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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]

To investigate the phenomenon of patient-physician mistrust in China, a qualitative study involving 107 physicians, nurses and health officials in Guangdong Province, southern China, was conducted through semi-structured interviews and focus groups. In this paper we report the key findings of the empirical study and argue for the essential role of medical professionalism in rebuilding patient-physician trust. Health professionals are trapped in a vicious circle of mistrust. Mistrust (particularly physicians' distrust of patients and their relatives) leads to increased levels of fear and self-protection by doctors which exacerbate difficulties in communication; in turn, this increases physician workloads, adding to a strong sense of injustice and victimization. These factors produce poorer healthcare outcomes and increasingly discontented and angry patients, escalate conflicts and disputes, and result in negative media coverage, all these ultimately contributing to even greater levels of mistrust. The vicious circle indicates not only the crisis of patient-physician relationship but the crisis of medicine as a profession and institution. Underlying the circle is the inherent conflict of interest in the healthcare system by which health professionals and hospitals have become profit-driven. This institutional conflict of interest seriously compromises the fundamental principle of medical professionalism-the primacy of patient welfare-as well as the traditional Chinese ideal of "medicine as the art of humanity". Patient trust can be restored through rectifying this institutional conflict of interest and promoting medical professionalism via a series of recommended practical measures. [ABSTRACT FROM AUTHOR]

Trust is indispensable not only for interpersonal relationships and social life, but for good quality healthcare. As manifested in the increasing violence and tension in patient-physician relationships, China has been experiencing a widespread and profound crisis of patient-physician trust. And globally, the crisis of trust is an issue that every society, either developing or developed, has to face in one way or another. Yet, in spite of some pioneering works, the subject of patient-physician trust and mistrust - a crucial matter in healthcare especially because there are numerous ethical implications - has largely been marginalized in bioethics as a global discourse. Drawing lessons as well as inspirations from China, this paper demonstrates the necessity of a trust-oriented bioethics and presents some key theoretical, methodological and philosophical elements of such a bioethics. A trust-oriented bioethics moves beyond the current dominant bioethical paradigms through putting the subject of trust and mistrust in the central agenda of the field, learning from the social sciences, and reviving indigenous moral resources. In order for global bioethics to claim its relevance to the things that truly matter in social life and healthcare, trust should be as vital as such central norms like autonomy and justice and can serve as a potent theoretical framework. [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]

Abstract: Introduction: HIV testing has rapidly expanded into diverse, decentralized settings. While increasing accessibility to HIV testing is beneficial, it may lead to unintended consequences such as being pressured to test. We examined the frequency, correlates and contexts of pressured HIV testing among Chinese men who have sex with men (MSM) using mixed methods. Methods: We conducted an online survey of MSM (N = 1044) in May 2017. Pressured HIV testing was defined as being forced to test for HIV. We conducted logistic regression analysis to determine the associations between pressured HIV testing and socio‐demographic and sexual behavioural factors. Follow‐up interviews (n = 17) were conducted with men who reported pressured testing and we analysed qualitative data using a thematic analysis approach. Results: Ninety‐six men (9.2%) reported experiencing pressure to test for HIV. Regular male sex partners were the most common source of pressure (61%, 59/96), and the most common form of pressure was a threat to end a relationship with the one who was being pressured (39%, 37/96). We found a higher risk of pressured testing in men who had only used HIV self‐testing compared to men who had never self‐tested (AOR 2.39 (95%CI: 1.38 to 4.14)). However, this relationship was only significant among men with low education (AOR 5.88 (95% CI: 1.92 to 17.99)) and not among men with high education (AOR 1.62 (95% CI: 0.85 to 3.10)). After pressured testing, about half of men subsequently tested for HIV (55%, 53/96) without pressure – none reported being diagnosed with HIV. Consistent with this finding, qualitative data suggest that perceptions of pressure existed on a continuum and depended on the relationship status of the one who pressured them. Although being pressured to test was accompanied by negative feelings, men who were pressured into testing often changed their attitude towards HIV testing, testing behaviours, sexual behaviours and relationship with the one who pressured them to test. Conclusion: Pressured HIV testing was reported among Chinese MSM, especially from men with low education levels and men who received HIV self‐testing. However, in some circumstances, pressure to test helped MSM in several ways, challenging our understanding of the role of agency in the setting of HIV testing. [ABSTRACT FROM AUTHOR]

Introduction: Migration of men who have sex with men (MSM) from rural to urban areas is common across low- and middleincome countries and is widely believed to contribute to elevated HIV risk among migrant MSM in urban areas. Little consensus exists on whether their risk is due to their transplantation or their being from resource-constrained rural areas. This study seeks to clarify the relationship between migration and HIV risks by comparing differences in HIV-related risky sexual behaviours and healthcare utilization across competing conceptualizations of migratory statuses. Methods: In July 2016, MSM ≥16 years old currently residing in one of eight urban cities in China were recruited for an online cross-sectional survey, which collected information on socio-demographics, sexual behaviours, HIV care-seeking behaviours, and healthcare utilization. Based on a question about residency status, each participant was classified as an urban local resident, urban transplant, or rural transplant. Multivariable multinomial logistic regression was used to examine the associations between risky behaviours and healthcare utilization among these three groups. Results: Among 2007 MSM, the proportion of local, urban transplant and rural transplant were 32% (648/2007), 24% (478/ 2007), and 44% (881/2007), respectively. Compared with urban local resident MSM, urban transplant MSM were more likely to have ever tested for HIV (adjusted odds ratio (aOR) = 1.39, 95% confidence interval (CI): 1.08 to 1.80). Compared with urban transplant MSM, rural transplant MSM were less likely to have utilized any governmental sexual health services in the past three months (aOR = 0.75, 95% CI: 0.60 to 0.93), ever tested for HIV (aOR = 0.77, 95% CI: 0.61 to 0.96), ever initiated antiretroviral therapy (ART) (aOR = 0.16, 95% CI: 0.05 to 0.52), and ever purchased sex (aOR = 0.57, 95% CI: 0.38 to 0.85). No other significant differences were found in sexual behaviours among three groups. Conclusions: The widely used local/migrant categorization obscures important differences in HIV risk present between urban/ rural subgroups among them. Previous studies of HIV risks in Chinese "migrant" may have failed to consider the role of structural factors such as discrimination or barriers to healthcare when interpreting their findings of higher HIV prevalence in this population. Low ART uptake among rural transplant MSM in this study is particularly concerning and underscore the need for HIV-related interventions tailored for this group. [ABSTRACT FROM AUTHOR]

Background: HIV 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.Methods: This 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.Discussion: MSM 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 Registration: ClinicalTrials.gov, NCT02796963 . Registered on 23 May 2016. [ABSTRACT FROM AUTHOR]

Graph Table 4 HIV/STI testing and sexual behaviors self-reported by men who had syphilis testing during the trial and initiated at least 1 follow-up survey. [Extracted from the article]

