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HIV partner notification services (HIV PS) have been poorly implemented in most low- and middle-income countries, including China. Understanding the social context of partner services for key populations is important for scaling up HIV testing services. This study aims to examine facilitators and barriers of HIV PS using qualitative analysis.This article qualitatively analyzed the texts obtained from a crowdsourcing open call and adopted the socioecological framework to understand the social context of Chinese men who have sex with men (MSM) living with HIV that influenced their uptake of HIV partner services. Crowdsourcing means collecting ideas from and sharing solutions with the public. The open call was held to solicit ideas to enhance HIV partner services for Chinese MSM. Two coders conducted a content analysis of the texts from the submissions using inductive and deductive coding methods to identify facilitators and barriers of HIV PS.Textual data from 53 submissions were analyzed. The most mentioned barrier, stigma associated with HIV PS, was deeply embedded at several levels, highlighting the urgent need for stigma reduction. Among the facilitators, many people mentioned anonymous online notification could protect the privacy and avoid social harm for index partners. Differentiated partner services may improve HIV PS uptake by providing tailored intervention according to the individual circumstances. Some people suggested implicit notification, which meant testing the attitude of the partner before direct disclosure. This was feasible and acceptable in many settings.The unique social context of MSM living with HIV provides opportunities for embedding HIV partner services. More clinical trials that test the acceptability and effectiveness of the HIV PS interventions are needed.

BackgroundHIV self-testing (HIVST), especially the secondary distribution of HIVST (SD-HIVST) initiated by sexual health influencers (SHIs), has been recognized as an effective strategy in promoting HIV testing, especially among men who have sex with men (MSM). This quasi-experimental study aimed to evaluate whether SHIs identified through the ensemble machine learning approach can distribute more HIVST than those who identified by the empiricalscale.MethodsWe will recruit eligible adults (≥18 years old) who were assigned male gender at birth, and willing to participate in potential SD-HIVST online. Participants will be assigned randomly to two groups (scale group or machine learning group), followed by a separate process of SHI identification based on the group assignment. After identification, all index participants (defined as identified SHIs who are verbally consented to participate in SD-HIVST or who directly order HIVST kits) will follow the same procedure for SD-HIVST acquisition and distribution. Index participants can order HIVST online and distribute them to members within their social networks (defined as alters) in-person or virtually through a personalized peer referral link. Once a unique alter uploads a photographed test result to the platform, both the alter and the corresponding index participant will receive a fixed incentive of 3 USD. The index MSM can order up to five HIVST in the first three months and ten HIVST in the following three months. Each index participant will need to complete a baseline survey at the first-time ordering and one to two follow-upbased on the times of ordering,, three months after ordering. This trial will be comparing 1) the mean number of alters motivated by each index participant in each group and 2) the mean number of newly-tested alters motivated by each index participant in each group.DiscussionIn promoting the efficacy of identifying SHIs for SD-HIVST, our study has the potential to enhance testing coverage, particularly among marginalized individuals and those who are reluctant to for HIV and other sexually transmitted infections.Trial registrationWe registered the study on the Chinese Clinical Trial Registry website on 4th November 2021, with registration numberChiCTR2000039632.

Background Public health measures, such as social isolation, are vital to control the spread of the coronavirus disease 2019 (COVID-19), but such measures may increase the risk of depression. Thus, this study examines the influencing and moderating factors of depressive symptoms among individuals subjected to mandatory social isolation. Methods An online cross-sectional survey was conducted to collect data from people under mandatory home or centralized social isolation in Shenzhen, China, from February 28 to March 6, 2020. The perceived risk of infection with COVID-19, perceived tone of media coverage, perceived quality of people-oriented public health services, and their depressive symptoms were assessed. Three rounds of stepwise multiple regression were performed to examine the moderating effects after controlling various variables, such as demographics, duration and venue of mandatory social isolation, infection and isolation status of family, time spent on COVID-related news, and online social support. Results Among the 340 participants, 57.6% were men, the average age was 35.5 years old (SD = 8.37), and 55.6% held a bachelor’s degree or above. Individuals subjected to mandatory social isolation generally reported low levels of depressive symptoms. Perceived susceptibility to infection was relatively low, whereas perceived tone of media coverage was mainly positive. In terms of perceived quality of public health services, 12 (3.5%), 103 (30.3%), and 225 (66.2%) participants reported low, medium, and high quality of people-oriented services, respectively. Perceived susceptibility was positively associated with depression, whereas perceived tone of media coverage was negatively associated. The quality of people-centered public health services moderated the association between perceived risk and depressive symptoms and between perceived tone of media coverage and depressive symptoms. Conclusions This study revealed the depressive symptoms among individuals subjected to mandatory social isolation during the COVID-19 pandemic and highlighted that frontline public health workers play a critical role in protecting public mental health.

Background Adherent pre-exposure prophylaxis (PrEP) uptake can prevent HIV infections. Despite the high HIV incidence, Chinese key populations have low PrEP uptake and adherence. New interventions are needed to increase PrEP adherence among key populations in China. Co-creation methods are helpful to solicit ideas from the community to solve public health problems. The study protocol aims to describe the design of a stepped-wedge trial and to evaluate the efficacy of co-created interventions to facilitate PrEP adherence among key populations in China. Methods The study will develop intervention packages to facilitate PrEP adherence among Chinese key populations using co-creation methods. The study will then evaluate the efficacy of the co-created intervention packages using a stepped-wedge randomized controlled trial. This four-phased closed cohort stepped-wedge design will have four clusters. Each cluster will start intervention at three-month intervals. Seven hundred participants who initiated PrEP will be recruited. Participants will be randomized to the clusters using block randomization. The intervention condition includes receiving co-created interventions in addition to standard of care. The control condition is the standard of care that includes routine clinical assessment every 3 months. All participants will also receive an online follow-up survey every 3 months to record medication adherence and will be encouraged to use a WeChat mini-app for sexual and mental health education throughout the study. The primary outcomes are PrEP adherence and retention in PrEP care throughout the study period. We will examine a hypothesis that a co-created intervention can facilitate PrEP adherence. Generalized linear mixed models will be used for the primary outcome analysis. Discussion Developing PrEP adherence interventions in China faces barriers including suboptimal PrEP uptake among key populations, the lack of effective PrEP service delivery models, and insufficient community engagement in PrEP initiatives. Our study design addresses these obstacles by using co-creation to generate social media-based intervention materials and embedding the study design in the local healthcare system. The study outcomes may have implications for policy and intervention practices among CBOs and the medical system to facilitate PrEP adherence among key populations. Trial registration The study is registered in Clinical Trial databases in China (ChiCTR2100048981, July 19, 2021) and the US (NCT04754139, February 11, 2021).

BACKGROUND: China has low seasonal influenza vaccination rates among priority populations. In this study, we aimed to evaluate a pay-it-forward strategy to increase influenza vaccine uptake in rural, suburban, and urban settings in China. METHODS: We performed a quasi-experimental pragmatic trial to examine the effectiveness of a pay-it-forward intervention (a free influenza vaccine and an opportunity to donate financially to support vaccination of other individuals) to increase influenza vaccine uptake compared with standard-of-care user-paid vaccination among children (aged between 6 months and 8 years) and older people (≥60 years) in China. Recruitment took place in the standard-of-care group until the expected sample size was reached and then in the pay-it-forward group in primary care clinics from a rural site (Yangshan), a suburban site (Zengcheng), and an urban site (Tianhe). Participants were introduced to the influenza vaccine by project staff using a pamphlet about influenza vaccination and were either asked to pay out-of-pocket at the standard market price (US$8·5-23·2; standard-of-care group) or to donate any amount anonymously (pay-it-forward group). Participants had to be eligible to receive an influenza vaccine and to have not received an influenza vaccine in the past year. The primary outcome was vaccine uptake. Secondary outcomes were vaccine confidence and costs (from the health-care provider perspective). Regression methods compared influenza vaccine uptake and vaccine confidence between the two groups. This trial is registered with ChiCTR, ChiCTR2000040048. FINDINGS: From Sept 21, 2020, to March 3, 2021, 300 enrolees were recruited from patients visiting three primary care clinics. 55 (37%) of 150 people in the standard-of-care group (40 [53%] of 75 children and 15 [20%] of 75 older adults) and 111 (74%) of 150 in the pay-it-forward group (66 [88%] of 75 children and 45 [60%] of 75 older adults) received an influenza vaccine. People in the pay-it-forward group were more likely to receive an influenza vaccine compared with those in the standard-of-care group (adjusted odds ratio [aOR] 6·7 [95% CI 2·7-16·6] among children and 5·0 [2·3-10·8] among older adults). People in the pay-it-forward group had greater confidence in vaccine safety (aOR 2·2 [95% CI 1·2-3·9]), importance (3·1 [1·6-5·9]), and effectiveness (3·1 [1·7-5·7]). In the pay-it-forward group, 107 (96%) of 111 participants donated money for subsequent vaccinations. The pay-it-forward group had a lower economic cost (calculated as the cost without subtraction of donations) per person vaccinated (US$45·60) than did the standard-of-care group ($64·67). INTERPRETATION: The pay-it-forward intervention seemed to be effective in improving influenza vaccine uptake and community engagement. Our data have implications for prosocial interventions to enhance influenza vaccine uptake in countries where influenza vaccines are available for a fee. FUNDING: Bill & Melinda Gates Foundation and the UK National Institute for Health Research. ispartof: LANCET INFECTIOUS DISEASES vol:22 issue:10 pages:1484-1492 ispartof: location:United States status: published

