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Background: Sexual health among older adults is a major public health concern globally. The syphilis burden is increasing in older adults in China. This study aimed to describe factors associated with syphilis infection and diagnosis among older adults in China during a 16 year period.Methods: Using 16 years of data (2004–2019) from the syphilis case report system of Guangdong, China, we compared data from older adults (aged ≥50 years) with those from younger people (aged 15–49 years). We compared the two age group with the Chi-square test for difference, and Joinpoint regression models to assess the temporal trends.Results: During the study period, 242,115 new syphilis diagnoses were reported in older adults. The mean notification rate of new diagnoses was 64.1 per 100,000 population across the entire 16-year period, which significantly increased over time (average annual percent change [AAPC] 16.2%, 95% CI 13.7–18.7). Syphilis diagnoses increased significantly over time among less developed cities and older women. In 2019, compared with younger adults, newly diagnosed older adults were more likely to be male, native to reporting city, had unknown transmission routes, and were diagnosed late.Conclusion: Our findings call for an urgent need to deliver more targeted prevention interventions for older adults, such as strengthen awareness among health care providers, and integration of syphilis services and primary health care for older adults.

ObjectivesTo assess the health utilisation status and associated factors among African migrants in China.DesignA national cross-sectional study was conducted among African migrants in China in 2019.SettingParticipants were recruited online and offline to participate in a self-report survey. Online participants were recruited through WeChat across China, and offline participants were recruited in Guangzhou.ParticipantsWe recruited participants who were from an African country; had spent at least 1 month cumulatively in China; were at least 18 years old; were willing to provide informed consent. A total of 1025 participants were recruited online and offline, 19 of them were excluded due to invalid response and 1006 people were finally included in the analysis.Outcome measuresThe primary outcome was health service utilisation and associated factors among African migrants during their stay in China in the past 12 months. The potential factors include the predisposing factors (demographic characteristics and social structure variables), enabling factors (annual income, health insurance in China) and need factors (non-communicable chronic and infectious diseases, depression) which determined by Anderson framework were measured.ResultsEight hundred and seven online and 218 offline participants completed the survey, including 624 males and 382 females, with an average age of 26.4±8.9 years. Around 28.5% reported health utilization in the past 12 months. Results showed that longer duration in China, migration to China for business (aOR=2.23, 95% CI:1.13-4.40) and study (aOR=5.00, 95% CI:2.74-9.11), living in apartment (aOR=2.59, 95% CI:1.62-4.14) or dormitory (aOR=3.22, 95% CI:2.17-4.80) in China, suffering from chronic diseases, communicable diseases, and greater depressive symptoms (aOR=1.91, 95% CI:1.42-2.56) facilitated health service utilization.ConclusionsThe healthcare service that African migrants received in China is low. The existing public health policies and intervention measures need to be improved to make health utilisation more accessible and feasible for African migrants.

BACKGROUND: Partner notification (PN) is an essential component of syphilis control and is recommended by Chinese Sexually Transmitted Disease guidelines. However, in China, studies examining local practice are limited. This study evaluated partner notification outcomes among persons with early syphilis infection in an urban district in China. METHODS: From 2011 to 2017, persons diagnosed with early syphilis were asked to participate in an evaluation of supportive patient referral partner services for all recent sex partners, and the contact and case finding indices were determined in Nanshan District, Shenzhen, China. RESULTS: During the study period, 642 index patients with early syphilis reported 1749 sex partners. Of those partners, 678 were potentially contactable and 525 (30%) were contacted. The overall contact index was 0.82. Among the 1749 partners reported, 1108 (63%) were described as casual partners and only 37 (3%) were contacted (contact index 0.13) compared to 641 partners who were either spouses and regular partners (contact index 1.37). Among those 525 partners contacted, 418 (80%) were tested and 205 (39%) were diagnosed with and treated for syphilis. Among those, 9 (4%) were primary, 26 (13%) were secondary, 16 (8%) were early latent, and 154 (49%) were other syphilis infections. The overall case finding index was 0.29. CONCLUSIONS: There is a need to improve PN practices in China, which include developing operational guidelines of PN and to develop and evaluate novel PN ways like using Internet-based strategy.

