Dianmin Kang

Predictors of consistent condom use based on the Information-Motivation-Behavioral Skills (IMB) model among female sex workers in Jinan, China

BackgroundFemale commercial sex workers (FSWs) are at high risk of human immunodeficiency virus (HIV) transmission in China. This study was designed to examine the predictors of condom use with clients during vaginal intercourse among FSWs based on the Information-Motivation-Behavioral Skills (IMB) model and to describe the relationships between IMB model constructs.MethodsA cross-sectional study was conducted in Jinan of Shandong Province, from May to October, 2009. Participants (N = 432) were recruited using Respondent-Driven Sampling (RDS). A self-administered questionnaire was used to collect data. Structural equation modeling was used to assess the IMB model.ResultsA total of 427 (98.8%) participants completed their questionnaires. Condom use was significantly predicted by social referents support, experiences with and attitudes toward condoms, self-efficacy, and health behaviors and condom use skills. Significant indirect predictors of condom use mediated through behavioral skills included HIV knowledge, social referents support, and substance use.ConclusionsThese results suggest that the IMB model could be used to predict condom use among Chinese FSWs. Further research is warranted to develop preventive interventions on the basis of the IMB model to promote condom use among FSWs in China.

Factors Associated with Willingness to Accept Oral Fluid HIV Rapid Testing among Most-at-Risk Populations in China

Background The availability of oral fluid HIV rapid testing provides an approach that may have the potential to expand HIV testing in China, especially among most-a-risk populations. There are few investigations about the acceptability of oral fluid HIV testing among most-at-risk populations in China. Method A cross-sectional study with men who have sex with men (MSM), female sex workers (FSW) and voluntary counseling and testing (VCT) clients was conducted in three cities of Shandong province, China from 2011 to 2012. Data were collected by face-to-face questionnaire. Results About 71% of participants were willing to accept the oral fluid HIV rapid testing, and home HIV testing was independently associated with acceptability of the new testing method among MSM, FSW and VCT clients (AOR of 4.46, 3.19 and 5.74, respectively). Independent predictors of oral fluid HIV rapid testing acceptability among MSM were having ever taken an oral fluid HIV rapid test (AOR= 15.25), having ever taken an HIV test (AOR= 2.07), and education level (AOR= 1.74). Engagement in HIV-related risk behaviors (AOR= 1.68) was an independent predictor of acceptability for FSW. Having taken an HIV test (AOR= 2.85) was an independent predictor of acceptability for VCT clients. The primary concern about the oral fluid HIV testing was accuracy. The median price they would pay for the testing ranged from 4.8 to 8.1 U.S. dollars. Conclusion High acceptability of oral fluid HIV rapid testing was shown among most-at-risk populations. Findings provide support for oral rapid HIV testing as another HIV prevention tool, and provide a backdrop for the implementation of HIV home testing in the near future. Appropriate pricing and increased public education through awareness campaigns that address concerns about the accuracy and safety of the oral fluid HIV rapid testing may help increase acceptability and use among most-at-risk populations in China.

An integrated individual, community, and structural intervention to reduce HIV/STI risks among female sex workers in China