Background Syphilis is a common sexually transmitted infection (STI) among men who have sex with men (MSM). Increasing syphilis testing is important to syphilis control. However, in low- and middle-income countries like China, syphilis testing rates remain low among MSM. We describe a randomized controlled trial protocol to examine the effectiveness of social network distribution approaches of syphilis self-testing among MSM in China. Methods We will recruit index and alter MSM. Indexes will be eligible if they: are born biologically male; aged 18 years or above; ever had sex with another man; are willing to distribute syphilis testing packages or referral links to their alters; and willing to provide personal contact information for future follow-up. Three hundred MSM will be recruited and randomly assigned in a 1:1:1 ratio into three arms: standard of care (control arm); standard syphilis self-testing (SST) delivery arm; and referral link SST delivery arm. Indexes will distribute SST packages or referral links to encourage alters to receive syphilis testing. All indexes will complete a baseline survey and a 3-month follow-up survey. Syphilis self-test results will be determined by photo verification via a digital platform. The primary outcome is the mean number of alters who returned verified syphilis testing results per index in each arm. Discussion The trial findings will provide practical implications in strengthening syphilis self-testing distribution and increasing syphilis testing uptake among MSM in China. This study also empowers MSM community in expanding syphilis testing by using their own social network. Trial registration Chinese Clinical Trial Registry, ChiCTR2000036988. Registered 26 August 2020 - Retrospectively registered.

BackgroundHepatitis C virus self-testing (HCVST) may increase test uptake especially among marginalized key populations such as men who have sex with men (MSM). We conducted an observational study to assess the usability, acceptability and feasibility of HCVST among MSM in China.MethodsAn observational study with convenience sampling was performed among MSM in Guangzhou, China in 2019. The OraQuick® HCV Rapid Antibody Test kits were used in this study. Participants performed all 12 HCVST steps and interpreted the results in the presence of a trained observer. Usability was defined as the number and percentage of participants who completed all testing steps correctly without assistance and interpreted the results correctly. Inter-reader concordance was calculated as the percentage agreement between the results interpreted by the participant and those interpreted by a trained staff member. The same process was used to estimate inter-operator agreement between the self-testing and professional use test results. Acceptability was assessed using an interviewer-administered semi-structured questionnaire.ResultsAmong 100 participants with median age 27 (interquartile range 23–30) years, 4% reported prior history of HCV testing, 41% reported using blood-based HIV self-testing in the past, 54% (95%CI: 43.7–64.0%) completed all self-testing steps correctly without assistance and interpreted the results correctly. Both the inter-reader and inter-operator concordance were excellent at 97% (95%CI: 91.5–99.4%) and 98% (95%CI: 93.0–99.8%), respectively. The majority rated the HCVST process as very easy (52%, 95%CI: 41.8–62.1%) or easy (41%, 95%CI: 31.3–51.3%), 76% (95%CI: 66.4–84.0%) were willing to use HCVST again, and 75% (95%CI: 65.3–83.1%) would recommend it to their family and friends.ConclusionsOur findings demonstrate that oral fluid HCVST has high usability and acceptability among Chinese MSM. More implementation research is needed to plan how best to position and scale-up HCVST alongside other facility-and community-based testing approaches and ensure data linkage into health systems.

Approximately 80% of primary healthcare facilities in China were ready to deliver hepatitis care services by 2021. This study aimed to assess hepatitis B and C test uptake, identify the factors associated with testing and determine the predictors of hepatitis stigma among primary care patients. We conducted a cross-sectional survey among patients seeking care in the family medicine and primary care unit of the University of Hong Kong-Shenzhen Hospital, China. Participants were 30 years or older and had not tested for HBV and HCV in the preceding 12 months. Test uptake was defined as self-reported previous HBV and HCV testing. Descriptive statistics, Chi-square test, forward multivariable logistic regression and stepwise multiple linear regression were conducted, and a p-value.05 was deemed statistically significant. A total of 750 eligible patients completed the survey, and 54.5% (404 ± 0.9) were between 30 and 40 years old. Most participants were heterosexuals 98.0% (n = 735), female 57.5% (n = 431), married 78.3% (587) and earned ≤1500 USD per month 54.4% (n = 408). A 66.1% (n = 496) and 13.7% (n = 103) self-reported previous HBV and HCV testing, respectively, and 62% (n = 468) were vaccinated. HCV testing was associated with HBV testing (aOR = 13.7, 95% CI:2.1-91.5); and HBV testing was associated with family history of HBV (aOR = 2.4, 95%CI:1.1-5.5). Overall hepatitis stigma was about average and decreased with family history of HBV (p = .017). In conclusion, HCV testing uptake among primary care patients was low and needs to be further promoted. Integrating HBV and HCV testing interventions and fostering family-based support for disclosure could effectively improve testing uptake.

BACKGROUND: Gonorrhea and chlamydia are common among Chinese men who have sex with men (MSM), but testing rates are low. We developed a pay-it-forward program where men receive a free gonorrhea/chlamydia test and can then donate toward future participants' tests. This study aims to investigate drivers of testing uptake and donation using a mixed methods approach. METHODS: We used a sequential explanatory design to explore drivers of testing uptake and donation unique to pay-it-forward through a quantitative cross-sectional survey and a qualitative thematic analysis of semistructured interviews. We collected data on sociodemographics and perceived benefits of pay-it-forward among men offered the pay-it-forward interventionand analyzed testing uptake and donations using descriptive statistics and logistic regression. We then conducted 30 semistructured interviews with men and coded interview data to identify themes. RESULTS: Three hundred and one MSM were offered pay-it-forward and 55% (165/301) received gonorrhea/chlamydia testing. Ninety-one percent (150 of 165) donated any amount with a mean of 58.31 ± 53.39 RMB (US $8.61 ± 7.88), or 39% of the standard price of gonorrhea/chlamydia testing. Getting tested was not associated with income, but donations were higher in the highest income bracket (adjusted odds ratio, 7.12; 95% confidence interval, 1.61-31.52). Fifty-eight percent (94 of 162) selected "more MSM can get tested," and 54% (88 of 162) selected "I can help someone else" as benefits of pay-it-forward. Qualitative themes for drivers of testing and donation included flexible pricing, generosity and reciprocity, and MSM community identity. CONCLUSIONS: Quantitative and qualitative results suggest that this pay-it-forward program may increase gonorrhea/chlamydia testing by reducing cost barriers, leveraging generosity and reciprocity, and mobilizing community altruism.

In China, men who have sex with men (MSM) shoulder a disproportionate HIV burden. Early initiation and adherence to HIV antiretroviral therapy (ART) will be critical to reversing the HIV epidemic in China, but ART usage remains suboptimal among MSM diagnosed with HIV. One understudied but potentially important factor underpinning suboptimal ART usage is personal belief in supernatural explanatory models of health and illness (supernatural explanatory models). This study examines associations between beliefs in supernatural explanatory models and ART usage among MSM in China. In 2017, an online survey was distributed nationwide throughout China by gay community–based organizations. Eligible study participants were self-identified MSM between 16 and 30 years old who had tested positive for HIV and who had seen a doctor in the last 2 years. Beliefs in supernatural explanatory models were measured using a three-item scale developed specifically for the Chinese population (range, 3–15). Of 73 participants, the majority were currently using ART (83.6%) and 42.5% expressed some endorsement of belief in supernatural explanatory models. However, among 21 participants with the strongest belief in supernatural explanatory models, prevalence of current ART usage was 61.9%. Stronger belief in supernatural explanatory models was significantly associated with lower likelihood of current ART usage (adjusted odds ratio = 0.52; 95% confidence interval = 0.13–0.75). Belief in supernatural explanatory models may be a powerful predictor of ART usage among MSM living with HIV in China. Further studies are needed to corroborate these findings and elucidate mechanisms of association.

Background Homoprejudiced violence, defined as physical, verbal, psychological and cyber aggression against others because of their actual or perceived sexual orientation, is an important public health issue. Most homoprejudiced violence research has been conducted in high-income countries. This study examined homoprejudiced violence among men who have sex with men (MSM) in Guangzhou, China. Methods MSM in a large Chinese city, Guangzhou, completed an online survey. Data about experiencing and initiating homoprejudiced violence was collected. Multivariable logistic regression analyses, controlling for age, residence, occupation, heterosexual marriage, education and income, were carried out to explore associated factors. Results A total of 777 responses were analyzed and most (64.9%) men were under the age of 30. Three-hundred-ninety-nine (51.4%) men experienced homoprejudiced violence and 205 (25.9%) men perpetrated homoprejudiced violence against others. Men who identified as heterosexual were less (AOR = 0.6, 95% CI: 0.4–0.9) likely to experience homoprejudiced violence compared to men who identified as gay. Men who experienced homoprejudiced violence were more likely to initiate homoprejudiced violence (AOR = 2.44, 95% CI: 1.6–3.5). Men who disclosed their sexual orientation to other people were more likely to experience homoprejudiced violence (AOR = 1.8, 95% CI:1.3–2.5). Conclusions These findings suggest the importance of further research and the implementation of interventions focused on preventing and mitigating the effects of homoprejudiced violence among MSM in China.