Background Mycoplasma genitalium (MG) causes urogenital tract infections and is associated with reproductive morbidity. Although MG has been reported across many regions and population groups, it is not yet routinely tested for in China. Our study contributes to current research by reporting the prevalence and correlates of MG infection in patients attending a sexually transmitted infection (STI) clinic in Guangdong from Jan 2017-May 2018. Methods Urethral (from 489 men) and endo-cervical (from 189 women) samples, blood samples, and patient histories (via questionnaires) were collected. Doctors clinically diagnosed anogenital warts (GW) during the examination (n = 678). The presence of MG was evaluated using an in-house via polymerase chain reaction protocol. We also tested all participants for herpes simplex virus-2 (HSV-2), Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), syphilis and HIV. Univariate and multivariate logistic regression were used to evaluate factors associated with MG. Results MG was detected in 7.2% (49/678) of the patients (men, 7.4%; women, 6.9%). The MG positivity rate was 14.2% among symptomatic patients, and 5.6% for asymptomatic patients, respectively. Only 36.7% (18/49) Mg positive patients were symptomatic. Among the MG-infected patients, 10.2% were co-infected with CT, 6.1% with NG, 8.2% with HSV-2, 4.1% with syphilis and 22.4% with GW. Presentation with clinical symptoms was significantly associated with MG infection [OR = 2.52 (2.03–3.13)]. In our analysis, MG was not associated with other STIs. Conclusions MG is a relatively common infection among individuals attending an STI clinic in Guangdong Province. Routine testing of symptomatic patients may be necessary, and more epidemiological studies are needed to provide evidence for future testing guidelines.

BackgroundTumor-infiltrating lymphocytes (TILs) are considered a manifestation of the host immune response against cancer and tertiary lymphoid structures (TLS) may contribute to lymphocytes recruitment. Both of them have been reported as potential prognostic parameters in some human malignancies. However, the roles of TILs, TLS, and their correlation in Epstein-Barr Virus-associated gastric carcinoma (EBVaGC) and EBV-negative gastric carcinoma (EBVnGC) are largely unknown.MethodsTo observe the correlation among TILs, TLS, and clinicopathological characteristics and their prognostic significance in EBVaGC and EBVnGC, respectively. TILs and TLS were assessed by morphology and/or immunohistochemistry, and accompanied by clinicopathological analysis from 846 gastric cancer patients in multiple institutions.ResultsForty-two (5.0%) cases of EBVaGC and 804 cases of EBVnGC were identified byin situhybridization, respectively. For EBVnGC, higher TILs grade was correlated with TLS-present. EBVnGC patients with high TILs grade and TLS-present exhibited survival benefits. TILs (P= 0.001) and TLS (P= 0.003), especially TILs & TLS (P< 0.001) were independent prognostic factors in EBVnGC. A nomogram was constructed and validated for predicting the probability of overall survival and performed well with a good calibration. No significant prognostic value was detected in EBVaGC.ConclusionTILs and TLS, especially TILs & TLS were promising prognostic indicators for overall survival in EBVnGC. TILs and TLS were highly overlapping in their extent and prognostic abilities, and may be considered as a coindicator of prognosis of gastric cancer. The evaluations of TILs and TLS are simple and can be assessed routinely in pathological diagnosis.

Background Urogenital Chlamydia trachomatis is the most prevalent bacterial sexually transmitted infection (STI) globally. Reviews suggest high and persistently endemic STI epidemics in low and middle income countries. However population-based prevalence estimates in these settings are less common, underscoring the need for analyses of available data to characterize patterns of disease burden. We identified spatio-temporal clusters and key behavioral, social, or environmental factors contribution to transmission in order to inform the prioritization and targeting of evidence based interventions. Methods Using 11 years of data (2006–2016) from the chlamydia case report system of Guangdong, China, we identified county level spatio-temporal hot and cold spots using the Getis-Ord Gi* statistic and discrete Poisson models in SaTScan 9.6. We also estimated associations between observed distribution patterns and area-level demographic, social, and economic factors using quasi-Poisson regression models that controlled for annual counts of certified laboratories to account for fluctuations in location-specific detection capacity. Findings Cluster analysis indicates an expanding chlamydia epidemic in Guangdong, with cases clustered in regions of greatest economic activity. Greater male-to-female sex ratio (RR, 3.63; 95% CI, 1.41–9.45) and greater urbanicity (RR, 2.44; 95% CI, 1.98–2.99) were predictive of higher chlamydia case occurrence. Interpretation We found that chlamydia case occurrence in Guangdong province has been accelerating over the past 11 years and that its expansion is tied to indicators of social and economic development. These estimates not only identify high prevalence regions to target but also areas where data gaps potentially remain. The salience of sex ratios and urbanicity may best be understood through the lens of China's modern history of labor migration which has reshaped the gender dynamics and health access landscape of urban China. Future chlamydia control efforts will require a population-based approach focused on reengaging sexually active adults of diverse economic and migratory backgrounds. Funding This was an unfunded study using routinely collected public health data.

