HIV epidemiology and responses among men who have sex with men and transgender individuals in China: a scoping review

Sequence Note: Characterization of Two HIV-1 Strains with Novel Unique Recombinant Genome in Hebei, China

In China, the proportion of HIV-1 infections due to men who have sex with men (MSM) has increased rapidly. More and more new subtypes are found among the MSM population besides known CRF01_AE, CRF07_BC, and B. The co-circulation of several HIV subtypes in the same population provides the opportunity to develop a new circulating recombinant form (CRF) and unique recombinant form (URF). Here we reported two new URFs from two HIV-1 positive subjects infected through homosexual contact in Hebei, China. Phylogenetic and recombinant analyses based on the near full-length genome (NFLG) of the two URFs are the second-generation recombinant strains that originated from B, CRF01_AE, and CRF07_BC. The CRF01_AE segments in the genome of two URFs originated from cluster 4 of CRF01_AE strains, while the CRF07_BC segments were clustered with 07BC_N in the phylogenetic tree. The emergence of the novel CRF01_AE/CRF07_BC and CRF01_AE/B recombinant forms indicated the importance of the continuous monitoring of the HIV-1 epidemic and new URFs among the MSM population.

mHealth-Based Gamification Interventions Among Men Who Have Sex With Men in the HIV Prevention and Care Continuum: Systematic Review and Meta-Analysis

Background

In the past few years, a burgeoning interest has emerged in applying gamification to promote desired health behaviors. However, little is known about the effectiveness of such applications in the HIV prevention and care continuum among men who have sex with men (MSM).

Objective

This study aims to summarize and evaluate research on the effectiveness of gamification on the HIV prevention and care continuum, including HIV-testing promotion; condomless anal sex (CAS) reduction; and uptake of and adherence to pre-exposure prophylaxis (PrEP), postexposure prophylaxis (PEP), and antiretroviral therapy (ART).

Methods

We comprehensively searched PubMed, Embase, the Cochrane Library, Web of Science, Scopus, and the Journal of Medical Internet Research and its sister journals for studies published in English and Chinese from inception to January 2024. Eligible studies were included when they used gamified interventions with an active or inactive control group and assessed at least one of the following outcomes: HIV testing; CAS; and uptake of and adherence to PrEP, PEP, and ART. During the meta-analysis, a random-effects model was applied. Two reviewers independently assessed the quality and risk of bias of each included study.

Results

The systematic review identified 26 studies, including 10 randomized controlled trials (RCTs). The results indicated that gamified digital interventions had been applied to various HIV outcomes, such as HIV testing, CAS, PrEP uptake and adherence, PEP uptake, and ART adherence. Most of the studies were conducted in the United States (n=19, 73%). The most frequently used game component was gaining points, followed by challenges. The meta-analysis showed gamification interventions could reduce the number of CAS acts at the 3-month follow-up (n=2 RCTs; incidence rate ratio 0.62, 95% CI 0.44-0.88). The meta-analysis also suggested an effective but nonstatistically significant effect of PrEP adherence at the 3-month follow-up (n=3 RCTs; risk ratio 1.16, 95% CI 0.96-1.38) and 6-month follow-up (n=4 RCTs; risk ratio 1.28, 95% CI 0.89-1.84). Only 1 pilot RCT was designed to evaluate the effectiveness of a gamified app in promoting HIV testing and PrEP uptake. No RCT was conducted to evaluate the effect of the gamified digital intervention on PEP uptake and adherence, and ART initiation among MSM.

Conclusions

Our findings suggest the short-term effect of gamified digital interventions on lowering the number of CAS acts in MSM. Further well-powered studies are still needed to evaluate the effect of the gamified digital intervention on HIV testing, PrEP uptake, PEP initiation and adherence, and ART initiation in MSM.

Willingness to use long-acting injectable PrEP among HIV-negative/unknown men who have sex with men in mainland China: A cross-sectional online survey

BACKGROUND

Men who have sex with men (MSM) are at high risk of HIV acquisition. Long-acting injectable-pre-exposure prophylaxis (LAI-PrEP), requiring less frequent dosing, is being studied as an alternative method to daily oral HIV PrEP. With the addition of this potential new prevention method, it expands the scope for a wider user choice and is expected to increase the acceptability and uptake of HIV prevention measures. The aim of our study was to explore the willingness to use LAI-PrEP and associated influential factors.

METHODS

Participants were recruited from December 2020 to March 2021 through banner advertisements on web- and mobile app-based platforms on Blued, a large gay Chinese social media platform. MSM in our cross-sectional study was HIV-negative and currently lived in mainland China. Participants were asked about their willingness to use LAI-PrEP and reasons why they might be or not be willing to use LAI-PrEP. Multivariable logistic regression was used to analyze the factors associated with the willingness to use LAI-PrEP.

RESULTS

In total, 969 participants met the inclusion criteria and finished the survey. Nearly twenty percent (19.5%) of participants had never tested for HIV; 66.8% of MSM had multiple male partners; and 51.6% of MSM engaged in condomless sex with their partner. About three-fifths (66.3%) of MSM were aware of PrEP, and only 3.9% of MSM had used PrEP before. The willingness to use LAI-PrEP among MSM was 74.0% (95% CI: 71.4%-76.6%). MSM with higher education levels were less likely to show a willingness to use LAI-PrEP (AOR = 0.56, 95%CI: 0.38-0.84). Participants who had a history of HIV test (AOR = 1.68, 95%CI: 1.11-2.55), were willing to use daily oral PrEP (AOR = 10.64, 95%CI:7.43-15.21), had multiple male sexual partners (AOR = 1.33, 95%CI:0.93-1.90), who used rush popper(AOR = 1.49, 95%CI:1.05-2.13), and who were aware of PEP (AOR = 1.66, 95%CI: 1.02-2.70) were more likely to show willingness to use LAI-PrEP.

CONCLUSIONS

In our study, MSM had quite high awareness but low uptake of PrEP. As LAI-PrEP is expected to be approved for use in China in the future, our study of MSM highlights the need for key population-focused education programs about PrEP and healthy sexual behavior. This study also provides some evidence for LAI-PrEP use among the Chinese MSM population in the future.

The relationship between non-suicidal self-injury and childhood abuse in transgender people: a cross-sectional cohort study

Objective

To explore the relationship between non-suicidal self-injury (NSSI) and childhood abuse in transgender people and the mediating effect of emotional dysregulation traits in the association between childhood abuse and non-suicidal self-injury.

Patients and methods

From May to October 2021, 296 female-to-male (FTM) and 675 male-to-females (MTF), with age of 24.5 ± 6.4 years, were recruited using peer-driven sampling and anonymous questionnaires in Guangdong Province. The Childhood Abuse Questionnaire (CTQ-SF), the Personality Diagnostic Questionnaire (PDQ-4+) emotion regulation ability scale and the DSM-5 Clinical Examination of Stereotypic Disorders were used to measure childhood abuse experiences, emotional dysregulation traits and self-injurious behaviour, respectively.

Results

Childhood abuse scores were positively correlated with both emotional dysregulation traits scores and non-suicidal self-injury (NSSI) behaviours (p < 0.01), and emotional dysregulation traits scores were positively correlated with NSSI behaviours (p < 0.01); emotional dysregulation traits partially mediated the association between childhood abuse and NSSI behaviours, with the mediating effect accounting for 23.23% of the total effect. In addition, among the factors of childhood abuse, emotional dysregulation traits mediated the association between emotional abuse, emotional neglect, sexual abuse, physical abuse, physical neglect and NSSI behaviour significantly, with the mediating effect accounting for 22.48%-32.58% of the total effect.

Conclusion

Transgender NSSI behaviours are associated with childhood abuse and emotional dysregulation traits, and emotional dysregulation traits partially mediates the association between childhood abuse and NSSI behaviours, and screening for emotional dysregulation traits in transgender people and timely interventions are needed to improve the current situation of discrimination against transgender people.

Performance of HIV Infection Prediction Models in Men Who Have Sex with Men: A Systematic Review and Meta-Analysis

Effective ways to identify and predict men who have sex with men (MSM) at substantial risk for HIV is a global priority. HIV risk assessment tools can improve individual risk awareness and subsequent health-seeking actions. We sought to identify and characterize the performance of HIV infection risk prediction models in MSM through systematic review and meta-analysis. PubMed, Embase, and The Cochrane Library were searched. Eighteen HIV infection risk assessment models with a total of 151,422 participants and 3643 HIV cases were identified, eight of which have been externally validated by at least one study (HIRI-MSM, Menza Score, SDET Score, Li Model, DHRS, Amsterdam Score, SexPro model, and UMRSS). The number of predictor variables in each model ranged from three to 12, age, the number of male sexual partners, unprotected receptive anal intercourse, recreational drug usage (amphetamines, poppers), and sexually transmitted infections were critical scoring variables. All eight externally validated models performed well in terms of discrimination, with the pooled area under the receiver operating characteristic curve (AUC) ranging from 0.62 (95%CI: 0.51 to 0.73, SDET Score) to 0.83 (95%CI: 0.48 to 0.99, Amsterdam Score). Calibration performance was only reported in 10 studies (35.7%, 10/28). The HIV infection risk prediction models showed moderate-to-good discrimination performance. Validation of prediction models across different geographic and ethnic environments is needed to ensure their real-world application.