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 Digital network–based methods may enhance peer distribution of HIV self-testing (HIVST) kits, but interventions that can optimize this approach are needed. We aimed to assess whether monetary incentives and peer referral could improve a secondary distribution program for HIVST among men who have sex with men (MSM) in China. Methods and findings Between October 21, 2019 and September 14, 2020, a 3-arm randomized controlled, single-blinded trial was conducted online among 309 individuals (defined as index participants) who were assigned male at birth, aged 18 years or older, ever had male-to-male sex, willing to order HIVST kits online, and consented to take surveys online. We randomly assigned index participants into one of the 3 arms: (1) standard secondary distribution (control) group (n = 102); (2) secondary distribution with monetary incentives (SD-M) group (n = 103); and (3) secondary distribution with monetary incentives plus peer referral (SD-M-PR) group (n = 104). Index participants in 3 groups were encouraged to order HIVST kits online and distribute to members within their social networks. Members who received kits directly from index participants or through peer referral links from index MSM were defined as alters. Index participants in the 2 intervention groups could receive a fixed incentive ($3 USD) online for the verified test result uploaded to the digital platform by each unique alter. Index participants in the SD-M-PR group could additionally have a personalized peer referral link for alters to order kits online. Both index participants and alters needed to pay a refundable deposit ($15 USD) for ordering a kit. All index participants were assigned an online 3-month follow-up survey after ordering kits. The primary outcomes were the mean number of alters motivated by index participants in each arm and the mean number of newly tested alters motivated by index participants in each arm. These were assessed using zero-inflated negative binomial regression to determine the group differences in the mean number of alters and the mean number of newly tested alters motivated by index participants. Analyses were performed on an intention-to-treat basis. We also conducted an economic evaluation using microcosting from a health provider perspective with a 3-month time horizon. The mean number of unique tested alters motivated by index participants was 0.57 ± 0.96 (mean ± standard deviation [SD]) in the control group, compared with 0.98 ± 1.38 in the SD-M group (mean difference [MD] = 0.41),and 1.78 ± 2.05 in the SD-M-PR group (MD = 1.21). The mean number of newly tested alters motivated by index participants was 0.16 ± 0.39 (mean ± SD) in the control group, compared with 0.41 ± 0.73 in the SD-M group (MD = 0.25) and 0.57 ± 0.91 in the SD-M-PR group (MD = 0.41), respectively. Results indicated that index participants in intervention arms were more likely to motivate unique tested alters (control versus SD-M: incidence rate ratio [IRR = 2.98, 95% CI = 1.82 to 4.89, p-value < 0.001; control versus SD-M-PR: IRR = 3.26, 95% CI = 2.29 to 4.63, p-value < 0.001) and newly tested alters (control versus SD-M: IRR = 4.22, 95% CI = 1.93 to 9.23, p-value < 0.001; control versus SD-M-PR: IRR = 3.49, 95% CI = 1.92 to 6.37, p-value < 0.001) to conduct HIVST. The proportion of newly tested testers among alters was 28% in the control group, 42% in the SD-M group, and 32% in the SD-M-PR group. A total of 18 testers (3 index participants and 15 alters) tested as HIV positive, and the HIV reactive rates for alters were similar between the 3 groups. The total costs were $19,485.97 for 794 testers, including 450 index participants and 344 alter testers. Overall, the average cost per tester was $24.54, and the average cost per alter tester was $56.65. Monetary incentives alone (SD-M group) were more cost-effective than monetary incentives with peer referral (SD-M-PR group) on average in terms of alters tested and newly tested alters, despite SD-M-PR having larger effects. Compared to the control group, the cost for one more alter tester in the SD-M group was $14.90 and $16.61 in the SD-M-PR group. For newly tested alters, the cost of one more alter in the SD-M group was $24.65 and $49.07 in the SD-M-PR group. No study-related adverse events were reported during the study. Limitations include the digital network approach might neglect individuals who lack internet access. Conclusions Monetary incentives alone and the combined intervention of monetary incentives and peer referral can promote the secondary distribution of HIVST among MSM. Monetary incentives can also expand HIV testing by encouraging first-time testing through secondary distribution by MSM. This social network–based digital approach can be expanded to other public health research, especially in the era of the Coronavirus Disease 2019 (COVID-19). Trial registration Chinese Clinical Trial Registry (ChiCTR) ChiCTR1900025433

China has low seasonal influenza vaccination rates among children and older adults. This quasi-experimental pragmatic trial examined the effectiveness of a pay-it-forward intervention on influenza vaccination compared to standard of care (user-paid vaccination) and free vaccination strategies among children and older people in China (ChiCTR2000040048). In pay-it-forward, people receive a free influenza vaccine from a local group and are offered an opportunity to donate financially to support vaccination among future individuals. The primary outcome was pre-specified as influenza vaccine uptake. Secondary outcomes included vaccine confidence and associated costs. Among 450 participants enrolled, 55/150 (36.7%) in the standard of care arm, 111/150 (74.0%) in the pay-it-forward arm, and 114/150 (76.0%) in the free vaccination arm received an influenza vaccine. The pay-it-forward arm had significantly higher vaccine confidence when compared to the standard of care arm. In the pay-it-forward arm, 107/111 (96.4%) of participants donated money for subsequent vaccinations and 19 of 60 invited (31.7%) created postcard messages.

BackgroundChina has low seasonal influenza vaccination rates among children and older adults. This quasi-experimental pragmatic trial examined the effectiveness of a pay-it-forward intervention on influenza vaccination compared to standard-of-care (user-paid vaccination) among children and older people in China. Pay-it-forward offered a free influenza vaccine from a local group and an opportunity to donate financially to support future individuals.MethodsAt each of the three study sites, participants were recruited into the standard-of-care arm first until expected sample size was reached and then recruited into the pay-it-forward arm. The primary outcome was vaccine uptake. Secondary outcomes included vaccine confidence and costs. Regression methods compared influenza vaccine uptake and vaccine confidence between the two arms.ResultsAmong 300 participants enrolled, 55/150(36.7%) in the standard-of-care arm 111/150(74.0%) in the pay-it-forward arm received an influenza vaccine. People in the pay-it-forward arm were more likely to receive the vaccine compared to people in the standard-of-care arm (adjusted odds ratio (aOR)= 6.7, 95%CI [2.7, 16.6] among children; aOR=5.0, [2.3, 10.8] among older adults). People in the pay-it-forward arm had greater confidence in vaccine safety, importance, and effectiveness. In the pay-it-forward arm, 107/111 (96.4%) of participants donated money for subsequent vaccinations, and 19 of 60 invited (31.7%) created postcard messages. The pay-it-forward arm had a lower economic cost per person vaccinated ($45.60) than the standard-of-care arm ($64.67).ConclusionsPay-it-forward was effective in improving influenza vaccine uptake and public engagement. Our data have implications for pro-social interventions to enhance influenza vaccine uptake in countries where influenza vaccines are available for a fee.Trial registrationChiCTR2000040048Main point summaryPay-it-forward substantially increased influenza vaccine uptake among children and older adults compared to standard of care user-paid vaccination.

PURPOSE OF REVIEW: To review literature on progress towards UNAIDS 90–90-90 targets for HIV prevention and treatment among men who have sex with men (MSM) in China. RECENT FINDINGS: China has made progress towards UNAIDS 90–90-90 targets among MSM. However, socio-structural barriers, including HIV-related stigma and homophobia, persist at each stage of the HIV care continuum, leading to substantial levels of attrition and high risk of forward HIV transmission. Moreover, access to key prevention tools, such as pre-exposure prophylaxis, is still limited. Multilevel interventions, many using digital intervention, have been shown effective in pragmatic randomized controlled trials in China. SUMMARY: Multilevel interventions incorporating digital health have led to significant improvement in engagement of Chinese MSM in the HIV care continuum. However, interventions that address socio-structural determinants, including HIV-related stigma and discrimination, towards Chinese MSM are needed.

Background HIV self-testing (HIVST) is a promising approach to expand HIV testing. HIVST is a process in which a person performs an HIV test and interprets the result. Negative HIVST results may encourage men who have sex with men (MSM) to use HIV prevention services. The objective of this study was to examine behaviors (e.g., facility-based HIV testing, condom use) after a negative HIVST test result among Chinese MSM. Methods We collected data from MSM in eight Chinese cities over a 12-month period. This is a secondary analysis of longitudinal cohort data collected as part of an intervention trial to increase HIV testing. Men completed a survey that described sociodemographic information, sexual behaviors, HIV self-testing, and facility-based HIV testing. Men who completed at least one follow-up survey were included in this analysis. Generalized linear mixed models were used to evaluate whether HIVST increased subsequent facility-based HIV testing and consistent condom use. Results We included 1219 men. Most men (78.7%) were under 30 years old and had never been married (87.0%). 755 (61.9%) men tested for HIV and 593 (49.3%) men self-tested during the study period. At baseline, among men who had never been tested for HIV, 44.9% (314/699) initiated HIVST during the study period. HIVST was associated with subsequent facility-based testing (aOR of 1.87, 95% CI: 1.47–2.37). HIVST was also associated with subsequent consistent condom use (aOR = 1.53, 95% CI: 1.13–2.06). Conclusion HIVST was associated with subsequent facility-based HIV testing and consistent condom use. HIVST may enhance uptake of related HIV prevention services at facilities, suggesting the need for more implementation research.

