Haochu Li

Socio-ecological factors associated with depression, suicidal ideation and suicidal attempt among female injection drug users who are sex workers in China.

OBJECTIVE Female injection drug users who are also sex workers (FSW-IDUs) occupy a pivotal population in HIV transmission, whereas their mental health problems are largely overlooked. We aimed to investigate prevalence and associated socio-ecological factors of depression, suicidal ideation and suicidal attempts among FSW-IDUs in China. METHODS Using snowball sampling methods, 200 FSW-IDUs were recruited from communities in Liuzhou, China. Anonymous face-to-face interviews were administered by trained doctors. RESULTS Thirty-nine percent of participants had severe or extremely severe depression, 44.7% had suicidal ideation in the last six months and 26.8% had suicidal attempts in the last six months. After adjusting for background variables, self-stigma was significantly associated with severe or extremely severe depression (OR=1.18, 95% CI: 1.07-1.31). Self-stigma (OR=1.08, 95% CI: 1.01-1.15), depression (OR=1.11, 95% CI: 1.05-1.18), having completely broken up with family (OR=2.60, 95% CI: 1.35-5.02) and having been abused by clients or gatekeepers (OR=2.15, 95% CI: 1.32-3.50) were associated with suicidal ideation in the last six months, while self-stigma (OR=1.03, 95% CI: 1.10-1.16), depression (OR=1.12, 95% CI: 1.04-1.20) and being abused by clients or gatekeepers (OR=2.15, 95% CI: 1.09-4.24) were associated with suicidal attempt in the last six months. In mediation analyses, the associations between self-stigma and the two suicidal outcomes were fully mediated by depression. CONCLUSIONS There are unmet mental health needs of FSW-IDUs. Screening of mental health problems should be integrated into current HIV-related services. Psychological intervention efforts should include components such as self-stigma, family support and abuse.

Enhancing Public Health HIV Interventions: A Qualitative Meta-Synthesis and Systematic Review of Studies to Improve Linkage to Care, Adherence, and Retention

Although HIV services are expanding, few have reached the scale necessary to support universal viral suppression of individuals living with HIV. The purpose of this systematic review was to summarize the qualitative evidence evaluating public health HIV interventions to enhance linkage to care, antiretroviral drug (ARV) adherence, and retention in care. We searched 19 databases without language restrictions. The review collated data from three separate qualitative evidence reviews addressing each of the three outcomes along the care continuum. 21,738 citations were identified and 24 studies were included in the evidence review. Among low and middle-income countries in Africa, men living with HIV had decreased engagement in interventions compared to women and this lack of engagement among men also influenced the willingness of their partners to engage in services. Four structural issues (poverty, unstable housing, food insecurity, lack of transportation) mediated the feasibility and acceptability of public health HIV interventions. Individuals living with HIV identified unmet mental health needs that interfered with their ability to access HIV services. Persistent social and cultural factors contribute to disparities in HIV outcomes across the continuum of care, shaping the context of service delivery among important subpopulations.

The Role of ARV Associated Adverse Drug Reactions in Influencing Adherence Among HIV-Infected Individuals: A Systematic Review and Qualitative Meta-Synthesis

Poor adherence remains a major barrier to achieving the clinical and public health benefits of antiretroviral drugs (ARVs). A systematic review and qualitative meta-synthesis was conduct to evaluate how ARV adverse drug reactions may influence ARV adherence. Thirty-nine articles were identified, and 33 reported that ARV adverse drug reactions decreased adherence and six studies found no influence. Visually noticeable adverse drug reactions and psychological adverse reactions were reported as more likely to cause non-adherence compared to other adverse drug reactions. Six studies reported a range of adverse reactions associated with EFV-containing regimens contributing to decreased adherence. Informing HIV-infected individuals about ARV adverse drug reactions prior to initiation, counselling about coping mechanisms, and experiencing the effectiveness of ARVs on wellbeing may improve ARV adherence.

Exploring Unprotected Anal Intercourse among Newly Diagnosed HIV Positive Men Who Have Sex with Men in China: An Ethnographic Study

Background Unprotected anal intercourse (UAI) is a major pathway towards secondary HIV transmission among men who have sex with men (MSM). We explored the socio-cultural environment and individual beliefs and experiences conducive to UAI in the context of Southern China. Methods We employed an ethnographic approach utilizing a socio-ecological framework to conduct repeated in-depth interviews with thirty one newly diagnosed HIV positive MSM as well as participant observations in Shenzhen based healthcare settings, MSM venues and NGO offices. Results Some men (6/31) reported continuing to practice UAI after an initial diagnosis of being HIV positive. For MSM who had existing lovers or stable partners, the fear of losing partners in a context of non-serostatus disclosure was testified to be a major concern. MSM with casual partners reported that anonymous sexual encounters and moral judgments played a significant role in their sexual risk behaviors. Simultaneously, self-reported negative emotional and psychological status, perception and idiosyncratic risk interpretation, as well as substance abuse informed the intrapersonal context for UAI. Conclusion UAI among these HIV positive MSM was embedded in an intrapersonal context, related to partner type, shaped by anonymous sexual encounters, psychological status, and moral judgments. It is important that prevention and intervention for secondary HIV transmission among newly diagnosed HIV positive MSM in China take into account these contextual factors.