Multi-dimensional mismatch and barriers for promoting PrEP among men who have sex with men in China: a cross sectional survey from the Demand-side

BACKGROUND

Men who have sex with men (MSM) is a key population for preventing HIV in China, yet pre-exposure prophylaxis (PrEP) is not widely accepted in this population. The objective of this manuscript was to assessed the barriers in the acknowledgement and uptake focusing the demand side.

METHODS

An online questionnaire survey was conducted from December 2018 to January 2019. All participants were required to scan two-dimensional code which was the online crowdsourcing survey platform to complete the electronic questionnaire anonymously.

RESULTS

Among 1915 MSM from thirty-four cities of China, 512 (26.7%) versus 1617 (84.4%) had an objective or subjective need of PrEP, respectively. One hundred and six (5.5%) reported affordability and only 23 (1.2%) had ever taken it. Age, living alone and occupation were associated with the objective needs. Age, income, sexual behavior were associated with actual usage. The participants who they had objective need to use PrEP are the population which we should focus on.

CONCLUSION

A wide disconnect exists among the objective need, willingness, affordability and uptake of PrEP. Cost was the most prevalent barrier, accounting for 78.22% of individuals who needed and wished for PrEP but finally failed to receive it. The findings might facilitate optimizing future allocation of resources to better promote PrEP in Chinese MSM.

Roles of Social Capital in the Association Between Internalized Homophobia and Condomless Sex Among Men Who Have Sex With Men in Southwest China: A Four-Way Decomposition

Objectives: This study examined whether social capital (SC) mediated the association between internalized homophobia (IH) and condomless sex among men who have sex with men (MSM), with the interaction of SC and IH considered. Methods: A cross-sectional study was conducted between November 2018 and April 2019 in Sichuan Province, China. A total of 540 participants were recruited to investigate their IH, SC, and condomless sex. A four-way decomposition of causal mediation analysis was used to test SC's roles in the association between IH and condomless sex. Results: Condomless sex was prevalent (46.7%) among the participants, which was significantly associated with IH [odds ratio (OR) = 1.70] and SC (OR = 0.55). A direct effect [excess risk ratio (RR = 0.32)] and an indirect effect (excess RR = 0.16) of SC were found to be significant in the association between IH and condomless sex. Heterogeneities in effects were observed when taking the SC's domains (e.g., individual and family-based SC) as mediators. SC's effects were significant only in the homosexual subgroup. Conclusion: IH-based intervention with consideration of SC can be tailored to MSM to decrease condomless sex and curb the spread of HIV, especially for the homosexual subgroup.

An integrated online-to-offline model for HIV post-exposure prophylaxis (O2O-PEP) scale-up among men who have sex with men (MSM): Protocol for developing a pilot randomized controlled trial

Background

HIV post-exposure prophylaxis (PEP) is an evidence-based biomedical HIV prevention strategy consisting of a 28-day course of highly active antiretroviral therapy after recent potential exposure to HIV. However, awareness and uptake of PEP among men who have sex with men (MSM) are very low. Innovative and effective methods are needed to support PEP implementation among MSM. This work reports a protocol to design and evaluate an online-to-offline-based delivery model for HIV PEP uptake (O2O-PEP) in Chinese MSM.

Methods and analysis

This will be a two-phase study. In phase 1, we will develop an O2O-PEP model delivered through the WeChat mini-app (an app built into the WeChat platform). The O2O-PEP model initially includes four core components: a gamification-based education package for PEP, an online HIV risk assessment tool, a free online booking system for PEP initiation, and offline PEP prescription in the study hospitals. In phase 2, a two-arm pilot stratified randomized controlled trial comparing the O2O-PEP group with the standard care group will be designed to assess the feasibility, usability, and preliminary evidence of the efficacy of the O2O-PEP model in increasing PEP uptake among Chinese MSM. Model feasibility and usability will be further explored for broader model implementation.

Discussion

The O2O-PEP model is one of the first interventions in China aiming to promote PEP initiation in Chinese MSM. Components in the O2O-PEP model could assist MSM in better understanding their HIV infection risk and increasing accessibility of PEP. Moreover, coupled with online and offline recruitment, the O2O-PEP model has great potential to reach and engage MSM who are not involved in care by traditional methods.

Clinical trial registration

No. ChiCTR2200062538.

Comparing access to sexual and reproductive health services among sexual minority youths and their peers: findings from a national survey in China

Background

Little is known about the access to measures of sexual and reproductive health (SRH) services among sexual minority communities in China, where sexuality-related stigma and discrimination remains high. The aim of this study is to investigate access to measures of SRH services among Chinese sexual minority youths (SMY) aged 17 to 24 years old.

Methods

This cross-sectional study utilizes data on 54,580 youths from the 2019–2020 National College Student Survey on Sexual and Reproductive Health, conducted across 31 provinces in mainland China. Multivariable logistic regression modelling was utilized to assess the access to SRH services among Chinese youth with different self-reported sexual orientation.

Results

The majority of respondents identified as heterosexual (77.6%). The remaining respondents identified as bisexual (9.0%), lesbian or gay (2.8%), others (3.02%), or unknown (7.51%). Gay men reported greater access to free contraceptives at health centers (OR 1.62, 95% CI: 1.32–1.99) and were more likely to have receive medical treatment for sexual and reproductive issues (OR 1.83, 95% CI: 1.26–2.63) compared to heterosexual men. Gay and bisexual men were also more likely to use condom at first sexual intercourse compared to heterosexual men (gay men: OR 1.38, 95% CI: 1.13–1.68; bisexual men: OR 1.33, 95% CI: 1.03–1.71). However, the associations were reversed among women (lesbians: OR 0.05, 95% CI: 0.03 to 0.08; bisexuals: 0.75, 95% CI: 0.65 to 0.86).

Conclusions

Although SMY reported higher utilization of SRH services compared to their heterosexual counterparts, access to SRH services remains low among Chinese youths. Greater focus should be placed on improving access to SMY-friendly SRH services among Chinese youths.

HIV Serostatus Disclosure Among Men Who Have Sex with Men in China in the Era of U=U and PrEP

Given the recent evidence on "Undetectable = Untransmittable" (U=U) and pre-exposure prophylaxis (PrEP), the present study aimed to investigate HIV disclosure behaviors and their associations with sexual risk behaviors and U=U and PrEP awareness among men who have sex with men (MSM) in China. A cross-sectional survey was conducted among 689 MSM recruited through a gay-friendly non-governmental organization located in Chengdu, China in 2018-2019. Information was collected by a structured self-administrated questionnaire. The enrolled sample included 554 (80.4%) participants who were HIV-negative and 135 (19.6%) participants with an unknown HIV status. In terms of disclosure, 41.4% of participants informed all partners about their HIV status all the time (informing behavior), while 30.4% asked all partners about their HIV status all the time (asking behavior). Only one-fifth knew about U=U, but this was not statistically associated with either informing or asking behavior. Half (50.5%) had heard of PrEP but this was not statistically associated with either informing or asking behavior. Common barriers to informing and asking behaviors were lower risk perception of HIV infection, a history of sexually transmitted infections, engagement in receptive sex, and a history of sex with casual partners. We found that both U=U and PrEP awareness and HIV serostatus disclosure were infrequent and not associated in this study of Chinese MSM. These data indicate huge information gaps among MSM in China.

HIV incidence and risk factors among transgender women and cisgender men who have sex with men in two cities of China: a prospective cohort study

Background

HIV epidemic among men who have sex with men (MSM) remains a major public health concern in China. Despite a growing body of research on transgender women worldwide, little is known about Chinese transgender women within MSM. We sought to estimate HIV incidence and distinguish risk factors of HIV acquisition among them from that among cisgener (non-transgender) MSM (cis-MSM).

Methods

We conducted an open cohort study among Chinese MSM, including those who were identified as transgender in Shanghai and Tianjin. Participants were initially recruited by local community-based organizations from January to June, 2016, and were followed up approximately every 6 months until June 2018. At each visit, a structured questionnaire was used to gather information on demographics, sexual risk behaviors, and HIV status. HIV incidence was calculated as the number of seroconversions divided by total number of person-years of follow-up among HIV-negatives at baseline. Risk factors of HIV acquisition were assessed by univariate and multivariate Cox regression models with time-dependent variables.