Background Chlamydia trachomatis (CT) is a major cause of infertility and adverse birth outcomes, but its epidemiology among childbearing-age women remains unclear in China. This study investigated the prevalence of CT and associated factors among Chinese women aged 16–44 years who were either (1) pregnant, (2) attending gynecology clinics, or (3) subfertile. Methods We conducted a cross-sectional survey and recruited participants from obstetrics, gynecology, and infertility clinics in Guangdong between March and December 2019. We collected information on individuals’ sociodemographic characteristics, previous medical conditions, and sexual behaviors. First-pass urine and cervical swabs were tested using nucleic acid amplification testing. We calculated the prevalence in each population and subgroup by age, education, and age at first sex. Multivariable binomial regression models were used to identify factors associated with CT. Results We recruited 881 pregnant women, 595 gynecology clinic attendees, and 254 subfertile women. The prevalence of CT was 6.7% (95% CI, 5.2%–8.5%), 8.2% (95% CI, 6.2%–10.7%), and 5.9% (95% CI, 3.5%–9.3%) for the above 3 populations, respectively. The subgroup-specific prevalence was highest among those who first had sex before age 25 years and older pregnant women (>35 years). The proportion of asymptomatic CT was 84.8%, 40.0%, and 60.0% among pregnant women, gynecology clinic attendees, and subfertile women, respectively. Age at first sex ( Conclusions Childbearing-age women in China have a high prevalence of CT. As most women with CT were asymptomatic, more optimal prevention strategies are urgently needed in China.

Background The purpose of this study was to develop and validate a simple-to-use nomogram for the prediction of syphilis infection among men who have sex with men (MSM) in Guangdong Province. Methods A serial cross-sectional data of 2184 MSM from 2017 to 2019 was used to develop and validate the nomogram risk assessment model. The eligible MSM were randomly assigned to the training and validation dataset. Factors included in the nomogram were determined by multivariate logistic regression analysis based on the training dataset. The receiver operating characteristic (ROC) curves was used to assess its predictive accuracy and discriminative ability. Results A total of 2184 MSM were recruited in this study. The prevalence of syphilis was 18.1% (396/2184). Multivariate logistic analysis found that age, the main venue used to find sexual partners, condom use in the past 6 months, commercial sex in the past 6 months, infection with sexually transmitted diseases (STD) in the past year were associated with syphilis infection using the training dataset. All these factors were included in the nomogram model that was well calibrated. The C-index was 0.80 (95% CI 0.76–0.84) in the training dataset, and 0.79 (95% CI 0.75–0.84) in the validation dataset. Conclusions A simple-to-use nomogram for predicting the risk of syphilis has been developed and validated among MSM in Guangdong Province. The proposed nomogram shows good assessment performance.

ObjectivesThe COVID-19 pandemic has overwhelmed health systems globally. With the increase of global migration, quantifying the health needs and key correlates of these outcomes is a global health priority. This study assessed migration characteristics, COVID-19 attitudes and the postmigration social environment as key correlates of depression, quality of life and alcohol misuse among international migrants in China.DesignA nationwide cross-sectional online survey was conducted from 17 February and 1 March 2020.SettingLinks to the online survey were disseminated by migrant-focused community-based organisations through WeChat.ParticipantsEnglish speaking international migrants who met the inclusion criteria. Inclusion criteria were being born in a country outside of China, aged 18 years or over, cumulatively living in China for 1 month or more and staying in China between December 2019 and February 2020.Outcome measuresDepression, quality of life and alcohol misuse.ResultsRegression models indicated that planning or considering leaving China due to COVID-19, lacking the confidence to protect themselves and not being confident that the epidemic would end soon was associated with greater depression, lower quality of life and greater levels of alcohol misuse. Worry about contracting COVID-19 and feeling helpless to prevent infection were associated with greater depression and lower quality of life. General perceived social support, and trust in Chinese people, institutions and systems were protective factors for depression and associated with higher reported quality of life.ConclusionsThis study identifies key correlates that, if adequately addressed through public health outreach, may safeguard migrant well-being during a public health emergency. Trust in people and systems within the postmigration environment is an important consideration for future public health planning efforts.

ObjectivesUnderscreening of HIV and syphilis in clinical settings is pervasive in resource-constrained settings. Heavy patient loads and competing health priorities in these settings inhibit provider’s ability to meet screening coverage targets. The objective of this study was to examine determinants of provider-initiated HIV and syphilis testing uptake at sexually transmitted disease (STD) clinics in China.DesignA cross-sectional study was performed between July 2016 and December 2016.SettingSeven STD clinics in Guangdong Province, China.ParticipantsHeterosexual STD clinic patients met the inclusion criteria, regardless of their interest in receiving HIV or syphilis testing.Outcome measuresThe syphilis and HIV testing uptake determined by patient receipt of results.ResultsA total of 1943 individuals were recruited in this study. Among those participants, 60.6% (1177/1943) and 74.3% (1443/1943) conducted HIV testing and syphilis testing during the study, respectively, of whom, 2.2% (26/1177) and 21.5% (310/1443) were found to be HIV-positive and syphilis-positive, respectively. The most common reason for rejecting HIV and syphilis testing was a low self-perceived risk of HIV and syphilis infection. After adjusting for covariates, condom use in the last sexual act, consistent condom use in the last 6 months, having paid sex in the last 6 months and having received any kind of HIV/STD-related knowledge during the last 12 years were positively associated with both HIV and syphilis testing uptake.ConclusionsThe low-level of HIV and syphilis testing uptake, alongside with the high-level of engagement in risky sexual behaviours among heterosexual STD clinic patients, warranted a more targeted and intensive behavioural interventions to promote HIV and syphilis testing in this population.

