among MSM were depression, obsessive-compulsive behavior, interpersonal sensitivity, and anxiety. Results of the univariate analysis revealed that the following groups had significantly higher SCL-90 scores (P < 0.05): peasantry, married MSM, respondents who reported condomless anal intercourse and a greater number of male partners, and respondents who had not undergone psychosocial counseling and whose family or friends did not know about their sexual identity. In a multivariate logistic regression model, the following parameters were independently associated with higher SCL-90 scores: being married (AOR [adjusted odds ratio] = 3.19; 95% CI [confidence interval]: 1.96 to 5.93), condomless anal intercourse (AOR = 1.16; 95% CI: 1.02 to 1.31), number of male partners (AOR = 1.66 and 1.81; 95% CI: 1.08 to 2.34 and 1.32 to 2.69), family or friends not knowing about sexual identity (AOR = 2.13; 95% CI: 1.17 to 4.92), and lack of psychosocial counseling (AOR = 2.09; 95% CI: 1.06 to 4.09).

Conclusions

Our results indicate that psychological health problems among MSM in China are of concern. It is thus necessary to strengthen intervention efforts, with more emphasis on intervention programs to improve psychological health among Chinese MSM.

Substance use, anxiety, and self-management efficacy in HIV-positive individuals: A mediation analysis

Context

In China, the social stigma of both substance use and HIV remains major barriers. HIV+ individuals have been demonstrated to have higher psychosocial distress in the literature. To ensure quality of life among HIV+ Chinese individuals, self-efficacy in HIV-related management including substance use and anxiety is the key to suppress viral load and maintain healthy lives.

Objectives

We examine the mediation relationship among substance use, anxiety, and self-management efficacy.

Method

A cross-sectional study design was used. 137 HIV+ individuals were recruited from two premier Chinese hospitals: Beijing's Ditan Hospital and Shanghai's Public Health Clinic Center (SPHCC).

Results

HIV+ substance users had significantly lower HIV-management efficacy and higher anxiety scores. About a third of the relations between substance use and anxiety was mediated by HIV-management self-efficacy. Those who used substances in the previous week had higher anxiety levels suggesting the presence of a recent effect. Their higher levels of anxiety could be largely explained by their lower HIV-management efficacy.

Conclusion

It is useful for healthcare providers to assess substance use behaviors in HIV+ individuals as well as provide support in managing anxiety in this population. Meanwhile, enhancing self-management efficacy to ensure healthy lifestyles may support achieving optimal lives with HIV.

Subsequent Sexual Risks Among Men Who Have Sex with Men May Differ by Sex of First Partner and Age at Sexual Debut: A Cross-Sectional Study in Beijing, China

Sexual debut experience may influence HIV/sexual risks among men who have sex with men (MSM). We assessed associations between age of sexual debut and sex of debut partner with recent (past-3-month) sexual/HIV/syphilis risks among 3588 community-based Chinese MSM. Sexual debut with women was associated with more recent (condomless) insertive anal sex with men, more recent (condomless) vaginal sex, and more lifetime female partners. Sexual debut with men was associated with more recent (condomless) receptive anal sex with men and more lifetime male partners. All associations were strongest among those having first sex ≤18 years in both groups. Earlier sexual debut was associated with higher HIV/syphilis risk; HIV risk was higher with first sex with a man, but syphilis was higher with first sex with a woman. Earlier age of sexual debut is associated with greater HIV/syphilis and sexual risks, but MSM risk differs with first sex with women versus men.

HIV Stigma and Unhealthy Alcohol Use Among People Living with HIV in Russia

Unhealthy alcohol use, highly prevalent in the Russian Federation (Russia), is associated with HIV risk behaviors among people living with HIV (PLWH). HIV stigma contributes to the HIV risk environment in Russia. To examine HIV stigma among Russian PLWH and to explore its association with unhealthy alcohol use, we conducted a longitudinal analysis of 700 PLWH in St. Petersburg, Russia. We assessed the association between alcohol dependence and HIV stigma measured at baseline and 12 months follow-up. Participants with alcohol dependence (n = 446) reported significantly higher HIV stigma scores over time than those without dependence (n = 254) (adjusted mean difference 0.60, 95% CI 0.03-1.17; p = 0.04). In secondary analyses, we examined recent risky alcohol use and did not detect an association with HIV stigma. Alcohol dependence is associated with high HIV stigma among Russian PLWH but the nature of the association is conjectural. HIV prevention efforts in Russia that address alcohol use disorders hold potential to mitigate HIV-related stigma and its possible adverse effects among PLWH.