Results

A total of 1056 participants contributed 1260.53 person-years (PYs) of follow-up, 33 HIV seroconversions occurred during the follow-up period, yielding an estimated HIV incidence of 2.62 (95% CI 1.80–3.68) per 100 PYs. HIV incidence among transgender women was 4.42 per 100 PYs, which was significantly higher than that of 1.35 per 100 PYs among cis-MSM, demonstrating a threefold higher odds of HIV infection than cis-MSM. For transgender women, those lived locally ≤ 2 years (adjusted hazard ratio [aHR] = 1.76, 95% CI 1.13–2.76) and unprotected anal sex last time (aHR = 4.22, 95% CI 1.82–9.79) were more likely to acquire HIV. For cis-MSM, factors associated with HIV acquisition were frequency of anal sex ≥ 3 times in past one month (aHR = 4.19, 95% CI 1.06–16.47) and unprotected anal sex last time (aHR = 5.33, 95% CI 1.52–18.73).

Conclusions

Compared to cis-MSM, transgender women were at higher risk of HIV acquisition, highlighting an urgent need of tailored prevention. Future HIV program should consider to include them to ensure that this population in China are not left behind.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-00947-3.

Optimal resource allocation in HIV self-testing secondary distribution among Chinese MSM: data-driven integer programming models

Human immunodeficiency virus self-testing (HIVST) is an innovative and effective strategy important to the expansion of HIV testing coverage. Several innovative implementations of HIVST have been developed and piloted among some HIV high-risk populations like men who have sex with men (MSM) to meet the global testing target. One innovative strategy is the secondary distribution of HIVST, in which individuals (defined as indexes) were given multiple testing kits for both self-use (i.e.self-testing) and distribution to other people in their MSM social network (defined as alters). Studies about secondary HIVST distribution have mainly concentrated on developing new intervention approaches to further increase the effectiveness of this relatively new strategy from the perspective of traditional public health discipline. There are many points of HIVST secondary distribution in which mathematical modelling can play an important role. In this study, we considered secondary HIVST kits distribution in a resource-constrained situation and proposed two data-driven integer linear programming models to maximize the overall economic benefits of secondary HIVST kits distribution based on our present implementation data from Chinese MSM. The objective function took expansion of normal alters and detection of positive and newly-tested 'alters' into account. Based on solutions from solvers, we developed greedy algorithms to find final solutions for our linear programming models. Results showed that our proposed data-driven approach could improve the total health economic benefit of HIVST secondary distribution. This article is part of the theme issue 'Data science approaches to infectious disease surveillance'.

User Preferences for an mHealth Approach to Support HIV Self-Testing and Linkage to HIV Prevention or Care Services for MSM in China

This research qualitatively explored user preferences for an app-based mHealth approach to support HIV self-testing and linkage to HIV prevention or care services developed for men who have sex with men (MSM) in China. We conducted 12 online focus group discussions with MSM participants (N = 48) about their preferences for using an app to meet their HIV self-testing and service linkage needs. Data were examined using thematic analysis. Participants specified four domains to align program delivery with their preferences for app-based intervention: (1) expanding HIV prevention/antiretroviral therapy concepts beyond basic knowledge; (2) enhancing the style and presentation of app-based messages; (3) incorporating interactive and dynamic app-engagement features; and (4) creating a "one station" app that covers the continuum of HIV services. Given the changing landscapes of HIV knowledge and community/user preferences for app-based interaction, findings underscore how engagement with end-user participants is essential to optimize mHealth interventions for HIV.

Comparative Outcomes of Partial and Full Facial Feminization Surgery: A Retrospective Cohort Study

BACKGROUND

The demand for facial feminization surgery (FFS) amongst transgender women is on the rise, and requests for a single-stage full FFS (F-FFS) are becoming more frequent. The specific aim of this article is to present our institutional experience with both partial-FFS (P-FFS) and F-FFS with a specific emphasis on safety of each approach.

METHODS

We examined the electronic medical record of all patients with the diagnosis of gender dysphoria that were referred to the senior author for FFS consultation at our institution, between June 2017 and October 2020. Patients were sub-grouped into those who underwent F-FFS (upper, middle, and lower facial thirds in a single anesthetic event) and those who underwent P-FFS. Univariate analysis was used to assess for difference in postoperative complications.

RESULTS

We identified 77 patients who underwent 382 total procedures. The mean follow-up time was 7.5 months (Sd = 7.3) (interquartile range 1.75-12.0 months). Fifty-one (71.4%) patients underwent F-FFS and 21 (28.6%) patients underwent P-FFS. Compared to P-FFS, F-FFS was not associated with an increase in postoperative complication (1 out of 21 [4.8%] versus 4 out of 51 [7.8%]) ( P < 0.556). When comparing characteristics of patients with postoperative complications to patients with no postoperative complications, the average body mass index was significantly higher (30.9 versus 25.4, respectively). ( P < 0.029).

CONCLUSIONS

Full-FFS is a set of procedures that has gained increased popularity among male-to-female transgender patients. Our results support the understanding that F-FFS is a safe and reliable approach, which may be preferable to patients and providers alike.

Effectiveness of sexual health influencers identified by an ensemble machine learning model in promoting secondary distribution of HIV self-testing among men who have sex with men in China: study protocol for a quasi-experimental trial

BACKGROUND

HIV self-testing (HIVST), especially the secondary distribution of HIVST (SD-HIVST) initiated by sexual health influencers (SHIs), has been recognized as an effective strategy in promoting HIV testing, especially among men who have sex with men (MSM). This quasi-experimental study aimed to evaluate whether SHIs identified through the ensemble machine learning approach can distribute more HIVST than those who identified by the empiricalscale.

METHODS

We will recruit eligible adults (≥18 years old) who were assigned male gender at birth, and willing to participate in potential SD-HIVST online. Participants will be assigned randomly to two groups (scale group or machine learning group), followed by a separate process of SHI identification based on the group assignment. After identification, all index participants (defined as identified SHIs who are verbally consented to participate in SD-HIVST or who directly order HIVST kits) will follow the same procedure for SD-HIVST acquisition and distribution. Index participants can order HIVST online and distribute them to members within their social networks (defined as alters) in-person or virtually through a personalized peer referral link. Once a unique alter uploads a photographed test result to the platform, both the alter and the corresponding index participant will receive a fixed incentive of 3 USD. The index MSM can order up to five HIVST in the first three months and ten HIVST in the following three months. Each index participant will need to complete a baseline survey at the first-time ordering and one to two follow-upbased on the times of ordering,, three months after ordering. This trial will be comparing 1) the mean number of alters motivated by each index participant in each group and 2) the mean number of newly-tested alters motivated by each index participant in each group.

DISCUSSION

In promoting the efficacy of identifying SHIs for SD-HIVST, our study has the potential to enhance testing coverage, particularly among marginalized individuals and those who are reluctant to for HIV and other sexually transmitted infections.

TRIAL REGISTRATION

We registered the study on the Chinese Clinical Trial Registry website on 4th November 2021, with registration number ChiCTR2000039632 .

The Epidemiological Analysis of HIV/AIDS Patients: Sexually Transmitted Diseases Department VS. Other Departments in A General Hospital of Shanghai, China

BACKGROUND

Hospital is an important place for HIV/AIDS screening, and a general hospital is composed of multiple departments. Different departments have different levels of understanding of HIV/AIDS, especially the sexually transmitted diseases (STD) department is the main place for HIV/AIDS screening.

OBJECTIVE

The study aims to validate the common knowledge that the STD department is an important place for HIV/AIDS screening by comparing the epidemiological characteristics of HIV/AIDS patients in the STD department and other departments in Tongji Hospital, which can provide a theoretical basis for the precise and differentiated control of HIV/AIDS.

METHODS

A total of 283,525 HIV screening cases were analyzed from January 1st 2006 to December 31st 2018 in the STD department and other departments. The epidemiological data of 226 HIV/AIDS cases were retrospectively analyzed.

RESULTS

Firstly, the incidence of HIV/AIDS in the population served by Tongji Hospital was higher than that in Shanghai and China. Secondly, the positive rate of HIV screening test in the STD department was ten times higher than that of other departments. Thirdly, the social-demographic characteristics of HIV/AIDS patients in the STD department were different from those in other departments. Fourthly, there were differences in age, education, marital status and number of sex partners between men who have sex with men (MSM) and men who have sex with women (MSW). Fifthly, there was no difference except age in social-demographic characteristics of MSM between the STD department and other departments. Sixthly, compared with other departments, the majority of HIV/AIDS patients in the STD department were MSM. Seventhly, syphilis and HIV co-infection were not statistically significant in HIV/AIDS patients between the STD department and other departments.

CONCLUSION

Firstly, the significantly higher positive rate of an HIV screening test in the STD department emphasizes its importance as a place for screening HIV/AIDS patients. Secondly, HIV/AIDS patients diagnosed in the general hospital were mainly transmitted by sexual contact, and MSM accounted for the most part of these patients. More attention should be paid to screen outpatients, especially in the STD department and young men.