BackgroundWe assessed the effectiveness of an integrated individual, community, and structural intervention to reduce risks of HIV and sexually transmitted infections (STIs) among female sex workers (FSWs).MethodsThe integration individual, community, and structural intervention was implemented from 2004 to 2009 in six counties of Shandong Province. Post-intervention cross-sectional surveys were conducted in six intervention counties and 10 control counties.ResultsOf 3326 female sex workers were recruited and analyzed in the post-intervention survey with 1157 from intervention sites and 2169 from control sites. No HIV positive was found in both intervention and control counties. The rate of syphilis was 0.17% for intervention sites and 1.89% for control sites (OR = 11.1, 95% CI: 2.7, 46.1). After adjusted for age, marital status, education, economic condition, recruitment venues, the rates of condom use in the last sex with clients(AOR = 2.7; 95% CI: 1.9, 3.8), with regular sex partners(AOR = 1.5; 95% CI: 1.1, 1.9) and consistent condom use in the last month with clients (AOR = 3.3; 95% CI: 2.6, 4.1) and regular sex partners (AOR = 1.7; 95% CI: 1.3, 2.3) were significantly higher in intervention sites than that in control sites. The proportion of participants correctly answered at least six out of eight HIV-related questions (83.3%) in intervention sites is significant higher than that (21.9%) in control sites (AOR = 24.7; 95% CI: 2.5, 42.7), the five indicators related to HIV-related intervention services ever received in the last year including HIV testing(AOR = 4.9; 95% CI: 2.8, 6.7), STD examination and/or treatment(AOR = 5.1; 95% CI: 4.2, 6.4), free condom(AOR = 20.3; 95% CI: 14.3, 28.9), peer education(AOR = 4.3; 95% CI: 3.5, 5.4), education materials(AOR = 19.8; 95%CI: 13.1, 29.8) were significantly higher in intervention sites than that in control sites, the participants in the intervention sites are more likely to seek medical treatment when they had any disorders (AOR = 3.2; 95% CI: 2.5, 4.2).ConclusionThis study found that the integrated individual, community, and structural intervention showed positive impact in reducing HIV and STI risks among FSWs.

Social support and HIV/STDs infections among a probability-based sample of rural married migrant women in Shandong Province, China

BackgroundThe increasing population of marriage-based migrant women is disproportionally affected by AIDS/STDs in China, and social support plays a critical role. This study aims to describe the social support level received by married migrant women in rural areas in Shandong province in comparison to non-migrant local women, identifies the relevant factors of this social support condition among married migrant women, and observes the correlation between social support level and infection status of AIDS and STDs among this group.MethodsA probability-based sample of 1,076 migrant and 1,195 local women were included in the study. A pre-tested field questionnaire was administered to participants through a direct face-to-face interview. Questionnaire contained questions on socio-demographic information, AIDS and STDs prevalence information and Social Support Rating Scale (SSRS) which measures objective support, subjective support, and utilization of social support.ResultsCompared to local women, married migrant women had lower levels of social support in most dimensions. Multi-variable analysis revealed that relationship with spouse, family average income, number of children, education, engagement and claimed reasons of moving have various correlations with one or all dimensions of social support scores. Higher social support is also related to awareness of infection status of HIV and STDs among this group.ConclusionOur findings provide further evidence that married migrant women have lower levels of social support which may be related to some social characteristics and their awareness status of AIDS and STDs infection status and that targeted interventions need to be developed for this population.

Prevalence and Trends of HIV, Syphilis, and HCV in Migrant and Resident Men Who Have Sex with Men in Shandong, China: Results from a Serial Cross-Sectional Study.

Background Migrant men who have sex with men (MSM) have a higher predisposition for HIV transmission. We aimed to determine and compare the prevalence and trends of HIV, Syphilis, and HCV between migrant and resident MSM in Shandong, China. Methods A serial cross-sectional study was conducted in eight cities in Shandong, China from 2010 to 2014. The surveys collected information on demographics, HIV-related knowledge, and HIV-related behaviors including the serologic status of HIV, syphilis, and HCV. Bivariate and multivariable logistic regressions were used to determine differences between migrant and resident MSM. Results The overall prevalence of HIV among the 15,705 MSM (14120 were resident, 1580 were migrant and 5 were missing) was 2.6%, with an increase of 1.0% in 2010 to 4.4% in 2014. Prevalence of HIV was higher among migrant MSMs (5.5%) compared to resident MSMs (2.3%). Compared to residents, migrants also had higher prevalence of syphilis (7.5% vs 4.9%) and HCV (1.1% vs 0.6%). We found that there was an increase in the proportion of migrant MSM engaging in anal sex [adjusted OR (AOR) = 1.41 in migrants vs 1.12 in residents], condom use during last anal sex (AOR = 1.14 in residents, P for trend = 0.32), consistent condom use (AOR = 1.04 residents, P for trend = 0.11) and drug use (AOR = 1.51 in migrants and 1.29 among residents). Except in the year 2011, receiving some health services in last year was significant for people who were HIV-positive compared to negative. (P for trend <0.05). Conclusions Prevalence of HIV increased in resident as well as migrant MSMs. The migrant MSMs had higher STIs compared to resident MSMs and therefore, should be targeted for effective interventions aimed at reducing their risk behaviors. Deeper understanding of the role of migration in health issues is required for combating the persistently high and gradually increasing HIV burden in MSM in China.