A Mixed-Method Study on Correlates of HIV-Related Stigma Among Gay and Bisexual Men in the Southern United States

Societal prejudice against people living with HIV infection is a formidable public health challenge that can negatively impact health and well-being. We recruited a multiethnic sample of 129 gay and bisexual men living with HIV who completed a brief survey; a subset of participants completed semi-structured qualitative interviews to contextualize the data. In bivariate analyses, stigma was positively and significantly correlated with depression (r = .402, p < .001) and negatively correlated with social support (r = -.482, p < .001). Qualitative interview results captured the mental suffering caused by stigma and coping strategies the men had developed. Although some of the coping strategies reduced the likelihood of experiencing acts of stigmatization, they also exacerbated the psychological stress of living with a stigmatized disease and limited the potential for social support. Our results highlight the need to scale up stigma-reduction programs, particularly those that can bolster social support networks.

Substance use and HIV-risk behaviors among HIV-positive men who have sex with men in China: repeated measures in a cohort study design

Global literature revealed that seropositive men who have sex with men (MSM) posed an even higher risk compared to their seronegative counterparts. Identifying risk factors that contribute to HIV-risk behaviors will help to curb the rapid HIV transmission among this group. Our hypothesis was that MSM with substance use were more likely to conduct HIV-risk behaviors, even after accounting for repeated measures. In the current study, we employed a cohort study design by following a group of 367 HIV-positive MSM up to four visits for one year to collect information regarding their sexual behaviors and history of substance use in the past three months. We used Generalized Estimating Equations (GEE) models to account both within- and between-subject variation when assessing associations between substance use and HIV-risk behaviors. A total of 367 MSM were included at the baseline with a mean age of 29.6 years. After accounting for potential confounders and time-varying effects, our models indicated that drug and alcohol use increase HIV risks at the population level by increasing risks of drinking alcohol before sex, having unprotected sex with men and seropositive partners, having more lifetime female sex partners and having a higher number of male sexual partners in the past three months. The current study is one of the first studies with repeated measures to evaluate the association between substance use and sexual risk behaviors among MSM in China. Findings in the current study have several implications for future research. We call for more rigorous study design for future research to better capture changes of risky behaviors among this at-risk population.

Alcohol misuse, risky sexual behaviors, and HIV or syphilis infections among Chinese men who have sex with men

BACKGROUND

Few studies have employed standardized alcohol misuse measures to assess relationships with sexual risk and HIV/syphilis infections among Chinese men who have sex with men (MSM).

METHODS

We conducted a cross-sectional study among MSM in Beijing during 2013-2014. An interviewer-administered survey was conducted to collect data on sociodemographics, high-risk behaviors, and alcohol use/misuse patterns (hazardous/binge drinking and risk of alcohol dependence) in the past 3 months using Alcohol Use Disorder Identification Test-Consumption (AUDIT-C). We defined AUDIT-C score ≥4 as recent hazardous drinkers, and drinking ≥6 standard drinks on one occasion as recent binge drinkers.

RESULTS

Of 3588 participants, 14.4% reported hazardous drinking, 16.8% reported binge drinking. Hazardous and binge drinking are both associated with these factors (p<0.05): older age, being migrants, living longer in Beijing, township/village origin, being employed, higher income, self-perceived low/no HIV risk, and sex-finding via non-Internet venues. Hazardous (vs non-hazardous) or binge (vs. non-binge) drinkers were more likely to use illicit drugs, use alcohol before sex, have multiple partnerships, pay for sex, and have condomless insertive anal intercourse. MSM who reported binge (AOR, 1.34, 95% CI, 1.02-1.77) or hazardous (AOR, 1.36, 95% CI, 1.02-1.82) drinking were more likely to be HIV-infected. MSM at high risk of current alcohol dependence (AUDIT-C ≥8) were more likely to be HIV- (AOR, 2.37, 95% CI, 1.39-4.04) or syphilis-infected (AOR, 1.96, 95% CI, 1.01-3.86).

