Trends of HIV incidence and prevalence among men who have sex with men in Beijing, China: Nine consecutive cross-sectional surveys, 2008-2016

Prevalence and factors associated with fertility desires among HIV-positive MSM

The National surveillance data showed that homosexual transmission played a considerable role in new HIV infections in China. The emphasis on antiretroviral therapy and prevention of mother-to-child transmission provided chances for reproduction among people living with HIV/AIDS. Issues of fertility desire have a paucity of data among HIV-positive men who have sex with men (MSM). This cross-sectional study has assessed fertility attitudes and associated factors, as well as the reproductive knowledge among HIV-positive MSM. Analysis was mainly based on the multinomial regression model. The study included 129 participants, and almost all of the participants (96.1%) were between 18 and 30 years old and 82.2% of them were single. About 35.6% expressed a fertility desire. MSM without siblings tended to have fertility desire (OR = 0.236, 95%CI: 0.078∼0.712, p = 0.010). Surrogacy (36.4%) was the most desired method among the 86 respondents who had the desire or did not make a decision. While the accuracy of the reproductive knowledge was only 69.6%. In summary, we recommend that providers offer much more professional information and develop assisted reproductive technology to meet the reproductive aspirations of HIV-positive MSM.

Distribution pattern, molecular transmission networks, and phylodynamic of hepatitis C virus in China

In China, few molecular epidemiological data on hepatitis C virus (HCV) are available and all previous studies were limited by small sample sizes or specific population characteristics. Here, we report characterization of the epidemic history and transmission dynamics of HCV strains in China. We included HCV sequences of individuals belonging to three HCV surveillance programs: 1) patients diagnosed with HIV infection at the Beijing HIV laboratory network, most of whom were people who inject drugs and former paid blood donors, 2) men who have sex with men, and 3) the general population. We also used publicly available HCV sequences sampled in China in our study. In total, we obtained 1,603 Ns5b and 865 C/E2 sequences from 1,811 individuals. The most common HCV strains were subtypes 1b (29.1%), 3b (25.5%) and 3a (15.1%). In transmission network analysis, factors independently associated with clustering included the region (OR: 0.37, 95% CI: 0.19-0.71), infection subtype (OR: 0.23, 95% CI: 0.1-0.52), and sampling period (OR: 0.43, 95% CI: 0.27-0.68). The history of the major HCV subtypes was complex, which coincided with some important sociomedical events in China. Of note, five of eight HCV subtype (1a, 1b, 2a, 3a, and 3b), which constituted 81.8% HCV strains genotyped in our study, showed a tendency towards decline in the effective population size during the past decade until present, which is a good omen for the goal of eliminating HCV by 2030 in China.

Characteristics of recent HIV infection among individuals newly diagnosed as HIV-positive in South Korea (2008-2015)

Most HIV-positive individuals diagnosed in Korea are infected through sexual contact, with the time of HIV infection therefore often being unknown. The aim of this study was to investigate the characteristics of diagnosed patients near the time of HIV seroconversion to establish useful HIV intervention strategies. Cross-sectional study. Newly diagnosed HIV cases based on the national HIV surveillance system in South Korea, 2008–2015. To distinguish recent from long-standing HIV infection among 5898 nationwide HIV-positive specimens, limiting antigen avidity assays (Sedia HIV-1 LAg-Avidity EIA, cut-off = 1.5) were performed. Data on CD4+ T cell count at HIV diagnosis and death from AIDS within one year after first HIV diagnosis were used to distinguish recent HIV infections. Acute HIV infection is characterized by detectable HIV RNA or HIV p24 antigen levels, along with a negative or indeterminate antibody western blot result, but with the subject subsequently testing positive after a predetermined period. We analyzed the characteristics of recent and acute HIV infections by sex, age, nationality, HIV testing site, region, and reason for HIV testing. Recent and acute HIV infections were described as the proportion of recent and acute HIV infections among newly-diagnosed cases in a given year. Recent and acute HIV infections over the 8-year study period were 20.5% (1210/5898) and 9.5% (562/5898), respectively. Both infections were generally higher in the following groups: males, younger age, Koreans, individuals who were tested due to disease, residents of smaller city or rural area, and individuals diagnosed in recent calendar years. Acute infections were significantly higher among individuals tested in hospitals and due to suspected HIV infection. The recent and acute HIV infection in younger age groups (< 30 years) has been increasing in a given year. There was an increase in the proportion of young individuals with recent HIV infection, and we identified risk groups more at risk of HIV infection recently in Korea. Therefore, our results could prove useful for the development and assessment of national HIV prevention strategies in Korea and provide valuable data for further HIV research.

