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Homoprejudiced violence is a type of aggression against an individual or a community based on their actual or perceived sexual orientation. It may be linked to risks of acquiring HIV/STI via psychosocial variables. This study explored the association between homoprejudiced violence experiences and high-risk sexual behaviors, and potential psychosocial mediators. Using cross-sectional survey data collected in China through Blued among men who have sex with men (MSM) in January 2021, this study conducted multiple mediation analyses. Standard instruments were used to collect data on depressive symptoms in the last two weeks (PHQ-9), recreational drug usage in the last three months, and ever experiencing homoprejudiced violence (12-item survey instrument). Dependent variables were having condomless anal sex and having three or more sexual partners in the last three months. Among 1828 MSM, nearly half (847, 46%) had experienced homoprejudiced violence. Twenty-three percent (427) reached a score that suggested moderate or severe depression and 35% (644) had used recreational drugs. In the last three months, 40% (731) had condomless anal sex and 34% (626) had three or more sexual partners. The indirect mediational coefficients through depression on condomless anal sex and multiple sexual partners were 0.04 (95% CI: [0.02, 0.07]) and 0.02 (95% CI: [0.001, 0.05]), respectively. The indirect mediational coefficient of homoprejudiced violence experience on multiple sexual partners through recreational drug use was 0.05 (95% CI: [0.03, 0.08]). These findings suggest that more comprehensive interventions are needed to address the syndemic of homoprejudiced violence, mental health issues, and HIV/STI-related risks.

BackgroundHIV testing for marginalized populations is critical to controlling the HIV epidemic. However, the HIV testing rate among men who have sex with men (MSM) in China remains low. Crowdsourcing, the process of shifting individual tasks to a group, has been increasingly adopted in public health programs and may be a useful tool for spurring innovation in HIV testing campaigns. We designed a multi-site study to develop a crowdsourced HIV test promotion campaign and evaluate its effectiveness against conventional campaigns among MSM in China.MethodsThis study will use an adaptation of the stepped wedge, randomized controlled trial design. A total of eight major metropolitan cities in China will be randomized to sequentially initiate interventions at 3-month intervals. The intervention uses crowdsourcing at multiple steps to sustain crowd contribution. Approximately 1280 MSM, who are 16 years of age or over, live in the intervention city, have not been tested for HIV in the past 3 months, and are not living with HIV, will be recruited. Recruitment will take place through banner advertisements on a large gay dating app along with other social media platforms. Participants will complete one follow-up survey every 3 months for 12 months to evaluate their HIV testing uptake in the past 3 months and secondary outcomes including syphilis testing, sex without condoms, community engagement, testing stigma, and other related outcomes.DiscussionMSM HIV testing rates remain poor in China. Innovative methods to promote HIV testing are urgently needed. With a large-scale, stepped wedge, randomized controlled trial our study can improve understanding of crowdsourcing's long-term effectiveness in public health campaigns, expand HIV testing coverage among a key population, and inform intervention design in related public health fields.Trial registrationClinicalTrials.gov, NCT02796963 . Registered on 23 May 2016.

Background: HIV self-testing (HIVST) was recommended to improve HIV testing services. China initiated some of the first HIVST pilots in the world, providing a unique opportunity for implementation research. We aim to investigate HIVST adoption and its following linkage to care among Chinese men who have sex with men (MSM). Methods: Data were collected using an online questionnaire distributed on major social media platforms in 2018, one year after HIVST was officially endorsed and allowed for sale. MSM who were at least 16 years old, assigned as male at birth, and ever tested for HIV were eligible. Primary outcome, adoption was defined as ever use of HIVST. Bivariate and multivariable logistic regressions were performed to explore the association between HIVST adoption and sociodemographic and behavioral factors. Linkage to care was also described via the following sequential events as indicators: (1) receiving result after recent test (2), seeking care from healthcare facility if test result was positive or indeterminate, and (3) delayed time before seeking care. Results: A total of 540 participants were included with an average age of 27.4 ± 6.6. Most were never married (87.4%) and half completed college (52.2%). Overall, 75.2% had adopted HIVST. Self-test kits were commonly obtained from community-based organizations (54.4%) and from online (46.6%). HIVST adoption was positively associated with having college or higher education (OR = 1.66, 95%CI: 1.07–2.57), and negatively associated with age older than 30 (AOR = 0.52, 95%CI: 0.32–0.84). Adoption was not associated with other socio-demographic or behavioral factors. After receiving HIV-positive or indeterminate results, 25/25 of HIVST adopters sought care while 3 out of 7 (42.9%) non-adopters sought care (p < 0.001). Delays before seeking care were not significantly different between HIVST adopters compared to non-adopters (P = 0.366). Conclusion: Many MSM adopted HIVST shortly after its launch. Our findings suggested that HIVST linkage to care is promising among MSM in China. Integration of HIVST with other essential sexual health services is needed. [ABSTRACT FROM AUTHOR]

BackgroundCrowdsourcing, the process of shifting individual tasks to a large group, may enhance human immunodeficiency virus (HIV) testing interventions. We conducted a noninferiority, randomized controlled trial to compare first-time HIV testing rates among men who have sex with men (MSM) and transgender individuals who received a crowdsourced or a health marketing HIV test promotion video.MethodsSeven hundred twenty-one MSM and transgender participants (≥16 years old, never before tested for HIV) were recruited through 3 Chinese MSM Web portals and randomly assigned to 1 of 2 videos. The crowdsourced video was developed using an open contest and formal transparent judging while the evidence-based health marketing video was designed by experts. Study objectives were to measure HIV test uptake within 3 weeks of watching either HIV test promotion video and cost per new HIV test and diagnosis.ResultsOverall, 624 of 721 (87%) participants from 31 provinces in 217 Chinese cities completed the study. HIV test uptake was similar between the crowdsourced arm (37% [114/307]) and the health marketing arm (35% [111/317]). The estimated difference between the interventions was 2.1% (95% confidence interval, -5.4% to 9.7%). Among those tested, 31% (69/225) reported a new HIV diagnosis. The crowdsourced intervention cost substantially less than the health marketing intervention per first-time HIV test (US$131 vs US$238 per person) and per new HIV diagnosis (US$415 vs US$799 per person).ConclusionsOur nationwide study demonstrates that crowdsourcing may be an effective tool for improving HIV testing messaging campaigns and could increase community engagement in health campaigns.Clinical trials registrationNCT02248558.

