Li Gang Yang

Female Sex Worker Social Networks and STI/HIV Prevention in South China

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 health-seeking behaviors, and dealing with violent clients. These data suggested that sex workers 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.

Primary syphilis cases in Guangdong Province 1995-2008: Opportunities for linking syphilis control and regional development

BackgroundSyphilis cases have risen in many parts of China, with developed regions reporting the greatest share of cases. Since syphilis increases in these areas are likely driven by both increased screening and changes in sexual behaviours, distinguishing between these two factors is important. Examining municipal-level primary syphilis cases with spatial analysis allows a more direct understanding of changing sexual behaviours at a more policy-relevant level.MethodsIn this study we examined all reported primary syphilis cases from Guangdong Province, a southern province in China, since the disease was first incorporated into the mandatory reporting system in 1995. Spatial autocorrelation statistics were used to correlate municipal-level clustering of reported primary syphilis cases and gross domestic product (GDP).ResultsA total of 52,036 primary syphilis cases were reported over the period 1995-2008, and the primary syphilis cases increased from 0.88 per 100,000 population in 1995 to 7.61 per 100,000 in 2008. The Pearl River Delta region has a disproportionate share (44.7%) of syphilis cases compared to other regions. Syphilis cases were spatially clustered (p = 0.01) and Morans I analysis found that syphilis cases were clustered in municipalities with higher GDP (p = 0.004).ConclusionsPrimary syphilis cases continue to increase in Guangdong Province, especially in the Pearl River Delta region. Considering the economic impact of syphilis and its tendency to spatially cluster, expanded syphilis testing in specific municipalities and further investigating the costs and benefits of syphilis screening are critical next steps.

Integrated syphilis/HIV screening in China: a qualitative analysis

BackgroundThe last decade has seen enormous advances in HIV treatment and care, but how to implement scaled up HIV testing, prevention, and treatment in low-income areas still presents a formidable public health challenge. South China faces expanding syphilis and sexually transmitted HIV epidemics, but health systems characteristics important for scaling up syphilis and HIV testing have not been defined.MethodsA purposive sample to ensure public, private, and public-private hybrid STI clinic inclusion was selected in a South China city. Eight key informant interviews were conducted with the STI clinic manager, followed by eight focus group discussions with physicians. Data collection relied on a semi-structured format that included questions in each of the following domains: 1) clinical facilities; 2) laboratory capacity with a focus on syphilis/HIV diagnosis; 3) clinic personnel; 4) physical space with a focus on locations to disclose confidential results; 5) financial support.ResultsPublic STI clinics had free syphilis testing/treatment and laboratory facilities to perform essential syphilis and HIV tests. However, despite serving a large number of STI patients, private STI clinics lacked nontreponemal syphilis testing, HIV testing, and had fewer connections to the public health infrastructure. Formally trained assistant physicians were 2.5 times as common as physicians at STI clinics. Only one of the 8 sites had onsite voluntary counseling and testing (VCT) services available.ConclusionThese STI case studies reveal the potential for expanding integrated syphilis/HIV services at public STI clinics in China. More health services research is needed to guide scale-up of syphilis/HIV testing in China.

A systematic review of syphilis serological treatment outcomes in HIV-infected and HIV-uninfected persons: rethinking the significance of serological non-responsiveness and the serofast state after therapy

BackgroundSyphilis remains a global public health threat and can lead to severe complications. In addition to resolution of clinical manifestations, a reduction in nontreponemal antibody titers after treatment is regarded as “proof of cure.” However, some patients manifestu2009<u20094-fold decline (“serological non-response”) or persistently positive nontreponemal titers despite an appropriate decline (“serofast”) that may represent treatment failure, reinfection, or a benign immune response. To delineate these treatment phenomena, we conducted a systematic review of the literature regarding serological outcomes and associated factors among HIV-infected and -uninfected subjects.MethodsSix databases (PubMed, Embase, CINAHL, Web of Science, Scopus, and BIOSIS) were searched with no date restrictions. Relevant articles that evaluated serological treatment responses and correlates of serological cure (≥ four-fold decline in nontreponemal titers) were included.ResultsWe identified 1693 reports in the literature, of which 20 studies met selection criteria. The median proportion of patients who had serological non-response was 12.1xa0% overall (interquartile range, 4.9–25.6), but varied depending on the time points after therapy. The serofast proportion could only be estimated from 2 studies, which ranged from 35.2–44.4xa0%. Serological cure was primarily associated with younger age, higher baseline nontreponemal titers, and earlier syphilis stage. The relationship between serological cure and HIV status was inconsistent; among HIV-infected patients, CD4 count and HIV viral load was not associated with serological cure.ConclusionsSerological non-response and the serofast state are common syphilis treatment outcomes, highlighting the importance of determining the immunological and clinical significance of persistent nontreponemal antibody titers after therapy.

A twin response to twin epidemics: integrated HIV/syphilis testing at STI clinics in South China.