Differences in Sexual Behaviors, HIV Testing, and Willingness to Use PrEP between Gay and Bisexual Men Who Have Sex with Men in China

Objectives: Accumulating evidence suggests that there may be differences in sexual behaviors, condom use, and HIV prevention service utilization (e.g., HIV testing, PrEP use) between gay and bisexual men, but this remains under-explored, especially among gay and bisexual men in China. Methods: We surveyed 4,142 gay and bisexual men on a geosocial networking app in China. Results: In adjusted model, bisexual men were less likely to have received HIV testing in their lifetime (AOR = .62, 95% CI [.53, .72]) or to have received a recent HIV test (AOR = .78, 95% CI [.68, .90]). Conversely, among those who reported having had anal sex in the past six months, bisexual men were more likely to report consistent condom use than gay men (OR = 1.38, 95% CI [1.17, 1.62]). Compared with gay men, bisexual men were significantly less likely to be aware of PrEP (AOR = .62, 95% CI [.52, .74]) and significantly less willing to use PrEP (AOR = .58, 95% CI [.46, .73]). Conclusions: Tailored HIV prevention interventions are needed to address bisexual men's needs in the context of the unique sociocultural influences on sexual behavior in China.

Characteristics of Four Novel Recombinant Strains from the Backbone of CRF55_01B and CRF65_cpx in Beijing by Near Full-Length Genome

The HIV-1 epidemic was mainly driven by men who have sex with men (MSM) recently in Beijing, China, with high genetic diversity. Novel recombinant strains were frequently reported at 3.4%-9.9%. It is imperative to interpret the recombinant modes and the putative transmission sources by near full-length genome (NFLG). Four individuals from the MSM population were identified as novel recombinant strains during surveillance of pretreatment drug resistance. NFLG sequences were harvested by near end-point dilution and nested PCR with two overlapping half fragments. Phylogenetic inference was performed with subtyping reference sequences and major parental strain sequences, to explore the patterns of genetic recombinant and potential sources of parent strains. The breakpoints were determined using SimPlot 3.5 to draw genome mosaic map, and the potential parental strains were confirmed by Mega 6.0 using segmental neighbor-joining trees. BL19487-00 and BL1948-00 sequences were obtained from epidemiologically linked individuals and shared similar breakpoints (HXB2 nt 4,497 ± 8 to 4,722) with substitution of subtype B pol gene segment in the backbone of CRF55_01B. BL3104-00 and BL4307-00 carried seven and eight breakpoints, respectively, in the backbone of CRF65_cpx with g5 CRF01_AE substitutions. The recombinant fragments were located around gag, pol, and env genes, with vpr-tat and nef-3'-LTR genes only for BL4307-00. No transmitted drug resistance was observed with the four unique recombinant forms (URFs), except for some drug resistance associated mutations. The advent of URFs around CRF55_01B and CRF65_cpx identified in recent years implied that the sexual behaviors were active and the epidemic of HIV was complicated among MSM in Beijing. Molecular epidemiological surveillance and precise control should be reinforced for this population.

Research Progress in the Epidemiology of HIV/AIDS in China

After thirty-two years since the first domestic outbreak of human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS) among injection drug users (IDUs) and almost two decades of comprehensive response efforts by the Chinese government, HIV/AIDS remains a major public health problem. The increasing burden of HIV/AIDS and comorbidities, the emergence of new HIV subtypes and/or circulating recombinant forms and drug mutations, the changing transmission networks, and the urgency of immediate antiretroviral therapy initiation upon an HIV diagnosis are increasingly challenging and altogether likely to have significant impact on the HIV epidemic in China. Upon the call for the global AIDS response to end AIDS by 2030, China needs to develop an innovative and pragmatic roadmap to address these challenges. This review is intended to provide a succinct overview of what China has done in efforts to achieve the global goal of ending AIDS by 2030 and the recently proposed "95-95-95-95" target (95% combination prevention, 95% detection, 95% treatment, 95% viral suppression), and to summarize the most recent progresses in the epidemiological research of HIV/AIDS in China with the aim of providing insights on the next generation of HIV control and prevention approaches and to shed light on upgrading the national strategy to end AIDS in this country.

