Hongyun Fu

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

Bridging the HIV-syphilis testing gap: dual testing among men who have sex with men living in China

Objectives The WHO recommends dual testing for HIV and syphilis among key populations, including men who have sex with men (MSM). We assessed the proportion of men who had dual tested and reasons for not dual testing. Methods In 2017, an online survey of MSM was conducted in eight cities from two provinces in China. Data on sociodemographics and sexual behaviours were collected. Descriptive analysis was used to examine the experience of dual testing. Multivariable logistic regression identified characteristics associated with men who had dual tested. Results Among 802 men who had ever tested for HIV, 297 dual tested (37%, 95% CI 34 to 40). Men dual tested in a variety of settings: public hospital (35%), voluntary counselling and testing sites (28%), self-testing at home (18%), community-based organisation (8%), community health centre (7%), other (3%) or private hospital (1%). Greater odds for dual testing was found in men who had disclosed their sexuality to a healthcare provider (adjusted OR (AOR) 1.81, 95% CI 1.27 to 2.59, p=0.001), and who had substantial (AOR 2.71, 95% CI 1.67 to 4.41, p<0.001) or moderate community engagement in sexual health (AOR 2.30, 95% CI 1.49 to 3.57, p<0.001), compared with those with no community engagement. The most common reasons for not dual testing were no knowledge that they could be dual tested (34%), did not ask the doctor to be dual tested (25%) and did not believe they were at risk for syphilis (19%). Conclusions Chinese MSM are dual testing through a variety of test sites, including home self-testing. However, the overall dual testing rate remains low despite recent efforts to integrate HIV and syphilis testing.

Missed Opportunities for Human Immunodeficiency Virus and Syphilis Testing among Men Who Have Sex with Men in China: A Cross-Sectional Study

BACKGROUNDnMen who have sex with men(MSM) are at high risk of HIV/syphilis. To inform strategies for dual testing, we describe patterns of HIV/syphilis testing, and examine factors associated with never testing for HIV/syphilis in China.nnnMETHODSnAn online survey(2016) was completed by MSM from eight cities: men born biologically male, age >16 years, and had sex with another man at least once during their lifetime. Demographic, sexual behavioural and HIV/syphilis testing data were collected. Multivariable multinomial logistic regression identified characteristics associated with men who never tested for HIV/syphilis, compared to men who ever tested for both infections.nnnRESULTSnOverall, 2,105 men participated. Among them, 35.1%(738/2105) never tested for HIV/syphilis, and in those ever tested for HIV, only half (54.0%,709/1312) had tested for syphilis. Relative to men who had ever tested for both infections, those with increased probability of never testing for HIV/syphilis include non-gay sexual identity (prevalence odds ratio(POR) 1.86, 95%CI[1.45-2.37]), not disclosed their sexuality/sexual history with men other than their regular partner (POR 2.22, [1.75-2.78]) or with health professionals (POR 11.11, [7.69-14.29]), no condomless sex with casual partners in the last three months (POR 1.89, [1.37-2.56]), no community engagement in sexual health (POR 15.16, [9.40-24.45]), and mainly met partners offline (POR 1.49, [1.16-1.92]).nnnCONCLUSIONnThere are significant gaps in lifetime testing for HIV/syphilis amongst Chinese MSM. Strategies to target never testers and integrate syphilis testing within HIV testing services are urgently needed. Future opportunities include point-of-care dual test kits, and testing in Chinas expanding primary healthcare system.Background Men who have sex with men (MSM) are at high risk of human immunodeficiency virus (HIV)/syphilis. To inform strategies for dual testing, we describe patterns of HIV/syphilis testing, and examine factors associated with never testing for HIV/syphilis in China. Methods An online survey (2016) was completed by MSM from 8 cities: men born biologically male, 16 years or older, and had sex with another man at least once during their lifetime. Demographic, sexual behavioral, and HIV/syphilis testing data were collected. Multivariable multinomial logistic regression identified characteristics associated with men who never tested for HIV/syphilis compared with men who ever tested for both infections. Results Overall, 2105 men participated. Among them, 35.1% (738/2105) never tested for HIV/syphilis, and in those ever tested for HIV, only half (54.0%, 709/1312) had tested for syphilis. Relative to men who had ever tested for both infections, those with increased probability of never testing for HIV/syphilis include non-gay sexual identity (prevalence odds ratio [POR] 1.86; 95% confidence interval [CI], 1.45–2.37), not disclosed their sexuality/sexual history with men other than their regular partner (POR, 2.22; 95% CI, 1.75–2.78]) or with health professionals (POR, 11.11; 95% CI, 7.69–14.29), no condomless sex with casual partners in the last 3 months (POR, 1.89; 95% CI, 1.37–2.56), no community engagement in sexual health (POR, 15.16; 95% CI, 9.40–24.45), and mainly met partners offline (POR, 1.49; 95% CI, 1.16–1.92). Conclusions There are significant gaps in lifetime testing for HIV/syphilis among Chinese MSM. Strategies to target never testers and integrate syphilis testing within HIV testing services are urgently needed. Future opportunities include point-of-care dual test kits, and testing in China’s expanding primary healthcare system.