Prevalence of co-infecting sexually transmitted infections (STIs) among patients newly diagnosed with anogenital warts is under-reported. Our objective is to determine the prevalence of six common STIs, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma genitalium (MG), genital herpes (herpes simplex virus type 2 [HSV-2]), HIV, and syphilis for patients visiting a sexual health clinic in Guangzhou, China. Demographics, sexual health, and medical histories were collected at patient intake. Patients diagnosed with anogenital warts (N = 200) were invited to participate. We collected urine samples, and urethral, cervical, and rectal swabs to test for CT, NG, and MG, and blood samples for serological detection of HSV-2, syphilis, and HIV. Overall 49 (24.5%) had a co-infection (22.2% of men and 27.7% of women). All six STIs were observed among men: CT (6.8%), NG (3.4%), MG (5.1%), HIV (4.3%), HSV-2 (4.3%), and syphilis (1.7%). Women had fewer STIs, but at higher rates: CT (13.3%), MG (6.0%), and HSV-2 (8.4%). Individual men had up to two co-infections, while women had no more than one co-infection. Chlamydia was the most common STI. Patients aged 18–25 years (35.4%) had the highest prevalence. Although opportunistic screening is often applied for high-risk groups, expansion to patients with anogenital warts in all health-care settings would improve detection of problematic asymptomatic co-infections, thereby increasing China’s capacity to contribute toward global surveillance systems.

Background Men who have sex with men (MSM) bear a high burden of syphilis infection. Expanding syphilis testing to improve timely diagnosis and treatment is critical to improve syphilis control. However, syphilis testing rates remain low among MSM, particularly in low- and middle-income countries. We describe the protocol for a randomised controlled trial (RCT) to assess whether provision of syphilis self-testing services can increase the uptake of syphilis testing among MSM in China. Methods Four hundred forty-four high-risk MSM will be recruited online and randomized in a 1:1:1 ratio to (1) standard syphilis self-testing arm; (2) a self-testing arm program enhanced with crowdsourcing and a lottery-based incentive, and (3) a standard of care (control). Self-testing services include a free syphilis self-test kit through the mail at monthly intervals. Participants in the lottery incentive arm will additionally receive health promotion materials generated from an open crowdsourcing contest and be given a lottery draw with a 10% chance to win 100 RMB (approximately 15 US Dollars) upon confirmed completion of syphilis testing. Syphilis self-test kits have step-by-step instructions and an instructional video. This is a non-blinded, open-label, parallel RCT. Participants in each arm will be followed-up at three and 6 months through WeChat (a social media app like Facebook messenger). Confirmation of syphilis self-test use will be determined by requiring participants to submit a photo of the used test kit to study staff via secure data messaging. Both self-testing and facility-based testing will be ascertained by sending a secure photographic image of the completed kit through an existing digital platform. The primary outcome is the proportion of participants who tested for syphilis in the past 3 months. Discussion Findings from this study will provide much needed insight on the impact of syphilis self-testing on promoting routine syphilis screening among MSM. The findings will also contribute to our understanding of the safety, effectiveness and acceptability of syphilis self-testing. These findings will have important implications for self-testing policy, both in China and internationally. Trial registration ChiCTR1900022409 (10 April, 2019).

ObjectiveTo estimate the potential effects of an intense sex work crackdown on syphilis transmission in Guangdong Province, China.MethodsWe developed a deterministic compartmental model of syphilis transmission among female sex workers (FSW) and their male clients in Guangdong Province, China. We based model assumptions on census data and scientific literature, and we fitted the model to sentinel surveillance estimates of syphilis prevalence (positive results in both treponemal and non-treponemal tests) among FSW between 2009 and 2013. We estimated the impact of an intense sex work crackdown in 2014 by comparing the number of new syphilis infections between 2014 and 2020 in crackdown versus basecase (no crackdown) scenarios. In modelling scenarios, we examined main crackdown mechanisms of impact, including changed number of FSW engaging in sex work, reduction of weekly transactions, condom usage rate and syphilis diagnosis rate.ResultsIn the basecase, predicted syphilis prevalence in FSW decreased from 2% in 2014 to 0.4% in 2020. In crackdown scenarios, syphilis incidence was predicted to transiently decrease and then to rebound relative to basecase levels a few years later. Shorter crackdowns led to higher, faster rebounds.ConclusionsShort-term intense crackdowns may exacerbate syphilis transmission among FSW and further marginalise an already vulnerable group. This study provides a quantitative, infection-related basis for changing sex work policies to reduce harms.

