Frank Y. Wong

Challenges in Addressing Depression in HIV Research: Assessment, Cultural Context, and Methods

Depression is one of the most common co-morbidities of HIV infection. It negatively impacts self-care, quality of life, and biomedical outcomes among people living with HIV (PLWH) and may interfere with their ability to benefit from health promotion interventions. State-of-the-science research among PLWH, therefore, must address depression. To guide researchers, we describe the main diagnostic, screening, and symptom-rating measures of depression, offering suggestions for selecting the most appropriate instrument. We also address cultural considerations in the assessment of depression among PLWH, emphasizing the need to consider measurement equivalence and offering strategies for developing measures that are valid cross-culturally. Finally, acknowledging the high prevalence of depression among PLWH, we provide guidance to researchers on incorporating depression into the theoretical framework of their studies and employing procedures that account for participants with depression.

Social Network and Other Correlates of HIV Testing: Findings from Male Sex Workers and Other MSM in Shanghai, China

Although the Chinese government provides free-of-charge voluntary HIV counseling and testing, HIV testing rates among men who have sex with men (MSM) are reported to be extremely low. This study examines the association of structural and psychosocial factors and social network characteristics with HIV testing behaviors among “money boys” and general MSM in Shanghai. Overall, 28.5% of “money boys” and 50.5% of general MSM had never tested for HIV despite high rates of reported HIV risk behaviors. Factors associated with not testing for HIV included: not knowing of a testing site, limited HIV knowledge, low perceived HIV risk, concern about HIV testing confidentiality, being a closeted gay, not using the Internet, and having a small social network or network with few members who had tested for HIV. Future efforts to promote HIV testing should focus on outreach to general MSM, confidentiality protection, decreasing the stigma of homosexuality, and encouraging peer education and support through the Internet and social networks.

STIS AND HIV AMONG MEN HAVING SEX WITH MEN IN CHINA: A TICKING TIME BOMB?

Over the past 10 years, HIV infection rate has increased annually from 30% to 40% in China, resulting in over 700,000 Chinese living with HIV/AIDS by the end of 2007. The Chinese National Medium and Long-Term Strategic Plan for HIV/AIDS Control and Prevention (1998-2010) identifies the men who have sex with men (MSM) population as a high-risk group for HIV infection. The latest statistics show that MSM account for 11.1% of all HIV/AIDS cases in China, an alarming rising rate in a country with one fourth of the worlds population. To help expanding the emerging foundation of scientific and empirical data on Chinese MSM, several multidivisional research initiatives have been initiated. For example, the China National Center for AIDS/STD Prevention and Control recently launched a national study targeting above 26,000 MSM in 61 cities in 2008. Other programs, targeted prevention measures for the estimated 5-10 million-Chinese MSM, including stronger promotion of condom use, expanded coverage and quality of HIV prevention activities, increased access to voluntary HIV counseling-and-testing services, and improved access to treatment for sexually transmitted infections. To complement these initiatives, this article aims to provide a comprehensive review and analysis of the (a) scientific and empirical literature (both in English and Chinese) on HIV/sexually tranmitted infection (STI) prevention targeting Chinese MSM, and (b) existing programmatic and policy efforts targeting Chinese MSM at risk for STIs (including HIV). Finally, four recommendations for future endeavors targeting this high-risk group are drawn from the above analyses.

Bridge population: sex workers or their clients?--STI prevalence and risk behaviors of clients of female sex workers in China.

Abstract As the HIV/AIDS epidemic and the spread of sexually transmitted infections (STIs) in China has come to the forefront of public health attention, female sex workers (FSWs) and their clients (CFSWs) are becoming increasingly important to HIV/STI prevention efforts. This secondary analysis uses data abstracted from the Chinese Health and Family Life Survey 1999–2000 to report prevalence rates of two STIs as well as sexual risk behaviors for CFSWs – men who paid for sex with FSWs in the past 12 months – in comparison with men who had not patronized FSWs. Among 1879 Chinese CFSWs who completed anonymous interviews and urine testing, 152 (6.3%, weighted) said they had paid for sex in the past 12 months and 18.8% of CFSWs (weighted) tested positive for gonorrhea. CFSWs were 10 times more likely to have an STI (either self-reported or tested) than non-client Chinese men, and they were equally likely to use condoms inconsistently with their spouses. This study highlights the importance of studying CFSWs who use condoms inconsistently and do not practice safe sex with their spouse as a potential bridge population. Prevention and intervention efforts should target this bridge population and include education on HIV/AIDS and STI transmission, condom promotion, marriage counseling, destigmatization of HIV and STIs, and promotion of STI diagnosis and treatment.

Disparities and Risks of Sexually Transmissible Infections among Men Who Have Sex with Men in China: A Meta-Analysis and Data Synthesis

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

STD prevalence risky sexual behaviors and sex with women in a national sample of Chinese men who have sex with men.