Pressured HIV testing “in the name of love”: a mixed methods analysis of pressured HIV testing among men who have sex with men in China

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.

Leading by example: online sexual health influencers among men who have sex with men have higher HIV and syphilis testing rates in China (Preprint)

Background The spread of healthy behaviors through social networks may be accelerated by influential individuals. Previous studies have used lay health influencers to prevent sexually transmitted infections (STIs) among internet-using men who have sex with men (MSM). However, there is a lack of understanding of the characteristics of this key subset of MSM. Objective This study aimed to examine sociodemographic characteristics, HIV and syphilis testing, and sexual behaviors of Web-based MSM sexual health influencers (SHIs) in China, defined as individuals with relatively stronger influence on spreading HIV and STI information online. Methods A Web-based survey of MSM was conducted in August 2017 as a final follow-up of a randomized controlled trial promoting HIV testing in 8 Chinese cities. Men were recruited through a gay social networking mobile phone app and were included if they were born biologically male, aged 16 years and above, ever had sex with another man, and HIV negative or with unknown HIV status. Information regarding sociodemographic characteristics, sexual behaviors, and HIV and syphilis testing was obtained. We assessed men’s Web-based sexual health influence using a standardized 6-item opinion leadership scale focused on HIV and STI information. Influencers were defined as those whose mean score ranked within the top 13% (a higher score means greater influence). We used multivariable linear and logistic regression models to measure Web-based sexual health influence’s association with HIV and syphilis testing, controlling for intervention trial effects, age, education, income, and marital status. Results Overall, 1031 men completed the survey. Most men were younger than 30 years (819/1031, 79.43%) and had at least college education (667/1031, 64.69%). Influencers were more likely to get tested for HIV (73/132, 55.3% vs 337/899, 37.5%; P<.001) and syphilis (35/132, 26.5% vs 137/899, 15.2%; P=.001) in the last 3 months compared with noninfluencers. There were no significant differences in condomless sex with male partners (26/132, 19.7% vs 203/899, 22.6%; P=.46), mean number of male sex partners (1.32 vs 1.11; P=.16) in the last 3 months, and mainly meeting male sex partners online in the last 12 months (97/132, 73.5% vs 669/899, 74.4%; P=.82) between influencers and noninfluencers. Regression analyses showed that influencers had higher odds of HIV testing (adjusted odds ratio, AOR 2.16, 95% CI 1.48-3.17) and syphilis testing (AOR 1.99, 95% CI 1.28-3.10) in the last 3 months. Conclusions We identified Web-based SHIs who might be more likely to help promote healthy HIV and syphilis testing behaviors through MSM populations. Leveraging existing influencers may help improve HIV and syphilis testing among their networks.

Expanding syphilis testing: a scoping review of syphilis testing interventions among key populations

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

Receiving HIV Serostatus Disclosure from Partners Before Sex: Results from an Online Survey of Chinese Men Who Have Sex with Men

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)xa0=xa01.92, 95% CI 1.50–2.44] and casual (aORxa0=xa02.34, 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 (aORxa0=xa05.18, 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.

HIV serostatus disclosure from partners before sex: results from an online survey of Chinese men who have sex with men