BackgroundThere is a high prevalence of HIV/syphilis among male sex workers, but no formal study has ever been conducted focusing on male clients of male sex workers (MCM). A detailed investigation was thus called for, to determine the burden and sociobehavioral determinants of HIV and syphilis among these MCM in China.MethodsAs part of a multicenter cross-sectional study, using respondent-driven and snowball sampling, 2958 consenting adult men who have sex with men (MSM) were recruited, interviewed, and tested for HIV and syphilis between 2008 and 2009. The distributions of sociodemographic characteristics, risk behaviors, and HIV/syphilis prevalence were determined and compared between MCM and other MSM.ResultsAmong recruited MSM, 5.0% (n = 148) were MCM. HIV prevalences for MCM and other MSM were 7.4% and 7.7%, whereas 18.9% and 14.0% were positive for syphilis, respectively. Condomless anal intercourse (CAI) was reported by 59.5% of MCM and 48.2% of MSM. Multiple logistic regression revealed that compared with other MSM, MCM were more likely to have less education [for ≤ elementary level, adjusted odds ratio (aOR) = 3.13, 95% confidence interval (95% CI): 1.42 to 6.90], higher income (for >500 US Dollars per month, aOR = 2.97, 95% CI: 1.53 to 5.77), more often found partners at parks/restrooms (aOR = 4.01, 95% CI: 2.34 to 6.85), reported CAI (aOR = 1.49, 95% CI: 1.05 to 2.10), reported a larger sexual network (for ≥ 10, aOR = 2.70, 95% CI: 1.44 to 5.07), and higher odds of syphilis (aOR = 1.54, 95% CI: 1.00 to 2.38).ConclusionsThe greater frequency of risk behaviors and high prevalence of HIV and syphilis indicated that HIV/syphilis prevention programs in China need to pay special attention to MCM as a distinct subgroup, which was completely ignored until date.

BackgroundThere is a high prevalence of HIV/syphilis among male sex workers, but no formal study has ever been conducted focusing on male clients of male sex workers (MCM). A detailed investigation was thus called for, to determine the burden and sociobehavioral determinants of HIV and syphilis among these MCM in China.MethodsAs part of a multicenter cross-sectional study, using respondent-driven and snowball sampling, 2958 consenting adult men who have sex with men (MSM) were recruited, interviewed, and tested for HIV and syphilis between 2008 and 2009. The distributions of sociodemographic characteristics, risk behaviors, and HIV/syphilis prevalence were determined and compared between MCM and other MSM.ResultsAmong recruited MSM, 5.0% (n = 148) were MCM. HIV prevalences for MCM and other MSM were 7.4% and 7.7%, whereas 18.9% and 14.0% were positive for syphilis, respectively. Condomless anal intercourse (CAI) was reported by 59.5% of MCM and 48.2% of MSM. Multiple logistic regression revealed that compared with other MSM, MCM were more likely to have less education [for ≤ elementary level, adjusted odds ratio (aOR) = 3.13, 95% confidence interval (95% CI): 1.42 to 6.90], higher income (for >500 US Dollars per month, aOR = 2.97, 95% CI: 1.53 to 5.77), more often found partners at parks/restrooms (aOR = 4.01, 95% CI: 2.34 to 6.85), reported CAI (aOR = 1.49, 95% CI: 1.05 to 2.10), reported a larger sexual network (for ≥ 10, aOR = 2.70, 95% CI: 1.44 to 5.07), and higher odds of syphilis (aOR = 1.54, 95% CI: 1.00 to 2.38).ConclusionsThe greater frequency of risk behaviors and high prevalence of HIV and syphilis indicated that HIV/syphilis prevention programs in China need to pay special attention to MCM as a distinct subgroup, which was completely ignored until date.

The available estimates of incidence and prevalence of syphilis among men who have sex with men (MSM) in Mainland China are high. We used respondent-driven sampling to recruit MSM in the study population. The participants were followed up to monitor the incidence and change of risk behaviours. A face-to-face interview was used to collect information about high-risk behaviours, demographics and recreational drug use. To test the difference between prevalent and incident cases, two nested matched case-control studies were carried out. The cases were the HIV or syphilis positives found at baseline and during follow-up. We used density sampling to sample six controls for each case. Our results indicate that compared to incident cases, prevalent cases had a higher proportion of reported unprotected anal intercourse for both HIV and syphilis. Regression analysis indicated that unprotected anal intercourse was the main risk factor among HIV-prevalent cases but not in HIV-incident cases. These differences could possibly be explained by the implementation of the risk reduction interventions. Syphilis was not a risk factor for HIV-prevalent cases but was highly associated with HIV-incident cases. Tailored interventions addressing unprotected anal intercourse and other risk factors can help to reduce the prevalence and incidence of HIV and syphilis.

