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Background Increased HIV testing is an effective strategy for HIV control among key populations, including men who have sex with men (MSM). We aimed to examine the interaction between social norms related to HIV testing and self-efficacy of HIV testing among Chinese MSM. Methods A cross-sectional online survey was conducted in eight Chinese cities in Shandong and Guangdong provinces in July 28–31, 2016. The inclusion criteria included: born as a male, age at least 16 years old, ever engaged in anal sex with men, and currently living in one of the designated cities. Information regarding sociodemographics, risk behaviours, and testing history for HIV and other sexually transmitted infections were collected. Social norm was operationalised by six items asking participants about the social norms of HIV testing. HIV testing self-efficacy was measured with a six-item scale. Higher mean scores indicated higher self-reported strength of social norms and self-efficacy for HIV testing. Univariate and multivariate logistic regressions were used to evaluate the interaction between self-efficacy and social norm on HIV testing. Findings 2105 men completed the survey. The mean age of the participants was 25·97 years (SD 6·42). More than four-fifths (1809 [86%]) of participants were unmarried, 477 (23%) were students, and 1359 (65%) had at least a college degree. Overall, 1315 (62%) participants had been ever tested for HIV, and 687 (33%) had been tested in the past 3 months. 685 (33%) had ever HIV self-tested in their lifetime. The main effect estimate on HIV testing in the past 3 months was 1·01 (95% CI 0·96–1·06) for social norm and 1·09 (95% CI 1·05–1·14) for self-efficacy, with an interaction effect of 1·02 (95% CI 1·01–1·03). Interpretation Our survey demonstrated the interaction between self-efficacy and social norm on HIV testing among Chinese MSM. Further research and interventions to increase self-efficacy and social norm on HIV testing are 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).

Background HIV-related stigma has been positively associated with low health-care utilisation and risky sexual behaviours in people living with HIV. However, the relationship between HIV-related stigma and the use of new technologies such as gay mobile applications and HIV self-testing is still not clear. We aimed to examine factors associated with HIV-anticipated stigma among men who have sex with men (MSM) and transgender individuals in China. Methods During July 28–31, 2016, MSM and transgender individuals aged 16 years or older who self-reported as HIV negative were recruited for an online cross-sectional survey on China's biggest MSM mobile application BlueD. Information regarding sociodemographics, sexual behaviours, sexual health service use, and anticipated HIV stigma (measured by a seven-item Likert scale, ranging from one to four) were collected. The mean values of the seven items were calculated to create an overall score, with a higher score indicating a higher level of anticipated HIV stigma. Univariate and multivariable linear regressions were conducted to examine the factors associated with anticipated HIV stigma, while age, education, income, sexual orientation, and marital status were adjusted in the multivariable models. Findings 2006 participants were recruited; most were MSM (1904 of 2006, 95%). The mean score for anticipated HIV stigma was 2·98 (SD 0·64). Having used social media platforms to seek sexual partners within in the past 3 months (adjusted β 0·11, 95% CI 0·05–0·17) was associated with increased anticipated HIV stigma, whereas having self-tested for HIV (adjusted β −0·07, 95% CI −0·13 to −0·01), and having disclosed one's sexuality to one's health-care provider (adjusted β −0·16, 95% CI −0·22 to −0·96) were associated with decreased anticipated HIV stigma. Interpretation Campaigns to combat HIV-related stigma are needed on gay mobile applications. Promotion of HIV self-testing and disclosure might be an effective method to reduce HIV-related stigma among MSM and transgender individuals in China. Funding National Institutes of Health (National Institute of Allergy and Infectious Diseases [NIAID] 1R01AI114310; National Center for Advancing Translational Sciences [UL1TR001111]), University of North Carolina–South China STD Research Training Centre (Fogarty International Centre 1D43TW009532), University of North Carolina Center for AIDS Research (NIAID 5P30AI050410), University of California San Francisco Center for AIDS Research (NIAID P30 AI027763), and the Bill & Melinda Gates Foundation to the MeSH Consortium (BMGF-OPP1120138).

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).

Background The wide range of interventions to promote HIV testing might inadvertently contribute to coerced testing. There has been concern about coerced HIV self-testing in non-research settings where there is minimal supervision. The aim of this study was to examine the prevalence and correlates of coerced HIV testing among men who have sex with men (MSM) in China. Methods In July 2016, we recruited MSM from eight cities through BlueD, a gay social network mobile application. Data on sociodemographics, HIV self-testing, HIV facility testing, test coercion, condomless sex in the past 3 months, and transactional sex were collected. Coerced testing was defined as someone (partner, friend, employer, or others) forcing the participant to take an HIV test. Multivariable logistic regression was used to examine correlates of coerced testing among MSM who had ever received HIV testing. Findings 1312 men were included, most of whom were young (mean age 26·9 years [SD 6·3]). 1002 (76%) men were identified as gay, and 685 (52%) men had used HIV self-testing. 64 (15%) men reported coerced testing, and 39 of these men were forced to have a self-test. Adjusting for age, education, income, and residence, men who reported coerced testing were more likely to have ever self-tested for HIV (adjusted odds ratio 4·25; 95% CI 2·23–8·09). Coerced testing was more common among men who had sex with casual partners in exchange for gifts or money (3·34; 1·90–5·86) than among men who did not report transactional sex. Coerced testing was also more common among MSM who reported condomless anal sex in the preceding 3 months (2·38; 1·43–3·98) than among men who did not report condomless anal sex. Interpretation HIV test coercion is uncommon among MSM in China, but is more likely in men who used HIV self-tests. As HIV self-testing is scaled up worldwide, research and enhanced post-test surveillance are needed. Funding National Institute of Allergy and Infectious Diseases (1R01AI114310-01) and the Australian National Health Medical Research Council (APP1104781). The funders had no role in the design of the study, the collection, analysis, and interpretation of data, or in the writing of the Abstract.