CONCLUSIONS

Recent alcohol misuse was associated with increased sexual and HIV/syphilis risks among Chinese MSM, emphasizing the needs of implementing alcohol risk reduction programs in this population.

Stigma against People Living with HIV/AIDS in China: Does the Route of Infection Matter?

In the current study, we tested the hypothesis that people who contracted HIV from “blameless” routes (e.g., blood transfusion, sex with stable partners) are less stigmatized compared to people who contracted HIV from “blamable” routes (e.g., injection drug use, sex with sex workers). A cross-sectional study was conducted among 2,987 participants in Guangxi province, China, between 2012 and 2013. We employed both explanatory and predictive modeling strategy by using multivariate linear regression models. In the explanatory models, we assessed the association between routes of infection and three types of stigma (perceived, internalized, and enacted). From identified routes of infection that significantly contributed to higher stigma, we employed predictive modeling to explore predictors for the specific type of stigma. Multiple-imputation was employed for sensitivity analyses. Of the total sample, 63% were male and the average age was 42.9 years (ranged between 18 and 88). Multivariate regression models revealed that contraction from commercial sex increased the perceived (β = 0.46, 95%CI = 0.02, 0.90) and internalized stigma (β = 0.60, 95%CI = 0.09, 1.10), while injecting drug use increased the perceived (β = 0.65, 95%CI = 0.07, 1.22) and enacted stigma (β = 0.09, 95%CI = 0.02, 0.16) after controlling for confounders. Among PLWHA who were infected via commercial sex partners, social support was negatively associated with perceived (β = -0.47, 95%CI = -0.79, -0.14) and internalized stigma (β = -0.80, 95%CI = -1.24, -0.35). Among PLWHA who were infected via injecting drugs, no adherence to antiretroviral treatment (β = 0.41, 95%CI = 0.01, 0.82) was positively associated with perceived stigma, and disclosure of serostatus to others was negatively associated with enacted stigma (β = -0.20, 95%CI = -0.34, -0.05). Knowledge of the association between routes of infection and stigma can guide health professionals and policy makers to develop tailored intervention strategies to mitigate the effects of stigma and enhance HIV care utilization among PLWHA in China.

Behavioral Risk Profile of Men Who Have Sex with Men in Beijing, China: Results from a Cross-sectional Survey with Randomized Response Techniques

Background:

Human immunodeficiency virus (HIV) is spreading rapidly among men who have sex with men (MSM) in China. Anonymous questionnaires or direct interviews have been frequently used to study their behavior. The aim of the study was to describe the behavioral risk profile of the MSM in Beijing using the randomized response techniques (RRTs).

Methods:

A cross-sectional survey of sexual behavior among a sample of MSM was conducted in two HIV counseling and testing clinics in Beijing. The survey was carried out with an anonymous questionnaire containing sensitive questions on sexual behavior. To obtain the honest responses to the sensitive questions, three distinctive RRTs were used in the questionnaire: (1) Additive randomized response model for quantitative questions, (2) randomized response model for multiple choice questions, and (3) Simmons randomized response model for binomial questions. Formulae for the point estimate, variance, and confidence interval (CI) were provided for each specific model.

Results:

Using RRTs in a sample of 659 participants, the mean age at first homosexual encounter was estimated to be 21.7 years (95% CI: 21.2–22.2), and each had sex with about three (2.9, 95% CI: 2.4–3.4) male partners on average in the past month. The estimated rate for consistent condom use was 56.4% (95% CI: 50.1–62.8%). In addition, condom was estimated to be used among 80.0% (95% CI: 74.1–85.9%) of the population during last anal sex with a male partner.