HIV incidence among men who have sex with men in mainland China: a systematic review protocol

BACKGROUND

Men who have sex with men (MSM) are disproportionately affected by HIV in China. Globally, younger MSM are at higher risk for incident HIV infections, but there has been substantial variation in the estimates of age-stratified HIV incidence among MSM in mainland China, potentially due to regional differences in the nature of the epidemic. Given the need for quality epidemiological data to meet the global goal of ending new HIV infections by 2030, this systematic review and meta-analysis aims to determine age-stratified HIV incidence in mainland China, including consideration by geographic region and time.

METHODS

This review will include longitudinal studies, cross-sectional surveys, and surveillance reports among MSM in mainland China that have reported HIV incidence. We will search studies and reports published from January 1, 2003, to April 30, 2020, in both English and Chinese language literature databases. For each study considered, two reviewers will independently screen, determine eligibility, and extract relevant data, with discrepancies resolved by consensus of a third reviewer. The methodological quality of included studies will be assessed by the Quality Assessment Tool for Systematic Reviews of Observational Studies Score (QATSO). We will develop age-stratified estimates of HIV incidence with geographic variations and temporal trends. Heterogeneity will be examined using statistical techniques appropriate to the dataset. For subgroup analyses, we will conduct mixed-effects meta-analysis models.

DISCUSSION

This review will contribute to a better understanding of the HIV epidemic among MSM in mainland China by providing age-stratified estimates of HIV incidence with a portrayal of geographic and temporal variations. Findings will reflect epidemic dynamics, informing local and national intervention programs and policies for HIV prevention, and providing estimation data to inform future research among MSM in China.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID 154834.

Measuring the uptake of continuous care among people living with HIV receiving antiretroviral therapy and social determinants of the uptake of continuous care in the southwest of China: a cross-sectional study

Background

Continuous care is essential for people living with HIV. This study aimed to measure continuous care uptake and investigate the association between higher uptake of continuous care and behavioral and social factors, including HIV-acquisition risk and socioeconomic characteristics.

Methods

A hospital-based cross-sectional study was conducted from April to November 2019 in an HIV treatment center of a specialized hospital in Kunming city, China. Fourteen service indicators were used to calculate composite care scores, which were classified into three levels (low, middle, and high), using principal component analysis. The Behavioral Model for Vulnerable Populations was employed to examine predisposing, enabling, and need factors associated with composite care scores among people living with HIV.

Results

A total of 702 participants living with HIV aged ≥ 18 years (median age: 41.0 years, 69.4% male) who had been on ART for 1–5 years were recruited. Based on ordinal logistic regression modeling, predisposing factors: being employed (adjusted odds ratio (AOR): 1.54, 95% confidence interval (CI): 1.13–2.11), heterosexuals (AOR: 1.58, 95% CI: 1.11–2.25) and men who have sex with men (AOR: 2.05, 95% CI: 1.39–3.02) and enabling factors: Urban Employee Basic Medical Insurance (AOR: 1.90, 95% CI: 1.03–3.54), middle socioeconomic status (SES) (AOR: 1.42, 95% CI: 1.01–2.01), were positively associated with the higher level of continuous care uptake, compared to the unemployed, people who inject drugs, those with no medical insurance and low SES, respectively.

Conclusion

There were large differences in continuous care uptake among people living with HIV. HIV-acquisition risk categories and socioeconomic factors were significant determinants of uptake of continuous care. Our findings could inform the development of evidence-based strategies that promote equitable healthcare for all people living with HIV.

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.

Increases in both HIV and syphilis among men who have sex with men in Vietnam: Urgent need for comprehensive responses

The objective of this study was to determine the temporal trends and factors associated with HIV and syphilis infection among men who have sex with men (MSM) in southern Vietnam. Data from the 2014-2018 national HIV sentinel surveillance of MSM aged 16 years or older were collected from three provinces, including An Giang (N = 761), Can Tho (N = 900), and Ho Chi Minh City (N = 1426), and examined for changes in prevalence rates of HIV and syphilis and risk behaviors over time. Multivariate logistic regression was performed to assess the trends and correlates of HIV and syphilis infections among MSM. There were upward trends for HIV (9.5% in 2014 to 14.2% in 2018, p-trend<0.01), syphilis (4.9% in 2014 to 8.0% 2018, p-trend<0.01), and HIV/syphilis co-infection (1.9% in 2014 to 3.1% in 2018, p-trend=0.01). Factors associated with HIV infection included place of residence, early sexual debut, consistent condom use and not engaging in anal sex during the past month, not knowing one's HIV test results, having ever injected drugs, and having active syphilis. Additionally, early sexual debut and being HIV positive were associated with syphilis infection. Rising prevalences of these infections among MSM suggests an urgent need for comprehensive intervention packages for HIV/STI prevention.