Introduction. While a growing literature documents the effectiveness of public health messaging on social media, our understanding of the factors that encourage individuals to engage with and share messages is limited. In the context of human immunodeficiency virus (HIV) among men who have sex with men (MSM) in China, rising incidence and low testing rates despite decades of interventions suggest the need for effective, targeted messaging to reach underserved populations. Social media platforms and sex-seeking apps present a promising avenue, as web-based strategies can take advantage of existing trust within dense social networks. Methods. We conducted an online discrete-choice experiment in January 2017 with MSM from across China. Participants were presented with 6 choice tasks, each composed of 2 messages about HIV testing, and were asked in which scenario they were more likely to share the content. Participants were given information about the source of the HIV testing message, the social media sharing platform, and the recipients with whom they would share the message. They were given the option of sharing 1 message or neither. Multinomial and mixed logit models were used to model preferences within 4 subgroups. Results. In total, 885 MSM joined the survey, completing 4387 choice tasks. The most important attribute for 3 of the 4 subgroups was social media sharing platform. Men were more willing to share messages on sex-seeking mobile applications and less willing to share materials on generic (non-MSM) social media platforms. We found that men with more active online presences were less willing to share HIV testing messages on generic social media platforms. Conclusions. Our findings suggest that sex-seeking platforms represent a targeted, efficient method of actively engaging MSM in public health interventions.

Background Condom use remains consistently low among Chinese men who have sex with men (MSM). This study aims to identify factors associated with condom use after online video intervention. Methods This is a secondary data analysis of data collected from an online non-inferiority trial comparing the effectiveness of two condom use promotion video interventions among Chinese MSM. Participants from the two groups were combined since the effectiveness of two video interventions were shown to be non-inferior. Univariable and multivariable logistic regression were used to identify factors associated with condomless sex after the intervention during the follow-up interval. Results Overall, 1173 participants were recruited at baseline and 791 (67.4%) completed the three-month follow-up survey. 57.3% (453/791) of the participants reported condomless sex after intervention in the three-month follow-up interval. MSM who have had sex under the influence of alcohol in the last 3 months (Odds Ratio(OR) = 1.90; 95% CI: 1.22, 2.97; Adjusted OR(AOR) = 1.79; 95% CI: 1.13, 2.83) and ever have had sex tourism (OR = 2.75; 95% CI: 1.34, 5.63; AOR = 2.40; 95% CI: 1.15, 5.07) at baseline were more likely to have condomless sex after intervention in the three-month follow-up period. MSM who had a higher level of community engagement in sexual health (OR = 0.54; 95% CI: 0.35, 0.82; AOR = 0.49; 95% CI: 0.32, 0.75 with substantial engagement) and who viewed additional condom promotion videos during the follow-up period by themselves (OR = 0.67; 95% CI = 0.50, 0.89; AOR = 0.67; 95% CI: 0.50, 0.91). were less likely to have condomless sex during the follow-up period. Conclusion The intervention appeared to be effective among MSM who reported viewing additional condom promotion videos by themselves and more community engagement after the intervention. In MSM who reported risky sexual behaviors at baseline, the intervention appeared less effective. Tailored intervention videos that target particular subgroups, active in-person community engagement, and optimized intervention frequency should be considered in future sexual health interventions. Electronic supplementary material The online version of this article (10.1186/s12889-019-7307-y) contains supplementary material, which is available to authorized users.

BACKGROUND: Although periodic chlamydia and gonorrhea testing is recommended for men who have sex with men (MSM), little is known about testing rates in China. This study examines chlamydia and gonorrhea testing rates and testing correlates among Chinese MSM. METHODS: An online survey of MSM was conducted in August 2017. Men aged 16 years or above who had ever had sex with a man were enrolled through a gay social networking mobile application. We asked men about their sexual behaviors, community engagement in sexual health, and previous testing for chlamydia, gonorrhea and HIV. Multivariable logistic regressions were used to examine the association of testing with community engagement and recent HIV testing. RESULTS: Of 1031 men, 819 (79.5%) were under 30 years of age, and 263 (25.5%) reported condomless sex in past three months. In total, 294 (28.5%) men tested for chlamydia, 315 (30.6%) men tested for gonorrhea, and 817(79.2%) men tested for HIV. One hundred and twenty-five (42.5%) men who received chlamydia testing and 134 (42.5%) men who received gonorrhea testing had substantial community engagement. Compared to men with no/minimal community engagement, men with substantial community engagement had greater odds of chlamydia testing (adjusted odds ratio [AOR] =2.8, 95%CI: 1.9–4.3) and gonorrhea testing (AOR=2.9, 95%CI: 2.0–4.4). Men with recent HIV testing were more likely to have received chlamydia testing (AOR=1.5, 95%CI: 1.1–2.0) and gonorrhea testing (AOR=1.6, 95%CI: 1.2–2.1). CONCLUSIONS: Chlamydia and gonorrhea testing levels are low among Chinese MSM. Integrating chlamydia and gonorrhea test promotion strategies into HIV prevention programs that engage MSM communities may help bridge the gap. SUMMARY: We found low chlamydia and gonorrhea lifetime testing rates among MSM in China and integrated STI/HIV testing programs that engage MSM may improve lifetime chlamydia and gonorrhea test uptake.

Men who have sex with men (MSM) disclose same-sex behaviors with others, creating disclosure networks. This study examined the characteristics of disclosure networks that are associated with HIV testing among MSM in China through an online nationwide survey. Name-generator questions were used to ask each participant (“ego”) to nominate up to five social network members (“alters”) with whom he had disclosed same-sex behaviors. Among the 806 men, the average disclosure network size was 4.05. MSM who reported larger disclosure networks were more likely to have been tested for HIV (aOR =1.21, 95%CI: 1.08–1.34). The most common disclosure network alters were friends (45.1%), followed by sex partners (18.7%) and healthcare professionals (2.5%). Men who disclosed to healthcare professionals were more likely to test for HIV compared to men who disclosed to family members (aOR =5.43, 95%CI: 2.11–14.04). Our findings can inform disclosure network-based interventions to promote MSM HIV testing.

Social media interventions may enhance HIV services among key populations, including men who have sex with men (MSM). This longitudinal analysis examined the effect of recalling, sharing, and participating in different components of a social media intervention on HIV testing among MSM. The social media intervention included six images/texts and information about an online local community contest to promote testing. Of the 1033 men, they recalled a mean of 2.7 out of six images and shared an average of one image online. 34.5% of men recalled information on the online local community contest and engaged in a mean of 1.3 contest. Recalling images/texts (aOR = 1.13, 95% CI: 1.02–1.25) and recalling a local contest (aOR = 1.59, 95% CI: 1.13–1.24) were associated with facility-based HIV testing. This study has implications for the development and evaluation of social media interventions to promote HIV testing.

Background Transgender and gender diverse individuals often face structural barriers to health care because of their gender minority status. The aim of this study was to examine the association between gender minority stress and access to specific health care services among transgender women and transfeminine people in China. Methods This multicenter cross-sectional study recruited participants between January 1st and June 30th 2020. Eligible participants were 18 years or older, assigned male at birth, not currently identifying as male, and living in China. Gender minority stress was measured using 45 items adapted from validated subscales. We examined access to health care services and interventions relevant to transgender and gender diverse people, including gender affirming interventions (hormones, surgeries), human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Multivariable regression was used to measure correlations between gender minority stress and access to health care service. Results Three hundred and twenty-four people completed a survey and data from 277 (85.5%) people were analyzed. The mean age was 29 years old (standard deviation [SD] = 8). Participants used hormones (118/277, 42.6%), gender affirming surgery (26/277, 9.4%), HIV testing (220/277, 79.4%), STI testing (132/277, 47.7%), PrEP (24/276, 8.7%), and PEP (29/267, 10.9%). Using gender affirming hormones was associated with higher levels of discrimination (adjusted odds ratio [aOR] 1.41, 95% confidence interval [CI] 1.17–1.70) and internalized transphobia (aOR 1.06, 95%CI 1.00–1.12). STI testing was associated with lower levels of internalized transphobia (aOR 0.91, 95%CI 0.84–0.98). Conclusions Our data suggest that gender minority stress is closely related to using health services. Stigma reduction interventions and gender-affirming medical support are needed to improve transgender health.