ObjectivesAn increased trend in the number of reported gonorrhoea cases has been observed between 2014 and 2017 in China. This study aims to describe the reported epidemic of gonorrhoea and potential driving forces in Guangdong Province, China.DesignA review of surveillance data.ParticipantsThree different sources of data from Guangdong Province were analysed: gonorrhoea cases reported to the Chinese sexually transmitted infections (STI) case report system (CRS); a clinic-based retrospective study conducted to collect information on annual gonorrhoea screening coverage and data from the Guangdong governmental sentinel surveillance network (SSN) to examine the gonorrhoea prevalence among males attending STI clinics.Outcome measuresReported incidence of gonorrhoea, number of reported gonorrhoea cases, number of screening tests for gonorrhoea and gonorrhoea prevalence.ResultsThe STI CRS data showed that the reported incidence of gonorrhoea has increased rapidly from 15.7 cases per 100 000 population in 2014 to 27.3 cases per 100 000 in 2017 in Guangdong (pConclusionsThe number of gonococcal infections is rapidly rising in Guangdong, China. Expanded screening coverage, use of more sensitive diagnostics and increase of gonorrhoea prevalence are three potential contributors to the epidemic. Additional targeted intervention strategies are necessary in the future to control the epidemic.

Background Female sex workers (FSWs) are vulnerable to sexual, physical or verbal violence in and outside their workplaces. This study aimed to assess the violence that FSWs experienced and its associated factors from a cross-sectional study in Guangdong Province, China. Methods A cross-sectional study was conducted in seven cities in Guangdong province in 2017. Venue-based sampling method was used to recruit FSWs who were ≥16 years old and worked in mid- and low-end entertainment venues. Data were collected on socio-demographics, sexual behavioral characteristics, as well as types and sources of violence that FSWs had experienced through face-to-face survey. Descriptive analyses and multivariate logistic regression were conducted to assess the prevalence of different types and sources of violence and their associated factors. Results In total, 1207 FSWs participated in the study with a mean age of 30.7±6.7 years old. 108/1207 (8.9%) women reported having experienced violence by clients or regular partners. Clients were most commonly reported as perpetrators of physical violence (94.4%, 34/36) and sexual abuse (100%, 2/2). FSWs who reported sexually transmitted infection (STI) symptoms in the past 12 months (aOR =36.8, 95%CI: 14.2–95.9), having regular partners (aOR=27.1, 95%CI: 8.8–83.1), having oral sex (aOR=16.7, 95%CI: 8.9–31.3) and having anal sex with clients (aOR=78.7, 95%CI: 37.8–163.9) were more likely to experience any type of violence from clients during sex work. Having STI symptoms in the past 12 months (aOR=70.0, 95%CI: 14.9–328.5), oral sex (aOR=18.5, 95%CI: 8.3–41.5) and anal sex (aOR=74.7, 95%CI: 30.6–182.3) with clients were also associated with experiencing violence from regular partners. Conclusion FSWs suffered violence mostly from clients. FSWs who had STI symptoms in the past 12 months, oral or/and anal sex with clients are the most vulnerable to violence. Interventions should address FSWs’ sexual health risks and human rights violation at the same time to ensure a safe work environment. Disclosure No significant relationships.

Background Female sex workers (FSW) are at high risk of gonorrhea and chlamydia infection. However, gonorrhea and chlamydia testing rate remain low in this population. This study aimed to assess the gonorrhea and chlamydia testing rates and its associated factors among FSW in Guangdong, China. Methods A cross-sectional study was conducted in seven cities in Guangdong province. We collected data on socio-demographic characteristics, gonorrhea and chlamydia testing uptake and health care services utilization from participants through face-to-face interview in 2017. We reported the outcomes adjusted for age, ethnic, education level, marital status, monthly income and local working time through multivariable logistic regressions. Results Overall, 1207 people participated in the survey. The mean age of FSW was 30.69±6.75 years. The average number of customers per week was 8.18±5.43. Ninety (7.46%) of them had gonorrhea testing and 125 (10.36%) people had chlamydia testing in the last 12 months. Multivariable analysis indicated that FSW who reported having abnormal vaginal discharge (aOR=3.33, 95%CI: 2.03–5.46) or having ulcers in the genital area (aOR=6.16,95%CI: 1.99–19.06) in the past year were more likely to have gonorrhea testing. Those who had stable partners (aOR=2.59, 95%CI: 135–4.99), had anal sex (aOR=2.23,95%CI: 1.76–2.84), had HIV testing (aOR=3.94,95%CI: 2.34–6.65) and syphilis testing (aOR=3.27,95%CI: 1.96–5.46) were also more likely to have gonorrhea testing. Similar as gonorrhea testing, participants who had abnormal vaginal discharge in the past year (aOR=4.09, 95%CI: 2.62–6.40), had ulcers in the genital (aOR=10.37, 95%CI: 3.23–33.31), had anal sex (aOR=2.36,95%CI:1.54–3.60), had HIV testing (aOR=5.16,95%CI: 3.21–8.30) and syphilis testing (aOR=6.90,95%CI: 4.21–11.32) were more likely to have chlamydia testing. Conclusion Gonorrhea and chlamydia testing rates remain low among FSW in China. Interventions that can further improve the uptake of gonorrhea and chlamydia are further needed. Providing gonorrhea and chlamydia testing at syphilis/HIV testing sites and among asymptomatic FSW may increase testing rate. Disclosure No significant relationships.