Barriers and facilitators of linkage to HIV care among HIV-infected young Chinese men who have sex with men: a qualitative study

BackgroundThe Four Free and One Care Policy (HIV/AIDS-related free services) has been in place in China since 2004. However, linkage to human immunodeficiency virus (HIV) care is not yet achieved very well among people living with HIV. We conducted a qualitative study to explore individual and contextual factors that may influence a linkage to HIV care from the perspective of young HIV-infected men who have sex with men (MSM) in a highly centralized HIV care context of China.MethodsPurposive sampling was used to recruit 21 HIV-infected MSM in Shandong Province, with in-depth interviews conducted between March and July 2015. Thematic content analysis was subsequently used for data analysis.ResultsKey barriers and facilitators related to a linkage to HIV care emerged from participants’ narratives. The barriers included perceived healthy status, low health literacy, and stigma associated with receiving HIV care. The facilitators included an awareness of responsibility, knowledge associated with health literacy, social support, and trusting and relying on services provided by the Center for Disease Control and Prevention (CDC) and the government. These were related to the quality of current HIV counselling and testing, service promotion, and the cost and placement of these HIV services.ConclusionsIn order to improve the MSM linkage to HIV care in China, it is imperative to improve the quality of the current on-going counselling and testing. Further critical linkage support includes increasing supportive services among local CDC systems, designated hospitals and community-based organizations (CBOs), and more financial support for HIV/AIDS related testing, medical checkups and treatments.

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

Objective To assess the correlates for bisexual behaviors, HIV knowledge, and HIV/AIDS-related stigmatizing/discriminatory attitudes among men who have sex with men (MSM). Methods A cross-sectional survey among MSM was conducted in 2011 to provide demographics, sexual behaviors, HIV knowledge, HIV/AIDS-related stigmatizing/discriminatory attitudes, and services in Jinan, Qingdao, and Yantai of Shandong Province of China. Results Of 1230 participants, 82.8% were single, 85.7% aged <35 years, and 47.2% received college or higher education. There were 28.6% MSM who reported to be married or cohabitating or ever had sex with woman in the past 6 months (P6M). 74.5% had ≥6 HIV-related knowledge score. The average total score of stigmatizing/discriminatory attitude was 37.4±4.4(standard deviation). Bisexual behavior was independently associated with higher levels of HIV/AIDS-related stigma/discrimination(AOR = 1.1, 95% CI:1.0–1.1), older age(AOR = 1.2, 95%CI:1.1–1.2), and lower HIV-related knowledge score(AOR = 1.6, 95%CI:1.2–2.2). HIV knowledge score ≥6 was independently associated with lower levels of HIV/AIDS-related stigma/discrimination(AOR = 1.3, 95%CI:1.2–1.3), less bisexual behaviors(AOR = 0.6, 95%CI:0.5–0.9), ever received a test for HIV in the past 12 months (P12M)(AOR = 3.2, 95%CI:2.3–4.5), college or higher level education(AOR = 1.9, 95%CI:1.4–2.6), consistent condom use with men in P6M(AOR=6.9, 95%CI:4.6–10.6), recruited from internet or HIV testing sites(AOR = 11.2, 95%CI:8.0–16.1) and bars, night clubs, or tea houses(AOR = 2.5, 95%CI:1.7–4.8). Expressing higher levels of HIV/AIDS-related stigmatizing/discriminatory attitudes was independently associated with bisexual behaviors(Aβ = 0.9, 95%CI:0.4–1.4), lower HIV-related knowledge score(Aβ = 3.6, 95%CI:3.0–4.1), the number of male sex partners in the past week ≥2(Aβ = 1.4, 95%CI:1.0–1.9), unprotected male anal sex in P6M(Aβ = 1.0, 95%CI:0.5–1.6), and inversely associated with ever received HIV test(Aβ = 1.4, 95%CI:0.8–2.0) and peer education in P12M(Aβ = 1.4, 95%CI:0.9–1.9). Conclusion HIV/AIDS-related stigmatizing/discriminatory attitudes were associated with bisexual behaviors, low HIV testing rate, lower HIV-related knowledge and risk behaviors. This study called for innovative programs that would reduce HIV/AIDS-related stigmatizing/discriminatory attitudes and bisexual behaviors and improve the uptake of prevention service among MSM.