Background: Community engagement strategies are often integrated in public health interventions designed to promote condom use among men who have sex with men (MSM), a key population for HIV prevention. However, the ways in which condom use peer norms and self-efficacy play a role in the association between community engagement and condom use is unclear. This study examines the potential mediating roles of peer norms and self-efficacy in this association.Methods: A nationwide cross-sectional online survey was conducted among Chinese MSM in 2015. Recruitment criteria included being born biologically male, being older than 16 years, having had anal sex with a man at least once during their lifetime, and having had condomless anal or vaginal sex in the past three months. Mplus 6.11 was used to conduct confirmatory factor analysis and path modeling analysis to examine the structural relationships between HIV/sexual health community engagement (e.g., joining social media and community events related to HIV and sexual health services), condom use peer norms, condom use self-efficacy, and frequency of condom use.Results: The study found that HIV/sexual health community engagement, condom use peer norms, condom use self-efficacy, and frequency of condom use were mutually correlated. A good data model was achieved with fit index: CFI = 0.988, TLI = 0.987, RMSEA = 0.032, 90% CI (0.028, 0.036). HIV/sexual health community engagement was associated with frequency of condom use, which was directly mediated by condom use peer norms and indirectly through self-efficacy.Conclusion: The study suggests that condom use peer norms and self-efficacy may be mediators in the pathway between community engagement and condom use, and suggests the importance of peer-based interventions to improve condom use. [ABSTRACT FROM AUTHOR]

Background: Many interventions find that social media engagement with health promotion materials can translate into behavioral changes. However, only a few studies have examined the ways in which specific actions on various social media platforms are correlated with health behaviors.Objective: The objective of this study was to examine the association between social media use and HIV testing behaviors among Chinese men who have sex with men (MSM).Methods: In July 2016, a Web-based survey was conducted to recruit MSM in 8 Chinese cities through Blued (Blue City Holdings Ltd.), the world's largest gay mobile phone app. Data on sociodemographic variables, social media use platforms and behaviors, sexual behaviors, and HIV testing histories were collected. HIV testing-related social media use was defined as having ever engaged with HIV testing content on social media, which was further divided into observing (ie, receiving), endorsing (eg, liking and sharing), and contributing (eg, posting or commenting on HIV testing materials). Confirmatory factor analysis (CFA) was conducted to determine the best division of HIV testing-related social media use. Univariate and multivariable logistic regressions were used to examine the association between HIV testing-related social media use and HIV testing behaviors.Results: A total of 2105 individuals participated in the survey. Among them, 46.75% (984) were under the age of 24 years, 35.43% (746) had high school education or less, and 47.74% (587) had condomless sex in the last 3 months. More than half of the respondents (58.14%, 1224/2105) reported HIV testing-related social media use. Additionally, HIV testing-related social media use, especially on multifunctional platforms such as WeChat, was found to be associated with recent HIV testing (adjusted odds ratio [aOR] 2.32, 95% CI 1.66-3.24). Contributing on social media was correlated with recent HIV testing (aOR 2.10, 95% CI 1.40-3.16), but neither observing (aOR 0.66, 95% CI 0.38-1.15) nor endorsing (aOR 1.29, 95% CI 0.88-1.90) were correlated.Conclusions: Our data suggest that social media use, particularly on multifunctional platforms such as WeChat and with contributing behaviors, is correlated with HIV testing among MSM in China. Campaigns that promote active participant contribution on social media beyond passive observation and endorsement of promotional materials are needed. This study has implications for the design and implementation of social media interventions to promote HIV testing. [ABSTRACT FROM AUTHOR]

Background: Scaling up HIV testing is the first step in the HIV treatment continuum which is important for controlling the HIV epidemic among men who have sex with men (MSM). Following an online HIV testing intervention among MSM, we aim to examine sociodemographic and spatial factors associated with HIV testing.Methods: We conducted a secondary analysis on data from an online HIV testing intervention among MSM who had never-tested for HIV. The survey was distributed through online networks connected to all provinces and regions of China. Univariate and multivariable analyses were performed to examine factors associated with testing three weeks post-intervention.Results: At three weeks after the intervention, 36% of 624 followed-up MSM underwent HIV testing, 69 men reported positive HIV test results. Having money for sex, ever tested for sexually transmitted infections and intimate partner violence experience were significant factors of post-intervention HIV testing. Students were less likely to undergo HIV testing at follow-up compared to others (adjusted odds ratio=0.69, 95% C.I.=0.47-0.99), adjusted by age and type of intervention. Moderate provincial spatial variation of testing was observed.Conclusions: While high risk men generally had higher HIV testing rates, some MSM like students had lower testing rates, suggesting the need for further ways to enhance HIV testing in specific MSM communities. [ABSTRACT FROM AUTHOR]

Introduction: HIV and syphilis testing rates remain low among men who have sex with men (MSM) in low- and middleincome countries (LMICs). Community engagement has been increasingly used to promote HIV testing among key populations in high-income countries, often in settings with stronger civil society. This study aimed to assess socio-demographic, behavioural, and community engagement factors associated with HIV and syphilis testing among MSM in China. Methods: MSM =16 years old who had condomless sex in the past three months were recruited nationwide to complete a cross-sectional online survey in November 2015. Data were collected on socio-demographics, sexual behaviours, HIV testing, syphilis testing, and community engagement in sexual health. We defined community engagement in sexual health using six items assessing awareness and advocacy of sexual health programmes. The underlying factor structure of a 6-item community engagement scale was determined through exploratory factor analysis. Univariate and multivariable logistic regressions identified correlates of HIV and syphilis testing. Results: 1189 MSM were recruited. 54% (647/1189) of men had ever tested for HIV and 30% (354/1189) had ever tested for syphilis. Factor analysis suggested three levels of community engagement (minimal, moderate, and substantial) and this model explained 79.5% of observed variance. A quarter (26%, 312/1189) reported none to minimal engagement, over one half (54%, 644/1189) reported moderate engagement, and a fifth (20%, 233/1189) reported substantial engagement. Multivariable logistic regression showed that MSM with greater community engagement in sexual health were more likely to have ever tested for HIV (substantial vs. no engagement: aOR 7.91, 95% CI 4.98-12.57) and for syphilis (substantial vs. no engagement: aOR 5.35, 95% CI 3.16-9.04). Conclusions: HIV and syphilis testing are suboptimal among MSM in China. Community engagement may be useful for promoting testing in China and should be considered in intervention development and delivery. Further research is needed to better understand the role of LMIC community engagement in HIV interventions. [ABSTRACT FROM AUTHOR]

Background: Early diagnosis of syphilis and timely treatment can effectively reduce ongoing syphilis transmission and morbidity. We examined the factors associated with the early diagnosis of syphilis to inform syphilis screening strategic planning.Methods: In an observational study, we analyzed reported syphilis cases in Guangdong Province, China (from 2014 to mid-2015) accessed from the national case-based surveillance system. We categorized primary and secondary syphilis cases as early diagnosis and categorized latent and tertiary syphilis as delayed diagnosis. Univariate analyses and multivariable logistic regressions were performed to identify the factors associated with early diagnosis. We also examined the factors associated with early diagnosis at the individual and city levels in multilevel logistic regression models with cases nested by city (n = 21), adjusted for age at diagnosis and gender.Results: Among 83,944 diagnosed syphilis cases, 22% were early diagnoses. The city-level early diagnosis rate ranged from 7 to 46%, consistent with substantial geographic variation as shown in the multilevel model. Early diagnosis was associated with cases presenting to specialist clinics for screening, being male and attaining higher education level. Cases received syphilis testing in institutions and hospitals, and diagnosed in hospitals were less likely to be in early diagnosis. At the city-level, cases living in a city equipped with more hospitals per capita were less likely to be early diagnosis.Conclusions: To enhance early diagnosis of syphilis, city-specific syphilis screening strategies with a mix of passive and client/provider-initiated testing might be a useful approach. [ABSTRACT FROM AUTHOR]