The effects of intimate relationship characteristics on unprotected anal intercourse among same-sex male couples in China: a dyadic analysis using the actor-partner interdependence model

BACKGROUND

Unprotected anal intercourse (UAI) within the context of concurrent sexual relationship are prevalent among men who have sex with men (MSM) who have regular male sex partners and it aggravates the risk of HIV infection among this community. The aim of this study was to assess the effect of intimate relationship characteristics on UAI among MSM couples at the dyadic level.

METHODS

Two hundred four MSM couples were recruited from a HIV testing clinic from April 2017 to April 2018 in Guangzhou, China. The actor-partner interdependence model (APIM) was applied for dyadic analysis. Each MSM couple was divided into the insertive role and the receptive role according to their regular anal sex role. In this context, actor effect is the impact of an MSM's intimate relationship characteristics on his own UAI, and partner effect is the impact of his partner's intimate relationship characteristics on his UAI.

RESULTS

Of the 408 participants, 58.82% had UAI with regular male sex partner (UAI-RP) and 8.09% had concurrent UAI. Intimate relationship characteristics were associated with concurrent UAI, but not associated with UAI-RP. For the receptive role, his relationship investment exerted significant actor and partner effects on concurrent UAI (AOR actor = 1.31, P < 0.001; AOR partner = 1.17, P < 0.001). Meanwhile, receptive role's violence experience within relationship exerted significant actor effects on his own concurrent UAI (AOR actor = 6.43, P = 0.044).

CONCLUSIONS

Relationship investment and violence experience influenced concurrent UAI among MSM couples and it varied in different sex roles. Additional assistance on empowerment, relationship therapy and sexual agreement is urgently needed to reduce their high possibility on engagement of HIV-related risk behaviors.

HIV incidence and sexual behavioral correlates among 4578 men who have sex with men (MSM) in Chengdu, China: a retrospective cohort study

Background

The prevalence of HIV among men who have sex with men (MSM) in southwest China is still increasing. This study aimed to investigate the trend in HIV incidence and its associated risk factors among MSM in Chengdu, China.

Method

Incidence data were collected from the largest local non-governmental organization (NGO) serving MSM in Chengdu between 2012 and 2018, while information on sexual behaviors was collected from 2014. All MSM who received voluntary counseling and testing services (VCT) in the collaborating NGO at least twice during the study period were included. We calculated the HIV incidence density among MSM every 2 years and the overall incidence rate. A Cox proportional hazards regression model was employed to identify risk factors for HIV infection.

Result

A total of 4578 HIV-negative participants were included in the cohort. The total incidence density was 5.95 (95% CI: 5.37–6.56)/100 person-years (PYs) between 2012 and 2018. The segmented incidence density was 9.02 (95% CI: 7.46–10.78), 5.85 (95% CI: 4.86–6.97), 5.43 (95% CI: 4.53–6.46), and 3.09 (95% CI: 2.07–4.41)/100 PYs in 2012–2013, 2014–2015, 2016–2017, and 2018, respectively. After adjusting for sociodemographic characteristics, compared to participants without sexual partners within 6 months, MSM with one fixed partner (Adjusted Hazard Ratio, AHR = 1.18, 95% CI: 0.44–3.19) and more than five partners (AHR = 2.24, 95% CI: 0.81–6.20) had increased risk of HIV infection. MSM who used condom inconsistently had a higher risk of HIV infection (AHR = 1.87, 95% CI: 1.46–2.38) compared to consistent condom users.

Conclusion

The decreased HIV incidence density among MSM was potentially related to the successful comprehensive HIV prevention strategies in Chengdu. Multiple male sexual partnerships and inconsistent condom use during anal intercourse were risk factors associated with HIV occurrence.