Secondary distribution of HIV self-testing (HIVST) among individual social networks was an effective approach to expanding HIV testing among men who have sex with men (MSM). However, understanding the factors associated with first-time HIV testing behaviors in the secondary distribution of HIVST programs is limited. Hence, this study aims to identify factors related to first-time testers in the secondary distribution of HIVST. Participants were recruited from five provinces in southern China through Blued, a geo-social gay networking app in China from January 2021 to December 2021. Eligible consented participants (referred to as "seeds") finished a baseline survey and then applied for up to five HIVST kits. They were encouraged to distribute HIVST kits to other MSM (referred to as "alters") and alters were encouraged to scan a QR code to return their photographed testing results. All alters were invited to finish an online survey. In total, 229 seeds reached 292 alters, among whom 126 (43.2%) were first-time testers whereas 166 (56.8%) were non-first-time testers. Importantly, our results demonstrated that the first-time HIV testers were more likely to self-report as heterosexual (aOR = 4.88, 95% CI 1.01–23.61), disclose sexual orientation and/or SSB (aOR = 1.73, 95% CI 1.01–2.96), and receive HIVST knowledge from the seeds (aOR = 3.25, 95% CI 1.02–10.34). However, those who had sex with male partners in the last three months were less likely to be first-time testers (aOR = 0.43, 95% CI 0.23–0.82). Practical implications and limitations were also discussed to improve future HIV prevention programs. [ABSTRACT FROM AUTHOR]

Background: Access to syphilis testing and treatment is frequently limited for men who have sex with men (MSM). A two-armed randomised controlled trial compared feasibility and costs of facility-based syphilis testing with self-testing among MSM in Zimbabwe. Methods: This randomised controlled trial was conducted in Harare, with participants randomised 1:1. Syphilis self-testing was offered in community-based settings. The primary outcome was the relative proportion of individuals taking up testing. Total incremental economic provider and user costs, and cost per client tested, diagnosed and treated were assessed using ingredients-based costing in 2020 US$. Results: A total of 100 men were enrolled. The two groups were similar in demographics. The mean age was 26 years. Overall, 58% (29/50) and 74% (37/50) of facility- and self-testing arm participants, respectively, completed syphilis testing. A total of 28% of facility arm participants had a reactive test, with 50% of them returning for confirmatory testing yielding 28% reactivity. In the self-testing arm, 67% returned for confirmatory testing, with a reactivity of 16%. Total provider costs were US$859 and US$736, and cost per test US$30 and US$15 for respective arms. Cost per reactive test was US$107 and US$123, and per client treated US$215 and US$184, respectively. The syphilis test kit was the largest cost component. Total user cost per client per visit was US$9. Conclusion: Syphilis self-testing may increase test uptake among MSM in Zimbabwe. However, some barriers limit uptake including lack of self-testing and poor service access. Bringing syphilis testing services to communities, simplifying service delivery and increasing self-testing access through community-based organisations are useful strategies to promote health-seeking behaviours among MSM. Access to syphilis testing and treatment for men who have sex with men is frequently limited. A two-armed randomised controlled trial compared feasibility and costs of facility-based syphilis testing with self-testing among men who have sex with men in Zimbabwe. Overall, 58% and 74% of facility- and self-testing arm participants took up and subsequently completed syphilis testing, respectively. Syphilis self-testing can increase test uptake among men who have sex with men in Zimbabwe. However, some barriers limit uptake, including lack of self-testing and poor service access. [ABSTRACT FROM AUTHOR]

Community participation in research involving stigmatized populations has been sub-optimal, and digital tools could potentially increase participation in qualitative research. This study aims to describe the implementation of an online chat-based FGD (Focus Group Discussion) with men who have sex with men (MSM) in China as part of formative research for the PIONEER project, determine the advantages and limitations associated with the approach, and assess the feasibility of deepening community participation in STI research. Participants were involved in four days of asynchronous FGDs on sexually transmitted diseases and answered questions about the online FGD method. Online FGDs allowed us to deepen participant engagement through bidirectional communication channels. Data from online FGDs directly informed recruitment strategies and community participation for a clinical trial. Overall, 63% (29/46) of men who had never participated in offline LGBTQ + activities joined online FGDs. Many participants (89%, 41/46) noted that online FGDs were more convenient, less socially awkward, and more anonymous than in-person qualitative research. We highlighted potential risks as well as mitigation strategies when using online FGDs. Online FGDs were feasible among this group of sexual minorities and may be particularly useful in many cities where stigma limits in-person research participation. [ABSTRACT FROM AUTHOR]

Syphilis testing uptake is low among men who have sex with men (MSM) around the world. Syphilis self-testing (SST) may complement facility-based testing; the distribution model is yet to be explored. This study aimed to investigate the effectiveness of peer distribution of syphilis self-testing on promoting syphilis testing. We conducted a three-arm, unblinded, parallel individually randomized controlled trial among MSM in three cities in Guangdong, China. Inclusion criteria were: men who were born biologically male, aged 18 or above, have ever had sex with a man, will refer the interventions to peers, and will take the three-month follow-up survey. Enrolled indexes were randomly assigned in a 1:1:1 ratio into standard-of-care arm (SOC arm), standard SST delivery arm (S-SST arm), and a web-based referral link SST delivery arm (RL-SST arm). The primary outcome was the number of returned photograph-verified syphilis testing results per index. A total number of 300 indexes were enrolled, with 100 indexes in each arm. The number of verified syphilis tests per index conducted by alters was 0.05 in the control arm, 0.51 in the S-SST arm, and 0.31 in the RL-SST arm. The cost per alter tested was $760.60 for SOC, $83.78 for S-SST, and $93.10 for RL-SST. Minimal adverse event was reported among both indexes and alters during the study. This study showed that peer distribution of SST could improve syphilis testing uptake among MSM in China compared to facility-based testing. This approach warrants further consideration as part of expanding syphilis self-testing. [ABSTRACT FROM AUTHOR]

Secondary distribution of HIV self-test is promising to increase testing uptake while the facilitators and barriers of secondary distribution remain unclear. In-depth interviews were conducted with 22 MSM who had participated in secondary distribution of HIVST in southern China. Data were thematically analyzed to capture participants' motivations, procedures, and challenges when accessing and distributing self-tests. MSM in China are willing to distribute HIVST to members in their social network, but their decision-making is impacted by their ability to broach sexual health conversations, evaluations of the recipients, and perceived trustworthiness of the self-test. Our study suggested that several strategies, including creating a friendly environment for sexual health conversations and establishing nationwide policies related to quality assured self-tests and standardized self-testing protocols, may be helpful to advance this approach in China. [ABSTRACT FROM AUTHOR]