Internalized Sexual Minority Stigma is Associated With HIV Testing Behavior Among Chinese Men Who Have Sex With Men: A Cross-Sectional Study

ABSTRACT

Although studies have examined the relationship between HIV-related stigma and HIV testing among men who have sex with men (MSM) in China, there is still a lack of knowledge regarding whether sexual minority stigma and HIV testing are associated. The purpose of this study was to identify the association between sexual minority- and HIV-related stigmas with HIV-testing behavior. A cross-sectional study was conducted in the Hunan Province of China. After controlling for covariates, the multivariate analyses showed that high internalized sexual minority stigma was negatively associated with HIV testing behavior in the previous year. However, anticipated sexual minority- and HIV-related stigmas were not associated with HIV-testing behavior. Findings suggest that internalized sexual minority stigma should be addressed in health care settings to encourage MSM to seek HIV testing services, especially considering the continuing HIV epidemic among MSM in China.

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.

Violence Victimization and Condomless Anal Intercourse Among Transgender Women in China: Mediating Role of Depression

Transgender women (TGW) worldwide report disproportionate violence victimization, depression and condomless anal intercourse (CAI), but the mechanism of the coexistence remains unclear. Using snowball sampling, we recruited 198 self-identified TGW in Shenyang, China between April 2017 and July 2017, and conducted confidential questionnaire survey among them. Positive HIV status was reported by 49 (24.7%) participants. 117 (59.1%) reported at least one type of lifetime violence victimization, with transactional sexual partners being the main violence perpetrators. 108 (54.5%) reported mild to severe depression. 105 (53.0%) reported having CAI with their sexual partners during the last 6 months. Path analysis showed that the association between participants' violence victimization and CAI was fully mediated by their depression (indirect effect: 0.083, p = 0.014; direct effect: 0.137, p = 0.121). We suggest to incorporate violence screening and prevention and mental health services into intervention strategies to prevent CAI among Chinese TGW.

Awareness of and Preferences for Preexposure Prophylaxis (PrEP) among MSM at High Risk of HIV Infection in Southern China: Findings from the T2T Study

This study is aimed at investigating the awareness of and preferences for oral and long-acting injectable HIV preexposure prophylaxis (PrEP) and their associated factors among men who have sex with men (MSM) at high risk of HIV infection in southern China. A cross-sectional survey was conducted among 603 MSM who were recruited through a cohort study called the T2T Study at three sexual health clinics in Guangzhou, Shenzhen, and Wuxi, China, from 2017 to 2018. We collected information on HIV-negative participants' awareness of and willingness to use PrEP and its potential correlations. Univariate and multivariate logistic regressions were used for data analyses. A total of 550 HIV-negative MSM were enrolled in the study. Less than half of at-risk MSM (43.1%) had heard of PrEP before, and the rate of overall willingness to use PrEP was 65.8%, while MSM were more willing to use daily oral PrEP than long-acting injectable- (LAI-) PrEP (62.2% vs. 38.5%). MSM who had university degrees or above (aOR = 1.55, 95% CI: 1.01-2.37), used condoms during last anal sex (1.52, 1.01-2.29), and tested 3 times or more for HIV (2.45, 1.10-5.47) were more likely to be aware of PrEP. MSM who had use of gay dating apps (1.51, 1.02-2.23), ever participated in HIV- or sexually transmitted disease (STD-) related studies (1.91, 1.24-2.94), and had heard of PrEP (3.06, 2.06-4.54) were more willing to use any regimen of PrEP. MSM at high risk of HIV infection had low awareness of PrEP and moderate willingness to use PrEP. Further studies of the implementation and promotion of PrEP targeting at-risk MSM should be performed.

Condom Use and Related Factors among Rural and Urban Men Who Have Sex With Men in Western China: Based on Information-Motivation-Behavioral Skills Model

This study aimed to determine the differences in condom use and related factors among rural–urban men who have sex with men (MSM) in Western China. A cross-sectional survey was conducted in Chongqing, Sichuan, and Guangxi, which recruited MSM by non-probability sampling. Data were collected through an anonymous, standardized, and self-reported questionnaire guided by an information–motivation–behavioral skills model. Structural equation model was applied to analyze the related factors. Out of the 1141 MSM included in this analysis, 856 (75%) and 285 (25%) were from urban and rural areas, respectively. The median age was 27 years for both groups. Self-reported consistent condom use for anal sex in the past 6 months was 57.58%. The rate of consistent condom use was lower in rural MSM than in urban MSM (50.88% vs. 59.81%, p = .008). Behavioral skills, HIV/AIDS intervention services, and response costs had direct positive and negative influences on condom use, respectively. By contrast, motivation and information exhibited indirect influence. All the factors were mediated by behavioral skills in rural and urban MSM, except for the information that had no effect among urban MSM but had an indirect effect among rural MSM. These findings suggest that service providers should pay attention to substantial rural–urban differences and design different AIDS prevention and intervention strategies targeting rural and urban MSM.

Use of multiple recreational drugs is associated with new HIV infections among men who have sex with men in China: a multicenter cross-sectional survey

Background

There is limited information about the types of recreational drugs used by men who have sex with men (MSM) in China or the consequent impact on sexual health and human immunodeficiency virus (HIV) acquisition.

Methods

We recruited MSM from seven cities in China between 2012 and 2013 using multiple approaches including advertisements on gay websites, collaborating with local MSM community-based organizations, peer referrals, and venues such as gay bars and bathrooms visited by MSM. We divided participants into four subgroups based on the number of recreational drugs (RDs) used in the previous 6 months. We defined use of multiple RDs as use of ≥2 types of RDs. Demographics and HIV-related high-risk behaviors were collected, and blood samples were tested for recent HIV infection by the HIV-1 subtypes B, E, and D immunoglobulin G capture enzyme immunoassay (BED-CEIA). We used multivariable logistic regression adjusted for sociodemographics to determine the adjusted odds ratios (aORs) and associated 95% confidence intervals (CIs) of the subgroups of RD use for recent or established HIV infection.

Results

A total of 4496 Chinese MSM participated; 28.4% used RDs, and 5% used multiple types of RDs. The prevalence of each RD use was as follows: poppers (25.9%), ecstasy (2.4%), ketamine (1.2%), amphetamine (0.6%), tramadol (0.4%), methamphetamine (3.8%), and codeine (1.9%). Users of multiple RDs commonly used poppers combined with one or more other types of RDs. Multiple RD users were likely to be aged 26–30 years (vs. 18–25 and > 30 years), live in non-local cities (vs. local cities), never married (vs. married), have a high monthly income (vs. no income and 1–599 USD), use versatile positions during anal intercourse (vs. top or bottom), and have inadequate HIV-related prevention knowledge (vs. adequate). As the number of RDs used in the previous 6 months increased, the prevalence of HIV-related high-risk behaviors increased (P < 0.05 for all). The odds of recent HIV infection were higher among those who used one type (aOR = 2.2, 95% CI: 1.5–3.0) or two types of RD (aOR=2.3, 95% CI: 1.0-5.2) in the previous 6 months compared to the odds among those who did not use RDs.

Conclusion

The level and pattern of multiple RD use among Chinese MSM were different from high-income countries. MSM who used more RDs are more likely to engage in high-risk sexual behaviors, and these behaviors may be associated with increases in new HIV infections.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10223-y.

Understanding How Gay, Bisexual, and Other Men Who Have Sex With Men in China Cope With HIV Care-Related Stressors

Understanding how Chinese gay, bisexual, and other men who have sex with men (GBMSM) cope with HIV care-related stressors could improve their care engagement. Qualitative semistructured interviews were conducted with 30 GBMSM living with HIV recruited through clinics and a community-based organization (CBO) in Chengdu, China. Interviews focused on treatment-related stress, coping strategies, social support, and well-being. Half reported symptoms consistent with mild or moderate depression as measured by the PHQ-9 scale. HIV care-related stressors included side effects, difficulty with adherence, and fear of drug resistance. Challenges to coping include navigating contradictory information about HIV and treatment, experiencing stigma and discrimination within medical and nonmedical settings, and managing financial concerns. CBOs, peer groups, and providers were salient sources of social support benefitting coping. To improve sustained HIV care that meets the needs of Chinese GBMSM living with HIV, tailored interventions that address the above-mentioned stressors and coping challenges are likely needed.

Association between rectal douching and HIV acquisition: the mediating role of condom use and rectal bleeding in a national online sample of Chinese men who have sex with men

OBJECTIVES

Previous studies have demonstrated that rectal douching (RD) is associated with HIV acquisition among men who have sex with men (MSM). However, the precise mechanism underlying the association between RD and HIV remains unclear.