Abstract Background HIV serostatus disclosure before sex can facilitate serosorting, condom use, and potentially decreased 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. Methods An online cross-sectional study was conducted among MSM in eight Chinese cities in July 28–31, 2016. Participants completed questions covering sociodemographic information, sexual behaviours, HIV testing history (including HIV self-testing), self-reported HIV status, and post-test violence (ie, violence after HIV test). Additionally, participants were asked whether they received HIV serostatus disclosure from different kinds of most recent partners before sex. Findings 2105 men completed the survey. 1809 (86%) were never married, and 746 (35%) had high school or less education. Overall, 1678 (80%) participants reported that they ever had regular male partners, and 1608 (76%) ever had casual male partners. 346 (21%) of 1678 men who ever had regular partners received HIV serostatus disclosure from their most recent regular male partners, while 704 (42%) of 1678 provided HIV status disclosure to their regular partners. Multivariable analysis indicated that participants who ever self-tested for HIV were more likely to have received HIV status disclosure from regular male partners (adjusted odds ratio [aOR] 1·92, 95% CI 1·50–2·44), compared with participants who had never self-tested. Compared with participants who had not received HIV status disclosure from regular partners, men who received disclosure from regular male partners had higher likelihood of experiencing post-test violence (aOR 5·18, 95% CI 1·53–17·58). Similar results were found for receiving HIV serostatus disclosure from casual partners. Interpretation HIV serostatus disclosure from partners was uncommon among Chinese MSM. Interventions and further implementation research to facilitate safe disclosure are urgently needed. Funding National Institutes of Health (National Institute of Allergy and Infectious Diseases 1R01AI114310, National Center for Advancing Translational Sciences grant number UL1TR001111)), UNC-South China STD Research Training Centre (Fogarty International Centre 1D43TW009532), UNC Center for AIDS Research (National Institute of Allergy and Infectious Diseases 5P30AI050410), University of California San Francisco Center for AIDS Research (National Institute of Allergy and Infectious Diseases P30 AI027763), and the Bill & Melinda Gates Foundation to the MeSH Consortium (BMGF-OPP1120138).

Community participation in healthy cities in China: an analysis of text data collected through a national crowdsourcing contest

Abstract Background Community participation is fundamental to defining and developing healthy cities. This study examined public perceptions of healthy cities in China. Methods A steering committee organised a crowdsourcing contest during 8 weeks from January to February, 2017. Crowdsourcing contests invite a large group of individuals to complete a task. The committee distributed an open call for entries to the public through social media soliciting descriptions of healthy cities and strategies for creating healthy cities. Participants submitted texts, images, and videos online. We extracted the text entries and analysed the data using a thematic approach. Three individuals independently coded the data. All contest data were de-identified and exempted from ethical review by the Institutional Review Committee at the University of North Carolina at Chapel Hill. Findings We received 251 text descriptions and 231 were eligible and coded. Thematic analysis revealed components of what a healthy city ought to include and strategies for creating healthy cities. The public noted that a healthy city ought to provide sustainable local environments, elements essential for livelihood (food and income security, clean water), physical infrastructure, a fair education system, just laws and judicial system, and a cohesive society. Strategies for creating healthy cities included public education, community engagement, urban planning, environmental improvements, and policies. Some remarked that urban floods were common and recommended sponge cities using water-permeable materials to capture, control, and recycle rainwater to mitigate the impact of floods. A few participants suggested that urban cities had limited space and vertical farming could take advantage of spare space in buildings and natural resources for planting. Another participant described an online waste recycling system in which people gain credits for recycling waste and use the credits to purchase other products. Interpretation Text descriptions from a crowdsourcing contest helped to understand public perceptions of healthy cities in China. Community participation might help healthy city planning to become more people-centred. Funding Tsinghua University and SESH Global. The listed grant funders played no role in any step of this study.

Coercion And Hiv Self-Testing In Men Who Have Sex With Men: Implementation Data From A Cross-Sectional Survey In China.

To the Editors: Many thanks to Dr. Clement et al for their interest in our brief report, which highlighted the disparate uptake of HIV preexposure prophylaxis (PrEP) by populations that are most affected by the HIV epidemic, in particular black men who have sex with men (MSM) in the United States Deep South. In our brief report, it was emphasized that community-based support systems, as well as, targeted messaging, and novel strategies may be necessary to increase uptake of HIV preexposure prophylaxis (PrEP) in this high-risk population. As evident by our primary referral source, most patients in our cohort were referred by a sexual partner (34%) or health care provider (21%), and not by a community-based organization (8%). This likely contributed to our initial HIV preexposure prophylaxis (PrEP) cohort demographics, with under-representation of black MSM. The authors of this letter provide proof of concept that partnerships with community-based organizations can be extremely successful as a referral source for black patients, whereas relying on selfreferrals and/or PCP referrals may not result in patient demographics reflective of the current epidemic. We are similarly relying on strong partnerships with community agencies and local health departments to leverage existing relationships within the community to increase uptake of PrEP among black MSM in our Southern state. Moreover, we are actively working with clinical, community, and public health partners across the state to provide awareness, education, and technical assistance in developing and implementing PrEP service delivery programs in traditional clinical settings, as well as alternative community-based venues. Qualitative studies we have conducted with black MSM have suggested that novel, nontraditional venues for PrEP delivery may be preferable and enhance the uptake of this biomedical prevention tool (Elopre, unpublished data, 2017). We feel that there is an urgent need for more public health and implementation science research to identify best practices for targeted outreach to increase uptake of PrEP among those in greatest need to prevent further amplification of HIV health disparities, which are particularly magnified in the Deep South among black MSM.