Introduction HIV self‐testing (HIVST) is a useful strategy to promote HIV testing among key populations. This study aimed to understand HIV testing behaviours among men who have sex with men (MSM) and specifically how HIVST was used during the coronavirus disease 2019 (COVID‐19) measures in China when access to facility‐based testing was limited. Methods An online cross‐sectional study was conducted to recruit men who have sex with men (MSM) in China from May to June of 2020, a period when COVID‐19 measures were easing. Data on socio‐demographic characteristics, sexual behaviours and HIV testing in the three months before and during COVID‐19 measures (23 January 2020) were collected. Chi‐square test and logistic regression were used for analyses. Results Overall, 685 MSM were recruited from 135 cities in 30 provinces of China, whose mean age was 28.8 (SD: 6.9) years old. The majority of participants self‐identified as gay (81.9%) and had disclosed their sexual orientation (66.7%). In the last three months, 69.6% ever had sex with men, nearly half of whom had multiple sexual partners (47.2%). Although the overall HIV testing rates before and during COVID‐19 measures were comparable, more MSM self‐tested for HIV during COVID‐19 measures (52.1%) compared to before COVID‐19 measures (41.6%, p = 0.038). Fewer MSM used facility‐based HIV testing during COVID‐19 measures (42.9%) compared to before COVID‐19 measures (54.1%, p = 0.038). Among 138 facility‐based testers before COVID‐19 measures, 59.4% stopped facility‐based testing during COVID‐19 measures. Among 136 self‐testers during COVID‐19 measures, 58.1% had no HIV self‐testing before COVID‐19 measures. Multivariable logistic regression showed that having sex with other men in the last three months (adjusted odds ratio, aOR = 2.04, 95% CI: 1.38 to 3.03), self‐identifying as gay (aOR = 2.03, 95% CI: 1.31 to 3.13), ever disclosing their sexual orientation (aOR = 1.72, 95% CI: 1.19 to 2.50) and tested for HIV in three months before COVID‐19 measures (aOR = 4.74, 95% CI: 3.35 to 6.70) were associated with HIV testing during COVID‐19 measures. Conclusions Facility‐based HIV testing decreased and HIVST increased among MSM during COVID‐19 measures in China. MSM successfully accessed HIVST as substitute for facility‐based testing, with no overall decrease in HIV testing rates.

Background There are limited studies on blocking and men who have sex with men (MSM) health outcomes. We need such data in China, to better understand the relationship between Chinese MSM gay app use and health outcomes, thus providing insight on risky sexual behaviors and HIV transmission among Chinese MSM - one of the world’s largest MSM communities. Blocking someone is when users select a function on an app to prevent another user from contacting them and being blocked is when someone is prevented from contacting another user. We studied the correlates of blocking on the world’s largest gay dating app among Chinese MSM (N = 208). Methods We conducted a cross-sectional survey as part of an HIV testing intervention in Guangzhou, China, May–December 2019. Using logistic regression models, we estimated the correlates of blocking (e.g. sociodemographic characteristics, sexual behavior, HIV testing history, social network data). Results MSM had a mean age of 27.9 years (SD = 7.1) and median of one sexual partner in the last 3 months. About 62% had blocked someone in their lifetime and 46% had been blocked in their lifetime. Each additional male partner was associated with an 87% (aOR = 1.87, 95%CI = 1.03, 3.40) increased chance of being blocked. Reporting a versatile sexual role was related with a 90% (aOR = 0.10, 95%CI = 0.02, 0.45) decreased likelihood of blocking behavior and an 86% (aOR = 0.14, 95%CI = 0.04, 0.46) reduced chance of being blocked. Conclusions Number of male partners may be associated with blocking behavior, with implications for the design of online sexual health interventions.

There is a rich literature on sexualized drug use (i.e., drug use before or during sex) for men who have sex with men but less data from female sex workers (FSW), particularly from low- and middle-income countries. We describe the sexual and reproductive health outcomes in FSW reporting sexualized drug use. In 2019, we conducted a cross-sectional study in eight cities from seven provinces in China. We recruited FSW through community organizations working with sex workers and included those aged 18 years or above, exchanged sex at least once for money or goods in the past three months, and had traded sex for longer than a year. Multivariable logistic regression models were used. In total, 650 women participated: average age was 38.8 years (SD 10.2), 57.1% reported a monthly income over 5000 RMB ($USD 707), and 12.8% completed high school or above. Among participants, 65 (10.0%, 95% confidence interval (CI) 7.8–12.6) reported a history of sexualized drug use. Compared to FSW who never reported a history of sexualized drug use, FSW who reported a history of sexualized drug use had greater odds of working for a manager compared to being self-employed (adjusted odds ratio (AOR) 4.04, 95% CI 2.12–7.69), work in a sauna (AOR 2.43, 95% CI 1.09–5.41), charging a higher price for vaginal sex (AOR 2.15, 95% CI 1.14–4.06), and ever diagnosed with STIs (AOR 4.51, 95% CI 2.61–7.80). One in ten FSW reported sexualized drug use. Although they had similar risk profiles in terms of consistency of condom use and reproductive health outcomes, these women were more likely to report past STIs than those who reported no sexualized drug use. Health workers who work with substance users should devote attention to the sexual practices of their clients to make sure that they have safer sex.

Background: Low syphilis testing uptake is a major public health issue among men who have sex with men (MSM) in many low- and middle- income countries. Syphilis self-testing (SST) may complement and extend facility-based testing. Objective: To evaluate the effectiveness and costs of providing SST on increasing syphilis testing uptake among MSM in China. Design: Three-arm randomized; controlled trial with concealed allocation. (Chinese Clinical Trial Registry: ChiCTR1900022409) Setting: Online. Participants: 451 MSM were recruited from 124 cities in 26 Chinese provinces. Intervention: Standard SST arm, lottery incentivized SST arm (1 in 10 chance to win $15 if they tested for syphilis), and standard-of-care arm. Both SST arms were offered free syphilis/HIV self-test kits at monthly intervals via mail. Measurements: The proportion of participants who tested for syphilis during the 6-month trial period and confirmed with photo-verification. Results: The proportion of men who had at least one syphilis test during the trial period was 63.4% (95% CI: 54.9 to 71.3) in the standard SST arm, 65.7% (95% CI: 57.1 to 73.6) in the lottery-incentivized SST arm, and 14.7% (95% CI: 9.2 to 21.8) in the standard-of-care arm. The estimated difference in proportions between the standard SST and standard-of-care arm was 48.7% (95% CI: 37.7 to 58.4). The majority (78.5%, 95% CI: 72.0 to 84.1) of syphilis self-testers reported never testing for syphilis. The cost per person tested was $26.55 for standard SST, $28.09 for the lottery incentivized SST, and $66.19 for the standard-of-care. Limitation: The impact of COVID restrictions may have accentuated demand for decentralized testing. Conclusion: Compared to standard-of-care, providing SST significantly increased the proportion of MSM testing for syphilis in China, particularly among men who had never tested for syphilis, and was cheaper (per person tested). Primary Funding Source: National Natural Science Foundation of China (81772240).

Background The need for strategies to encourage user-initiated reporting of results after HIV self-testing (HIVST) persists. Smartphone-based electronic readers (SERs) have been shown capable of reading diagnostics results accurately in point-of-care diagnostics and could bridge the current gaps between HIVST and linkage to care. Objective Our study aimed to assess the willingness of Chinese men who have sex with men (MSM) in the Jiangsu province to use an SER for HIVST through a web-based cross-sectional study. Methods From February to April 2020, we conducted a convenience web-based survey among Chinese MSM by using a pretested structured questionnaire. Survey items were adapted from previous HIVST feasibility studies and modified as required. Prior to answering reader-related questions, participants watched a video showcasing a prototype SER. Statistical analysis included descriptive analysis, chi-squared test, and multivariable logistic regression. P values less than .05 were deemed statistically significant. Results Of 692 participants, 369 (53.3%) were aged 26-40 years, 456 (65.9%) had ever self-tested for HIV, and 493 (71.2%) were willing to use an SER for HIVST. Approximately 98% (483/493) of the willing participants, 85.3% (459/538) of ever self-tested and never self-tested, and 40% (46/115) of unwilling participants reported that SERs would increase their HIVST frequency. Engaging in unprotected anal intercourse with regular partners compared to consistently using condoms (adjusted odds ratio [AOR] 3.04, 95% CI 1.19-7.74) increased the odds of willingness to use an SER for HIVST. Participants who had ever considered HIVST at home with a partner right before sex compared to those who had not (AOR 2.99, 95% CI 1.13-7.90) were also more willing to use an SER for HIVST. Playing receptive roles during anal intercourse compared to playing insertive roles (AOR 0.05, 95% CI 0.02-0.14) was associated with decreased odds of being willing to use an SER for HIVST. The majority of the participants (447/608, 73.5%) preferred to purchase readers from local Centers of Disease Control and Prevention offices and 51.2% (311/608) of the participants were willing to pay less than US $4.70 for a reader device. Conclusions The majority of the Chinese MSM, especially those with high sexual risk behaviors, were willing to use an SER for HIVST. Many MSM were also willing to self-test more frequently for HIV with an SER. Further research is needed to ascertain the diagnostic and real-time data-capturing capacity of prototype SERs during HIVST.

We assessed if same-sex sexual behavior disclosure of index men who have sex with men (MSM) was related to number of HIV self-testing (HIVST) kits requested by index participants, and number of test results successfully uploaded by alters in a network-based HIVST intervention. Index participants are men who accessed and distributed HIVST kits and alters are index's social contacts who received kits. We analyzed treatment arm data [N = 106, mean age = 27 (SD = 5.3)] of an intervention conducted among MSM in Guangzhou, China, May 2019-December 2019. Index MSM who disclosed sexual behavior to their family tended to request more kits [adjusted incidence rate ratio (aIRR) 1.42, 95% CI 1.06, 1.90, p .05]. Index men who disclosed sexual behavior to their family (aIRR 2.47, 95% CI 1.17, 5.24, p .05) tended to yield an increase in number of alter test results uploaded. Findings have implications for the development of network-based interventions for key populations.