Background Previous studies exploring the factors associated with the incidence of syphilis have mostly focused on individual-level factors. However, recent evidence has indicated that social-level factors, such as sociodemographic and socioeconomic factors, also affect the incidence of syphilis. Studies on the sociodemographic and socioeconomic factors associated with syphilis incidence are scarce, and they have rarely controlled for spatial effects, even though syphilis shows spatial autocorrelation. Methodology/Principal findings Syphilis data from 21 cities in Guangdong province between 2005 and 2017 were provided by the National Notifiable Infectious Disease Reporting Information System. The incidence time series, incidence map, and space-time scanning data were used to visualize the spatiotemporal distribution. The spatial panel data model was then applied to explore the relationship between sociodemographic factors (population density, net migration rate, male:female ratio, and the number of health institutions per 1,000 residents), socioeconomic factors (gross domestic product per capita, the proportion of secondary/tertiary industry), and the incidence of primary and secondary syphilis after controlling for spatial effects. The incidence of syphilis increased slowly from 2005 (11.91 per 100,000) to 2011 (13.42 per 100,000) and then began to decrease, reaching 6.55 per 100,000 in 2017. High-risk clusters of syphilis tended to shift from developed areas to underdeveloped areas. An inverted U-shaped relationship was found between syphilis incidence and gross domestic product per capita. Moreover, syphilis incidence was significantly associated with population density (β = 2.844, P = 0.006), the number of health institutions per 1,000 residents (β = -0.095, P = 0.007), and the net migration rate (β = -0.219, P = 0.002). Conclusions/Significance Our findings suggest that the incidence of primary and secondary syphilis first increase before decreasing as economic development increases further. These results emphasize the necessity to prevent syphilis in regions at the early stages of economic growth., Author summary Syphilis is a sexually transmitted infection that continues to cause morbidity and mortality worldwide. The primary and secondary stages of syphilis are the most transmissive stages in the entire process of the disease. We analyzed primary and secondary (P&S) syphilis data from 2005 to 2017 in Guangzhou, China, provided by the National Notifiable Infectious Disease Reporting Information System. The results showed that the annual incidence rates of P&S syphilis slightly increased from 2005 to 2011 and then began to decrease in 2017. Cases of P&S syphilis were spatially clustered. The high-risk syphilis clusters tended to shift from developed areas to underdeveloped areas. There may be an inverted U-shaped relationship between the level of economic development and the incidence of P&S syphilis, suggesting that the incidence of P&S syphilis first increased before decreasing as the level of economic development increased further. These results emphasize the necessity of preventing syphilis at locations in the early stage of economic growth. Investments in syphilis prevention education for people in regions at early development stages may mitigate the increasing cost of syphilis to future healthcare systems.

Background A high rectal and oropharyngeal sexually transmitted infection (STI) burden has been reported among men who have sex with men (MSM) in many regions, but little data exists on rectal and oropharyngeal STIs among MSM in China. The purpose of this study was to determine the prevalence of gonorrhea and chlamydia at different anatomic sites among MSM in Guangzhou, China. Methods We recruited a cross-sectional sample of MSM in one Chinese city and collected detailed information about socio-demographic characteristics and sexual behaviors. Men had urine, rectal, and pharyngeal swab samples tested for gonorrhea and chlamydia using nucleic acid amplification tests (NAAT). Univariate and multivariate logistic regressions were used to evaluate factors associated with gonorrhea and chlamydia. Among men without any STI symptoms, we also examined the prevalence of gonorrhea and chlamydia by anatomical site. Results We enrolled 463 men between January 2015 and March 2017. A total of 58/463 (12.5%) of men had gonorrhea and 84/463 (18.1%) had chlamydia. MSM with gonorrhea were more likely to have been recruited from the STI clinic (OR 3.41, 95% CI 1.94–5.99), living with HIV (OR 2.41, 95% CI 1.18–4.92), diagnosed had STI co-infection (OR 2.55, 95% CI 1.39–4.69). MSM with chlamydia were more likely to be students (OR 1.8, 95% CI 0.99–3.39). Most gonorrhea (34/58, 59%) and chlamydia (64/84, 76%) infections were not associated with STI symptoms. Conclusion Asymptomatic gonorrhea and chlamydia infection were common in this sample of Chinese MSM. Further research is necessary to determine optimal STI screening programs.