Conclusions:

Our study employed RRTs in a survey containing questions on sexual behavior among MSM, and the results showed that RRT might be a useful tool to obtain truthful feedback on sensitive information such as sexual behavior from the respondents, especially in traditional Chinese cultural settings.

Validity of the CAGE questionnaire for men who have sex with men (MSM) in China

BACKGROUND

Detection of heavy drinking among men who have sex with men (MSM) is crucial for both intervention and treatment. The CAGE questionnaire is a popular screening instrument for alcohol use problems. However, the validity of CAGE for Chinese MSM is unknown.

METHOD

Data were from three waves of cross-sectional assessments among general MSM (n=523) and men who sell sex to other men ("money boys" or MBs, n=486) in Shanghai, China. Specifically, participants were recruited using respondent-driven, community popular opinion leader, and venue-based sampling methods. The validity of the CAGE was examined for different cutoff scores and individual CAGE items using self-reported heavy drinking (≥14 drinks in the past week) as a criterion.

RESULTS

In the full sample, 75 (7.4%) of participants were classified as heavy drinkers. 32 (6.1%) of general MSM and 43 (8.9%) of MBs were heavy drinkers. The area under curve statistics for overall sample was 0.7 (95% CI: 0.36-0.77). Overall, the sensitivities (ranging from 18.7 to 66.7%), specificities (ranging from 67.5 to 95.8%), and positive predictive values (ranging from 14.1 to 26.4%) for different cutoff scores were inadequate using past week heavy drinking as the criterion. The ability of CAGE to discriminate heavy drinkers from non-heavy drinkers was limited.

CONCLUSIONS

Our findings showed the inadequate validity of CAGE as a screening instrument for current heavy drinking in Chinese MSM. Further research using a combination of validity criteria is needed to determine the applicability of CAGE for this population.

Alcohol drinking and HIV-related risk among men who have sex with men in Chongqing, China

To estimate the prevalence of any alcohol use and heavy alcohol drinking using the Alcohol Use Disorders Identification Test (AUDIT) and its correlates among men who have sex with men (MSM), a cross-sectional study was conducted among 391 MSM in Chongqing, China to collect data about sociodemographic characteristics, alcohol use, sexual behaviors, and other related factors through a computer-assisted self-administered questionnaire. Heavy alcohol drinking in the past 12 months was defined as an AUDIT-C score ≥ 4. Blood was collected from each potential participant to test for HIV and syphilis status. Twenty three percent of MSM had consumed a drink containing alcohol in the previous year. 7.2% had an AUDIT-C score ≥ 4, defined as heavy alcohol drinkers. 23.5% were unmarried, but planning to marry, who were more likely to report any alcohol drinking (adjusted odds ratio [AOR], 2.38; 95% confidence interval [CI], 1.40-4.06) and to have AUDIT-C scores ≥ 4 (AOR, 3.58; 95% CI, 1.60-8.00). MSM who had used any alcohol in the previous year, and MSM who were heavy alcohol drinkers, were more likely to have had anal sex with male casual partners in the previous 6 months, to have been tested for HIV, and to have decreased scores on the scales of general self-efficacy, increased scores on the scales of stigma and discrimination. Our findings provided further evidence of the associations of any alcohol use and heavy alcohol consumption with HIV-risky behaviors, lowered sense of general self-efficacy, and higher sense of HIV/AIDS-related stigma and discrimination among MSM in the city with the highest HIV epidemic among MSM in China.