METHODS

We recruited participants over WeChat from October 2017 to October 2018. Respondents received mailed HIV self-testing kits, uploaded images of HIV self-test results and completed an online electronic questionnaire simultaneously. The questionnaire assessed sociodemographic characteristics, RD practices and sexual risk behaviours. HIV status was measured as the result of the HIV self-testing. The Baron and Kenny statistical method was used to assess the association between RD and HIV, controlling for condomless anal intercourse (CAI) and rectal bleeding.

RESULTS

Of 1365 participants, 39.93% (545/1365) reported RD in the past 6 months, 60.07% had multiple male sexual partners and 43.08% had CAI in the past 6 months. The prevalence of HIV, based on self-testing, was 3.37% (46/1365). Multivariable logistic analysis showed RD was significantly associated with bottom sexual role (adjusted OR (aOR) 14.0; 95% CI 9.8 to 20.2), having multiple male sexual partners (aOR 1.8; 95% CI 1.4 to 2.2), CAI (aOR 1.3; 95% CI 1.0 to 1.6), rectal bleeding (aOR 2.0; 95% CI 1.6 to 2.6) and HIV infection (aOR 1.9; 95% CI 1.0 to 3.4). Baron and Kenny analysis found both CAI (aOR 2.2; 95% CI 1.2 to 4.1) and rectal bleeding (aOR 1.9; 95% CI 1.0 to 3.4) play a mediating role in the association between RD and HIV.

CONCLUSIONS

Our study results confirmed the relationship between RD and HIV, and found CAI and rectal bleeding mediated HIV infection in Chinese MSM who douched. Strategies should be encouraged to strengthen health education and reduce high-risk sexual behaviour in order to reduce the risk of HIV in MSM who use enemas. Rectal microbicides may represent an efficient means of providing HIV prophylaxis among MSM.

Modelling the impact of an HIV testing intervention on HIV transmission among men who have sex with men in China

OBJECTIVES

An intervention developed through participatory crowdsourcing methods increased HIV self-testing among men who have sex with men [MSM; relative risk (RR) = 1.89]. We estimated the long-term impact of this intervention on HIV transmission among MSM in four cities (Guangzhou, Shenzhen, Jinan and Qingdao).

METHODS

A mathematical model of HIV transmission, testing and treatment among MSM in China was parameterized using city-level demographic and sexual behaviour data and calibrated to HIV prevalence, diagnosis and antiretroviral therapy (ART) coverage data. The model was used to project the HIV infections averted over 20 years (2016-2036) from the intervention to increase self-testing, compared with current testing rates.

RESULTS

Running the intervention once would avert < 2.2% infections over 20 years. Repeating the intervention (RR = 1.89) annually would avert 6.4-10.7% of new infections, while further increases in the self-testing rate (hypothetical RR = 3) would avert 11.7-20.7% of new infections.

CONCLUSIONS

Repeated annual interventions would give a three- to seven-fold increase in long-term impact compared with a one-off intervention. Other interventions will be needed to more effectively reduce the HIV burden in this population.

Rectal douching among men who have sex with men in six cities in China: a cross-sectional study

Background Rectal douching, which is a common practice among men who have sex men (MSM) as a preparation for anal sex, may potentially increase the risk of HIV infection. However, little is known about the practice of rectal douching among Chinese MSM. This study investigated the characteristics of rectal douching and factors associated with rectal douching.

METHODS

Between January and March 2019, MSM aged ≥18 years in six cities in China were recruited to the study. Participants were asked to complete a self-administered online questionnaire. Chi-squared tests and multivariable logistic regression were used to examine factors associated with rectal douching by calculating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Of 485 MSM in this study, 278 (57.3%) practiced rectal douching in the preceding 6 months. The most common reasons for douching before and after anal sex were hygiene/cleanliness (78.6% and 66.1% respectively) and HIV/STI prevention (8.5% and 17.4% respectively). The most used enemas and equipment before and after anal sex were tap water (73.5% and 70.2% respectively) and showerhead hoses (76.1% and 75.2% respectively). Men who engaged in both insertive and receptive anal sex (OR 8.84; 95% CI 4.52-17.30), exclusively receptive anal sex (OR 6.56; 95% CI 3.55-12.13), condom-less anal intercourse (OR 1.64; 95% CI 1.03-2.63) and anal sex after alcohol use (OR 1.54; 95% CI 1.00-2.35) were more likely to perform douching.

CONCLUSION

Rectal douching is common in MSM, some of whom may not realise the potential risks associated with douching. The co-occurrence of douching and other high-risk behaviours would make MSM more vulnerable to HIV. Health education aimed at informing MSM of the potential risks and addressing the high prevalence of douching are urgently needed.

Risk assessment and identification of HIV infection among men who have sex with men: a cross-sectional study in Southwest China

OBJECTIVES

The HIV epidemic is around 7%-20% among men who have sex with men (MSM) in Southwest China. The low HIV-testing rate highlights the need for tools to identify high-risk MSM in resource-limited regions. Our aim was, therefore, to evaluate the HIV RISK Assessment Tool for HIV prediction and to characterise the primary infection among MSM in Southwest China.

DESIGN

A cross-sectional survey was conducted in Guizhou province between January and December 2018. Participants were recruited from gay communities, among whom the HIV RISK Assessment Tool was evaluated. Logistic regression was used to analyse items associated with HIV and the area under the curve (AUC) of the receiver operating curve was calculated to quantify discrimination performance.

PARTICIPANTS

1330 MSM participants, of which 83 (6.2%) tested as HIV positive.

RESULTS

A higher composite score of the tool (adjusted OR (aOR) 9.33, 95% CI 4.57 to 19.05) was independently associated with HIV infection. Items positively associated with HIV infection included having 2-5 same sex partners (aOR 2.43, 95% CI 1.28 to 4.64), always (aOR 5.93, 95% CI 1.59 to 22.13) or sometimes (aOR 4.25, 95% CI 2.09 to 8.64) having unprotected anal intercourse, taking both insertive and receptive sex roles (aOR 4.95, 95% CI 2.57 to 9.53) or only the receptive sex role (aOR 2.26, 95% CI 1.21 to 4.24). The tool showed an optimal discrimination ability (AUC=0.827), with a specificity of 0.747 and sensitivity of 0.785. Five MSM were identified with primary infection and had similar sexual risk behaviors as HIV-positive participants.

CONCLUSIONS

The HIV RISK Assessment Tool showed an overall good performance in predicting HIV risk among MSM in Guizhou province where the prevalence is still severe. This tool also demonstrated a potential to identify primary infection and is worth being promoted in resource-limited regions.

Low awareness of and willingness to use PrEP in the Chinese YMSM: An alert in YMSM HIV prevention

OBJECTIVES

Despite being a key population in whom to initiate pre-exposure prophylaxis (PrEP), the awareness of and willingness to use PrEP are still unclear in Chinese young men who have sex with men (YMSM). We report factors associated with PrEP awareness and willingness in the population.

METHODS

From 1 August to 31 December 2018, 495 participants aged 15-24 years were included in a cross-sectional study about awareness of and willingness to use PrEP among YMSM. Logistic regression models were used to identify factors associated with two outcomes: awareness of PrEP; and willingness to use PrEP.

RESULTS

Among 495 eligible participants, 129 participants (26.1%) knew about PrEP. PrEP awareness among YMSM was associated with higher education level [adjusted odds ratio (aOR) = 1.812, 95% CI: 1.113-2.951] and previous HIV testing (aOR = 3.507, 95% CI: 1.261-9.752). YMSM with shorter local residence time (aOR = 0.317, 95% CI: 0.101-0.992) and internet-based partner-seeking (aOR = 0.171, 95% CI: 0.096-0.305) were less likely to be aware of PrEP. In those with previous knowledge of PrEP, 36 (27.9%) conveyed their willingness to use it. PrEP willingness was associated with internet-based partner-seeking (aOR = 9.593, 95% CI: 1.965-46.844). The main barriers influencing those who knew about PrEP but refused to use it were the high price of PrEP (69.9%), the need to use condoms consistently (52.7%), and concerns about side effects (39.8%) and effectiveness of prevention (22.6%).

CONCLUSIONS

Chinese YMSM have low awareness of and willingness to use PrEP. Adequate PrEP promotions should be implemented, especially on the Internet and dating software.

Adolescent and non-consensual anal sexual debut among Chinese men who have sex with men: a cross-sectional study

BACKGROUND

Adolescent sexual debut and non-consensual sex have been linked to higher sexual risk and STI infection in adulthood among men who have sex with men (MSM) in high-income countries. This study aimed to examine adolescent and non-consensual anal sexual debut among Chinese MSM and to evaluate factors associated with adolescent sexual debut and non-consensual anal sex.

METHODS

A cross-sectional study was conducted recently among Chinese men assigned male sex at birth, ≥18 years old, and who had ever engaged in anal sex with a man. Participants answered questions regarding socio-demographics, condomless sex, age at anal sexual debut with a man, and whether the first anal sex was consensual. Factors associated with an adolescent sexual debut (< 18 years old) and non-consensual sex at sexual debut were evaluated. We defined adolescent sexual debut as having anal sex with another man at 17 years old or younger, and the participants were asked whether their first male-to-male anal sex was non-consensual.