Crowdsourcing health communication about condom use in men who have sex with men in China: a randomised controlled trial.

BACKGROUND The Chinese government now encourages innovation, and more specifically, crowdsourcing. Crowdsourcing, the process of shifting individual tasks to a large group, might reimagine health communication, making it more people-centred. We aimed to compare the effectiveness of a crowdsourced versus social marketing condom promotion video to promote condom use. METHODS A non-inferiority randomised controlled trial was conducted in November 2015 in China. Men who have sex with men (MSM) aged 16 years or older who reported having had sexual contact without use of a condom in the preceding 3 months were recruited through a nationwide MSM website. Men were randomly allocated to one of the two arms in a 1:1 ratio using a computer algorithm and then watched one of two videos. The crowdsourced video was developed through an open contest and the social marketing video was designed by a company. Participants completed a baseline survey and follow-up surveys at 3 weeks and 3 months post-intervention. The primary outcome was incidence of sexual contact without a condom. Intention-to-treat analysis was used, with a non-inferiority margin of 10%. The trial is registered with ClinicalTrials.gov, number NCT02516930. All participants gave informed consent and the protocol was approved by Chinese (Guangdong Provincial Centre for Skin Diseases and STI Control) and American (University of North Carolina at Chapel Hill and the University of California San Francisco) institutional review boards. FINDINGS 1173 participants were recruited to the study; 907 (77%) completed the 3-week follow up and 791 (67%) the three-month follow up. At three weeks, 146/434 (33·6%) participants in the crowdsourced group and 153/473 (32·3%) in the social marketing group reported having sexual contact without a condom. The crowdsourced intervention achieved our pre-specified non-inferiority criterion (estimated difference: +1·3% [95%CI: 4·8-7·4]). At 3 months, 196/376 (52·1%) men in the crowdsourced group and 206/415 (49·6%) in the social-marketing group reported having sexual contact without a condom (estimated difference: +2·5% [95%CI -4·5-9·5%]). The two groups reported similar HIV testing rates and other condom-related secondary outcomes. The cost of the crowdsourcing intervention was substantially lower than the social marketing intervention (16 686 vs 26 845 USD). No adverse outcomes were reported. INTERPRETATION Crowdsourcing could be a useful tool in China, which has a large population and government support. Crowdsourcing provides a structured system for multi-sectoral input into health policy in China. FUNDING US National Institute of Allergy and Infectious Diseases (NIAID; 1R01AI114310); University of North Carolina (UNC)-South China Sexually Transmitted Disease Research Training Centre (Fogarty International Centre; 1D43TW009532); UNC Center for AIDS Research (NIAID; 5P30AI050410); University of California San Francisco Centre for AIDS Research (NIAID; P30 AI027763); US National Institute of Mental Health (R00MH093201 to CW); UNC Chapel Hill, Johns Hopkins University, Morehead School of Medicine and Tulane University (UJMT) Fogarty Fellowship (FIC R25TW0093); Doris Duke International Clinical Research Fellowship; US National Center for Advancing Translational Sciences (UL1TR001111).