Barriers and Facilitators of Linkage to and Engagement in HIV Care Among HIV-Positive Men Who Have Sex with Men in China: A Qualitative Study

Linking and engaging HIV-positive patients in care is the key bridging step to glean the documented health and prevention advantages of antiretroviral therapy (ART). In China, HIV transmission among men who have sex with men (MSM) is surging, yet many HIV-positive MSM do not use HIV care services. We conducted a qualitative study in order to help positive interventions to promote linkage-to-care in this key population. Four focus group discussions (FGD) were held among HIV-positive MSM in Beijing, China, to ascertain knowledge, beliefs, attitudes, and practices related to HIV care. FGD participates highlighted six major barriers of linkage to/engagement in HIV care: (1) perceived discrimination from health care workers; (2) lack of guidance and follow-up; (3) clinic time or location inconvenience; (4) privacy disclosure concerns; (5) psychological burden of committing to HIV care; and (6) concerns about treatment. Five major sub-themes emerged from discussions on the facilitators of linkage to/engagement in care: (1) peer referral and accompaniment; (2) free HIV care; (3) advocacy from HIV-positive MSM counselors; (4) extended involvement for linking MSM to care; and (5) standardization of HIV care (i.e., reliable high quality care regardless of venue). An understanding of the barriers and facilitators that may impact the access to HIV care is essential for improving the continuum of care for MSM in China. Findings from our study provide research and policy guidance for how current HIV prevention and care interventions can be enhanced to link and engage HIV-positive MSM in HIV care.

Predictors of antiretroviral therapy initiation: a cross-sectional study among Chinese HIV-infected men who have sex with men

Background

Early antiretroviral therapy (ART) initiation is crucial to achieve HIV viral suppression and reduce transmission. HIV-infected Chinese men who have sex with men (MSM) were less likely to initiate ART than other HIV-infected individuals. We assessed predictors of ART initiation among Chinese MSM.

Methods

In 2010–2011, a cross-sectional study was conducted among MSM in Beijing, China. We examined ART initiation within the subgroup who were diagnosed with HIV infection prior to participation in the survey. Logistic regression models were fitted to evaluate socio-demographic and behavioral factors associated with ART initiation. The eligibility criterion in the 2010/2011 national HIV treatment guidelines was CD4 cell count <350 cells/μL or World Health Organization (WHO) clinical stage III/IV.

Results

Of 238 eligible HIV-infected participants, the median duration of HIV infection was 15 months (range: 31 days-12 years); 62 (26.1 %) had initiated ART. Among 103 men with CD4 counts <350 cells/μL, 38 (36.9 %) initiated ART. Being married to a woman (adjusted odd ratios [aOR]: 2.50; 95 % confidence interval [CI]: 1.07-5.87), longer duration of HIV infection (aOR: 10.71; 95 % CI: 3.66-31.32), and syphilis co-infection (aOR: 2.58; 95 % CI: 1.04-6.37) were associated with a higher likelihood of ART initiation. Of 135 men with CD4 count ≥350 cells/μL, 24 (18 %) initiated ART. Being married to a woman (aOR: 4.21; 95 % CI: 1.60-11.06), longer duration of HIV infection (aOR: 22.4; 95 % CI: 2.79-180), older age (aOR: 1.26; 95 % CI: 1.1-1.44), Beijing Hukou (aOR: 4.93; 95 % CI: 1.25-19.33), presence of AIDS-like clinical symptoms (aOR: 3.97; 95 % CI: 1.32-14.0), and history of sexually transmitted infections (aOR: 4.93; 95 % CI: 1.25-19.43) were associated with ART initiation. Compared with men who did not initiated ART, those with ART were more likely to receive counseling on benefits of ART (96.8 % vs. 66.4 %, P = 0 < 0.01), HIV stigma coping strategy (75.8 % vs. 65.9 %, P = 0.04), mental health (66.1 % vs. 52.9 %, P = 0.02), and substance use (46.7 % vs. 36.6 %, P = 0.04).

Conclusions

We documented low rates of ART initiation among Chinese MSM. Policy changes for expanding ART eligibility and interventions to improve the continuum of HIV care are in progress in China. Impact evaluations can help assess continuing barriers to ART initiation among MSM.

Sexual Risk Behaviors and HIV Infection among Men Who Have Sex with Men and Women in China: Evidence from a Systematic Review and Meta-Analysis

OBJECTIVES

To understand the current risk of HIV infection and transmission and further elucidate the underlying risk factors among men who have sex with men and women (MSMW) in China.