HIV incidence among men who have sex with men using geosocial networking smartphone application in Beijing, China: an open cohort study

Background

Sexual transmission among men who have sex with men (MSM) is the dominant route of HIV transmission in China. Extensive use of geosocial networking (GSN) smartphone application (app) has dramatically changed the pattern of sexual behaviors and HIV risk among MSM, but data on HIV incidence and the changing risk behaviors of GSN app-using MSM are limited. We aims to assess the HIV incidence and its correlates among gay GSN app-using MSM in China.

Methods

We constructed an open cohort which was initiated and maintained using a GSN app to assess the HIV incidence among app-using MSM, recruited from June 2017 to December 2018. MSM completed an online questionnaire on their sociodemographic characteristics, sexual behaviors, recreational drug use and sexually transmitted infections status. Then each man had an HIV test, and those tested negatives were enrolled into the cohort. Participants completed follow-ups with additional HIV tests though the app during the study period, and were censored at HIV seroconversion or study end date. HIV incidence was calculated by dividing the sum of observed HIV seroconversions by the observed person-time. Univariate (Chi-square test and Fisher’s exact test) and multivariate (proportional hazards regression) analyses were used to examine correlates of HIV incidence.

Results

A total of 6957 HIV negative MSM were enrolled in the open cohort, 37 seroconversions occurred among 1937 men contributing 1065 observed person-years: HIV incidence was 3.47 per 100 person-years [95% confidence interval (CI): 2.37–4.57]. More than five sexual partners [hazard ratio (HR) = 2.65, 95% CI: 1.04–6.67], and sex with HIV positive partners (HR = 3.82, 95% CI: 1.16–12.64) in the preceding six months were positively associated with HIV seroconversion. Consistent condom use for anal sex (HR = 0.27, 95% CI: 0.07–0.96), and reporting insertive anal sex only (HR = 0.23, 95% CI: 0.08–0.62) in the preceding six months were protective factors for HIV seroconversion.

Conclusions

Tailored interventions targeting app-using MSM are urgently needed given their high risk of HIV. As a new tool for accessing MSM at higher HIV risk, GSN smartphone app could play an important role in HIV research among MSM.

The impact of disruptions due to COVID-19 on HIV transmission and control among men who have sex with men in China

INTRODUCTION

The COVID-19 pandemic is impacting HIV care globally, with gaps in HIV treatment expected to increase HIV transmission and HIV-related mortality. We estimated how COVID-19-related disruptions could impact HIV transmission and mortality among men who have sex with men (MSM) in four cities in China, over a one- and five-year time horizon.

METHODS

Regional data from China indicated that the number of MSM undergoing facility-based HIV testing reduced by 59% during the COVID-19 pandemic, alongside reductions in ART initiation (34%), numbers of all sexual partners (62%) and consistency of condom use (25%), but initial data indicated no change in viral suppression. A mathematical model of HIV transmission/treatment among MSM was used to estimate the impact of disruptions on HIV infections/HIV-related deaths. Disruption scenarios were assessed for their individual and combined impact over one and five years for 3/4/6-month disruption periods, starting from 1 January 2020.

RESULTS

Our model predicted new HIV infections and HIV-related deaths would be increased most by disruptions to viral suppression, with 25% reductions (25% virally suppressed MSM stop taking ART) for a three-month period increasing HIV infections by 5% to 14% over one year and deaths by 7% to 12%. Observed reductions in condom use increased HIV infections by 5% to 14% but had minimal impact (<1%) on deaths. Smaller impacts on infections and deaths (<3%) were seen for disruptions to facility HIV testing and ART initiation, but reduced partner numbers resulted in 11% to 23% fewer infections and 0.4% to 1.0% fewer deaths. Longer disruption periods (4/6 months) amplified the impact of disruption scenarios. When realistic disruptions were modelled simultaneously, an overall decrease in new HIV infections occurred over one year (3% to 17%), but not for five years (1% increase to 4% decrease), whereas deaths mostly increased over one year (1% to 2%) and five years (1.2 increase to 0.3 decrease).

CONCLUSIONS

The overall impact of COVID-19 on new HIV infections and HIV-related deaths is dependent on the nature, scale and length of the various disruptions. Resources should be directed to ensuring levels of viral suppression and condom use are maintained to mitigate any adverse effects of COVID-19-related disruption on HIV transmission and control among MSM in China.