RESULTS

Overall, 2031 eligible men completed the survey. The mean age of sexual debut was 20.7 (SD = 4.3) years old. 17.6% (358/2031) of men reported adolescent sexual debut, and 5.0% (101/2031) reported a non-consensual sexual debut. The adolescent sexual debut was associated with having more male sexual partners (adjusted OR 1.10, 95% CI 1.06-1.15) and condomless anal sex in the last three months (AOR = 1.71, 95% CI 1.34-2.18). MSM whose sexual debut was non-consensual were more likely to have condomless anal sex (AOR = 1.76, 95% CI 1.17-2.66), and to have reported an adolescent sexual debut (AOR = 2.72, 95% CI 1.75-4.21).

CONCLUSIONS

Many Chinese MSM reported adolescent sexual debut and non-consensual sex, both of which are associated with sexual risk behaviors and drive STI transmission. These findings highlight the need for designing tailored interventions for MSM who experienced adolescent sexual debut and non-consensual sex at debut.

The Role of Social Support in HIV Testing and PrEP Awareness among Young Black Men and Transgender Women Who Have Sex with Men or Transgender Women

Young black men and transgender women (transwomen) who have sex with men or transwomen are most vulnerable in terms of risk for HIV infection, also reflected in their extremely high incidence rates. As testing rates and pre-exposure prophylaxis (PrEP) uptake remain suboptimal among these groups, primarily due to unique structural barriers, the present analyses draw on data from an online survey, administered October 2014 to August 2015, to explore social support-related predictors of knowledge and behavior around HIV prevention.Participants were 169 biological men who identified as black, with a mean age of 24 (SD = 2.97, range 17-29); 8% identified as transwomen. Logistic regression models assessed whether HIV-related social support predicted HIV testing patterns, PrEP awareness, and use. Those with higher HIV-related social support reported having been more likely to have ever tested (adjusted odds ratio (aOR) = 1.48; p < 0.001) and tested in the past 6 months (aOR = 1.22; p < 0.01). They were also more likely to intend to test in the next 6 months (aOR = 1.16; p < 0.001), including at a medical office or community-based organization (aOR = 1.20; p < 0.001), yet less likely to intend to self-test (aOR = 0.81; p < 0.001). Lastly, higher social support was significantly associated with prior knowledge of self-testing (aOR = 1.19; p < 0.05), couples testing (aOR = 1.26; p < 0.001), and PrEP (aOR = 1.22; p < 0.01), as well as prevention self-efficacy (aOR = 1.30; p < 0.001), but inversely associated with prior self-testing (aOR = 0.80; p < 0.05). For young black men and transwomen who have sex with men or transwomen, HIV-related social support, which likely has a strong peer component, appears to be a facilitator of optimal testing and intentions to test, as well as awareness of novel prevention strategies (like self-testing or PrEP). However, community resourcefulness needs to be bolstered by other mechanisms, such as changes within healthcare settings, to increase actual use of novel prevention modalities.

HIV Infection Does Not Increase 10-Week Mortality of Chinese Cryptococcal Meningitis Patients

The role of HIV infection in precipitating different clinical features in cryptococcal meningitis (CM) patients remains controversial. One hundred twelve CM patients living with HIV/AIDS (CM+HIV+ patients) and 112 CM patients living without HIV/AIDS (CM+HIV- patients) were enrolled after propensity score matching. Demographic characteristics, symptoms, routine blood tests, and biochemical and cerebrospinal fluid (CSF) profiles were compared between the two groups. Kaplan-Meier analysis and Cox proportional hazards model was used to assess 10-week mortality. CM+HIV+ patients frequently occurred in young (mean age 40.3 ± 10.5) and male (89.3%) populations who also experienced leukopenia, neutropenia, lymphocytopenia, thrombocytopenia, and hypoalbuminemia, less headaches (66.9%), and higher cryptococcemia (23.2%) (all p < .050); they also had higher glucose (2.6 ± 1.1 mmol/L), increased smear positivity (78.8%), and decreased white blood cells [8.0 (2.0-28.0) × 10⁶/L] in initial CSF assay (all p < .050). The 10-week cumulative survival rate was 84.6% for CM+HIV+ patients and 88.5% for CM+HIV- patients (p = .345). Age <35.0 years (hazard ratio (HR) 3.0 (1.0-8.9), p = .046), intracranial pressure (ICP) >250.0 mmH₂O (HR: 4.8 (1.1-21.6), p = .041), and treatment lacking amphotericin B [HR: 6.5 (1.9-21.4), p = .003] were independent risk factors for 10-week mortality in CM+HIV+ patients. There are significant clinical differences in CM patients living with or without HIV/AIDS. However, the 10-week survival rate was similar between the two groups. Younger population, high ICP, and treatment lacking amphotericin B were independent risk factors for 10-week mortality of Chinese CM+HIV+ patients.

Gender Differences in Sleep Problems Among Drug Users

BACKGROUND

Illicit drug use has been recognized as a major problem. Clinical studies demonstrated that poor sleep quality was associated with increased frequency of drug use and relapse. However, few studies addressed the issue of sleep quality and gender differences in illicit drug dependent subjects. The present study aimed to explore the gender differences in sleep problems in drug users.

METHODS

In this cross-sectional study, a total of 2,178 illicit drug users, including 1,875 male users [884 methamphetamine (MA) users and 991 heroin or other drug users] and 303 female users (78 MA users and 225 heroin or other drug users, 13.9%), from drug rehabilitation centers in Changsha, and 2,236 non-drug-using subjects, including 1,910 males and 326 females (14.6%) completed the self-report Pittsburgh Sleep Quality Index (PSQI).

RESULTS

We found that the prevalence of suggestive sleep problems (PSQI>5) between male and female was 67.4 and 75.2% in overall illicit drug use sample (p<0.001), 52.4 and 75.6% in MA users (<0.001), 80.8 and 75.1% in heroin or other drugs users (p=0.054), 26.0 and 28.8% in healthy controls (p=0.287). For sleep quality, the mean of PSQI total score (M±SD) between male and female was 7.8±4.42 and 8.9±4.15 in overall illicit drug users (p<0.001), 6.4±4.45 and 9.1±4.00 in MA users (<0.001), 9.1±3.96 and 8.9±4.21 in heroin or other drugs users (p=0.394), 4.2±2.46 and 4.4±2.51 in healthy control sample (p=0.090). These results indicated that only MA users, rather than heroin or other drugs users and healthy controls, showed gender differences in sleep problems.

CONCLUSIONS

In this study, female users reported higher frequency of sleep problems and poorer sleep quality than male users in MA users' group, but not in heroin or other drug users group. Future studies aim at quantifying the benefits of treatment interventions should not neglect the influence of sleeping problems and its gender differences.

Prevalence and risk factors of paradoxical tuberculosis associated immune reconstitution inflammatory syndrome among HIV-infected patients in Beijing, China

Background

In this study, we aimed to describe the prevalence, clinical presentation and risk factors of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) cases in China.

Methods

We performed a descriptive analysis of demographic and clinical data of HIV/TB coinfected patients receiving ART at Beijing Ditan Hospital between January 2014 and October 2018.

Results

Of 199 patients included, 45 (22.6%) developed paradoxical TB-IRIS, and 19 (9.5%) TB-IRIS cases presented miliary TB. The pre-ART CD4 count lower than 50 cells/mm³ was found to be significantly associated with development of TB-IRIS. Similarly, patients with higher than 4-fold increase in CD4 cell count after antiretroviral therapy (ART) had significantly higher odds of having TB-IRIS. When patients aged 25–44 years were utilized as the control group, youths (< 25 years old) were more likely to have miliary TB. No significant difference was observed in the intervals from initiation of ART to IRIS presentation between miliary and non-miliary group.

Conclusions

In conclusion, our data demonstrate that approximate one quarter of patients coinfected with TB and HIV develop paradoxical TB-IRIS after initial of ART therapy in China. Lower baseline CD4 count and rapid increase in CD4 count are the major risk factors associated with the occurrence of paradoxical TB-IRIS.

HIV Self-Testing to Promote Serostatus Disclosure Among Men Who Have Sex With Men in China: Protocol for a Stepped Wedge Randomized Controlled Trial

BACKGROUND

Disclosure of HIV serostatus is important for the prevention of HIV infection among men who have sex with men (MSM). However, knowledge of sexual partners' HIV status among MSM in China is low. As a complement to HIV testing services, HIV self-testing (HIVST) has considerable potential to promote serostatus disclosure.