Background Human immunodeficiency virus (HIV) self-testing may help improve test uptake among female sex workers. China has implemented many HIV self-testing programs among men who have sex with men, creating an opportunity for promotion among female sex workers. However, there is a limited literature on examining HIV self-testing among female sex workers. This study aimed to examine HIV self-testing experiences and its determinants among female sex workers in China. Methods A venue-based, cross-sectional study was conducted among Chinese female sex workers in 2019. Participants completed a survey including social-demographic characteristics, sexual behaviors, and HIV self-testing history, the distribution of which were analyzed using descriptive analysis. Multivariable logistic regression was conducted to identify associations with HIV self-testing. Results Among 1287 Chinese female sex workers, 1072 (83.3%, 95% confidence interval [CI] 81.2–85.3%) had ever tested for HIV, and 103 (8.0%, 95% CI 6.6–9.6%) had ever used HIV self-testing. More than half reported that the self-test was their first HIV test (59.2%, 61/103), around one-fifth reported HIV self-testing results influenced the price of sex (21.4%, 22/103). A minority of individuals reported ever experiencing pressure to undertake HIV self-testing (6.8%, 7/103). After adjusting for covariates, HIV self-testing was positively associated with receiving anal sex in the past month (adjusted odds ratio [aOR] = 2.2, 95% CI 1.4–3.5), using drugs before or during sex (aOR = 2.8, 95% CI 1.8–4.5), injecting drugs in the past 6 months (aOR = 2.6, 95% CI 1.2–6.0), being diagnosed with other sexually transmitted infections (aOR = 1.6, 95% CI 1.0–2.5), tested for other sexually transmitted infections in the past six months (aOR = 3.4, 95% CI 2.1–5.5), ever tested in the hospital (aOR = 3.4, 95% CI 2.0–5.6), and ever tested in the community (aOR = 1.5, 95% CI 1.2–1.9). Conclusions Our findings suggest that HIV self-testing could expand overall HIV testing uptake, increase HIV testing frequency, reach sub-groups of high-risk female sex workers and has limited potential harms among female sex workers. HIV self-testing should be incorporated among Chinese female sex workers as a complement to facility-based HIV testing services.

Background Adolescent sexual debut and non-consensual sex have been linked to higher sexual risk and STI infection in adulthood among men who have sex with men (MSM) in high-income countries. This study aimed to examine adolescent and non-consensual anal sexual debut among Chinese MSM and to evaluate factors associated with adolescent sexual debut and non-consensual anal sex. Methods A cross-sectional study was conducted recently among Chinese men assigned male sex at birth, ≥18 years old, and who had ever engaged in anal sex with a man. Participants answered questions regarding socio-demographics, condomless sex, age at anal sexual debut with a man, and whether the first anal sex was consensual. Factors associated with an adolescent sexual debut ( Results Overall, 2031 eligible men completed the survey. The mean age of sexual debut was 20.7 (SD = 4.3) years old. 17.6% (358/2031) of men reported adolescent sexual debut, and 5.0% (101/2031) reported a non-consensual sexual debut. The adolescent sexual debut was associated with having more male sexual partners (adjusted OR 1.10, 95% CI 1.06–1.15) and condomless anal sex in the last three months (AOR = 1.71, 95% CI 1.34–2.18). MSM whose sexual debut was non-consensual were more likely to have condomless anal sex (AOR = 1.76, 95% CI 1.17–2.66), and to have reported an adolescent sexual debut (AOR = 2.72, 95% CI 1.75–4.21). Conclusions Many Chinese MSM reported adolescent sexual debut and non-consensual sex, both of which are associated with sexual risk behaviors and drive STI transmission. These findings highlight the need for designing tailored interventions for MSM who experienced adolescent sexual debut and non-consensual sex at debut.

IntroductionThe COVID-19 pandemic is impacting HIV care globally, with gaps in HIV treatment expected to increase HIV transmission and HIV-related mortality. We estimated how COVID-19-related disruptions could impact HIV transmission and mortality among men who have sex with men (MSM) in four cities in China.MethodsRegional data from China indicated that the number of MSM undergoing facility-based HIV testing reduced by 59% during the COVID-19 pandemic, alongside reductions in ART initiation (34%), numbers of sexual partners (62%) and consistency of condom use (25%). A deterministic mathematical model of HIV transmission and treatment among MSM in China was used to estimate the impact of these disruptions on the number of new HIV infections and HIV-related deaths. Disruption scenarios were assessed for their individual and combined impact over 1 and 5 years for a 3-, 4- or 6-month disruption period.ResultsOur China model predicted that new HIV infections and HIV-related deaths would be increased most by disruptions to viral suppression, with 25% reductions for a 3-month period increasing HIV infections by 5-14% over 1 year and deaths by 7-12%. Observed reductions in condom use increased HIV infections by 5-14% but had minimal impact (ConclusionsThe overall impact of COVID-19 on new HIV infections and HIV-related deaths is dependent on the nature, scale and length of the various disruptions. Resources should be directed to ensuring levels of viral suppression and condom use are maintained to mitigate any adverse effects of COVID-19 related disruption on HIV transmission and control among MSM in China.

BACKGROUND: WHO recommends that men who have sex with men (MSM) receive gonorrhoea and chlamydia testing, but many evidence-based preventive services are unaffordable. The pay-it-forward strategy offers an individual a gift (eg, a test for sexually transmitted diseases) and then asks whether they would like to give a gift (eg, a future test) to another person. This study examined the effectiveness of a pay-it-forward programme to increase gonorrhoea and chlamydia testing among MSM in China.METHODS: We did a randomised controlled superiority trial at three HIV testing sites run by MSM community-based organisations in Guangzhou and Beijing, China. We included MSM aged 16 years or older who were seeking HIV testing and met indications for gonorrhoea and chlamydia testing. Restricted randomisation was done using computer-generated permuted blocks. 30 groups were randomised into three arms (1:1:1): a pay-it-forward arm in which men were offered free gonorrhoea and chlamydia testing and then asked whether they would like to donate for testing of prospective participants, a pay-what-you-want arm in which men were offered free testing and given the option to pay any desired amount for the test, and a standard-of-care arm in which testing was offered at ¥150 (US$22). There was no masking to arm assignment. The primary outcome was gonorrhoea and chlamydia test uptake ascertained by administrative records. We used generalised estimating equations to estimate intervention effects with one-sided 95% CIs and a prespecified superiority margin of 20%. The trial is registered with ClinicalTrials.gov, NCT03741725.FINDINGS: Between Dec 8, 2018, and Jan 19, 2019, 301 men were recruited and included in the analysis. 101 were randomly assigned to the pay-it-forward group, 100 to the pay-what-you-want group, and 100 to the standard-of-care group. Test uptake for gonorrhoea and chlamydia was 56% (57 of 101 participants) in the pay-it-forward arm, 46% (46 of 100 participants) in the pay-what-you-want arm, and 18% (18 of 100 participants) in the standard-of-care arm. The estimated difference in test uptake between the pay-it-forward and standard-of-care group was 38·4% (95% CI lower bound 28·4%). Among men in the pay-it-forward arm, 54 of 57 (95%) chose to donate to support testing for others.INTERPRETATION: The pay-it-forward strategy can increase gonorrhoea and chlamydia testing uptake among Chinese MSM and could be a useful tool for scaling up preventive services that carry a mandatory fee.FUNDING: US National Institute of Health; Special Programme for Research and Training in Tropical Diseases, sponsored by UNICEF, UNDP, World Bank, and WHO; the National Key Research and Development Program of China; Doris Duke Charitable Foundation; and Social Entrepreneurship to Spur Health.

Background Whole-genome sequencing (WGS) of Treponema pallidum subspecies pallidum (TPA) has been constrained by the lack of in vitro cultivation methods for isolating spirochetes from patient samples. Methods We built upon recently developed enrichment methods to sequence TPA directly from primary syphilis chancre swabs collected in Guangzhou, China. Results By combining parallel, pooled whole-genome amplification with hybrid selection, we generated high-quality genomes from 4 of 8 chancre-swab samples and 2 of 2 rabbit-passaged isolates, all subjected to challenging storage conditions. Conclusions This approach enabled the first WGS of Chinese samples without rabbit passage and provided insights into TPA genetic diversity in China.

Objective: Human immunodeficiency virus (HIV) test uptake among college and university students in China remains suboptimal. This study aimed to identify and weigh the relative importance of HIV testing preferences among university students in China. Participants and methods: Qualitative interviews and discrete choice experiments (DCE) were used to identify and assess HIV testing preferences in hypothetical HIV testing scenarios. Study participants were sexually experienced university students in Suzhou city, China. Results: 198 participants completed 1980 DCE choice tasks. Risk of nosocomial HIV infection, accuracy, and distance were identified as the most important factors when deciding whether to test for HIV. Risk of nosocomial HIV infection was the most influential factor, accounting for 35.5% of the variation in participants' DCE stated choices. Conclusions: Fear of HIV nosocomial infection may be influencing HIV test preferences and possibly test uptake among university students in China. Interventions should consider addressing students' fear of HIV nosocomial infection as a potential barrier to HIV testing.