Background:HIV testing is still stigmatized among many high-risk groups in China, whereas routine syphilis testing has been widely accepted at sexually transmitted infection (STI) clinics. This project used the platform of a rapid syphilis screening test to expand HIV test uptake. The objective of this study was to use multilevel modeling to analyze determinants of syphilis and HIV-testing uptake at STI clinics in China. Methods:2061 STI patients at 6 clinics in Guangdong Province were offered free rapid syphilis and free rapid HIV testing. Test uptake was defined by patient receipt of results and a multilevel model was used to analyze predictors of uptake. Results:This was the first syphilis or HIV test for the large majority (1388, 77.7%) of participants. Syphilis test uptake and HIV test uptake were high (1681, 81.6%, syphilis test uptake; 1673, 81.2% HIV test uptake). HIV test uptake was significantly concordant with syphilis test uptake (τb = 0.89, P < 0.001). The most parsimonious model of refusing HIV test uptake included the following variables: being married, having a previous HIV test, being unaccompanied, and participating in the last 2 months of the study. Conclusions:STI clinic-based screening for syphilis and HIV represents an excellent opportunity for scaling up integrated services, especially in South China where syphilis and sexually transmitted HIV cases are both rapidly increasing. Effective integration of HIV testing into routine clinical practice requires an understanding not only of individual test uptake but also of the broader social context of HIV testing.

Syphilis Screening among 27,150 Pregnant Women in South Chinese Rural Areas Using Point-of-Care Tests

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 womens health services (OB GYN, family planning) may be useful for controlling Chinas syphilis epidemic.

Organizational characteristics of HIV/syphilis testing services for men who have sex with men in South China: a social entrepreneurship analysis and implications for creating sustainable service models

BackgroundUNAIDS has called for greater HIV/syphilis testing worldwide just as local HIV/syphilis testing programs are cut or altered. New models are needed to make HIV/syphilis testing services sustainable while retaining their essential public health function. Social entrepreneurship, using business principles to promote a social cause, provides a framework to pilot programs that sustainably expand testing. Drawing on fieldwork in two South Chinese cities, we examined organizational and financial characteristics of current HIV/syphilis testing systems for men who have sex with men (MSM) in addition to new pilot programs focused on revenue-generation for sustainability.MethodsWe undertook a qualitative study to explore organizational and financial characteristics of HIV/syphilis testing for MSM. Data were collected from men who have sex with men and policy stakeholders in Guangzhou and Hong Kong. Framework analysis was used to identify themes and then code the data.ResultsOur qualitative research study included MSM and policy stakeholders (n = 84). HIV/syphilis testing services were implemented at a wide range of organizations which we grouped broadly as independent community-based organizations (CBOs), independent clinics, and hybrid CBO-clinic sites. From an organizational perspective, hybrid CBO-clinic sites offered the inclusive environment of an MSM CBO linked to the technical capacity and trained staff of a clinic. From a financial perspective, stakeholders expressed concern about the sustainability and effectiveness of sexual health services reliant on external funding. We identified four hybrid CBO-clinic organizations that launched pilot testing programs in order to generate revenue while expanding HIV testing.ConclusionMany MSM CBOs are searching for new organizational models to account for decreased external support. Hybrid CBO-clinic organizations create a strong foundation to increase HIV/syphilis testing using social entrepreneurship models in China.

Sexually transmitted infections among heterosexual male clients of female sex workers in China: a systematic review and meta-analysis.

Background Female sex workers have been the target of numerous sexually transmitted infection (STI) prevention strategies in China, but their male clients have attracted considerably less public health attention and resources. We sought to systematically assess the prevalence of HIV, syphilis, gonorrhea, and chlamydia among heterosexual male clients of female sex workers in China. Methods/Principal Findings Original research manuscripts were identified by searching Chinese and English language databases, and 37 studies analyzing 26,552 male clients were included in the review. Client STI prevalence across studies was heterogeneous. Pooled prevalence estimates and 95% confidence intervals were 0.68% (0.36–1.28%) for HIV, 2.91% (2.17–3.89%) for syphilis, 2.16% (1.46–3.17%) for gonorrhea, and 8.01% (4.94–12.72%) for chlamydia. Conclusions/Significance The pooled prevalence estimates of HIV, syphilis, gonorrhea, and chlamydia among clients in this review exceed the prevalences previously reported among population-representative samples and low-risk groups in China. However, heterogeneity across studies and sampling limitations prevent definitive conclusions about how the prevalence of STIs in this population compares to the general population. These findings suggest a need for greater attention to clients’ sexual risk and disease prevalence in China’s STI research agenda in order to inform effective prevention policies.

A Spatial Analysis of County-level Variation in Syphilis and Gonorrhea in Guangdong Province, China

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 (nu200a=u200a97) 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.

Syphilis test availability and uptake at medical facilities in southern China

OBJECTIVEnTo examine syphilis testing capacity, screening coverage rates and types of syphilis tests used in medical facilities in southern China.nnnMETHODSnEleven 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 (nu2009=u2009109). A total of 494u2009680 women who delivered during 2004-2008 were studied.nnnFINDINGSnIn 2008, 54u2009196 pregnant women (43.1%) were not screened for syphilis. Among such women, 32u2009863 (60.6%) attended clinics without any syphilis testing capacity and 21u2009333 (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 ≤u20091000 deliveries per year (OR: 1.002; 95% CI: 1.001-1.003). These same service characteristics correlated with lower screening coverage rates (Pu2009<u20090.01). Only one antenatal clinic had the capacity to conduct both treponemal and non-treponemal tests for diagnosing syphilis.nnnCONCLUSIONnSyphilis 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.