A qualitative analysis of barriers to accessing HIV/AIDS-related services among newly diagnosed HIV-positive men who have sex with men in China.

Summary In China, specific HIV/AIDS-related services have been in place since 2004. However, utilisation of these services remains limited among people living with HIV. We explored barriers to accessing HIV/AIDS-related services from the perspective of newly diagnosed HIV-positive men who have sex with men. We conducted repeated in-depth interviews with 31 newly diagnosed HIV-positive men who have sex with men, using the socio-ecological framework and thematic content analysis. Multiple barriers for utilisation of HIV/AIDS-related services were identified, including perceptions of subjective health and poor quality of services, mental and emotional health problems, lack of trust and understanding of the services on offer, low economic status, lack of insurance, and high medical fees, being refused access to services, and restrictive attendance policies. The findings provide information on potential multi-level obstacles preventing newly diagnosed HIV-positive men who have sex with men to use services that they need. It is recommended that policy makers should create a trustful and non-discriminating environment and services integrating physical and mental healthcare.

Benefits and Potential Harms of Human Immunodeficiency Virus Self-Testing Among Men Who Have Sex With Men in China: An Implementation Perspective

Background Human immunodeficiency virus self-testing (HIVST) holds great promise for reaching high-risk key populations who do not access facility-based services. We sought to characterize unsupervised HIVST implementation among men who have sex with men in China. Methods We conducted a nationwide online survey in China. Eligible men were at least 16 years, had anal sex with a man, and had recent condomless sex. We assessed benefits (first-time testing, increased testing frequency, confirmatory testing) and potential harms (coercion, violence, suicidality) of HIVST. Among men who have sex with men who reported ever testing for human immunodeficiency virus (HIV), we identified correlates of HIVST as first-time HIV test being a self-test using multivariable logistic regression. Results Among 1610 men who met the eligibility criteria and started the survey, 1189 (74%) completed it. Three hundred forty-one (29%) of 1189 reported ever self-testing for HIV. Human immunodeficiency virus prevalence was 7% (24/341) among self-testers and 5% (15/306) among non–self-testers. Two hundred (59%) of 341 men who self-tested reported HIVST as a first-time HIV test. Thirty-one (9%) men experienced coercion with HIVST. Thirty-one (78%) of 40 men with positive HIV self-tests sought confirmation. Multivariable analysis revealed that HIVST as first-time HIV test was associated with younger age (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.92–0.99), not being “out” (OR, 2.28; 95% CI, 1.60–3.28), not using the internet to meet sex partners (OR, 0.39; 95% CI, 0.22–0.69), and group sex (OR, 1.74; 95% CI, 1.02–2.9). Conclusions Human immunodeficiency virus self-testing reached high-risk individuals that had never received facility-based testing. Further implementation research is needed to better understand HIVST outside of research programs.

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.

Crowdsourcing designathon: a new model for multisectoral collaboration

Public health programmes are frequently developed by experts with limited feedback from communities.1 Crowdsourcing, allowing a group to solve a problem and then sharing the solution with the public, may help to improve public health programmes. Crowdsourcing can often take the form of participatory contests.2 Previous crowdsourcing contests have focused on producing individual components of communication programmes, such as videos,3 4 images5 6 or logos.7 However, crowdsourcing contests have not focused on designing the final programme and plan for implementation. The purpose of this project was to crowdsource the development of an HIV testing programme using a designathon. The concept of a crowdsourcing designathon is related to, but distinct from, a hackathon. Hackathons are intensive, approximately 72-hour contests that bring together young people to complete a task.8 9 For example, hackathons organised by a university have brought together students and others interested in technology to create a mobile application.10 Medical hackathons have challenged participants to create devices that help people with dementia, disability and other illnesses.9 11 12 We propose the concept of a crowdsourcing designathon, drawing on the principles of crowdsourcing in order to design a public health programme with strong community input. The purpose of this article is to describe a crowdsourcing designathon, summarise designathon outputs and discuss designathon implications for public health. The purpose of our crowdsourcing designathon was to develop a community-based HIV testing programme to be implemented in eight Chinese cities. This concept was influenced by theories of crowdsourcing13 and community-based participatory research.14 Our designathon was implemented in the following steps: forming a local steering committee; open call for participants; prepare for the event; 72-hour implementation; sustaining engagement and evaluation (table 1). View this table: Table 1 Stages of a designathon Our SESH (Social Entrepreneurship to Spur Health) group …

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).

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