Background: Social network approaches to testing allow individuals (indexes) to distribute tests to social networks (alters). This quasi-experimental study compared two social network-based testing strategies in promoting human immunodeficiency virus (HIV) testing among Chinese gay, bisexual, and other men who have sex with men (GBMSM).Methods: GBMSM aged ≥18years were recruited from Guangzhou, China. From May to September 2019, indexes could distribute blood-based HIV/syphilis dual self-testing kits to people within their social network. Indexes recruited from October 2019 to January 2020 could send HIV testing cards to their social networks for free facility-based tests. Alters were encouraged to upload a photo verification of test results. Indexes and alters received incentives during both periods.Results: There were 245 participants who were assessed for eligibility and 208/245 (84.9%) were eligible. 106 and 102 indexes were recruited in the secondary distribution and testing card arms respectively. 154/208 (74.0%) completed follow up at 1 month. 92 indexes in the secondary distribution arm self-reported distributions to 179 unique alters, and 62 in the testing card arm to 26 unique alters. An average of 1.95 (standard deviation [s.d.]=1.90) HIV/syphilis dual self-tests and 0.42 (s.d.=0.78) HIV testing cards were distributed, generating a risk difference of 1.53 (95% confidence interval [CI] 1.09, 1.96). Indexes self-identifying as gay (P =0.007) or having previously tested (P =0.02) distributed more tests. Secondary distribution cost less per alter tested (USD120 vs USD9408).Conclusions: Secondary distribution engaged more GBMSM to distribute tests and reached more GBMSM to test compared to referral cards, suggesting advantage in facilitating testing uptake among Chinese GBMSM. [ABSTRACT FROM AUTHOR]

Background: Low syphilis testing uptake is a major public health issue among men who have sex with men (MSM) in many low- and middle-income countries. Syphilis self-testing (SST) may complement and extend facility-based testing. We aimed to evaluate the effectiveness and costs of providing SST on increasing syphilis testing uptake among MSM in China.Methods and Findings: An open-label, parallel 3-arm randomized controlled trial (RCT) was conducted between January 7, 2020 and July 17, 2020. Men who were at least 18 years of age, had condomless anal sex with men in the past year, reported not testing for syphilis in the last 6 months, and had a stable residence with mailing addresses were recruited from 124 cities in 26 Chinese provinces. Using block randomization with blocks of size 12, enrolled participants were randomly assigned (1:1:1) into 3 arms: standard of care arm, standard SST arm, and lottery incentivized SST arm (1 in 10 chance to win US$15 if they had a syphilis test). The primary outcome was the proportion of participants who tested for syphilis during the trial period and confirmed with photo verification and between arm comparisons were estimated with risk differences (RDs). Analyses were performed on a modified intention-to-treat basis: Participants were included in the complete case analysis if they had initiated at least 1 follow-up survey. The Syphilis/HIV Duo rapid test kit was used. A total of 451 men were enrolled. In total, 136 (90·7%, 136/150) in the standard of care arm, 142 (94·0%, 142/151) in the standard of SST arm, and 137 (91·3%, 137/150) in the lottery incentivized SST arm were included in the final analysis. The proportion of men who had at least 1 syphilis test during the trial period was 63.4% (95% confidence interval [CI]: 55.5% to 71.3%, p = 0.001) in the standard SST arm, 65.7% (95% CI: 57.7% to 73.6%, p = 0.0002) in the lottery incentivized SST arm, and 14.7% (95% CI: 8.8% to 20.7%, p < 0.001) in the standard of care arm. The estimated RD between the standard SST and standard of care arm was 48.7% (95% CI: 37.8% to 58.4%, p < 0.001). The majority (78.5%, 95% CI: 72.7% to 84.4%, p < 0.001) of syphilis self-testers reported never testing for syphilis. The cost per person tested was US$26.55 for standard SST, US$28.09 for the lottery incentivized SST, and US$66.19 for the standard of care. No study-related adverse events were reported during the study duration. Limitation was that the impact of the Coronavirus Disease 2019 (COVID-19) restrictions may have accentuated demand for decentralized testing.Conclusions: Compared to standard of care, providing SST significantly increased the proportion of MSM testing for syphilis in China and was cheaper (per person tested).Trial Registration: Chinese Clinical Trial Registry: ChiCTR1900022409. [ABSTRACT FROM AUTHOR]