Anti-HIV-1 antibodies based confirmatory results in Wuhan, China, 2012-2018

The number, intensity and order of emergence of HIV-1 specific antibodies in serum or plasma were associated with the stage of HIV-1 infection. In this study, we retrospectively analyzed the HIV-1 confirmatory results tested by western blot (WB) or recombination immunoblot assay (RIBA) in Wuhan, 2012-2018, to access the profiles of HIV-1 specific antibodies. A total of 14432 HIV-suspected serum or plasma samples collected from local hospitals and other HIV screening laboratories were further screened by two 4th generation enzyme-linked immunosorbent assay (ELISA) kits in our laboratory, of which 11068 specimens (76.69%) had at least one positive ELISA result and thereby were finally confirmed with WB or RIBA. RIBA had identified 652 (81.09%) positive and 13 (1.62%) indeterminate cases from July 1, 2014 to January 7, 2015, while WB had identified 8358 (81.43%) positive and 643 (6.26%) indeterminate cases in the other times during 2012-2018. The indeterminate rate of WB was significant higher than that of RIBA (p<0.001). Although the number of HIV-1 infected subjects increased significantly from 2012 (n = 911) to 2018 (n = 1578), the positive rate of HIV-1 antibodies decreased markedly from 70.08% in 2012 to 58.79% in 2018 (p<0.001). The most commonly observed antibody profile was gp160+gp120+p66+(p55+)p51+gp41+p31+p24+p17+ (4131, 49.43%) for WB-MP and gp160+gp120+gp41+p31+p24+p17+ (382, 58.59%) for RIBA-WANTAI, and the absence of reactivity to three possible serologic markers for recent HIV-1 infection, p31, p66, and p51, increased significantly from 2012 to 2018, with the overall rate of 17.03%, 9.40%, and 15.15%, respectively. The suspected acute HIV-1 infection was also observed to be increased in recent years, with an overall rate of 1.00%. Our results indicated the detection rate had decreased for HIV-1 infection, but increased for suspected recent and acute HIV-1 infection during 2012-2018, reflecting the efforts of intervention among high risk population.

"I'll Change His Sexual Orientation, I Don't Think About HIV": A Qualitative Study to Explore Attitudes, Behaviors, and Experiences Among Wives of Men Who Have Sex With Men in Mainland China

In mainland China, HIV prevalence among men who have sex with men (MSM) has risen sharply in the past decade. However, few HIV studies have directly addressed the female spouses' (tongqi) experiences, a population estimated at 14 million [Cheng, F. K. (2016). I want to come forward: Voices from Chinese tongqi. Cogent Social Sciences, 2(1), 1158343. doi:10.1080/23311886.2016.1158343; Zhu, J. (2018). "Unqueer" kinship? Critical reflections on "marriage fraud" in mainland China. Sexualities, 21(7), 1075-1091. doi:10.1177/1363460717719240]. We conducted this exploratory qualitative study to understand tongqi's attitudes toward same-sex sexuality and HIV risk as well as their sexual history. Semistructured interviews were conducted with 24 tongqi between October 2015 and September 2016. Data were coded and analyzed using thematic analysis. We identified four primary themes: (a) surprise, initial disbelief, and negative attitudes toward their husbands' same-sex sexuality; (b) maintenance of regular sexual contact, particularly before pregnancy; (c) unprotected sex with marital and extramarital partners; and (d) low perception of HIV risk. Strategies to increase HIV knowledge and testing uptake are urgently needed among these vulnerable women but must be implemented with caution to avoid exacerbating high levels of homophobia.

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.

Sexual network distribution of HIV self-testing kits: Findings from the process evaluation of an intervention for men who have sex with men in China

BACKGROUND

The World Health Organization has recommended HIV self-testing (HIVST) as an alternative testing strategy given the limitations of facility-based testing. While the benefits of HIV self-testing have been demonstrated at the individual level among men who have sex with men (MSM), limited data exist on if this testing approach can be effectively diffused through individuals' social or sexual networks. The objectives of this study were to examine patterns and correlates of HIVST distribution within Chinese MSM's sexual networks.

METHODS

Data used for this analysis was a part of the process evaluation of an HIVST intervention trial among MSM in Nanjing, China. Between May and October 2017, we enrolled 400 men into the trial. Participants assigned to the intervention group (N = 200) were given three HIVST kits at baseline and could request more during the follow-up periods. We incorporated measures for process evaluation in the self-administered online follow-up surveys. This analysis reported findings from the three-month follow-up survey in the intervention group. Frequencies and percentages were used to describe characteristics of participants who distributed kits to their sexual partners as well as patterns of distribution. Multivariable logistic regression was conducted to identify independent correlates of participants who distributed the kits.