Background Hepatitis C virus (HCV) is a growing public health problem with a large disease burden worldwide. In China many people living with HCV are unaware of their hepatitis status and not connected to care and treatment. Crowdsourcing is a technique that invites the public to create health promotion materials and has been found to increase HIV testing uptake, including in China. This trial aims to evaluate crowdsourcing as a strategy to improve HCV awareness, testing and linkage-to-care in China. Methods A randomized controlled, two-armed trial (RCT) is being conducted in Shenzhen with 1006 participants recruited from primary care sectors of The University of Hong Kong-Shenzhen Hospital. Eligible participants are ≥30 years old; a resident in Shenzhen for at least one month after recruitment; no screening for HCV within the past 12 months and not known to have chronic HCV; and, having a WeChat social media account. Allocation is 1:1. Both groups will be administered a baseline and a follow-up survey (4-week post-enrollment). The intervention group will receive crowdsourcing materials to promote HCV testing once a week for two weeks and feedback will be collected thereafter, while the control group will receive no promotional materials. Feedback collected will be judged by a panel and selected to be implemented to improve the intervention continuously. Those identified positive for HCV antibodies will be referred to gastroenterologists for confirmation and treatment. The primary outcome will be confirmed HCV testing uptake, and secondary outcomes include HCV confirmatory testing and initiation of HCV treatment with follow-ups with specialist providers. Data will be collected on Survey Star@ via mobile devices. Discussion This will be the first study to evaluate the impact of crowdsourcing to improve viral hepatitis testing and linkage-to-care in the health facilities. This RCT will contribute to the existing literature on interventions to improve viral hepatitis testing in primary care setting, and inform future strategies to improve HCV care training for primary care providers in China. Trial registration Chinese Clinical Trial Registry. ChiCTR1900025771. Registered September 7th, 2019, http://www.chictr.org.cn/showprojen.aspx?proj=42788

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).

Background:Public health measures including social isolationare essential forCOVID-19 control,but also increase the risk of depression. This study examined the influencing and moderating factors on socially isolated people’s depressive symptoms. Methods: Data were collected from people in mandatory home or centralizedsocial isolation in Shenzhen, China from February 28 to March 6 in 2020. We assessed their perceived COVID-19risk, perceived tone of media coverage, perceived quality of people-oriented public health services, and depressive symptoms.Three stepwise multiple regressions were performed to examine the moderating effects controlling age, gender, education, monthly income, socially isolated venue,time spent on COVID-related news, and online social support.Results:We examined data from 340 people. 57.6% men, averaged age at 35.5 years old (SD = 8.37), 55.6% held bachelor’s degree or above.Overall, people in social isolation reported a moderate level ofdepressive symptoms (M =1.24, SD = 0.4). The perceived susceptibility of being infected was relatively low (M = 1.36, SD = 0.54), and the perceived tone of media coverage was mainly positive (M = 1.97, SD = 1.05). In terms of perceived quality of public health services, 3.2% (n = 11) participants reported low-level, 49.1% (n = 167) medium-level, and 47.6 (n =162) high-level quality ofpeople-oriented services. Perceived riskwas significantly associated with depression (β= .12, p< 0.01), and perceived tone of media coverage was negatively associated with depression (β= -.05, p< 0.01).The quality of people-centered public health service moderated the association between perceived riskand depressive symptoms(β= -.15, p< 0.05), and the relationship between perceived tone of media coverage and depressive symptoms(β= .01, p< 0.01).Conclusions:This studyfound thatpeople-oriented public health servicesreduced the effect of risk perception and media tone on depressive symptoms among COVID-19 socially isolated people, suggesting a critical role for frontline public health workers in protecting public mental health.

Background Human immunodeficiency virus (HIV) testing is a crucial strategy for HIV prevention. HIV testing rates remain low among men who have sex with men (MSM) in China. Digital network-based secondary distribution is considered as an effective model to enhance HIV self-testing (HIVST) among key populations. Digital platforms provide opportunities for testers to apply for HIVST kits by themselves, and secondary distribution allows them to apply for multiple kits to deliver to their sexual partners or members within their social network. We describe a three-arm randomized controlled trial to examine the effect of monetary incentives and peer referral in promoting digital network-based secondary distribution of HIVST among MSM in China. Methods Three hundred MSM in China will be enrolled through a digital platform for data collection. The eligibility criteria include being biological male, 18 years of age or over, ever having had sex with another man, being able to apply for kits via the online platform, and being willing to provide personal telephone number for follow-up. Eligible participants will be randomly allocated into one of the three arms: standard secondary distribution arm, secondary distribution with monetary incentives arm, and secondary distribution with monetary incentives plus peer referral arm. Participants (defined as “index”) will distribute actual HIV self-test kits to members within their social network (defined as “alter”) or share referral links to encourage alters to apply HIV self-test kits by themselves. All index participants will be requested to complete a baseline survey and a 3-month follow-up survey. Both indexes and alters will complete a survey upon returning the results by taking a photo of the used kits with the unique identification number. Discussion HIV testing rates remain suboptimal among MSM in China. Innovative interventions are needed to further expand the uptake of HIV testing among key populations. The findings of the trial can provide scientific evidence and experience on promoting secondary distribution of HIVST to reach key populations who have not yet been covered by existing testing services. Trial registration The study was registered in the Chinese Clinical Trial Registry (ChiCTR1900025433) on 26, August 2019, http://www.chictr.org.cn/showproj.aspx?proj=42001. Prospectively registered.

In China, men who have sex with men (MSM) shoulder a disproportionate HIV burden. Early initiation and adherence to HIV antiretroviral therapy (ART) will be critical to reversing the HIV epidemic in China, but ART usage remains suboptimal among MSM diagnosed with HIV. One understudied but potentially important factor underpinning suboptimal ART usage is personal belief in supernatural explanatory models of health and illness (supernatural explanatory models). This study examines associations between beliefs in supernatural explanatory models and ART usage among MSM in China.In 2017, an online survey was distributed nationwide throughout China by gay community-based organizations. Eligible study participants were self-identified MSM between 16 and 30 years old who had tested positive for HIV and who had seen a doctor in the last 2 years. Beliefs in supernatural explanatory models were measured using a three-item scale developed specifically for the Chinese population (range, 3-15).Of 73 participants, the majority were currently using ART (83.6%) and 42.5% expressed some endorsement of belief in supernatural explanatory models. However, among 21 participants with the strongest belief in supernatural explanatory models, prevalence of current ART usage was 61.9%. Stronger belief in supernatural explanatory models was significantly associated with lower likelihood of current ART usage (adjusted odds ratio = 0.52; 95% confidence interval = 0.13-0.75).Belief in supernatural explanatory models may be a powerful predictor of ART usage among MSM living with HIV in China. Further studies are needed to corroborate these findings and elucidate mechanisms of association.

Background Men who have sex with men (MSM) are an important HIV key population in China. However, HIV testing rates among MSM remain suboptimal. Digital crowdsourced media interventions may be a useful tool to reach this marginalized population. We define digital crowdsourced media as using social media, mobile phone applications, Internet, or other digital approaches to disseminate messages developed from crowdsourcing contests. The proposed cluster randomized controlled trial (RCT) study aims to assess the effectiveness of a digital crowdsourced intervention to increase HIV testing uptake and decrease risky sexual behaviors among Chinese MSM. Methods A two-arm, cluster-randomized controlled trial will be implemented in eleven cities (ten clusters) in Shandong Province, China. Targeted study participants will be 250 MSM per arm and 50 participants per cluster. MSM who are 18 years old or above, live in the study city, have not been tested for HIV in the past 3 months, are not living with HIV or have never been tested for HIV, and are willing to provide informed consent will be enrolled. Participants will be recruited through banner advertisements on Blued, the largest gay dating app in China, and in-person at community-based organizations (CBOs). The intervention includes a series of crowdsourced intervention materials (24 images and four short videos about HIV testing and safe sexual behaviors) and HIV self-test services provided by the study team. The intervention was developed through a series of participatory crowdsourcing contests before this study. The self-test kits will be sent to the participants in the intervention group at the 2nd and 3rd follow-ups. Participants will be followed up quarterly during the 12-month period. The primary outcome will be self-reported HIV testing uptake at 12 months. Secondary outcomes will include changes in condomless sex, self-test efficacy, social network engagement, HIV testing social norms, and testing stigma. Discussion Innovative approaches to HIV testing among marginalized population are urgently needed. Through this cluster randomized controlled trial, we will evaluate the effectiveness of a digital crowdsourced intervention, improving HIV testing uptake among MSM and providing a resource in related public health fields. Trial registration ChiCTR1900024350. Registered on 6 July 2019.

Background In China, while the overall HIV prevalence has been decreasing within key populations, the epidemic among men who have sex with men (MSM) is still on the rise. This study aims to assess the HIV incidence rate and identify driving forces of HIV seroconversion among MSM in a closed cohort. Methods This study is a secondary analysis of a large trial of HIV testing promotion among Chinese MSM in 2016–2017. Sexual behaviors, HIV testing activities, and HIV serostatus were measured at baseline and follow-up every 3 months. HIV seroconversion in this study was defined as a self-reported HIV-positive test result. Participants who reported testing for HIV at least twice during different follow-up periods were included. Subgroup analysis and Cox regression were used to examine the correlates with HIV seroconversion. Results Overall, 347 participants were included in this study, with a mean age of 25.3 ± 6.1, and 71.2% were migrants. The sociodemographic characteristics of the included participants were similar to the rest of the participants in the trial (n = 1034); 7.2% (25/347) of participants seroconverted during the study period, resulting in an incidence rate of 15.56/100 person-years. In subgroup analysis, the HIV incidence rate was higher among migrants than nonmigrants (incidence rate ratio, 1.26; 95% confidence interval [CI], 0.47–3.87). In the time-dependent Cox regression model, bisexual MSM had a higher risk of contracting HIV than gay men (adjusted hazard ratio, 2.19; 95% CI, 1.02–4.72). Conclusions Our findings suggest a high HIV incidence rate among Chinese MSM. Further expansion of pre-exposure prophylaxis and other effective HIV prevention interventions are urgently needed.