Background: Digital network-based methods may enhance peer distribution of HIV self-testing (HIVST) kits, but interventions that can optimize this approach are needed. We aimed to assess whether monetary incentives and peer referral could improve a secondary distribution program for HIVST among men who have sex with men (MSM) in China.Methods and Findings: Between October 21, 2019 and September 14, 2020, a 3-arm randomized controlled, single-blinded trial was conducted online among 309 individuals (defined as index participants) who were assigned male at birth, aged 18 years or older, ever had male-to-male sex, willing to order HIVST kits online, and consented to take surveys online. We randomly assigned index participants into one of the 3 arms: (1) standard secondary distribution (control) group (n = 102); (2) secondary distribution with monetary incentives (SD-M) group (n = 103); and (3) secondary distribution with monetary incentives plus peer referral (SD-M-PR) group (n = 104). Index participants in 3 groups were encouraged to order HIVST kits online and distribute to members within their social networks. Members who received kits directly from index participants or through peer referral links from index MSM were defined as alters. Index participants in the 2 intervention groups could receive a fixed incentive ($3 USD) online for the verified test result uploaded to the digital platform by each unique alter. Index participants in the SD-M-PR group could additionally have a personalized peer referral link for alters to order kits online. Both index participants and alters needed to pay a refundable deposit ($15 USD) for ordering a kit. All index participants were assigned an online 3-month follow-up survey after ordering kits. The primary outcomes were the mean number of alters motivated by index participants in each arm and the mean number of newly tested alters motivated by index participants in each arm. These were assessed using zero-inflated negative binomial regression to determine the group differences in the mean number of alters and the mean number of newly tested alters motivated by index participants. Analyses were performed on an intention-to-treat basis. We also conducted an economic evaluation using microcosting from a health provider perspective with a 3-month time horizon. The mean number of unique tested alters motivated by index participants was 0.57 ± 0.96 (mean ± standard deviation [SD]) in the control group, compared with 0.98 ± 1.38 in the SD-M group (mean difference [MD] = 0.41),and 1.78 ± 2.05 in the SD-M-PR group (MD = 1.21). The mean number of newly tested alters motivated by index participants was 0.16 ± 0.39 (mean ± SD) in the control group, compared with 0.41 ± 0.73 in the SD-M group (MD = 0.25) and 0.57 ± 0.91 in the SD-M-PR group (MD = 0.41), respectively. Results indicated that index participants in intervention arms were more likely to motivate unique tested alters (control versus SD-M: incidence rate ratio [IRR = 2.98, 95% CI = 1.82 to 4.89, p-value < 0.001; control versus SD-M-PR: IRR = 3.26, 95% CI = 2.29 to 4.63, p-value < 0.001) and newly tested alters (control versus SD-M: IRR = 4.22, 95% CI = 1.93 to 9.23, p-value < 0.001; control versus SD-M-PR: IRR = 3.49, 95% CI = 1.92 to 6.37, p-value < 0.001) to conduct HIVST. The proportion of newly tested testers among alters was 28% in the control group, 42% in the SD-M group, and 32% in the SD-M-PR group. A total of 18 testers (3 index participants and 15 alters) tested as HIV positive, and the HIV reactive rates for alters were similar between the 3 groups. The total costs were $19,485.97 for 794 testers, including 450 index participants and 344 alter testers. Overall, the average cost per tester was $24.54, and the average cost per alter tester was $56.65. Monetary incentives alone (SD-M group) were more cost-effective than monetary incentives with peer referral (SD-M-PR group) on average in terms of alters tested and newly tested alters, despite SD-M-PR having larger effects. Compared to the control group, the cost for one more alter tester in the SD-M group was $14.90 and $16.61 in the SD-M-PR group. For newly tested alters, the cost of one more alter in the SD-M group was $24.65 and $49.07 in the SD-M-PR group. No study-related adverse events were reported during the study. Limitations include the digital network approach might neglect individuals who lack internet access.Conclusions: Monetary incentives alone and the combined intervention of monetary incentives and peer referral can promote the secondary distribution of HIVST among MSM. Monetary incentives can also expand HIV testing by encouraging first-time testing through secondary distribution by MSM. This social network-based digital approach can be expanded to other public health research, especially in the era of the Coronavirus Disease 2019 (COVID-19).Trial Registration: Chinese Clinical Trial Registry (ChiCTR) ChiCTR1900025433. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Given the synergistic relationship between HIV and sexually transmitted infections (STI), the integration of services has the potential to reduce the incidence of both HIV and STIs. We explored the extent to which STI testing has been offered within HIV pre‐exposure prophylaxis (PrEP) programmes worldwide. Methods: We conducted a systematic review of PrEP programmes implementing STI testing services in nine databases. We approached PrEP implementers for additional unpublished data and implementation details. Descriptive statistics were used to present the characteristics of STI testing within PrEP programmes. Content analysis of the input from PrEP implementers was conducted to summarize the barriers to and facilitators of STI testing. Results: Of 9,161 citations, 91 studies conducted in 32 countries were included: 69% from high‐income countries (HICs) and 64% from programmes targeting men who have sex with men (MSM) and transgender women (TGW) only. The majority of programmes (70%, 64/91) conducted STI testing before the initiation of PrEP. The most common STIs tested were gonorrhoea (86%, 78/91), chlamydia (84%, 76/91) and syphilis (84%, 76/91). The majority provided STI testing at three‐month intervals (70%, 53/76, for syphilis; 70% 53/78, for chlamydia; 68%, 53/78, for gonorrhoea). Relative to low‐ and middle‐income countries (LMICs), a higher proportion of PrEP programmes in HICs offered testing for gonorrhoea (92% vs. 71%, p < 0.05), chlamydia (92% vs. 64%, p < 0.01), syphilis (87% vs. 75%, p < 0.05), hepatitis A (18% vs. 4%, p < 0.05) and hepatitis C (43% vs. 21%, p < 0.05); offered testing for a higher number of STIs (mean 3.75 vs. 3.04, p < 0.05); and offered triple (throat, genital/urine and anorectal) anatomical site screening (54% vs. 18%, p < 0.001). Common implementation challenges included costs, access to STI diagnostics, programme logistics of integrating STI testing into PrEP delivery models and lack of capacity building for staff involved in PrEP provision. Conclusions: Significant gaps and challenges remain in the provision of STI testing services within HIV PrEP programmes. We recommend more active integration of STI testing and management into PrEP programmes, supported by standardized practice guidelines, staff capacity building training and adequate funding. This could lead to improved sexual health and HIV outcomes in key populations. [ABSTRACT FROM AUTHOR]

Background: In China, men who have sex with men (MSM) shoulder a disproportionate HIV burden. Early initiation and adherence to HIV antiretroviral therapy (ART) will be critical to reversing the HIV epidemic in China, but ART usage remains suboptimal among MSM diagnosed with HIV. One understudied but potentially important factor underpinning suboptimal ART usage is personal belief in supernatural explanatory models of health and illness (supernatural explanatory models). This study examines associations between beliefs in supernatural explanatory models and ART usage among MSM in China. Method: In 2017, an online survey was distributed nationwide throughout China by gay community–based organizations. Eligible study participants were self-identified MSM between 16 and 30 years old who had tested positive for HIV and who had seen a doctor in the last 2 years. Beliefs in supernatural explanatory models were measured using a three-item scale developed specifically for the Chinese population (range, 3–15). Results: Of 73 participants, the majority were currently using ART (83.6%) and 42.5% expressed some endorsement of belief in supernatural explanatory models. However, among 21 participants with the strongest belief in supernatural explanatory models, prevalence of current ART usage was 61.9%. Stronger belief in supernatural explanatory models was significantly associated with lower likelihood of current ART usage (adjusted odds ratio = 0.52; 95% confidence interval = 0.13–0.75). Conclusion: Belief in supernatural explanatory models may be a powerful predictor of ART usage among MSM living with HIV in China. Further studies are needed to corroborate these findings and elucidate mechanisms of association. [ABSTRACT FROM AUTHOR]