OBJECTIVE

The primary objective of our trial is to evaluate the effect of HIVST on improving serostatus disclosure to sexual partners. We hypothesize that MSM in an intervention condition will have a higher awareness of the HIV status of their sexual partners compared with MSM in the control condition. The secondary aims are to evaluate (i) changes in sexual behaviors after disclosure of HIV status by sexual partners, (ii) promotion of the frequency of HIV and syphilis testing on participants and their sexual partners, and (iii) factors that restrict the disclosure of HIV infection to sexual partners. We hypothesize that MSM in the intervention condition will exhibit safer sexual decision making and a higher rate of HIV testing uptake compared with MSM in the control condition.

METHODS

A stepped wedge randomized controlled trial will be conducted throughout China. Study recruitment of 800 MSM will be promoted through advertisements released on WeChat public accounts. Individuals who are born biologically male, aged ≥18 years, HIV negative, and who have not undergone HIV testing in the past 3 months will be recruited. Eligible men will be randomly divided (1:1:1:1) into four groups and randomized. The group cluster will initiate the intervention so that participants will be provided with 2-4 free finger prick-based HIVST kits until trial completion. The intervention period for participants in each of the four groups will be initiated at 3-month intervals. Men in both groups will be required to complete a baseline and four follow-up surveys every 3 months. The primary intervention outcome will evaluate the effect of the distribution of HIVST kits on improvement in the disclosure of sexual partners' HIV status. The secondary outcomes will be changes in sexual behaviors after disclosure of HIV status from sexual partners, the promotion of the frequency of HIVST on participants and their sexual partners, and the factors that restrict disclosure of HIV status to sexual partners.

RESULTS

Subject recruitment began in August 2018. The first round of follow-up surveys post intervention is complete, with three rounds remaining to be done. Data analysis was scheduled for April 2020 and the results will be disseminated through conferences and peer-reviewed publications.

CONCLUSIONS

Few studies have evaluated interventions to increase knowledge of sexual partners' HIV status among MSM. Our trial will provide information on the link between HIVST and HIV serostatus disclosure. The findings of this trial will facilitate the implementation of HIVST services to help control the spread of HIV among MSM in China.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1800019453; http://www.chictr.org.cn/showproj.aspx?proj=30158.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17788.

A Secondary Mixed Methods Analysis of a Pay-it-Forward Gonorrhea/Chlamydia Testing Program Among Men Who Have Sex With Men in China

BACKGROUND

Gonorrhea and chlamydia are common among Chinese men who have sex with men (MSM), but testing rates are low. We developed a pay-it-forward program where men receive a free gonorrhea/chlamydia test and can then donate toward future participants' tests. This study aims to investigate drivers of testing uptake and donation using a mixed methods approach.

METHODS

We used a sequential explanatory design to explore drivers of testing uptake and donation unique to pay-it-forward through a quantitative cross-sectional survey and a qualitative thematic analysis of semistructured interviews. We collected data on sociodemographics and perceived benefits of pay-it-forward among men offered the pay-it-forward interventionand analyzed testing uptake and donations using descriptive statistics and logistic regression. We then conducted 30 semistructured interviews with men and coded interview data to identify themes.

RESULTS

Three hundred and one MSM were offered pay-it-forward and 55% (165/301) received gonorrhea/chlamydia testing. Ninety-one percent (150 of 165) donated any amount with a mean of 58.31 ± 53.39 RMB (US $8.61 ± 7.88), or 39% of the standard price of gonorrhea/chlamydia testing. Getting tested was not associated with income, but donations were higher in the highest income bracket (adjusted odds ratio, 7.12; 95% confidence interval, 1.61-31.52). Fifty-eight percent (94 of 162) selected "more MSM can get tested," and 54% (88 of 162) selected "I can help someone else" as benefits of pay-it-forward. Qualitative themes for drivers of testing and donation included flexible pricing, generosity and reciprocity, and MSM community identity.

CONCLUSIONS

Quantitative and qualitative results suggest that this pay-it-forward program may increase gonorrhea/chlamydia testing by reducing cost barriers, leveraging generosity and reciprocity, and mobilizing community altruism.

Evolving HIV Epidemiology in Mainland China: 2009-2018

PURPOSE OF REVIEW

This review is intended to provide an overview of the evolution of HIV epidemiology over the past decade in China.

RECENT FINDINGS

We provided a succinct overall view of the epidemic, followed by surveillance data, profiles of key populations, HIV molecular epidemiology, and drug resistance, as well as survival in the age of antiretroviral therapy usage. For each topical issue, we first reviewed the latest empirical evidence, followed by a brief summary assessment. We briefly addressed the challenges and opportunities of the next generation of HIV control and prevention efforts in China. Notably, macro-social factors need to be integrated into the next generation of clinical and/or behavioral HIV research to inform disease progression and management, as well as control and prevention.

Large Transmission Clusters of HIV-1 Main Genotypes Among HIV-1 Individuals Before Antiretroviral Therapy in the Hebei Province, China

In recent 10 years, the sexual contact transmission has led to the consecutive upsurge of HIV in Hebei. Especially, the risk behaviors such as homosexual contact in Hebei have presented challenges for HIV prevention and treatment efforts. In this study, we found that 98.9% of subjects attributed their HIV-1 infections to sexual contact, and men who have sex with men (MSM) accounted for 77.5%. CRF01_AE (49.6%), CRF07_BC (29.7%), and subtype B (13.0%) were three main genotypes. AE_cluster 1 (73 cases), AE_cluster 2 (62 cases), and 1 large 07_BC cluster (75 cases) were identified, and only closely clustered with MSM sequences from Beijing. Further, all of HIV-1-resistant strains were circulating in transmission clusters. Particularly, 76.5% of subjects resistant to drugs were circulating in above three large transmission clusters associated with MSM from Beijing. Our study proved that the busy movement of MSM between Beijing and Hebei could meet conveniently, which might result in the bidirectional exchange of HIV-1 strains between Beijing and Hebei. As the most frequent genotypes, large transmission clusters associated with CRF01_AE and CRF07_BC have become one of the main factors resulting in the rapid increase of HIV in Hebei. Therefore, the enhanced surveillance for HIV should be planned early among the floating population traveling between Beijing and Hebei. Hebei should construct the cooperative mechanism for HIV prevention and control together with Beijing.

Information-Motivation-Behavioral Skills model of consistent condom use among transgender women in Shenyang, China

BACKGROUND

The Information-Motivation-Behavioral Skills (IMB) model has received consistent empirical support in the context of HIV prevention among various key populations, but not yet among transgender women (TGW). None effective interventions has been carried out among TGW so far to control their high prevalence of unprotected anal intercourse. The intent of the current study is to examine the application of the IMB model to clarifying the association between condom use correlates and condom use frequency among TGW in China.

METHODS

Using snowball sampling, we recruited 198 self-identified TGW in Shenyang, China from April 2017 to July 2017. Participants were required to complete a questionnaire assessing their background characteristics and IMB model constructs. Structural equation modeling (SEM) was conducted to demonstrate the utility of the IMB model.

RESULTS

The consistent condom use (CCU) rate was 47.0%. Results of SEM indicated that HIV-preventive motivation (comprising condom use attitude and subjective norms; β = 0.823, P <  0.001) and behavioral skills (including condom use skills and self-efficacy; β = 0.979, P = 0.004) were related to more frequent condom use, whereas HIV knowledge was unrelated to condom use (β = 0.052, P = 0.540).

CONCLUSIONS

The low CCU rate suggested that TGW in China were at high risk of HIV infection and transmission and a key intervention population. HIV-preventive interventions for this population should focus on enhancing motivation and strengthening behavioral skills to increase condom use frequency and reduce HIV infection.

Challenges for accessing and maintaining good quality of HIV care among men who have sex with men living with HIV in China: a qualitative study with key stakeholders

HIV care in China is shifting toward a community-based model involving a wide range of stakeholders. We aimed to understand key stakeholders' perceived challenges of providing high-quality care for men who have sex with men (MSM) living with HIV. In-depth interviews were conducted with a diverse sample of stakeholders (N = 17) in two Chinese cities, including providers, policymakers, and community workers. Interviews focused on stakeholders' challenges in HIV-related work and perceived barriers for MSM in accessing and maintaining HIV care. Thematic analysis strategies were used. Three cross-cutting themes related to accessibility and quality of care (QoC) emerged. First, MSM- and HIV-related stigma were perceived to increase the risk of MSM dropping out of care. While acknowledging stigma, some providers also expressed discriminatory views such as stereotypes of the MSM community. Second, stakeholders expressed concerns about QoC including healthcare workforce shortages, limited training opportunities, and high work stress while facing increasingly unmet needs from clients. Third, stakeholders shared challenges in mobilizing community resources to expand HIV care including unclear division of responsibility and strict auditing. Supportive policies and resources may be needed to bolster China's primary care workforce and MSM-competent care and, more broadly, high QoC for sexual and gender minority patients.