We describe the behavioral characteristics and sexually transmitted disease (STD) prevalence of Chinese men who have sex with men (MSM) (n = 41) from a national probability sample of men (n = 1861). Most MSM were partnered with females (97%) and had a low rate of consistent condom use (7%). More MSM than heterosexual men self-reported a prior STD and risky sexual behaviors. MSM may act as a bridge for HIV transmission to female partners. Targeted interventions may help prevent a generalized HIV epidemic in China.

Male-on-male intimate partner violence and sexual risk behaviors among money boys and other men who have sex with men in Shanghai, China

Background Intimate partner violence (IPV) is known to increase HIV risk among heterosexual women, but less is known about IPV and HIV among men who have sex with men (MSM), with almost no data from non-Western countries. This study examined the prevalence of IPV and links between IPV and HIV risks among MSM in Shanghai, China. Methods A cross-sectional sample of 404 money boys (male sex workers) and other MSM were recruited via respondent-driven sampling. Results Overall, 51% of the sample reported emotional, physical, or sexual abuse from a male sexual partner. Money boys reported more overall abuse than did other MSM, and more were likely than other MSM to report experiencing multiple types of abuse. MSM who reported violence or abuse from male partners reported more overall sexual risk behavior, and specifically, more unprotected sex and more sex linked to alcohol and other substance use. The association between experience of abuse from male partners and increased HIV risk did not differ between money boys and other Chinese MSM. Conclusions We conclude that violence and abuse from male partners are highly prevalent among Chinese MSM, and that experience of violence from male sexual partners is linked to increased HIV risk. HIV prevention targeting Chinese MSM must address the increased risk associated with experience of male-on-male IPV. Future research should explore links between HIV risk and MSM’s perpetration of violence against male partners, as well as exploring the role of violence in the male-female relationships of men who have sex with and men and women.

Prevalence and Correlates of Tobacco Use Among a Sample of MSM in Shanghai, China

INTRODUCTION Men who have sex with men (MSM) have higher smoking rates than the general population in the United States, but less is known about smoking among MSM in developing countries. Thus, we examined the prevalence and correlates of smoking among MSM in China. METHODS We conducted a cross-sectional study of 404 MSM in Shanghai, China (half of whom were male sex workers), recruited through respondent-driven sampling. Assessments included sociodemographics; tobacco, alcohol, and drug use; the Center for Epidemiological Studies Depression Scale (CES-D); the Social Provisions Scale (SPS); and the Lesbian, Gay, and Bisexual Identity Scale (LGBIS). RESULTS Smoking prevalence was 65.9% in this sample. Recent smoking (i.e., in the past 3 months) was significantly associated with lower education, greater alcohol use, and higher LGBIS scores, after controlling for important sociodemographics. Among smokers, smoking ≥10 cigarettes per day (CPD), in comparison with <10 CPD, was related to older age and lower LGBIS scores and marginally related to heavy alcohol use. Although bivariate analyses indicated a relationship of CES-D and SPS scores to recent smoking, these factors did not contribute to the regression models. CONCLUSIONS Smoking rates among MSM in China are higher than MSM in the United States and men in China. Less comfort with ones sexual orientation was related to smoking, particularly light smoking. Heavier alcohol consumption, lower education, and older age were also associated with smoking. Future research should confirm these findings and examine mediators and moderators of these relationships in order to inform cessation interventions and tobacco control policy.

HIV testing and care systems focused on sexually transmitted HIV in China

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.

Prevalence and correlates of alcohol use among a sample of general MSM and money boys in Shanghai, China

Abstract The use and misuse of alcohol and their relation to risky sex have received modest scholarly attention in China. This type of research in high HIV/STI groups such as men who have sex with men (general MSM) and men who sell sex to other men (“money boys”) (MB) in China is essentially absent. Therefore, the primary purpose of this exploratory study was to describe the types of alcohol consumed and levels of daily alcohol consumption among Chinese general MSM and MB in Shanghai, China. A secondary purpose was to explore demographic, lifetime sexual behavior, and psychosocial correlates of daily consumption levels. The sample consisted of 404 MSM (200 MB) who live in Shanghai, China. Participants were recruited using respondent-driven sampling and filled out a cross-sectional behavioral survey. Where appropriate, comparisons were made between MB and general MSM. Over 73% of participants reported drinking at least moderately every day. MB reported drinking Western red wine and other Western hard liquors (e.g., vodka) more frequently than general MSM. Conversely, general MSM consumed Chinese white wine more frequently than MB. Results from the regression analyses showed that MSM having higher lifetime sexual risks were more likely to drink in excess; though MB with greater social provisions were less likely to drink in excess. These results begin to highlight high levels of drinking and drinking-sexual risk relationships among groups of general MSM and MB and are useful for guiding intervention efforts among high-risk groups in China.