Background Syphilis self-testing may help expand syphilis testing among men who have sex with men (MSM). China has rapidly scaled up human immunodeficiency virus (HIV) self-testing, creating an opportunity for integrated syphilis self-testing. However, there is a limited literature on implementing syphilis self-testing. Methods A cross-sectional online survey was conducted among Chinese MSM in 2018. Participants completed a survey instrument including sociodemographic characteristics, sexual behaviors, syphilis self-testing, and HIV self-testing history. Multivariable logistic regression was conducted to identify correlates of syphilis self-testing. We also recorded potential harms associated with syphilis self-testing. Results Six hundred ninety-nine MSM from 89 cities in 21 provinces in China completed the study. A total of 361/699 (51.7%) men tested for syphilis, of whom 174/699 (24.9%) men used syphilis self-testing. Among 174 who had self-tested, 90 (51.7%) reported that the self-test was their first syphilis test and 161 (92.5%) reported that they undertook syphilis self-testing together with HIV self-testing. After adjusting for covariates, syphilis self-testing was correlated with disclosure of sexual orientation to family or friends (adjusted odds ratio [aOR], 1.90; 95% confidence interval [CI], 1.32–2.73), reporting 2–5 male sexual partners (aOR, 1.81; 95% CI, 1.04–3.16), HIV self-testing (aOR, 39.90; 95% CI, 17.00–93.61), and never tested for syphilis in the hospital (aOR, 2.96; 95% CI, 1.86–4.72). Self-reported harms associated with syphilis self-testing were minimal. Conclusions Scaling up syphilis self-testing could complement facility-based testing in China among MSM. Self-testing may increase first-time testing and has limited harms. Our findings suggest that syphilis self-testing could be integrated into HIV self-testing services. [ABSTRACT FROM AUTHOR]

Background: Men who have sex with men (MSM) globally have a high burden of curable sexually transmitted infections (STIs). MSM do not frequently receive rectal STI testing because of several barriers, such as not being out (disclosure of sexual behavior). We evaluate whether Chinese MSM select an STI test (rectal vs urethral) appropriate for their sexual behavior (insertive and/or receptive), and the interactions with being out.Methods: This was a secondary analysis of data from a cross sectional MSM survey conducted at a multisite randomized controlled trial (RCT) (December 2018 to January 2019) around uptake of gonorrhea and chlamydia testing among Chinese MSM (N = 431). We collected socio demographics, relevant medical and sexual history, and disclosure of sexual behavior (outness). We estimated the decision to test and test choice, and the extent to which disclosure plays a role in decision making.Results: Among 431 MSM, mean age was 28 years (SD = 7.10) and 65% were out to someone. MSM who indicated versatile sexual behavior and were out to someone had a 26.8% (95%CI = 6.1, 47.5) increased likelihood for selecting the rectal test vs the ure thral test, compared to those versatile and not out. Versatile MSM out to their health provider outside of the study context had a 29.4% (95%CI = 6.3, 52.6) greater likelihood for selecting the rectal STI test vs the urethral test, compared to versatile MSM not out to their health provider.Conclusions: Sexual behavior and outness may affect gonorrhea and chlamydia testing provision. Apart from clinicians, community based efforts may reduce stigma based barriers to testing. [ABSTRACT FROM AUTHOR]

Data from a randomized controlled trial in 2015 were used to estimate the growth trajectories of peer norms, self-efficacy, and condom use behavior, and to identify associated sociodemographic and behavioral factors among a sample of 804 Chinese men who have sex with men (MSM). Latent class analysis and growth mixture modeling were conducted using Mplus. Two growth trajectories were estimated for each outcome variable with good model fit. The growth trajectories of peer norms were related to age (β = − 0.066, p < 0.05). The growth trajectories of self-efficacy were related to age (β = 0.057, p < 0.01) and using a condom during first sexual encounter with another man (β = 0.777, p < 0.001). The growth trajectories of condom use behavior were related to income (β = 0.366, p < 0.01) and having casual male partners (β = − 1.016, p < 0.001). Predictors for the growth factors within each latent class were also estimated. For subsets of MSM who are older, richer, used a condom during their first sexual encounter with another man, and do not have a casual male partner, condom videos may not have sufficient efficacy and other interventions may be necessary. [ABSTRACT FROM AUTHOR]

Stigma against people with hepatitis B virus (HBV) is a barrier to prevention, diagnosis and treatment of HBV in China. Our study examined an innovative intervention to reduce HBV stigma among men who have sex with men (MSM) in China. We extracted data from a randomized controlled trial conducted in May 2018, where the intervention consisted of crowdsourced images and videos to promote viral hepatitis testing and reduce HBV stigma. HBV stigma was assessed using a 20‐item scale at baseline and four weeks post‐enrolment. Participants were divided into three groups based on their exposure to intervention: full exposure, partial exposure and no exposure. Linear regression was used to determine associations between baseline stigma and participant characteristics. Data from 470 MSM were analysed. Mean participant age was 25 years old and 56% had less education than a college bachelor's degree. Full exposure to intervention was associated with significant stigma reduction (adjusted beta = −3.49; 95% CI = −6.11 to −0.87; P =.01), while partial exposure led to stigma reduction that was not statistically significant. The mean stigma score was 50.6 (SD ± 14.7) at baseline, and stigma was most prominent regarding physical contact with HBV carriers. Greater HBV stigma was associated with not having a recent doctor's visit (adjusted beta = 4.35, 95% CI = 0.19 to 8.52; P =.04). In conclusion, crowdsourcing can decrease HBV stigma among MSM in China and may be useful in anti‐stigma campaigns for vulnerable populations in low‐ and middle‐income countries. [ABSTRACT FROM AUTHOR]