METHODS

Following PRISMA guidelines, we conducted a systematic review and meta-analysis of searching through Chinese and English available literature databases between January 2000 and June 2014 to identify articles.

RESULTS

Thirty-six articles (including 19,730 MSMW and 53,536 MSMO) met the selection criteria and the aggregated results found that MSMW have significantly higher HIV prevalence than MSMO (6.6% versus 5.4%, OR = 1.27, 95% CI = 1.01-1.58). A higher proportion of MSMW had commercial male partners in the past 6 months (18.3% versus 12.2%, OR = 1.56, 95% CI = 1.01-2.42). Additionally, substance use in the past 6 months was significantly more frequent among MSMW than MSMO (alcohol use: 27.1% versus 13.1%, OR = 2.53, 95% CI = 2.14-2.99; illicit drug use: 5.3% versus 2.5%, OR = 2.09, 95% CI = 1.48-2.95).

CONCLUSION

A higher proportion of commercial sex and substance use among MSMW may be a potentially indicative factor for significantly higher HIV prevalence compared to MSMO. Targeted interventions should aim at increasing the frequency of HIV/STIs screening and preventing high risk commercial sex and substance use among MSMW to decrease their HIV transmission to the general population.

Bisexual Behaviors, HIV Knowledge, and Stigmatizing/Discriminatory Attitudes among Men Who Have Sex with Men

OBJECTIVE

To assess the correlates for bisexual behaviors, HIV knowledge, and HIV/AIDS-related stigmatizing/discriminatory attitudes among men who have sex with men (MSM).

METHODS

A cross-sectional survey among MSM was conducted in 2011 to provide demographics, sexual behaviors, HIV knowledge, HIV/AIDS-related stigmatizing/discriminatory attitudes, and services in Jinan, Qingdao, and Yantai of Shandong Province of China.

RESULTS

Of 1230 participants, 82.8% were single, 85.7% aged <35 years, and 47.2% received college or higher education. There were 28.6% MSM who reported to be married or cohabitating or ever had sex with woman in the past 6 months (P6M). 74.5% had ≥6 HIV-related knowledge score. The average total score of stigmatizing/discriminatory attitude was 37.4±4.4(standard deviation). Bisexual behavior was independently associated with higher levels of HIV/AIDS-related stigma/discrimination(AOR = 1.1, 95% CI:1.0-1.1), older age(AOR = 1.2, 95%CI:1.1-1.2), and lower HIV-related knowledge score(AOR = 1.6, 95%CI:1.2-2.2). HIV knowledge score ≥6 was independently associated with lower levels of HIV/AIDS-related stigma/discrimination(AOR = 1.3, 95%CI:1.2-1.3), less bisexual behaviors(AOR = 0.6, 95%CI:0.5-0.9), ever received a test for HIV in the past 12 months (P12M)(AOR = 3.2, 95%CI:2.3-4.5), college or higher level education(AOR = 1.9, 95%CI:1.4-2.6), consistent condom use with men in P6M(AOR=6.9, 95%CI:4.6-10.6), recruited from internet or HIV testing sites(AOR = 11.2, 95%CI:8.0-16.1) and bars, night clubs, or tea houses(AOR = 2.5, 95%CI:1.7-4.8). Expressing higher levels of HIV/AIDS-related stigmatizing/discriminatory attitudes was independently associated with bisexual behaviors(Aβ = 0.9, 95%CI:0.4-1.4), lower HIV-related knowledge score(Aβ = 3.6, 95%CI:3.0-4.1), the number of male sex partners in the past week ≥2(Aβ = 1.4, 95%CI:1.0-1.9), unprotected male anal sex in P6M(Aβ = 1.0, 95%CI:0.5-1.6), and inversely associated with ever received HIV test(Aβ = 1.4, 95%CI:0.8-2.0) and peer education in P12M(Aβ = 1.4, 95%CI:0.9-1.9).

CONCLUSION

HIV/AIDS-related stigmatizing/discriminatory attitudes were associated with bisexual behaviors, low HIV testing rate, lower HIV-related knowledge and risk behaviors. This study called for innovative programs that would reduce HIV/AIDS-related stigmatizing/discriminatory attitudes and bisexual behaviors and improve the uptake of prevention service among MSM.