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).

Background HIV self-testing holds great promise for reaching high-risk key populations who do not access facility-based services, but it has rarely been evaluated outside of structured research settings. HIV self-testing is a process by which a person takes and interprets a test. We aimed to characterise implementation of unsupervised HIV self-testing among men who have sex with men (MSM) in China. Methods We undertook a nationwide online survey of MSM in November, 2015, in China. Men were invited to participate by clicking through banner adverts on social network sites. Eligible men were at least 16 years of age, had ever had anal sex with a man, and had had sex without use of a condom in the past 3 months. Among MSM who ever self-tested for HIV, we assessed benefits (eg, first-time HIV test, increased testing frequency, confirmatory testing) and adverse outcomes, (eg, coercion, violence, suicidality). First-time HIV test was defined by what an individual reported was their first ever test for HIV (a self-test or a facility test). Among MSM who reported ever testing for HIV, we identified correlates of HIV self-testing as first-time HIV test with use of multivariable logistic regression. The institutional review boards of the Guangdong Provincial Center for Skin Diseases and STI Control, the University of North Carolina at Chapel Hill, and the University of California San Francisco approved this study. Findings Of 1610 eligible men, 1189 (73·9%) completed the survey. 28·7% (341/1189) reported ever self-testing for HIV. The HIV prevalence among self-testers was 7·0% (24/341) and among non-self-testers was 4·9% (15/306). Among self-testers, 58·7% (200/341) reported HIV self-testing as a first-time HIV test and 22·6% (77/341) had increased testing frequency. 77·5% (31/40) of those with a positive HIV self-test received confirmatory facility-based testing. Minimal adverse outcomes were noted. Multivariable analysis showed that self-testing as first-time HIV test was associated with younger age (odds ratio 0·95, 95% CI 0·91–0·99), not telling health-care providers about having sex with men (2·22, 1·56–3·17), not using the internet to meet sex partners (2·53, 1·45–4·43), and having group sex (1·76, 1·03–2·98). Interpretation HIV self-testing increases first-time HIV testing and testing frequency among those with previous testing. This tool could be useful to scale up HIV testing among high-risk men in China and other settings. Funding National Institutes of Health (NIAID 1R01AI114310-01), UNC-South China STD Research Training Center (FIC 1D43TW009532-01), UNC Center for AIDS Research (NIAID 5P30AI050410-13), UCSF Center for AIDS Research (NIAID P30 AI027763), NIMH (R00MH093201), Fulbright-Fogarty Fellowship (FIC R25TW0093), and SESH Global.

Background Sex tourism among men who have sex with men (MSM) provides a risk for spread of HIV and other sexually transmitted infections. Sex tourism is defined as travelling outside of one's home town and purchasing sex with gifts or money. Our objective was to characterise the frequency, sociodemographic characteristics, and sexual risk behaviours among Chinese MSM sex tourists. Methods We undertook an online, cross-sectional survey of high-risk MSM throughout China in November, 2015. Men were invited to participate by clicking through banner adverts on social network sites. Eligible men were at least 16 years of age, had ever had anal sex with a man, and had had sex without use of a condom in the past 3 months. Questions covered sociodemographic characteristics and sexual risk behaviours. Univariate and multivariable logistic regressions were done to identify correlates of sex tourism. We also compared the mean MSM HIV prevalence in each sex tourist's origin and destination locations. Ethics approval was obtained from the ethics review boards of the Guangdong Provincial Center for Skin Diseases and STI control, the University of North Carolina at Chapel Hill, and the University of California at San Francisco. Findings Among 1610 eligible men, 1189 (74%) completed the survey and 62 (5%) were identified as sex tourists. 20 (32%) of these men travelled primarily to purchase sex and the remainder purchased sex while travelling for another purpose. We noted little difference in sociodemographics and sexual risk behaviours between the two groups. 45 (73%) of sex tourists used a mobile app or website to find sex partners. In multivariable analyses, adjusting for age and income, sex tourism was correlated with high-risk sexual behaviours (adjusted odds ratio 1·83, 95% CI 1·06–3·17), higher income (4·44, 1·77–11·18), and living with HIV (2·79, 1·03–7·55). Sex tourism was more often from a location with a lower MSM HIV prevalence (mean prevalence 4·47, SD 2·01) to a location with a higher MSM HIV prevalence (6·86, 5·24; p Interpretation MSM sex tourists were more likely to have risky sexual behaviours and travel from locations with low to high HIV prevalence rather than high to low HIV prevalence. MSM sex tourists might be part of core groups that disproportionately contribute to MSM HIV transmission. Enhanced surveillance and interventions tailored to MSM sex tourists should be considered. Funding National Institutes of Health, Doris Duke Charitable Foundation.