Background Increasing human immunodeficiency virus (HIV) testing is critical for HIV control. This study aimed to evaluate the interaction between social norms and self-efficacy on HIV testing among Chinese men who have sex with men (MSM). Methods We conducted an online survey in eight Chinese cities in Shandong and Guangdong Provinces in July 2016. We included participants who were born as a male, at least 16 years old, currently living in one of the designated cities, and had ever engaged in anal sex with a man. We collected information regarding socio-demographics, high-risk behaviors, and history of HIV and other STI testing. We coded sensitivity to social norms using six items asking participants about their perceived social norm regarding HIV testing. We coded HIV testing self-efficacy using a separate six-item scale. We interpreted higher mean scores as higher sensitivity to social norms and higher self-efficacy, respectively. We conducted logistic regressions to evaluate the interaction between self-efficacy and social norms on HIV testing. Results A total of 2105 men completed the survey. The mean age of the participants was 25.97 ± 6.42 years. Over four-fifths (85.9%) of participants were unmarried, 22.7% were students, and 64.6% at least had a college degree. 62.5 and 32.6% of participants ever and tested HIV in the last three months, respectively. With respect to uptake of HIV testing in the last three months, the adjusted odds ratio was 1.01(95% CI: 0.96–1.06) for higher sensitivity to social norms and 1.09 (95% CI: 1.05–1.14) for higher self-efficacy, with an interaction effect of 1.02 (95% CI: 1.01–1.03), respectively. With respect to uptake of lifetime HIV testing, the adjusted odds ratio was 1.03(95% CI: 0.99–1.07) for higher sensitivity to social norms and 1.15 (95% CI: 1.11–1.19) for higher self-efficacy, with an interaction effect of 1.02 (95% CI: 1.01–1.04), respectively. Conclusions Our survey demonstrated that there is a significant association between the uptake of HIV testing with sensitivity to the social norm, higher self-efficacy, as well as the interaction between them. Tailored studies for improving HIV testing among MSM in China can combine these two interventions together. Electronic supplementary material The online version of this article (10.1186/s12879-018-3454-5) contains supplementary material, which is available to authorized users.

Objective We aimed to assess the positive percentages of urine morphine tests and correlates among methadone maintenance treatment (MMT) clients with HIV/AIDS in Guangdong, China. Setting Fourteen MMT clinics located in nine cities of Guangdong were chosen as study sites. Participants In this study, we reviewed 293 clients with opioid dependence, who were HIV seropositive, 18 years or older, provided informed consent and had at least 10 records of urine morphine tests during the study period. Primary and secondary outcome measures The positive percentages of urine morphine tests were calculated and underlying predictors were estimated. Results The highest positive percentage (95.9%) was observed in the first month. After excluding the highest percentage in the first month, the average positive percentage was 40.9% for month 2 to month 12. Positive percentages of urine morphine tests that were 80% were 25.4%, 36.1% and 38.5% respectively. Lower percentages of continued heroin use were associated with being young (OR≤30=0.31, 95% CI 0.12 to 0.78; OR31-=0.44, 95% CI 0.20 to 1.00), and financial sources depending on family or friends (OR=0.55, 95% CI 0.32 to 0.93). Higher percentages of continued heroin use were associated with being unemployed (OR=1.99, 95% CI 1.13 to 3.49) and poor MMT attendance (OR

BackgroundRecreational drug use has increased considerably among Chinese men who have sex with men (MSM). The phenomenon has the potentially to increase HIV transmission among Chinese MSM. The aims of this study were: 1) to investigate the prevalence of recreational drug use among Chinese MSM, and 2) to explore the correlation between gay smartphone based sex-seeking applications (gay apps), HIV/STIs testing, group sex, commercial sex, sexual roles and poppers use among Chinese MSM.MethodsMSM who were born biologically male, were at least 16 years of age and had engaged in anal sex with a man at least once were recruited through a nation-wide online survey in 2014. Information regarding socio-demographics, risk behaviors, recreational drug use, HIV and other STIs testing history and gay app use were collected. Univariate and multivariate analysis were used to determine factors associated with recreational drug use among Chinese MSM.ResultsAmong 1424 participating MSM, 1100 (77.3%) reported ever using recreational drugs in their lifetime. In the last 12 months, 303 (21.3%) used poppers, 34 (2.4%) used crystal meth and 15 (1.0%) used ecstasy. The mean age of respondents was 25.6±6.8 years, 72.9% identified as gay, 41.3% were students, and 83.8% had never been married. Multiple logistic regression models revealed that compared with non-popper users, popper users were more likely to have been tested for HIV (adjusted OR (aOR) = 1.50, 95% CI: 1.15-1.96) and other STIs (aOR = 1.65, 95% CI: 1.26-2.17). In addition, popper users were more likely to engage in group sex (aOR = 2.63, 95% CI:1.80-3.86), commercial sex (aOR = 1.86, 95% CI:1.13-3.06) and used gay mobile apps to seek sexual partners (aOR = 2.10, 95% CI:1.58-2.80).ConclusionChinese MSM has a high rate of recreational drug use, including poppers. Public health programs serving MSM may consider integrating intervention programs to decrease recreational drug use related harms.