Background: Innovation contests call on non-experts to help solve problems. While these contests have been used extensively in the private sector to increase engagement between organizations and clients, there is little data on the role of innovation contests to promote health campaigns. We implemented an innovation contest in China to increase sexual health awareness among youth and evaluated community engagement in the contest.Methods: The sexual health image contest consisted of an open call for sexual health images, contest promotion activities, judging of entries, and celebrating contributions. Contest promotion activities included in-person and social media feedback, classroom didactics, and community-driven activities. We conducted 19 semi-structured interviews with a purposive sample to ensure a range of participant scores, experts and non-expert participants, submitters and non-submitters. Transcripts of each interview were coded with Atlas.ti and evaluated by three reviewers.Results: We identified stages of community engagement in the contest which contributed to public health impact. Community engagement progressed across a continuum from passive, moderate, active, and finally strong engagement. Engagement was a dynamic process that appeared to have little relationship with formally submitting an image to the contest. Among non-expert participants, contest engagement increased knowledge, healthy attitudes, and empowered participants to share ideas about safe sex with others outside of the contest. Among experts who helped organize the contest, the process of implementing the contest fostered multi-sectoral collaboration and re-oriented public health leadership towards more patient-centered public health campaigns.Conclusion: The results of this study suggest that innovation contests may be a useful tool for public health promotion by enhancing community engagement and re-orienting health campaigns to make them more patient-centered. [ABSTRACT FROM AUTHOR]

Despite global efforts to increase HIV test uptake among men who have sex with men (MSM), social stigma and negative attitudes toward homosexuality hinder the effectiveness of traditional test promotion campaigns. Increasing HIV test uptake requires greater understanding of the conditions that facilitate decisions to get tested. We conducted an online survey hosted by two of the most highly frequented MSM web portals in China. A generalised ordered logistic regression analysis was conducted to determine factors associated with HIV testing behaviour. Compared to men who had never tested for HIV, men who had tested in the past year were more likely to have never engaged in sex with women, have multiple male sex partners in the past 3 months and have disclosed their sexual orientation to others. MSM found testing at local Chinese Centers for Disease Control and Prevention (80.7%), gay men's community-based organisations (80.2%) and public hospitals (70.9%) to be acceptable, while saunas (50.5%) and gay bars (41.8%) were found to be unacceptable testing venues. Our study shows that MSM in China prefer to test at venues that guarantee confidentiality, quality and quick results. Our study also suggests that self-testing may be a feasible approach to increase test uptake. [ABSTRACT FROM PUBLISHER]

Background: Despite global efforts to control HIV among key populations, new infections among men who have sex with men (MSM) and transgender (TG) individuals are still increasing. The increasing HIV epidemic among MSM/TG in China indicates that more effective services are urgently needed. However, policymakers and program managers must have a clear understanding of MSM/TG sexual health in China to improve service delivery. To meet this need, we undertook a scoping review to summarize HIV epidemiology and responses among MSM and TG individuals in China. Methods: We searched MEDLINE, EMBASE and the Cochrane Library for recent studies on MSM/TG HIV epidemiology and responses. We also included supplemental articles, grey literature, government reports, policy documents, and best practice guidelines. Results: Overall, HIV prevalence among Chinese MSM was approximately 8 % in 2015 with a higher prevalence observed in Southwest China. TG are not captured in national HIV, STD, or other sexual health surveillance systems. There is limited data sharing between the public health authorities and community-based organizations (CBOs). Like other low and middle income countries, China is challenged by low rates of HIV testing, linkage, and retention. Several pilot interventions have been shown to be effective to increase HIV testing among MSM and TG individuals, but have not been widely scaled up. Data from two randomized controlled trials suggests that crowd-sourcing contests can increase HIV testing, creating demand for services while engaging communities. Conclusion: Improving HIV surveillance and expanding HIV interventions for Chinese MSM and TG individuals are essential. Further implementation research is needed to ensure high-quality HIV services for MSM and TG individuals in China. [ABSTRACT FROM AUTHOR]

Background: Increased trade between China and Uganda has fueled trafficking of female Ugandans into China. These women may face challenges accessing health services. This study focused on examining barriers to health care access among female Ugandan sex workers in China. Methods: In 2014, we undertook in-depth interviews with 19 female Ugandan sex workers in Guangzhou, China. Interviews focused on barriers to health service access and were analyzed using an a priori coding framework followed by open-coding to capture emergent themes. Results: Out of 19 women, 12 women reported a history of being trafficked into China. None of the women had a valid Chinese visa. Fear of being arrested for lack of documentation discouraged women in this sample from accessing hospital services. Low pay, housing exploitation, and remittances contributed to participants' lack of financial resources, which further inhibited their ability to access health services. Participants expressed feeling social isolation from the local community and reported mistrust of local individuals and organizations, including hospitals. Conclusion: Ugandan sex workers in China faced substantial structural barriers that limited health service access. Policy changes and the development of new programs are urgently needed to ensure these women have improved access to health services. [ABSTRACT FROM AUTHOR]

Guangzhou is China's third most populous city, and the region's burgeoning manufacturing economy has attracted many young African businessmen and entrepreneurs to the city. The aims of this study were to examine strategies that African migrants in Guangzhou have adopted in response to health-care barriers, and explore their perceptions of how to address their needs. Twenty-five semi-structured interviews and two focus groups were conducted among African migrants residing in Guangzhou, China. Facing multiple barriers to care, African migrants have adopted a number of suboptimal and unsustainable approaches to access health care. These included: using their Chinese friends or partners as interpreters, self-medicating, using personal connections to medical doctors, and travelling to home countries or countries that offer English-speaking doctors for health care. Health-care providers and health organisations in Guangzhou have not yet acquired sufficient cultural competence to address the needs of African migrants residing in the city. Introducing linguistically and culturally competent health-care services in communities concentrated with African migrants may better serve the population. With the growing international migration to China, it is essential to develop sustainable approaches to improving health-care access for international migrants, particularly those who are marginalised. [ABSTRACT FROM PUBLISHER]

Military metaphors are pervasive in biomedicine, including HIV research. Rooted in the mind set that regards pathogens as enemies to be defeated, terms such as “shock and kill” have become widely accepted idioms within HIV cure research. Such language and symbolism must be critically examined as they may be especially problematic when used to express scientific ideas within emerging health-related fields. In this article, philosophical analysis and an interdisciplinary literature review utilizing key texts from sociology, anthropology, history, and Chinese and African studies were conducted to investigate the current proliferation of military metaphors. We found the use of these metaphors to be ironic, unfortunate, and unnecessary. To overcome military metaphors we propose to (1) give them less aggressive meanings, and/or (2) replace them with more peaceful metaphors. Building on previous authors' work, we argue for the increased use of “journey” (and related) metaphors as meaningful, cross-culturally appropriate alternatives to military metaphors. [ABSTRACT FROM PUBLISHER]