RESULTS

Of the 177 participants retained (88.5%) at the three-month follow-up, 72 (40.7%) distributed one or more kits to either primary or casual partners. About half of distributors (51.4%) gave one HIVST kit to their sexual partners while 15.3% distributed 3 or more. Over half gave these kits (58.3%) to primary sexual partners while 27.8% reported giving the kits to both primary and casual partners. About half (54.2%) of distributors used the kits together with their partners. Compared to participants who had an HIV test in the past six months, those who tested over six months ago or never tested had significantly lower odds of distributing the kits (AOR = 0.484, 95% CI: 0.250-0.983, p = 0.032). Compared to those who had not used the kits themselves, participants who did had significantly higher odds of distributing the kits (AOR = 3.345, 95% CI: 1.488-7.517, p = 0.003). Participants who reported higher HIV testing efficacy had 2.051 fold greater odds (95% CI: 1.062-3.961, p = 0.033) of distributing the kits compared to those who had lower efficacy.

CONCLUSION

Our study demonstrated that a sexual network-based approach to distributing HIVST among Chinese MSM is feasible and can be a promising strategy to improve the effectiveness of HIVST programs including its reach to untested men. Such approach should be complimented by intervention components that enhance HIV testing efficacy and improve experiences of HIVST.

Interventions to improve the HIV continuum of care in China

PURPOSE OF REVIEW

To describe HIV epidemic and interventions for improving HIV continuum of care in China.

RECENT FINDINGS

The reported HIV epidemic has been continuously increasing, partially due to the expansion of active HIV testing campaign. Public health intervention programs have been effective in containing HIV spread among former plasma donors and people who inject drugs (PWID), but more infections occur among heterosexual men and women and young men who have sex with men. Of 1.25 million Chinese people are living with HIV, one-third do not know their status. About two-thirds of diagnosed individuals have used antiretroviral therapy (ART) and two-thirds of those on ART have achieved viral suppression, but some risk groups such as PWID have lower rates. The national free ART program has reduced adult and pediatric mortality and reduced heterosexual transmission. China faces great challenges to reduce HIV sexual transmission, improve the HIV continuum of care, and close the gaps to the UNAIDS Three "90" Targets.

History of the HIV Epidemic in China

PURPOSE OF REVIEW

This study aims to review the history of the human immunodeficiency virus (HIV) infection epidemic in China.

RECENT FINDINGS

The HIV infection epidemic in China has evolved significantly over the past 35 years, from initially exclusively within people who inject drugs (PWID), to outbreaks due to plasma collection contamination in the mid-1990s, to now almost exclusive transmission via sexual contact. The number of newly-diagnosed cases and the number HIV-related deaths have increased each year since 2004, coinciding with a massive scale-up of both HIV testing and antiretroviral therapy initiation. The proportion of cases diagnosed later in their disease progression has remained constant. The initial outbreaks of HIV across China were identified quickly and the overall trends have been monitored. While the HIV epidemic among PWID has been well managed, the growing HIV epidemic via sexual contact has grown more complex and even more difficult to control.

"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.

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.

What has changed HIV and syphilis infection among men who have sex with men (MSM) in Southwest China: a comparison of prevalence and behavioural characteristics (2013-2017)

Background

Chongqing reportedly has a large MSM population and a high STI prevalence in previous studies. However, most studies are attributed to independent cross-sectional studies, few studies have investigated trends in the prevalence of syphilis and HIV, as well as behavioural characteristics among MSM using serial surveillance surveys.

Methods

Data were collected in Chongqing through face-to-face questionnaire interview and laboratory testing in Chongqing. The respondents were recruited among MSM by snowball sampling from May 2013 to December 2017. The self-report questionnaire primarily included socio-demographics, HIV knowledge, and HIV-related behaviour characteristics over the year. Blood specimens were tested to diagnose HIV and syphilis infection by Chongqing CDC. Cochran-Armitage trend test and multivariate logistic regression were conducted to compare the changes in STI prevalence and independent behavioural factors among MSM.