Disparities in HIV Care Along the Path From Infection to Viral Suppression: a Cross-Sectional Study of HIV/AIDS Patient Records in 2013, Shandong Province, China

BACKGROUND The 90-90-90 targets recommended by the Joint United Nations Programme on HIV/AIDS require strengthening human immunodeficiency virus (HIV) care, which includes diagnosis, linkage to and retention in care, assessment for treatment suitability, and optimization of HIV treatment. We sought to quantify patient engagement along the continuum, 10 years after introduction of Chinese HIV care policies. METHODS We included patients from Shandong, China, who were diagnosed with HIV from 1992 to 2013. Records were obtained from the HIV/AIDS Comprehensive Response Information Management System to populate a 7-step HIV care continuum. Pearson χ(2) test and multivariate logistic regression were used for analysis. RESULTS Of 6500 estimated HIV-infected persons, 60.1% were diagnosed, of whom 41.9% received highly active antiretroviral therapy (HAART). Only 59.6% of patients on HAART and 15% of all infected persons achieved viral suppression. Children infected by mother-to-child transmission (MTCT) and persons infected by intravenous drug use were less likely to be linked to and retained in care (odds ratio [OR], 0.33 [95% confidence interval {CI}, .14-.80] and OR, 0.58 [95% CI, .40-.90], respectively). Persons tested in custodial institutions were substantially less likely to be on HAART (OR, 0.22 [95% CI, .09-.59]) compared with those tested in medical facilities. Patients on HAART infected by homosexual or heterosexual transmission and those infected by MTCT were less likely to achieve viral suppression (OR, 0.18 [95% CI, .09-.34]; OR, 0.12 [95% CI, .06-.22]; OR, 0.07 [95% CI, .02-.20], respectively). CONCLUSIONS Our report suggests, at the current rate, Shandong Province has to accelerate HIV care efforts to close disparities in HIV care and achieve the 90-90-90 goals equitably.

Crowdsourcing to expand HIV testing among men who have sex with men in China: A closed cohort stepped wedge cluster randomized controlled trial

Background HIV testing rates are suboptimal among at-risk men. Crowdsourcing may be a useful tool for designing innovative, community-based HIV testing strategies to increase HIV testing. The purpose of this study was to use a stepped wedge cluster randomized controlled trial (RCT) to evaluate the effect of a crowdsourced HIV intervention on HIV testing uptake among men who have sex with men (MSM) in eight Chinese cities. Methods and findings An HIV testing intervention was developed through a national image contest, a regional strategy designathon, and local message contests. The final intervention included a multimedia HIV testing campaign, an online HIV testing service, and local testing promotion campaigns tailored for MSM. This intervention was evaluated using a closed cohort stepped wedge cluster RCT in eight Chinese cities (Guangzhou, Shenzhen, Zhuhai, and Jiangmen in Guangdong province; Jinan, Qingdao, Yantai, and Jining in Shandong province) from August 2016 to August 2017. MSM were recruited through Blued, a social networking mobile application for MSM, from July 29 to August 21 of 2016. The primary outcome was self-reported HIV testing in the past 3 months. Secondary outcomes included HIV self-testing, facility-based HIV testing, condom use, and syphilis testing. Generalized linear mixed models (GLMMs) were used to analyze primary and secondary outcomes. We enrolled a total of 1,381 MSM. Most were ≤30 years old (82%), unmarried (86%), and had a college degree or higher (65%). The proportion of individuals receiving an HIV test during the intervention periods within a city was 8.9% (95% confidence interval [CI] 2.2–15.5) greater than during the control periods. In addition, the intention-to-treat analysis showed a higher probability of receiving an HIV test during the intervention periods as compared to the control periods (estimated risk ratio [RR] = 1.43, 95% CI 1.19–1.73). The intervention also increased HIV self-testing (RR = 1.89, 95% CI 1.50–2.38). There was no effect on facility-based HIV testing (RR = 1.00, 95% CI 0.79–1.26), condom use (RR = 1.00, 95% CI 0.86–1.17), or syphilis testing (RR = 0.92, 95% CI 0.70–1.21). A total of 48.6% (593/1,219) of participants reported that they received HIV self-testing. Among men who received two HIV tests, 32 individuals seroconverted during the 1-year study period. Study limitations include the use of self-reported HIV testing data among a subset of men and non-completion of the final survey by 23% of participants. Our study population was a young online group in urban China and the relevance of our findings to other populations will require further investigation. Conclusions In this setting, crowdsourcing was effective for developing and strengthening community-based HIV testing services for MSM. Crowdsourced interventions may be an important tool for the scale-up of HIV testing services among MSM in low- and middle-income countries (LMIC). Trial registration ClinicalTrials.gov NCT02796963