Differences in risk behaviours between men who have sex with men (MSM) and men who have sex with both men and women (MSMW) have important implications for HIV and sexually transmitted infection (STI) transmission. We examined differences in risk behaviours, HIV/STI testing, self-reported HIV/STI diagnoses, and linkage to HIV care between MSM and MSMW across China. Participants were recruited through three MSM-focused websites in China. An online survey containing items on socio-demographics, risk behaviours, testing history, self-reported HIV/STI diagnosis, and linkage to and retention in HIV care was completed from September to October 2014. Chi square tests and logistic regression analyses were conducted. MSMW were less likely to use a condom during last anal sex (p ≤ 0.01) and more likely to engage in group sex (p ≤ 0.01) and transactional sex (p ≤ 0.01) compared to MSM. Self-reported HIV/STI testing and positivity rates between MSM and MSMW were similar. Among HIV-infected MSM, there was no difference in rates of linkage to or retention in antiretroviral therapy when comparing MSM and MSMW. Chinese MSM and MSMW may benefit from different HIV and STI intervention and prevention strategies. Achieving a successful decrease in HIV/STI epidemics among Chinese MSM and MSMW will depend on the ability of targeted and culturally congruent HIV/STI control programmes to facilitate a reduction in risk behaviours. [ABSTRACT FROM AUTHOR]

Background: Syphilis is prevalent among men who have sex with men (MSM) in China. Syphilis partner notification (PN) programs targeting MSM has been considered as one of effective strategies to prevention and control of the infection in the population. We examined willingness and preferences for PN among MSM to measure feasibility and optimize uptake. Methods: Participation in a syphilis PN program was measured using a factorial survey from both the perspective of the index patient and the partner. Respondents were recruited from April-July 2011 using convenience sampling at two sites—a MSM sexually transmitted disease (STD) clinic and a MSM community based organization (CBO). Respondents first evaluated three factorial survey vignettes to measure probability of participation and then an anonymous sociodemographic questionnaire. A two-level mixed linear model was fitted for the factorial survey analysis. Results: In 372 respondents with mean age (± SD) 28.5 (± 6.0) years, most were single (82.0%) and closeted gays (66.7%). The Internet was the most frequent place to search for sex. Few (31.2%) had legal names for casual partners, but most had instant messenger (86.5%) and mobile phone numbers (77.7%). The mean probability of participation in a syphilis PN program was 64.5% (± 32.4%) for index patients and 63.7% (± 32.6%) for partners. Referral of the partner to a private clinic or MSM CBO for follow-up decreased participation compared to the local Center for Disease Control and Prevention (CDC) or public STD clinic. Conclusions: Enhanced PN services may be feasible among MSM in South China. Internet and mobile phone PN may contact partners untraceable by traditional PN. Referral of partners to the local CDC or public STD clinic may maximize PN participation. [ABSTRACT FROM AUTHOR]

Objectives: To assess associations between residences location, risky sexual behaviours and sexually transmitted diseases (STDs) among adults living in Guangzhou, China.Methods: Data were obtained from 751 Chinese adults aged 18-59 years in Guangzhou, China, using stratified random sampling by using spatial epidemiological methods. Face-to-face household interviews were conducted to collect self-report data on risky sexual behaviours and diagnosed STDs. Kulldorff's spatial scan statistic was implemented to identify and detect spatial distribution and clusters of risky sexual behaviours and STDs. The presence and location of statistically significant clusters were mapped in the study areas using ArcGIS software.Results: The prevalence of self-reported risky sexual behaviours was between 5.1% and 50.0%. The self-reported lifetime prevalence of diagnosed STDs was 7.06%. Anal intercourse clustered in an area located along the border within the rural-urban continuum (p=0.001). High rate clusters for alcohol or other drugs using before sex (p=0.008) and migrants who lived in Guangzhou <1 year (p=0.007) overlapped this cluster. Excess cases for unprotected sex (p=0.031) overlapped the cluster for college students (p<0.001). Five of nine (55.6%) students who had sexual experience during the last 12 months located in the cluster of unprotected sex.Conclusions: Short-term migrants and college students reported greater risky sexual behaviours. Programmes to increase safer sex within these communities to reduce the risk of STDs are warranted in Guangzhou. Spatial analysis identified geographical clusters of risky sexual behaviours, which is critical for optimising surveillance and targeting control measures for these locations in the future. [ABSTRACT FROM AUTHOR]

Patients’ rights are central in today's legislation and social policies related to health care, including HIV care, in not only Western countries but around the world. However, given obvious socio-cultural differences it is often asked how or to what extent patients’ rights should be respected in non-Western societies such as China. In this paper, it is argued that the patients’ rights framework is compatible with Chinese culture, and that from the perspective of contemporary patient rights healthcare providers have a duty to disclose truthfully the diagnosis and prognosis to their patients, that the Chinese cultural practice of involving families in care should – with consent from the patient – be promoted out of respect for patients’ rights and well-being, and that healthcare providers should be prepared to address the issue of disclosing a patient's HIV status to sexual partner(s). Legally, the provider should be permitted to disclose without consent from the patient but not obliged to in all cases. The decision to do this should be taken with trained sensitivity to a range of ethically relevant considerations. Post-disclosure counseling or psychological support should be in place to address the concerns of potentially adverse consequences of provider-initiated disclosure and to maximize the psychosocial and medical benefits of the disclosure. There is an urgent need for healthcare providers to receive training in ethics and disclosure skills. This paper concludes also with some suggestions for improving the centerpiece Chinese legislation, State Council's “Regulations on AIDS Prevention and Control” (2006), to further safeguard the rights and well-being of HIV patients. [ABSTRACT FROM AUTHOR]

Background: Sexually Transmitted Infections (STIs) are a global challenge. China, once said to have eradicated STIs, is now facing a rapid rise in the prevalence of HIV/STIs. This review of reviews aims to map HIV/STI risk factors among the Chinese population, with the objective of identifying risk factors to inform the formulation of effective prevention strategies. Methods: A systematic search using key terms related to HIV/STIs, risk factors and the Chinese population in both English and Chinese databases (PubMed, PsycINFO, the Cochrane Library; Wanfang data, CNKI, VIP and SINOMED) was conducted, and peer-reviewed systematic reviews on the topic from 1991 to 2014 were selected. Identified risk factors were grouped into different level determinants based on the HIV Social Epidemiology Model, and then evaluated and reported based on the PRISMA checklist. Findings: Of the twenty-eight reviews included, the majority were focused on well-established, individual level risk factors within key populations, with some highlighting the complexity of interacting factors (e.g., alcohol use and higher income in male migrants). While twenty-two reviews covered individual factors, only ten mentioned social factors and five had contents on structural factors. There are gaps in the evidence on social and structural level impacts of HIV/STIs, such as on stigma, discrimination, health policy, access to care, and illicit drug control policies. Migration and social expectation appear to pose a significant threat in aggravating the HIV/STI situation in China; for example, incarceration patterns indicated a significant risk of HIV/STIs for female sex workers. Conclusions: Since international guidelines recommend an integrated and multi-level approach to HIV/STI prevention, a comprehensive approach targeting interventions at all levels along the continuum of care is needed to effectively curtail HIV/STI transmission in China. More research is needed to better understand the impact of socio-political interventions within a Chinese context. [ABSTRACT FROM AUTHOR]