The objective of this study was to examine direct and indirect relationships among peer norms, self-efficacy, and condom use among Chinese men who have sex with men (MSM). A longitudinal study determined the effectiveness of a condom use video promotion among Chinese MSM in 2015. In this analysis, 804 Chinese MSM were recruited at baseline and then followed at 3 weeks and 3 months after the intervention. Parallel process latent growth curve modeling (LGM) with multiple indicators and bootstrapping was conducted using Mplus 7.4. The LGM model fit indexes were good with RMSEA = 0.046, 90% CI (0.044, 0.048), CFI = 0.956, TLI = 0.955. Our results showed that the initial measure of peer norms affected the initial measure of condom use indirectly through the initial measure of self-efficacy (αβ = 0.414, 95% CI 0.260-0.759). The rate of change in peer norms over time also significantly affected the rate of change in condom use through the rate of change in self-efficacy (αβ = 0.101, 95% CI 0.014-0.262). Self-efficacy mediated the association between peer norms and condom use, indicating a strong potential of causal relationship between peer norms and self-efficacy among Chinese MSM. [ABSTRACT FROM AUTHOR]

People's beliefs in supernatural explanatory models of health and illness – beliefs in divine and/or supernatural forces to inform how they perceive, interpret, and respond to health and illness – may have important implications for their use of healthcare services, especially among individuals with lower socioeconomic status (SES). However, the relevance of such research for contexts with strong Confucian and Buddhist traditions and sexual minority subpopulations remains unclear. We conducted a nation-wide survey in China of 503 men who have sex with men (MSM) to test hypotheses examining how supernatural beliefs impact commitment to a primary healthcare provider and testing history for HIV and syphilis. We also tested hypotheses regarding how SES may moderate such effects. Results indicate that strength of supernatural beliefs is associated with less commitment to a primary care provider and lower likelihood of HIV testing, particularly among men with lower educational attainment. However, among men with low income, supernatural belief was associated with higher likelihood of testing for HIV and syphilis. Belief in supernatural explanatory models of health and illness may have substantial influence on healthcare use among MSM in China. As religion and spirituality evolves within China, additional research concerning supernatural beliefs and healthcare use is warranted. [ABSTRACT FROM AUTHOR]

Men who have sex with men (MSM) disclose same-sex behaviors with others, creating disclosure networks. This study examined the characteristics of disclosure networks that are associated with HIV testing among MSM in China through an online nationwide survey. Name-generator questions were used to ask each participant ("ego") to nominate up to five social network members ("alters") with whom he had disclosed same-sex behaviors. Among the 806 men, the average disclosure network size was 4.05. MSM who reported larger disclosure networks were more likely to have been tested for HIV (aOR 1.21, 95% CI 1.08–1.34). The most common disclosure network alters were friends (45.1%), followed by sex partners (18.7%) and healthcare professionals (2.5%). Men who disclosed to healthcare professionals were more likely to test for HIV compared to men who disclosed to family members (aOR 5.43, 95% CI 2.11–14.04). Our findings can inform disclosure network-based interventions to promote MSM HIV testing. [ABSTRACT FROM AUTHOR]

Social media interventions may enhance HIV services among key populations, including men who have sex with men (MSM). This longitudinal analysis examined the effect of recalling, sharing, and participating in different components of a social media intervention on HIV testing among MSM. The social media intervention included six images/texts and information about an online local community contest to promote testing. Of the 1033 men, they recalled a mean of 2.7 out of six images and shared an average of one image online. 34.5% of men recalled information on the online local community contest and engaged in a mean of 1.3 contest. Recalling images/texts (aOR = 1.13, 95% CI 1.02–1.25) and recalling a local contest (aOR = 1.59, 95% CI 1.13–1.24) were associated with facility-based HIV testing. This study has implications for the development and evaluation of social media interventions to promote HIV testing. [ABSTRACT FROM AUTHOR]

In China, some health departments and gay community-based organizations have begun to offer home-based HIV testing kits in order to augment test uptake among men who have sex with men (MSM). However, HIV test preferences and motivations for home-testing among MSM in China are not well understood. The HIV testing preferences of 803 MSM throughout China were evaluated using single-item assessment and a discrete choice experiment (DCE). In both the single-item assessment and DCE, participants expressed strong preference for free and anonymous testing by health professionals. Both approaches also indicated that naïve testers most prefer home testing. However, among previous testers, the single-item assessment indicated that "home" was the most preferred testing location (vs. hospital or clinic), while the DCE indicated that "home" was the least preferred testing location after controlling for anonymity. HIV home-testing may have limited appeal to previously tested Chinese MSM if anonymity is not maintained. [ABSTRACT FROM AUTHOR]