Background. Our study aimed to assess the burden of depression and evaluate factors associated with depression and status of HIV risk behaviors among female sex workers (FSWs) in Guangdong, China. Method. We recruited FSWs from massage parlors, saunas, restaurants, hotels, hair salons, and streets in Guangdong, China, in 2014. Information on demographic characteristics, HIV testing history, and sexual behaviors was collected using a questionnaire. A blood sample was collected to test for HIV, syphilis, and HCV. A participant was defined as being depressed if she obtained 6 points or above using the 12-item General Health Questionnaire. Results. Among the 653 participants, 41.7% were 21–30 years old and 43.6% married. Overall, 52.4% were found to be depressed. FSWs who had correct syphilis related knowledge [aOR = 1.45; 95% CI: 1.04–2.03] and had primary sex partner (1.63, 1.14–2.33) were more likely to be depressed. FSWs who did not use a condom during their last sex with the primary sex partner were less likely to be depressed (0.47, 0.31–0.71). Conclusion. Our study observed high level of depression and HIV risk behaviors among Chinese FSWs. Future interventions should integrate mental health services in comprehensive interventions to prevent depression among Chinese FSWs.

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 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.

Objective: To assess concurrent heroin use and correlates among Methadone Maintenance Treatment (MMT) clients in Guangdong Province, China. Method: Demographic and drug use data were collected with a structured questionnaire, and MMT information was obtained from the MMT clinic registration system in Guangdong. Human immunodeficiency virus (HIV-) and hepatitis C virus (HCV) infected status and urine morphine results were obtained from laboratory tests. Logistic regressions were employed to investigate the factors associated with concurrent heroin use. Results: Among the 6848 participants, 75% continued using heroin more than once during the first 12 months after treatment initiation. Concurrent heroin use was associated with inharmonious family relationship (OR (odds ratio) = 1.49, 95% CI (confidence intervals): 1.24–1.78), HIV positivity (OR = 1.25, 95% CI: 1.01–1.55), having multiple sex partners (OR = 1.34, 95% CI: 1.07–1.69), having ever taken intravenous drugs (OR = 0.81, 95% CI: 0.69–0.95), higher maintenance dose (OR = 1.13, 95% CI: 1.01–1.28) and poorer MMT attendance (OR

Objective Client adherence is vital for effective methadone maintenance treatment (MMT). This study explores the pattern and associated factors of client adherence, drop-out and re-enrolment in the Chinese MMT programme over the period of 2006–2013. Methods This retrospective study was conducted in 14 MMT clinics in Guangdong Province, China. We employed Kaplan-Meier survival analysis to estimate the rates of drop-out and re-enrolment of MMT clients and multivariate Cox regression to identify associated factors. Results Among 1,512 study participants, 79% have experienced ‘drop-out’ during the 7-year study period. However, 82% ‘dropped-out’ clients resumed treatment at a later time. Low education level (junior high or below versus otherwise, HR = 1.21, 1.05–1.40), low methadone dosage in the first treatment episode (

Background Early diagnosis of syphilis and timely treatment can effectively reduce ongoing syphilis transmission and morbidity. We examined the factors associated with the early diagnosis of syphilis to inform syphilis screening strategic planning. Methods In an observational study, we analyzed reported syphilis cases in Guangdong Province, China (from 2014 to mid-2015) accessed from the national case-based surveillance system. We categorized primary and secondary syphilis cases as early diagnosis and categorized latent and tertiary syphilis as delayed diagnosis. Univariate analyses and multivariable logistic regressions were performed to identify the factors associated with early diagnosis. We also examined the factors associated with early diagnosis at the individual and city levels in multilevel logistic regression models with cases nested by city (n = 21), adjusted for age at diagnosis and gender. Results Among 83,944 diagnosed syphilis cases, 22% were early diagnoses. The city-level early diagnosis rate ranged from 7 to 46%, consistent with substantial geographic variation as shown in the multilevel model. Early diagnosis was associated with cases presenting to specialist clinics for screening, being male and attaining higher education level. Cases received syphilis testing in institutions and hospitals, and diagnosed in hospitals were less likely to be in early diagnosis. At the city-level, cases living in a city equipped with more hospitals per capita were less likely to be early diagnosis. Conclusions To enhance early diagnosis of syphilis, city-specific syphilis screening strategies with a mix of passive and client/provider-initiated testing might be a useful approach.