Background: End-stage liver disease and hepatocellular carcinoma due to hepatitis C virus (HCV) co-infection are increasingly common causes of death among HIV-infected individuals. However, there are few clinical investigations of HIV/HCV co-infected individuals from low and middle-income nations. Here, we compare the epidemiology of HCV-infected and HIV/HCV co-infected individuals in Southern China and examine hepatic fibrosis scores in co-infected individuals.Methods: We conducted a retrospective cross-sectional study of treatment-naïve HIV/HCV co-infected and HCV mono-infected subjects. Bivariate and multivariate models were used to examine the association between demographics and HCV genotype. Among co-infected individuals, we also studied the relationship between fibrosis scores derived from non-invasive studies and HCV genotype.Results: Data were collected from 175 HCV-infected individuals, including 89 (51 %) HIV/HCV co-infected individuals. HIV/HCV co-infection was correlated with intravenous drug use (AOR 46.25, p < 0.001) and not completing high school (AOR 17.39, p < 0.001) in a multivariate model. HIV/HCV co-infected individuals were more likely to be infected with HCV genotype 6a (p < 0.0001) or 3a (p < 0.023), whereas increased fibrosis (FIB-4 score) was associated with HCV genotype 3a infection (β 2.18, p < 0.001).Discussion: Our results suggest that intravenous drug use is driving HIV/HCV co-infection in Southern China. While additional studies are needed, HCV genotype 6a is more common and genotype 3a appears to be associated with more severe hepatic fibrosis in co-infected individuals.Conclusions: Future HIV/HCV co-infection research in China should focus on at risk populations, HCV testing uptake, and genotype-specific treatment. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various articles in the issue on topics including socio-political, cultural and healthcare context of patient-physician mistrust; and implications of patient–physician trust and mistrust in the Chinese context.

Condomless commercial sex work is a common mode of HIV transmission in China. This study systematically reviews the impacts of behavioral interventions on condom use and HIV testing uptake among female sex workers (FSW) in China. Chinese and English language peer-reviewed articles published between January 2000 and December 2013 were searched in five electronic databases. Odds ratios (OR) were calculated by comparing the levels of improvements in condom use and HIV testing uptake by various intervention strategies. Study quality was assessed for included studies. This review followed the PRISMA guidelines and was registered in PROSPERO. One hundred and twenty-eight studies met inclusion criteria. Meta-analyses indicated that FSW in the post-intervention period were 2.3-5.0 times more likely to use condoms with male clients in their last sexual act and 2.3-3.4 times more likely to use condoms consistently in the last month than in the pre-intervention period. In particular, multiple session intervention were more effective in improving condom use among FSW with male clients ( OR=5.6, [4.0-7.8]) than a single session intervention ( OR=3.3, [2.8-3.8]). Behavioral interventions also improved past-12-month HIV testing uptake 4.6-fold (95% CI, 2.9-7.4). Comprehensive intervention programs were more effective ( OR=8.1, [4.0-16.7]) in improving HIV testing uptake compared with health education only programs ( OR=2.7, [1.6-4.5]). Longer intervention duration (>12 months) did not increase effectiveness in improving condom use or HIV testing rate among Chinese FSWs. Behavioral interventions are effective in improving condom use and HIV testing uptake among Chinese FSW. This review highlights both the potentials and limitations of condom promotion interventions targeting female sex workers. [ABSTRACT FROM AUTHOR]

Background: The increasing burden of sexually transmitted infections (STIs) including HIV and syphilis among male sex workers (MSWs) is a major global concern. The aim of our study was to evaluate the difference between MSWs and non-commercial MSMs in China. Methods: During 2008-09, in a cross-sectional study, 2618 adult MSM were recruited through respondent-driven and snowball sampling from seven cities of China. Information regarding socio-demographics, risk behaviors, HIV-related knowledge and STI-related symptoms were collected and participants were tested for HIV and syphilis. Results: Among 2618 participating MSM, 9.97% sold sex to males. HIV prevalence was 7.45% (6.13% among MSWs and 7.59% among non-MSW MSM) and syphilis prevalence was 14.32% (10.73% for MSWs and 14.72% for non-MSW MSM). Compared to non-MSW MSM, MSWs were more likely to be younger (adjusted odds ratio: aOR = 0.91, 95% confidence interval: 95%CI=0.88-0.93), never married (aOR = 4.38, 95% CI = 2.38-6.80), less educated, heterosexual (aOR = 13.04, 95% CI = 6.08-27.95), less knowledgeable regarding HIV (aOR = 0.70, 95% CI=0.51-0.96), experiencing symptoms of STI (aOR = 2.16, 95% CI = 1.47-3.19), engaging in condomless vaginal intercourse (aOR = 2.16, 95% CI = 1.47-3.19) and less likely to engage in condomless anal intercourse (aOR = 0.62, 95% CI = 0.46-0.85). Conclusions: High HIV and syphilis prevalence warranted urgent intervention targeting MSWs as a separate sentinel group for efficient surveillance owing to their different distribution from non-MSW MSM. Although male sex workers and non-commercial homosexuals have similar rates of HIV and syphilis, MSWs have different characteristics which should be considered in designing intervention programs targeting them. [ABSTRACT FROM AUTHOR]

Background: Health services for men who have sex with men (MSM) are inadequate in many areas around the world. HIV and syphilis test uptake remain suboptimal among MSM in China and many other regions. To inform the development of more comprehensive sexually transmitted disease (STD) testing programs among MSM, we collected descriptive data on MSM testing practices and preferences. Methods: MSM in two large urban Chinese cities were recruited through community-based organizations and clinics to participate in semi-structured interviews. We purposively sampled MSM across a range of sociodemographic characteristics and testing history, and assessed preferences for HIV and syphilis testing in the context of facilitators and barriers to testing and previous testing experiences. Each interview transcript was coded and thematically analyzed using Atlas.ti 7.0. Results: 35 MSM were interviewed. Confidentiality and privacy were the most important factors influencing participants’ decisions about whether and where to get tested. Men preferred rapid testing (results available within 30 minutes) compared to conventional tests where results take several hours or days to return. Participants described concerns about quality and accuracy of rapid tests offered in non-clinical settings such as community-based organizations. Men preferred testing service providers who were MSM-friendly, non-discriminatory, and medically trained. Preferred service center environments included: convenient but discrete location, MSM-friendly atmosphere, and clean/standard medical facilities. Conclusion: Our data highlight the need for HIV/syphilis testing services that are confidential and inclusive of MSM. Rapid testing in decentralized (i.e. peripheral health facilities and community-level, non-clinical venues) settings provides an opportunity to reach individuals who have not been tested before, but must be accompanied by quality assurance systems and technical competence. Implementation research could further evaluate HIV/syphilis testing programs responsive to MSM preferences. Short Summary: A qualitative study of MSM in South China found that men preferred rapid STD testing at MSM-focused test centers, but were concerned about test quality assurance and confidentiality. [ABSTRACT FROM AUTHOR]