Background Most men who have sex with men (MSM) in China do not publicly disclose their sexual orientation. This low rate of disclosure may affect sexual behaviours, testing for HIV or other sexually transmitted infections (STIs), and disease transmission. This study examined factors associated with overall sexual orientation disclosure and disclosure to a healthcare professional. Methods We did a cross-sectional online survey of MSM in China from September 23, 2014, to October 8, 2014, through three national websites. Participants completed questions covering sociodemographic information, sexual behaviors, HIV and syphilis test history, and self-reported HIV status. We defined overall disclosure as having ever disclosed sexual orientation to anyone other than a sexual partner, and healthcare professional disclosure as disclosing to a doctor or other medical provider. Eligible participants gave informed consent electronically before beginning the survey. Findings A total of 1819 men started the survey and 1424 (78%) completed it. Of 1424 participants, 62% (886/1424) reported overall disclosure, and 16% (232/1424) had disclosed to healthcare providers. In multivariate analyses, the odds of overall sexual orientation disclosure were 56% higher among MSM who used smartphone-based sex-seeking applications (adjusted OR 1·56 [95% CI 1·25–2·95]), but were lower among MSM reporting high-risk sexual risk behaviors such as sex while drunk (0·55 [0·37–0·81]) and sex while using drugs (0·66 [0·50–0·87]). The odds of disclosure to a healthcare professional were greater among MSM who had ever been tested for HIV (3·36 [2·50–4·51]) or STIs 4·92 [3·47–6·96]) or self-reported as HIV positive (1·59 [0·93–2·72]). Interpretation More than 80% of MSM surveyed had not disclosed their sexual orientation to health professionals. This low level of disclosure probably represents a major obstacle to serving the unique needs of MSM in clinical settings. Further research and action to facilitate disclosure of sexual orientation by MSM, especially to healthcare professionals, is urgently needed. Funding US National Institute of Allergy and Infectious Diseases (NIAID; 1R01AI114310); University of North Carolina (UNC)-South China STD 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); 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).

Background In the past decade, recreational drug use has considerably increased among Chinese men who have sex with men (MSM). This increase has a great potential to worsen the scenario of the heavy burden of HIV among Chinese MSM. This study aimed to investigate the prevalence of recreational drug use, and to explore the association between poppers use and testing history for HIV or STIs, gay app use, and other sexual behaviours. Methods We recruited MSM who were born male and were aged 16 years or older through a nation-wide online survey in 2014. We collected information regarding socio-demographics, risk behaviours, recreational drug use, sexual orientation, testing history for HIV and other STIs, and gay app use. We did univariate and multivariate analyses to determine factors associated with recreational drug use among Chinese MSM. Written informed consent was gained from each participants, and the ethical approval was obtained from institution review committees in China and the United States. Findings Among 1424 participating MSM, 1100 (77%) had used any recreational drugs in their life-time. In the past 12 months, 303 (21%) had used poppers, 34 (2%) had used crystal meth, and 15 (1%) had used ecstasy. The mean age of all participants was 25·6 years (SD 6·8), 1038 (73%) were self-identified as gay, 588 (41%) were students, and 1194 (84%) had never been married. Multiple logistic regression revealed that compared with non-poppers users, poppers users were more likely to have been tested for HIV (adjusted odds ratio [aOR]=1·50, 95% CI 1·15–1·96) and for other STIs except HIV (1·65, 1·26–2·17). Additionally, poppers users were more likely to engage in group sex (2·63, 1·80–3·86) or in commercial sex (1·86, 1·13–3·06), and to use gay apps for partner seeking (2·10, 1·58–2·80). Interpretation High-risk MSM in China have a high rate of recreational drug use. Public health programmes serving MSM may consider integration of interventions to decrease harms associated with recreational drug use. Funding This work was supported by National Institutes of Health (National Institute of Allergy and Infectious Diseases 1R01AI114310 to JT and CW); UNC-South China STD Research Training Centre (Fogarty International Centre 1D43TW009532 to JT); UNC Center for AIDS Research (National Institute of Allergy and Infectious Diseases 5P30AI050410 to JT); University of California San Francisco Centre for AIDS Research (National Institute of Allergy and Infectious Diseases P30 AI027763 to CW); National Institute of Mental Health (R00MH093201 to CW); the UNC Chapel Hill, Johns Hopkins University, Morehead School of Medicine and Tulane University (UJMT) Fogarty Fellowship (FIC R25TW0093 to WT). This publication was also supported by Grant Number UL1TR001111 from the National Center for Advancing Translational Sciences (NCATS) at the National Institutes of Health. These funders played no role in any step of this study.