Recreational drug use and risks of HIV and sexually transmitted infections among Chinese men who have sex with men: Mediation through multiple sexual partnerships

Background

Recreational drug use (RDU) may result in sexual disinhibition and higher risk for HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM) in China. We assessed whether RDU was associated with HIV, syphilis, and herpes simplex virus type 2 (HSV-2) within the context of multiple sexual partnerships and unprotected sex.

Methods

We conducted a cross-sectional study among sexually-active MSM in six Chinese cities (Kunming, Jinan, Changsha, Zhengzhou, Nanjing, and Shanghai) in 2012–2013. We interviewed participants regarding RDU and sexual activity and drew blood for HIV, syphilis, and HSV-2. We fit multiple logistic regression models to assess associations of drug use and HIV, syphilis and HSV-2 infections, controlling for number of sexual partners and unprotected sex.

Results

Of 3830 participants, 28% reported ever using ≥1 of these drugs in the past 6 months: popper (alkyl nitrites), ecstasy, ice (methamphetamine), amphetamine, tramadol, and ketamine. In the past six months, 62% of MSM reported ≥2 sexual partners and 76% did not use condoms at last sexual encounter. HIV, syphilis and HSV-2 prevalences were 9.2%, 12.2%, and 10.3%, respectively.RDU was associated with HIV infection (aOR = 1.67; 95% CI, 1.31-2.13). Men with RDU were more likely to report multiple sexual partners (OR = 1.69; 95% CI, 1.44-1.98) and unprotected sex (aOR = 1.25; 95% CI, 1.05-1.49). The RDU-HIV association persisted (aOR = 1.58; 95% CI = 1.23-2.02) after adjusting for numbers of partners.

Conclusions

RDU was associated with multiple sexual partnerships, unprotected sex, and HIV among Chinese MSM. It is plausible that RDU is a driver of increased sexual/HIV risk and/or may be an associated behavior with sexually risky lifestyles. Community engagement is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0642-9) contains supplementary material, which is available to authorized users.

HIV-testing behavior and associated factors among MSM in Chongqing, China: results of 2 consecutive cross-sectional surveys from 2009 to 2010

The high and climbing human immunodeficiency virus (HIV) rates among Chinese men who have sex with men (MSM) bring huge pressure and challenge to acquired immune deficiency syndrome response work in China. This study examined HIV-testing behavior and describes the characteristics of recently tested MSM in Chongqing to address targeting HIV prevention interventions. Two consecutive cross-sectional surveys were conducted among Chongqing MSM using respondent-driven sampling in 2009 and 2010. Information was collected regarding details on demographic characteristics, sexual practices with male and female partners, and HIV-testing experiences. Univariate and multivariate logistic regression analyses were performed to identify factors independently associated with recent HIV testing.The final sample size included in our analyses was 992. The overall HIV prevalence was 13.4%, and HIV prevalence increased significantly from 11.6% in 2009 to 15.4% in 2010 (P = 0.08). The overall rate of HIV testing in the past 12 months was 44.6%, and the self-reported rates decreased significantly from 47.8% in 2009 to 41.1% in 2010 (P = 0.03). Factors independently associated with recent HIV testing included living in Chongqing >1 year (adjusted odds ratio [AOR] 1.8, 95% confidence interval [CI] 1.1-2.9), the age of most recent male partner ≤ 25 (AOR 1.5, 95% CI 1.1-2.1), not having unprotected insertive anal sex with most recent male partner in the past 6 months (AOR 1.5, 95% CI 1.1-2.0), disclosing HIV status to most recent male partner (AOR 2.8, 95% CI 2.0-3.8), and holding lower level of HIV-related stigma (AOR 1.1 per scale point, 95% CI 1.0-1.1). The extremely high HIV prevalence and low annual testing level put MSM at high risk of HIV infection and transmission, and it is a priority to promote regular HIV testing among this group in order to control the spread of HIV in Chongqing, China.