Results

There were 6568 eligible participants (98.4%). The overall HIV prevalence was 20.5% among MSM in Chongqing, with a decrease from 23.0% in 2013 to 19.2% in 2017. The overall syphilis prevalence was 5.8%, with an increase from 3.2% in 2013 to 6.7% in 2017. The proportion of consistent condom use (CCU) during anal intercourse (46.3 to 57.7%, P<0.001),CCU with regular male partners(47.7 to 59.7%, P<0.001), CCU with casual male partners (51.5 to 62.3%, P<0.001) and drug use during anal intercourse (0.3 to 1.4%, P<0.05) were increasing. By contrast, a significant decrease was reported in the percentage of MSM with more than two regular male partners (66.0 to 21.4%, P<0.001) and more than two casual male partners (38.3 to 20.7%, P<0.001). A significant difference was observed in syphilis infection, testing for HIV antibodies and drug use during anal intercourse in the past years between the HIV-positive and HIV-negative respondents.

Conclusion

A decreasing trend of HIV prevalence was showed during among MSM from 2013 to 2017 in Chongqing. While gradual reduction of high-risk behaviors along with HIV prevalence supported development of STI counselling and testing, increasing syphilis infection and drug use during anal intercourse warrants further understanding.

Dynamic Characteristics and HIV Infection of Men who have Sex with Men from 2011 to 2017 in Yinchuan, Ningxia, China

OBJECTIVES

Ningxia Hui Autonomous Region, an important area for ethnic Hui settlement in Northwest China, is a low HIV prevalence region. However, HIV infection rates among men who have sex with men (MSM) in Ningxia have increased to an alarming level, despite scale-up of control measures in recent years. This study aimed to understand the demographical and sexual behavior dynamics of MSM and to explore the factors associated with HIV infection.

METHODS

Annual cross-sectional surveys were carried out among MSM during 2011~2017 in Yinchuan, the capital city of Ningxia. Information regarding social demographics, sexual behavior and HIV prevention knowledge was collected. Blood samples were taken for HIV, HCV serological and genetic analysis, and syphilis serological analysis. The dynamic trend was analyzed with trend χ2 test and factors associated with HIV infection were identified by multivariate logistic regression analysis.

RESULTS

The study found a decreasing trend for mean age of the MSM population over the study period. MSMs with a college education or higher increased significantly, while the proportions that were in a marriage significantly decreased over the study period. The rate of HIV positive among MSM increased during the study period (p<0.05), however, the rate of recently diagnosed infections decreased from 2012 (p<0.05). Overall, a very high proportion (98%) of MSM had basic knowledge of HIV prevention, however, only approximately 40% of them used condoms consistently during anal sex with male partners. Unprotected anal sex was identified as a risk factor associated with HIV infection, as was syphilis infection. Local residency status and MSM who received intervention and detection services were the factors that decreased HIV infection risk. Sequence analysis identified the HIV-1 CRF55_01B subtype from MSM for the first time in Yinchuan.

CONCLUSION

The reduction of recent HIV diagnoses is an encouraging sign of successful HIV control measures in MSM in Ningxia. The finding that a high proportion of MSM had knowledge of HIV prevention but still conducted unprotected sex highlights the need for further control measures to change unsafe sexual practices among MSM.

Willingness to Use and Adhere to HIV Pre-Exposure Prophylaxis (PrEP) among Men Who Have Sex with Men (MSM) in China

This study aimed to investigate the levels of willingness to use pre-exposure prophylaxis (PrEP) and intention to adhere to PrEP and to further explore factors associated with PrEP uptake among men who have sex with men (MSM) in China. A total of 524 MSM were recruited from Chengdu, China. Half of the participants had heard of PrEP, and the awareness rate varied from 33.8%, 30.7%, and 7.1% for daily oral PrEP, on-demand PrEP, and long-acting injectable PrEP (LAI-PrEP), respectively. The overall willingness to use any type of PrEP in the next six months was 84.9% if PrEP is effective and provided for free. Participants were less likely to say that they would use PrEP if they used a condom consistently with their regular partners. However, participants were more likely to say that they would use PrEP if they had casual partners in the past month and had higher HIV prevention literacy. The majority of participants intended to adhere to PrEP prescription. More than forty percent (43.1%) of the participants reported that they might reduce condom use if they took PrEP. We found that the overall willingness to use PrEP was high among MSM living in China, but willingness varied across the different types of PrEP.