Facilitators and Barriers Associated with Uptake of HIV Self-Testing among Men Who Have Sex with Men in Chongqing, China: A Cross-Sectional Survey

While studies on human immunodeficiency virus self-testing (HIVST) continue to accumulate after the World Health Organization’s recommendation of HIVST as an additional approach to HIV testing services in 2016, few studies have focused on men who have sex with men (MSM) in Chinese cities. A cross-sectional study was conducted to describe the HIVST status of MSM in Chongqing, China. MSM participants were recruited by random sampling, and qualified interviewers collected data, using confidential self-administered questionnaires. Blood specimens were collected for HIV antibody detection. The survey evaluated the uptake and accuracy of HIVST kits and identified factors that may be associated with HIVST. The proportion of HIVST uptake was 15.6%. The sensitivity and specificity of HIVST were 74.2% (95% confidence interval [CI] 66.6%–80.7%) and 99.0% (95% CI 96.9%–99.7%), respectively. The consistency between the HIVST kit and antibody detection results was 90.5% (95% CI 87.5%–93.0%), and the Kappa value was 0.777 (p < 0.001). The positive predictive value of self-testing kits is 80.9% and the negative predictive value is 17.7%. Having been tested ≥2 times in the last year, higher educational levels, and higher scores of basic HIV/AIDS knowledge facilitated higher uptake of HIVST. Self-reported existing barriers for HIVST uptake included older age, marital status, and having resided in Chongqing for more than two years.

Multilevel factors associated with perpetration of five types of intimate partner violence among men who have sex with men in China: an ecological model-informed study

In China, intimate partner violence (IPV) among men who have sex with men remains poorly investigated. Informed by the ecological model, this study explored multilevel factors associated with perpetration of IPV among men who have sex with men. The participants were recruited from 15 cities in mainland China. Univariate and multivariate regression analyses showed that the prevalence of committing physical, sexual, monitoring, controlling and emotional IPV was 8.6%, 7.1%, 15.2%, 7.6% and 17.1%, respectively. Committing physical IPV showed a positive association with perceived public discrimination and self-stigma towards homosexuality. Committing sexual IPV showed a positive association with involvement with a homosexual support agency and more sex partners. Monitoring IPV was positively associated with higher education and perceived stress, but negatively associated with instrumental and emotional support. Committing controlling IPV showed a positive association with drug use during sex and self-stigma but a negative association with self-esteem, self-efficacy and older age at first homosexual sex. Committing emotional IPV showed a positive association with commercial sex behaviour and perceived stress, but a negative association with resilience. Committing IPV was prevalent in this population. It is necessary to distinguish the various types of IPV in future studies, given their differences in associated factors.

Protecting Men Who Have Sex With Men From HIV Infection With an mHealth App for Partner Notification: Observational Study

Background

Traditional partner notification methods have been implemented for HIV-infected patients, as well as HIV treatment, in order to identify people at risk of HIV infection, especially men who have sex with men (MSM), since they are more likely to have casual sex partners. These traditional methods have some limitations.

Objective

Our study focused on developing an mHealth app to improve partner notification in practice for MSM; the study then focused on evaluating the effects of the app.

Methods

We developed an mHealth app with different modules using Java and HTML5 and tested it in an MSM community to prevent HIV transmission. The HIV incidence stratified by different follow-up periods were calculated. Poisson regression and social networks were used to estimate the risk ratios and to identify the connection among MSM, respectively.

Results

In addition to the partner notification module, which is the kernel of the app, we developed a test result self-query module to enable MSM to get their approved test results in a timely manner, a prompt and warning module to alert users to protect themselves from high-risk conditions, and a health education module to teach users more skills regarding HIV/AIDS prevention. Over a 1-year duration, a total of 3186 MSM used the app, of which 678 had at least two HIV test results since becoming app users; they were included in the final analysis. Among 678 users, a total of 6473 self-queries and 623 partner notifications were recorded, which identified 180 social networks of MSM app users. Those who used the partner notification function were more likely to have self-queries (P<.001). The 678 MSM app users covered 296.47 person-years and contributed to 20 HIV seroconversions; the cumulative HIV infection incidence was estimated as 6.75 per 100 person-years (95% CI 4.38-10.01). We found that the longer the app was used, the lower the HIV incidence (>5 months vs ≤5 months: 2.22 per 100 person-years vs 6.99 per 100 person-years; risk ratio 0.32, 95% CI 0.12- 0.87).

Conclusions

The app developed in this study is consistent with the World Health Organization’s sensitivity and confidentiality recommendations; it has the potential to reduce the risk of HIV infection among MSM.

The epidemic of major sexually transmitted diseases in Shanghai, China, 2009-2018

Acquired immune deficiency syndrome (AIDS), hepatitis B virus (HBV), hepatitis C virus (HCV), gonorrhea and syphilis are the major sexually transmitted diseases (STDs) in the world, which are the focus of epidemic prevention and control in China. The epidemiological trend analysis of STDs in Shanghai could reflect the epidemic situation of these diseases in high-income areas of China, providing a reference for how to control their epidemic. Although the overall incidence rate of infectious diseases levelled off after 2009, Shanghai still faces many new obstacles in the fight against STDs. Without effective prevention and control strategies for high-risk behaviors, such as active sexual activity without protection, for key susceptible populations, there may be a more serious epidemic of STDs in the future. Given these situations, strategies for controlling STDs in Shanghai should be more targeted with the development of epidemics, focusing on the following key areas for future work: i) attaching importance to health education; ii) strengthening epidemic surveillance; and iii) developing Community Health Service Centers (CHSC) as intervention subjects.

"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.

Effects of a Mobile Health Intervention to Promote HIV Self-testing with MSM in China: A Randomized Controlled Trial

This study tested a mobile health (mHealth) intervention program entitled WeTest, delivered via the WeChat mobile app, to promote oral HIV self-testing (HIVST) among MSM in Hefei, China. A total of 100 MSM participants enrolled, completed baseline assessment, were randomly assigned to intervention or control, and completed 6-month follow-up surveys. Intervention participants (n = 50) received two oral HIVST kits and access to WeTest, a private WeChat group which provided app-based messages and referrals to health services related to HIV. Control participants (n = 50) received two oral HIVST kits only. All participants received instructions to upload photographic results of their oral HIVST, which were sent to the project counselor via a secure WeChat online portal; immediate contact and referrals were made to any participants who tested HIV-positive. In GEE analyses adjusting for time effects and baseline confounders, intervention participants had significantly higher rates of HIV testing (adjusted rate ratio RR = 1.99, 95% confidence interval (CI) 1.07–3.84) and, in particular, higher rates of testing via oral HIVST (adjusted RR = 2.17, 95% CI 1.08–4.37) compared with the control group. Significant time effects were also found such that all participants, regardless of group allocation, had significantly higher rates of reporting consistent condom use with main partners (adjusted RR = 18.13, 95% CI 5.19–63.31) and with non-main partners (adjusted RR = 5.33, 95% CI 2.35–12.08). Findings from this study provide evidence for the feasibility, acceptability and preliminary effects of this mHealth approach to promoting oral HIVST among MSM in China.

High HIV prevalence and associated risk factors among transgender women in China: a cross-sectional survey

INTRODUCTION

Transgender women may face the highest prevalence of HIV of any population, experiencing a disproportionate burden of disease frequently confirmed in surveys throughout the developing and developed world. However, few studies have been conducted specifically for transgender women in China. This study aimed to measure HIV prevalence and explore risk factors for infection in a diverse sample of Chinese transgender women to help advocate for prevention and care interventions for this population.

METHODS

From July 2018 to May 2019, we adapted a respondent-driven sampling (RDS) approach to recruit a diverse sample of 250 transgender women through chains of peer referrals in two cities of eastern China, Nanjing and Suzhou. Eligible participants (i.e. 18 years of age or older, living in Jiangsu province and assigned male sex at birth but currently self-identified as a gender different from male) completed a self-administered questionnaire on a mobile phone to collect demographic characteristics and risk behaviours and underwent HIV testing.

RESULTS AND DISCUSSION

The survey sample was young (82% under age 35 years), with 28.8% having a university degree, 39.2% reporting work at entertainment venues, 47.6% ever having taken hormones and 6.4% being diagnosed with an STI in the last year. One in five (20.8%) reported having engaged in sex work. HIV prevalence was 14.8% (95% CI 10.6 to 19.8), with 75.6% of those testing HIV positive reporting they were already aware of their serostatus. In multivariate analysis, HIV prevalence was significantly higher among transgender women above the age of 24 years, those who work at entertainment venues, who never have taken hormones, and who had been diagnosed with an STI in the last year.

CONCLUSIONS

The prevalence of HIV among transgender women in our study, at 14.8%, is among the highest detected in any population in eastern China. Chinese transgender women may therefore follow the disparity in the burden of HIV noted worldwide. Data support policies to prioritize transgender women for HIV testing outreach, for in-depth research to better understand the specific drivers of infection in this population, and for trans-friendly HIV care and prevention programmes to address their specific needs.