BackgroundMen who have sex with men (MSM) globally have a high burden of curable sexually transmitted infections (STIs). MSM do not frequently receive rectal STI testing because of several barriers, such as not being out (disclosure of sexual behavior). We evaluate whether Chinese MSM select an STI test (rectal vs urethral) appropriate for their sexual behavior (insertive and/or receptive), and the interactions with being out.MethodsThis was a secondary analysis of data from a cross sectional MSM survey conducted at a multisite randomized controlled trial (RCT) (December 2018 to January 2019) around uptake of gonorrhea and chlamydia testing among Chinese MSM (N = 431). We collected socio demographics, relevant medical and sexual history, and disclosure of sexual behavior (outness). We estimated the decision to test and test choice, and the extent to which disclosure plays a role in decision making.ResultsAmong 431 MSM, mean age was 28 years (SD = 7.10) and 65% were out to someone. MSM who indicated versatile sexual behavior and were out to someone had a 26.8% (95%CI = 6.1, 47.5) increased likelihood for selecting the rectal test vs the ure thral test, compared to those versatile and not out. Versatile MSM out to their health provider outside of the study context had a 29.4% (95%CI = 6.3, 52.6) greater likelihood for selecting the rectal STI test vs the urethral test, compared to versatile MSM not out to their health provider.ConclusionsSexual behavior and outness may affect gonorrhea and chlamydia testing provision. Apart from clinicians, community based efforts may reduce stigma based barriers to testing.

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.

Data from a randomized controlled trial in 2015 were used to estimate the growth trajectories of peer norms, self-efficacy, and condom use behavior, and to identify associated sociodemographic and behavioral factors among a sample of 804 Chinese men who have sex with men (MSM). Latent class analysis and growth mixture modeling were conducted using Mplus. Two growth trajectories were estimated for each outcome variable with good model fit. The growth trajectories of peer norms were related to age (β = − 0.066, p

Background Pre-exposure prophylaxis (PrEP) is not widely available in China. Previous studies reported low awareness and inconclusive findings on the acceptability of PrEP among Chinese men who have sex with men (MSM). Methods We conducted a secondary analysis of an online national survey comparing preferences for oral and long-acting injectable PrEP among MSM and identifying correlates of preferences. The study did not collect detailed information about partner types that may influence negotiated safety and PrEP uptake. Results Nine-hundred and seventy-nine men from the larger sample of 1045 men responded to the PrEP survey questions. Most men (81.9%) had never heard of PrEP, but reported interest in using PrEP. More participants chose injectable PrEP (36.3%) as their preferred formulation than oral PrEP (24.6%). Men who had at least two HIV tests (adjusted OR = 1.36, 95%CI 1.04, 1.78) more commonly preferred injectable PrEP. Conclusion Our findings may help inform PrEP messaging in areas where PrEP has yet to be scaled up.

Background As HIV cure research advances, there is an increasing need for community engagement in health research, especially in low- and middle-income countries with ongoing clinical trials. Crowdsourcing contests provide an innovative bottom-up way to solicit community feedback on clinical trials in order to enhance community engagement. The objective of this study was to identify facilitators and barriers to participating in crowdsourcing contests about HIV cure research in a city with ongoing HIV cure clinical trials. Methods We conducted in-depth interviews to evaluate facilitators and barriers to participating in crowdsourcing contests in Guangzhou, China. Contests included the following activities: organizing a call for entries, promoting the call, evaluating entries, celebrating exceptional entries, and sharing entries. We interviewed 31 individuals, including nine HIV cure clinical trial participants, 17 contest participants, and five contest organizers. Our sample included men who have sex with men (20), people living with HIV (14), and people who inject drugs (5). We audio-recorded, transcribed, and thematically analyzed the data using inductive and deductive coding techniques. Results Facilitators of crowdsourcing contest participation included responsiveness to lived experiences, strong community interest in HIV research, and community trust in medical professionals and related groups. Contests had more participants if they responded to the lived experiences, challenges, and opportunities of living with HIV in China. Strong community interest in HIV research helped to drive the formulation and execution of HIV cure contests, building support and momentum for these activities. Finally, participant trust in medical professionals and related groups (community-based organizations and contest organizers) further strengthened the ties between community members and researchers. Barriers to participating in crowdsourcing contests included persistent HIV stigma and myths about HIV. Stigma associated with discussing HIV made promotion difficult in certain contexts (e.g., city squares and schools). Myths and misperceptions about HIV science confused participants. Conclusions Our data identified facilitators and barriers of participation in HIV cure crowdsourcing contests in China. Our findings could complement existing HIV community engagement strategies and help to design HIV contests for community engagement in other settings, particularly in low- and middle-income countries.

BackgroundAnticipated HIV stigma, i.e., the expectation of adverse experiences from one’s seroconversion, is associated with both negative psychological and behavioral outcomes. We know little about anticipated HIV stigma’s relationship with emerging technologies, such as HIV self-testing (HIVST) and online sex-seeking platforms, that have become popular among populations that are disproportionately affected by HIV/AIDS. This study examined correlates of anticipated HIV stigma among Chinese men who have sex with men (MSM).MethodsIn July 2016, MSM, who were ≥ 16 years old and self-reported as HIV negative or unknown, were recruited from a gay mobile phone application in China. Information regarding socio-demographics, sexual behaviors, sexual health service utilization, and anticipated HIV stigma were collected. Anticipated HIV stigma (i.e., negative attitude toward future stigmatization of HIV seroconversion by others) was measured as the mean score from a 7-item Likert-scale ranging from 1 (low) to 4 (high). Generalized linear models were conducted to examine the factors associated with the anticipated HIV stigma scores.ResultsOverall, 2006 men completed the survey. Most men completed high school (1308/2006, 65.2%) and had an annual personal income of ≤9200 USD (1431/2006, 71.3%). The mean anticipated HIV stigma score for the participants was 2.98 ± 0.64. Using social media to seek sexual partners was associated with higher anticipated HIV stigma (Adjusted β = 0.11, 95% confidence interval (CI): 0.05 to 0.17,p = 0.001). HIV self-testing (Adjusted β = − 0.07, 95%CI: − 0.13 to − 0.01,p = 0.02) and having disclosed one’s sexual orientation to a healthcare provider (Adjusted β = − 0.16, 95%CI: − 0.22 to − 0.96,p ConclusionOur data suggested that anticipated HIV stigma is still common among Chinese MSM not living with HIV. Tailored anti-HIV stigma campaigns on social media are especially needed, and the promotion of HIVST may be a promising approach.

Background Low syphilis testing uptake is a major public health issue among men who have sex with men (MSM) in many low- and middle-income countries. Syphilis self-testing (SST) may complement and extend facility-based testing. We aimed to evaluate the effectiveness and costs of providing SST on increasing syphilis testing uptake among MSM in China. Methods and findings An open-label, parallel 3-arm randomized controlled trial (RCT) was conducted between January 7, 2020 and July 17, 2020. Men who were at least 18 years of age, had condomless anal sex with men in the past year, reported not testing for syphilis in the last 6 months, and had a stable residence with mailing addresses were recruited from 124 cities in 26 Chinese provinces. Using block randomization with blocks of size 12, enrolled participants were randomly assigned (1:1:1) into 3 arms: standard of care arm, standard SST arm, and lottery incentivized SST arm (1 in 10 chance to win US$15 if they had a syphilis test). The primary outcome was the proportion of participants who tested for syphilis during the trial period and confirmed with photo verification and between arm comparisons were estimated with risk differences (RDs). Analyses were performed on a modified intention-to-treat basis: Participants were included in the complete case analysis if they had initiated at least 1 follow-up survey. The Syphilis/HIV Duo rapid test kit was used. A total of 451 men were enrolled. In total, 136 (90·7%, 136/150) in the standard of care arm, 142 (94·0%, 142/151) in the standard of SST arm, and 137 (91·3%, 137/150) in the lottery incentivized SST arm were included in the final analysis. The proportion of men who had at least 1 syphilis test during the trial period was 63.4% (95% confidence interval [CI]: 55.5% to 71.3%, p = 0.001) in the standard SST arm, 65.7% (95% CI: 57.7% to 73.6%, p = 0.0002) in the lottery incentivized SST arm, and 14.7% (95% CI: 8.8% to 20.7%, p < 0.001) in the standard of care arm. The estimated RD between the standard SST and standard of care arm was 48.7% (95% CI: 37.8% to 58.4%, p < 0.001). The majority (78.5%, 95% CI: 72.7% to 84.4%, p < 0.001) of syphilis self-testers reported never testing for syphilis. The cost per person tested was US$26.55 for standard SST, US$28.09 for the lottery incentivized SST, and US$66.19 for the standard of care. No study-related adverse events were reported during the study duration. Limitation was that the impact of the Coronavirus Disease 2019 (COVID-19) restrictions may have accentuated demand for decentralized testing. Conclusions Compared to standard of care, providing SST significantly increased the proportion of MSM testing for syphilis in China and was cheaper (per person tested). Trial registration Chinese Clinical Trial Registry: ChiCTR1900022409.