Background: Commercial sex is one of the major modes of HIV transmission in China. Understanding HIV risk behaviours in female sex workers (FSW) is of great importance for prevention. This study aims to assess the magnitude and temporal changes of risk behaviours in Chinese FSW. Method: Five electronic databases were searched to identify peer-reviewed English and Chinese language articles published between January 2000 and December 2012 that reported risk behaviours among FSW in China, including condom use, HIV testing, and drug use. Linear regression and Spearman's rank correlation were used to examine temporal trends in these risk factors. The study followed PRISMA guidelines for meta-analyses and was registered in the PROSPERO database for systematic reviews. Results: A total of 583 articles (44 English, 539 Chinese) investigating 594,583 Chinese FSW were included in this review. At last sex, condom use was highest with commercial partners (clients), increasing from 53.7% in 2000 to 84.9% in 2011. During this same time period, condom use increased with regular partners from 15.2% to 40.4% and with unspecified partners from 38.6% to 82.5%. Increasing trends were also found in the proportion of sampled FSW who reported testing for HIV in the past 12 months (from 3.2% in 2000 to 48.0% in 2011), while drug use behaviours decreased significantly from 10.9% to 2.6%. Conclusion: During the first decade of 2000, Chinese FSWs’ self-reported risk behaviours have decreased significantly while HIV testing has increased. Further outreach and intervention efforts are needed to encourage condom use with regular partners, continue promotion of HIV testing, and provide resources for the most vulnerable FSW, particularly low tier FSW, who may have limited access to sexual health and prevention programs. [ABSTRACT FROM AUTHOR]

Objectives Low rates of HIV testing drive the rapidly growing HIV epidemic among men who have sex with men (MSM) in China. We examined the potential usefulness of couple-based and collective HIV testing strategies among Chinese MSM. Methods A cross-sectional online survey was conducted among 1113 MSM in 2013. Multivariable logistic regression analyses were conducted to identify factors associated with willingness to receive couple- based and collective testing. Results Acceptability of couple-based testing was very high among participants (86.1%), with a moderate level of interest in collective testing (43.2%). Being 'out' to others about one's sexual identity (adjusted OR (AOR)=1.48, 95% CI 1.01 to 2.17) and having ever had an HIV test (AOR=3.05, 95% CI 2.10 to 4.33) were associated with willingness to receive couple-based testing. Having multiple male anal sex partners in the past 3 months was associated with willingness to participate in collective testing (AOR=1.43, 95% CI 1.03 to 1.99). Discussion Couple-based and collective HIV testing could help better control the HIV epidemic among Chinese MSM if implemented and promoted in a culturally competent manner. [ABSTRACT FROM AUTHOR]

Despite China's free antiretroviral therapy (ART) program, there are high rates of treatment failure, large sociodemographic disparities in care outcomes and emerging medication resistance. Understanding patient medication adherence behaviors and challenges could inform adherence interventions to maximize the individual and prevention benefits of ART. This study assessed recent nonadherence and treatment interruption among 813 HIV-infected adult outpatients in Guangzhou, China. Participants completed a behavioral survey, underwent chart review, and were tested for syphilis, gonorrhea, and chlamydia. Factors associated with suboptimal adherence were identified using univariate and multivariate logistic regression. Among 721 HIV-infected adults receiving ART, 18.9% reported recent nonadherence (any missed ART in the past four weeks) and 6.8% reported treatment interruption (four or more weeks of missed ART in the past year). Lower education, living alone, alcohol use, and being on ART one to three years were associated with recent nonadherence. Male gender, lower education, and being on ART one to three years were associated with treatment interruption. ART medication adherence interventions are needed in China that include individualized, long-term adherence plans sensitive to patients' educational and economic situations. These interventions should also consider possible gender disparities in treatment outcomes and address the use of alcohol during ART. Successful ART medication adherence interventions in China can inform other international settings that face similar adherence challenges and disparities. [ABSTRACT FROM PUBLISHER]

Global health has become an increasingly prominent component of foreign policy in the last decade. The term health diplomacy has been used to describe this growing interface between foreign policy and global health, and it encompasses both the concept of using health to further foreign policy objectives as well as the idea that diplomatic tools can be helpful for attaining public health goals. The Chinese presence in Africa has grown in the last 15 years, generating increased interest in Sino-African relations. While much has been written in recent years about the Chinese presence in Africa, the growing numbers of Africans in China have attracted considerably less attention. Many are small-scale traders and might be expected to face many of the health challenges common among foreign migrants, but their health needs have been largely unrecognised. In this paper, we consider how a health diplomacy approach could be applied to African migrants in China, and the potential advantages and limitations of this strategy. We identify areas of overlap between public health, trade and foreign policy goals that can be emphasised to generate support for improved services for African migrants in China and to engage partners from a diversity of sectors. [ABSTRACT FROM AUTHOR]

Background: Sexually transmitted infections (STIs), including Hepatitis B and C virus, are emerging public health risks in China, especially among men who have sex with men (MSM). This study aims to assess the magnitude and risks of STIs among Chinese MSM. Methods: Chinese and English peer-reviewed articles were searched in five electronic databases from January 2000 to February 2013. Pooled prevalence estimates for each STI infection were calculated using meta-analysis. Infection risks of STIs in MSM, HIV-positive MSM and male sex workers (MSW) were obtained. This review followed the PRISMA guidelines and was registered in PROSPERO. Results: Eighty-eight articles (11 in English and 77 in Chinese) investigating 35,203 MSM in 28 provinces were included in this review. The prevalence levels of STIs among MSM were 6.3% (95% CI: 3.5–11.0%) for chlamydia, 1.5% (0.7–2.9%) for genital wart, 1.9% (1.3–2.7%) for gonorrhoea, 8.9% (7.8–10.2%) for hepatitis B (HBV), 1.2% (1.0–1.6%) for hepatitis C (HCV), 66.3% (57.4–74.1%) for human papillomavirus (HPV), 10.6% (6.2–17.6%) for herpes simplex virus (HSV-2) and 4.3% (3.2–5.8%) for Ureaplasma urealyticum. HIV-positive MSM have consistently higher odds of all these infections than the broader MSM population. As a subgroup of MSM, MSW were 2.5 (1.4–4.7), 5.7 (2.7–12.3), and 2.2 (1.4–3.7) times more likely to be infected with chlamydia, gonorrhoea and HCV than the broader MSM population, respectively. Conclusion: Prevalence levels of STIs among MSW were significantly higher than the broader MSM population. Co-infection of HIV and STIs were prevalent among Chinese MSM. Integration of HIV and STIs healthcare and surveillance systems is essential in providing effective HIV/STIs preventive measures and treatments. Trial Registration: PROSPERO No: CRD42013003721 [ABSTRACT FROM AUTHOR]