Background: Men who have sex with men (MSM) are at high risk of human immunodeficiency virus (HIV) infection and sexually transmitted infection (STI) in China. Inadequate clinical services and poor clinical competency among physicians are major barriers to improving the sexual health of MSM. This study aims to understand physician clinical competency in providing MSM health services in China.Methods: We conducted an online cross-sectional survey among Chinese physicians who have seen male patients for STI complaints in the past year. We obtained information on individual demographics, clinical practice, attitudes toward MSM, and interest in contributing to MSM clinical services. We defined an MSM-competent physician as one who asked male patients about sexual orientation, sexual practices, and recommended HIV/ STI testing during a clinic visit. We conducted multivariable logistic regression to identify factors associated with MSM competency.Results: In total, 501 physicians completed the survey. The most common subspecialties were dermatovenereology (33.1%), urology (30.1%), and general medicine (14.4%). Roughly half (n = 267, 53.3%) reported seeing MSM in the past 12 months. Among physicians who saw MSM in the past 12 months, 60.3% (n = 161) met criteria as MSM-competent physicians, and most (n = 234, 87.6%) MSM-competent physicians reported positive or neutral attitudes towards MSM. Over 60% of all physicians were willing to participate in activities for improving MSM services, such as training and being on a list of physicians willing to serve MSM. MSM-competent physicians showed no sociodemographic differences compared with non MSM-competent physicians. MSM-competent physicians were more willing to have their medical institution named on a public clinic list capable of serving MSM (aOR: 1.70, 95%CI: 1.01-2.86) and being on a public physician list capable of serving MSM (aOR: 1.77, 95%CI: 1.03-3.03).Conclusions: MSM-competent physicians included a broad range of individuals that practiced in diverse clinical settings. Most physicians were interested in improving and expanding MSM clinical services, despite having neutral attitudes toward same-sex behavior. Future interventions should focus on developing MSM clinical competency and expanding services that meet the needs of MSM. [ABSTRACT FROM AUTHOR]

HIV serostatus disclosure before sex can facilitate serosorting, condom use and potentially decrease the risk of HIV acquisition. However, few studies have evaluated HIV serostatus disclosure from partners before sex. We examined the rate and correlates of receiving HIV serostatus disclosure from regular and casual male partners before sex among an online sample of men who have sex with men (MSM) in China. An online cross-sectional study was conducted among MSM in eight Chinese cities in July 2016. Participants completed questions covering sociodemographic information, sexual behaviors, HIV testing (including HIV self-testing) history, self-reported HIV status, and post-test violence. In addition, participants were asked whether they received HIV serostatus disclosure from their most recent partners before sex. Overall, 2105 men completed the survey. Among them, 85.9% were never married, and 35.4% had high school or less education. A minority (20.6%, 346/1678; 17.8%, 287/1608) of men received HIV serostatus disclosure from their most recent regular and casual male partners, respectively. Multivariate analysis indicated that participants who ever self-tested for HIV were more likely to have received HIV status disclosure from regular [adjusted OR (aOR) = 1.92, 95% CI 1.50-2.44] and casual (aOR = 2.34, 95% CI 1.80-3.04) male partners compared to never self-tested participants. Compared to participants who had not received HIV status disclosure from regular partners, participants who received disclosure from regular male partners had higher likelihood in experiencing post-test violence (aOR = 5.18, 95% CI 1.53-17.58). Similar results were also found for receiving HIV serostatus disclosure from casual partners. This study showed that HIV serostatus disclosure from partners was uncommon among Chinese MSM. Interventions and further implementation research to facilitate safe disclosure are urgently needed for MSM. [ABSTRACT FROM AUTHOR]

Despite global progress in HIV stigma reduction, persistent HIV stigma thwarts effective HIV service delivery. Advances in HIV biomedical research toward a cure may shift perceptions of people living with HIV and HIV stigma. The purpose of this study was to examine how men who have sex with men (MSM) living with HIV in Guangzhou, China perceive HIV cure research and its potential impact on MSM and HIV stigma. We conducted in-depth interviews with 26 MSM living with HIV about their perceptions of HIV cure research and the potential impact of an HIV cure on their lives. Thematic coding was used to identify themes and structure the analysis. Two overarching themes emerged. First, participants stated that an HIV cure may have a limited impact on MSM-related stigma. Men noted that most stigma toward MSM was linked to stereotypes of promiscuity and high rates of sexual transmitted diseases in the MSM community and might persist even after a cure. Second, participants believed that an HIV cure could substantially reduce enacted, anticipated, and internalized stigma associated with HIV. These findings suggest that a biomedical cure alone would not remove the layered stigma facing MSM living with HIV. Comprehensive measures to reduce stigma are needed. [ABSTRACT FROM AUTHOR]

Introduction: Syphilis is an important sexually transmitted infection (STI). Despite inexpensive and effective treatment, few key populations receive syphilis testing. Innovative strategies are needed to increase syphilis testing among key populations. Areas covered: This scoping review focused on strategies to increase syphilis testing in key populations (men who have sex with men (MSM), sex workers, people who use drugs, transgender people, and incarcerated individuals). Expert commentary: We identified many promising syphilis testing strategies, particularly among MSM. These innovations are separated into diagnostic, clinic-based, and non-clinic based strategies. In terms of diagnostics, self-testing, dried blood spots, and point-of-care testing can decentralize syphilis testing. Effective syphilis self-testing pilots suggest the need for further attention and research. In terms of clinic-based strategies, modifying default clinical procedures can nudge physicians to more frequently recommend syphilis testing. In terms of non-clinic based strategies, venue-based screening (e.g. in correctional facilities, drug rehabilitation centres) and mobile testing units have been successfully implemented in a variety of settings. Integration of syphilis with HIV testing may facilitate implementation in settings where individuals have increased sexual risk. There is a strong need for further syphilis testing research and programs. [ABSTRACT FROM AUTHOR]

Quantifying HIV service provision along the HIV care continuum is increasingly important for monitoring and evaluating HIV interventions. We examined factors associated with linkage and retention in care longitudinally among MSM (n = 1974, 4933 person-years) diagnosed and living in Guangzhou, China, in 2008–2014. We measured longitudinal change of retention in care (≥2 CD4 tests per year) from linkage and antiretroviral therapy initiation (ART). We examined factors associated with linkage using logistic regression and with retention using generalized estimating equations. The rate of linkage to care was 89% in 2014. ART retention rate dropped from 71% (year 1) to 46% (year 2), suggesting that first-year retention measures likely overestimate retention over longer periods. Lower CD4 levels and older age predicted retention in ART care. These data can inform interventions to improve retention about some subgroups. [ABSTRACT FROM AUTHOR]