Background: HIV and hepatitis C (HCV) co-infection is highly common among Chinese injection drug users but it is difficult to reach IDUs at traditional VCT (Voluntary HIV counseling treatment) clinics. A new national model integrating HIV/HCV testing with methadone maintenance treatment was started in 2006. The purpose of this study was to investigate HIV and HCV test uptake and associated factors at methadone clinics in Guangdong Province, China. Methods: A cross-sectional design using routine surveillance data and laboratory testing confirmation was applied to determine rates of HIV and HCV test uptake. Multi-level modeling was used to examine individual-level and clinic-level correlates of increased test uptake. Results: 45 out of 49 methadone clinics in Guangdong Province agreed to participate in the study. Among all 13,270 individuals, 10,046 (75.7%) had HIV test uptake and 10,404 (78.4%) had HCV uptake. At the individual level, methadone clients 30 years or older were more likely to have HIV and HCV test uptake (p <0.001 for both). At the clinic level, methadone clinics with greater health care personnel were more likely to have HIV (p =0.01) and HCV (p = 0.044) test uptake. HIV test uptake significantly correlated with HCV test uptake (correlation coefficient=0.64). Conclusion: Methadone clinics provide an opportunity for routine integrated HIV and HCV screening among drug users in China. Increased test uptake in young drug users and increased health care personnel at clinics may further improve screening [ABSTRACT FROM AUTHOR]

Objectives: To determine the prevalence and correlates of syphilis among pregnant women in rural areas of South China. Methods: Point-of-care syphilis testing was provided at 71 health facilities in less developed, rural areas of Guangdong Province. Positive samples were confirmed at a local referral center by toluidine red unheated serum tests (TRUST) and Treponema pallidum particle agglutination (TPPA) tests. Results: Altogether 27,150 pregnant women in rural Guangdong were screened for syphilis. 106 (0.39%) syphilis cases were diagnosed, of which 78 (73.6%) received treatment for syphilis. Multivariate analysis revealed that older pregnant women (31–35 years old, aOR 2.7, 95% CI 0.99–7.32; older than 35 years old, aOR 5.9, 95% CI 2.13–16.34) and those with a history of adverse pregnant outcomes (aOR 3.64, 95% CI 2.30–5.76) were more likely to be infected with syphilis. Conclusions: A high prevalence of syphilis exists among pregnant women living in rural areas of South China. Enhanced integration of syphilis screening with other routine women's health services (OB GYN, family planning) may be useful for controlling China's syphilis epidemic. [ABSTRACT FROM AUTHOR]

Background: In China, female sex workers (FSWs) are at high risk of syphilis infection, but are hard to reach for interventions. Point-of-care testing introduces opportunities for expanding syphilis control measures. Modelling is used to estimate the impact of using rapid tests to screen FSWs for syphilis. In other settings, modelling has predicted large rebounds in infectious syphilis following screening, which may undermine any impact achieved. Methods: A deterministic syphilis transmission model among FSWs and clients was fitted to data from Yunnan Province (FSW syphilis prevalence = 7.5%), and used to estimate the impact of rapid syphilis testing and treatment for FSWs. Impact projections were compared for different model structures that included risk heterogeneity amongst FSWs, incoming syphilis infections amongst new FSWs and clients and re-infection from FSWs' regular non-commercial partners. The rebound in syphilis prevalence after screening ceased was explored. Results: All model structures suggest yearly syphilis screening could substantially reduce (by 72-88%) syphilis prevalence amongst FSWs in this setting over five years. However, incoming syphilis infections amongst new FSWs and clients or re- infections from regular non-commercial partners of FSWs can considerably reduce (>0%) the proportion of infections averted. Including heterogeneity in risk amongst FSWs had little effect upon the proportion of infections averted. In this setting, the rebound in syphilis prevalence after screening ceased is predicted to be slight, but it could be large in high prevalence settings. Conclusions: Rapid test screening could dramatically reduce syphilis prevalence amongst hard-to-reach groups, but strategies to reduce re-infection from regular non-commercial partners are needed to maximise impact. [ABSTRACT FROM AUTHOR]

Background. Syphilis has made a rapid resurgence in China, especially among high-risk groups including female sex workers (FSWs).Methods. Two cities in each of 3 provinces in South China were chosen and allocated to intervention or control arms. The intervention consisted of enhancing community-based syphilis screening outreach intervention with comprehensive sexually transmitted infection services at designated clinics while the control maintained routine intervention activities. Generalized linear modeling was used to examine effect of the intervention on incident syphilis infection.Results. A total of 8275 women were eligible, and 3597 women enrolled (n = 2011 in control arm, n = 1586 in intervention arm) in the study. The median follow-up duration was 375 days (interquartile range, 267–475). Syphilis incidence density in the intervention group was reduced by 70% (95% confidence interval, 53%–81%) compared with the incidence in the control arm. The syphilis prevention intervention benefits were robust among FSWs at low-tier venues, individuals with less than high school education, migrants, and women who did not report condom use during the last episode of sex.Conclusions. Integrated sexually transmitted infection and human immunodeficiency virus prevention strategies substantially reduce syphilis incidence among FSWs, especially among those at low-tier venues. This intervention suggests the need for scaling up comprehensive FSW programs in China. [ABSTRACT FROM PUBLISHER]

Objectives The present study investigates the varied spatial distribution of syphilis cases in Shenzhen, China, and explores the individual-, neighbourhood- and district-level factors affecting the distribution. Methods This study uses spatial analysis and multi-level generalised estimating equations to explore the spatial distribution of reported syphilis cases among individuals in Shenzhen, Guangdong Province, China. The spatial distribution of primary/secondary and latent cases was investigated using the Moran's I-statistic. Primary/ secondary syphilis cases were compared with all syphilis cases using a three-level model with individual (n=6496), neighbourhood (n=55) and district (n=6) levels. Results A total of 6496 syphilis cases were reported in 2009 with 35.8% primary and secondary syphilis cases. Both primary/secondary syphilis cases (Moran's I value=0.33, p<0.01) and latent syphilis cases (Moran's I value=0.19, p<0.01) showed significant spatial clustering at the neighbourhood level. Adjusting for the number of reporting hospitals, the best model found that the following characteristics were associated with primary/secondary syphilis infection: individuals who are younger in age (p=0.003), male (p<0.001), migrant labourers (p=0.047) and those who live in districts with a higher gross domestic product (p<0.001). Conclusions There is substantial clustering of primary and secondary syphilis cases at the neighbourhood level in Shenzhen, suggesting the need for greater STD health service provision in these clustered neighbourhoods. Spatially targeted syphilis control measures may be useful to optimise testing, treatment and partner services. [ABSTRACT FROM AUTHOR]

Objective China's sexually transmitted infection (STI) epidemic requires comprehensive control programmes. Partner services are traditional pillars of STI control but have not been widely implemented in China. This study was a systematic literature review to examine STI partner notification (PN) uptake in China. Methods Four English and four Chinese language databases were searched up to March 2011 to identify articles on PN of STIs including HIV in China. PN uptake was defined as the number of partners named, notified, evaluated or diagnosed per index patient. Results A total of 11 studies met inclusion criteria. For STI (excluding HIV) PN, a median 31.6% (IQR 27.4%--65.8%) of named partners were notified, 88.8% (IQR 88.4%--90.8%) of notified partners were evaluated and 37.9% (IQR 33.1%--43.6%) of evaluated partners were diagnosed. For HIV PN, a median 15.7% (IQR 13.2%--36.5%) of named partners were notified, 86.7% (IQR 72.9%--90.4%) of notified partners were evaluated and 27.6% (IQR 24.1%--27.7%) of evaluated partners were diagnosed. A mean of 80.6% (SD=12.6%) of patients attempted PN, and 72.4% (IQR 63.8%--81.1%) chose self-referral when offered more than one method of PN. Perceived patient barriers included social stigma, fear of relationship breakdown, uncertainty of how to notify and lack of partner contact information. Perceived infrastructure barriers included limited time and trained staff, mistrust of health workers and lack of PN guidelines. Conclusion PN programmes are feasible in China. Further research on STI PN, particularly among men who have sex with men and other high-risk groups, is an important public health priority. PN policies and guidelines are urgently needed in China. [ABSTRACT FROM AUTHOR]

Background Over three-quarters of new HIV infections in China during 2009 were estimated to be from sexual transmission. Over half of those living with HIV do not know their serostatus and identifying and treating individuals with sexually transmitted HIV infection has been challenging. Objective This global assessment explores Chinese systems for detecting and treating those with HIV infection with a particular focus on groups at increased risk of sexually transmitted HIV. Methods Published literature, grey sources and non-governmental reports were reviewed to describe HIV testing and care systems in China. Results HIV testing and care in China involve several parallel health systems and have been largely successful in reaching large numbers of vulnerable individuals. Provider-initiated testing and counselling has been more effective than voluntary counselling and testing programmes for expanding HIV testing efforts in China. Individuals with sexually transmitted HIV infection are underrepresented in the antiretroviral care system compared with other high-risk groups. Conclusions Comprehensive HIV testing and care bring together a number of Chinese health systems, but there are still gaps and challenges. Research and programmes focused on HIV testing and care for those with increased sexual risk are needed. [ABSTRACT FROM AUTHOR]

Objective To examine syphilis testing capacity, screening coverage rates and types of syphilis tests used in medical facilities in southern China. Methods Eleven of the 14 municipalities in Guangdong province participated. Data on syphilis testing capacity, screening coverage and types of syphilis tests used were collected from all types of public medical facilities offering prenatal care (n = 109). A total of 494680 women who delivered during 2004-2008 were studied. Findings In 2008, 54196 pregnant women (43.1%) were not screened for syphilis. Among such women, 32863 (60.6%) attended clinics without any syphilis testing capacity and 21333 (39.4%) attended clinics that performed testing but were not screened. The likelihood of not having syphilis test capacity was much higher for hygiene stations (odds ratio, OR: 10; 95% confidence interval, CI: 4-25), services at the township level (OR: 33; 95% CI: 10-100) and services with ≤ 1000 deliveries per year (OR: 1.002; 95% CI: 1.001-1.003). These same service characteristics correlated with lower screening coverage rates (P < 0.01 ). Only one antenatal clinic had the capacity to conduct both treponemal and non-treponemal tests for diagnosing syphilis. Conclusion Syphilis screening is available in very few of the basic medical facilities offering prenatal care where most neonates in southern China are delivered. In light of this and of the increasing incidence of syphilis in the area, expanding point-of-care rapid syphilis testing is a priority. [ABSTRACT FROM AUTHOR]

Background: Reducing harm associated with selling and purchasing sex is an important public health priority in China, yet there are few examples of sustainable, successful programs to promote sexual health among female sex workers. The limited civil society and scope of nongovernmental organizations circumscribe the local capacity of female sex workers to collectively organize, advocate for their rights, and implement STI/HIV prevention programs. The purpose of this study was to examine social networks among low-income female sex workers in South China to determine their potential for sexual health promotion. Methods/Principal Findings: Semi-structured interviews with 34 low-income female sex workers and 28 health outreach members were used to examine how social relationships affected condom use and negotiation, STI/HIV testing and healthseeking behaviors, and dealing with violent clients. These data suggested that sex worker's laoxiang (hometown social connections) were more powerful than relationships between women selling sex at the same venue in establishing the terms and risk of commercial sex. Female sex workers from the same hometown often migrated to the city with their laoxiang and these social connections fulfilled many of the functions of nongovernmental organizations, including collective mobilization, condom promotion, violence mitigation, and promotion of health-seeking behaviors. Outreach members observed that sex workers accompanied by their laoxiang were often more willing to accept STI/HIV testing and trust local sexual health services. Conclusions/Significance: Organizing STI/HIV prevention services around an explicitly defined laoxiang social network may provide a strong foundation for sex worker health programs. Further research on dyadic interpersonal relationships between female sex workers, group dynamics and norm establishment, and the social network characteristics are needed. [ABSTRACT FROM AUTHOR]

Background: Sexually transmitted infections (STI) have made a resurgence in many rapidly developing regions of southern China, but there is little understanding of the social changes that contribute to this spatial distribution of STI. This study examines county-level socio-demographic characteristics associated with syphilis and gonorrhea in Guangdong Province. Methods/Principal Findings: This study uses linear regression and spatial lag regression to determine county-level (n = 97) socio-demographic characteristics associated with a greater burden of syphilis, gonorrhea, and a combined syphilis/ gonorrhea index. Data were obtained from the 2005 China Population Census and published public health data. A range of socio-demographic variables including gross domestic product, the Gender Empowerment Measure, standard of living, education level, migrant population and employment are examined. Reported syphilis and gonorrhea cases are disproportionately clustered in the Pearl River Delta, the central region of Guangdong Province. A higher fraction of employed men among the adult population, higher fraction of divorced men among the adult population, and higher standard of living (based on water availability and people per room) are significantly associated with higher STI cases across all three models. Gross domestic product and gender inequality measures are not significant predictors of reported STI in these models. Conclusions/Significance: Although many ecological studies of STIs have found poverty to be associated with higher reported STI, this analysis found a greater number of reported syphilis cases in counties with a higher standard of living. Spatially targeted syphilis screening measures in regions with a higher standard of living may facilitate successful control efforts. This analysis also reinforces the importance of changing male sexual behaviors as part of a comprehensive response to syphilis control in China. [ABSTRACT FROM AUTHOR]

Public health education in China and India has a long history that has been both deeply responsive to the unique needs and medical traditions of each country, and sensitive to global influences. The history of public health education in China reaches back several centuries, with substantial input from American and European organizations during the Republican Era, 1911-1949. In India, centuries-old health care traditions were influenced during the colonial period by the British Empire prior to independence in 1947. Political upheaval in both countries during the 1940s further impacted the public health systems as well as public health education. The primary goal of this review is to outline public health education in India and Mainland China, with a focus on describing the historical systems and structures that have promoted the development of formalized public health education. We examine current challenges, and analyze opportunities for improvement. Health reforms in China and India need to consider new and modern models for public health education, perhaps in independent faculties of public health, to reinvigorate public health education and strengthen the position of public health in addressing the health challenges of the 21st century. [ABSTRACT FROM AUTHOR]

China is experiencing a syphilis epidemic of enormous proportions. The regions most heavily affected by syphilis correspond to regions where sexually transmitted HIV infection is also a major public health threat. Many high-risk patients in China fail to receive routine syphilis screening. This missed public health opportunity stems from both a failure of many high-risk individuals to seek clinical care and a disconnect between policy and practice. New point-of-care syphilis testing enables screening in non-traditional settings such as community organizations or sex venues. This paper describes the current Chinese syphilis policies, suggests a spatiotemporal framework (based on targeting high-risk times and places) to improve screening and care practices, and emphasizes a syphilis control policy extending beyond the clinical setting. [ABSTRACT FROM AUTHOR]