Abstinence Versus Comprehensive Methods

The purpose of this paper is to investigate the gap in HIV diagnosis in MSM population in China and to identify the interventions targeted to this population to control their increasing HIV rates.

Methods

A systematic literature review was performed to collect the necessary data for this paper. Information for this paper was collected from UNAIDS & WHO websites, PubMed research papers, articles were searched using keywords-MSM HIV in China, Interventions for MSM HIV China. Information was also used from University of Pittsburgh-IDM Monday seminar presentation by Dr.Chongyi Wei.

According to statistics from Chinese ministry of health and UNAIDS, MSM comprised only 0.3% of all cases between 1985 and 2005. However, this number spiked to 2.55 in 2006 and reached 25.8% in 2014, shown in figure 1[5]. A study in 2015 found high-risk behaviors among the MSM population in China to be high. Around 45.7% of respondents reported having unprotected sex with male partners and 10.9% with female partners [5]. About 22.9% of infected MSM have a history of blood donation increasing likelihood of HIV-1 transmission through blood products. Such high-risk behavior not only makes MSM populations significantly more vulnerable to infection, but also creates an open door for disease transmission to the general population.

Rapid changes in the demographic profile of Chinese MSM and the biological complexity of HIV-1 pose tremendous challenges to prevention strategies, antiretroviral therapies and vaccine development [5]. Homosexual sex was decriminalized in China in 1997 and removed from the official list of mental disorders in 2008 [6]. However, economic and cultural factors mean men who have sex with men often face stigma and discrimination and hide their sexual identity. Due to this stigmatization, few men feel comfortable approaching the existing health resources to seek treatment or get HIV tested. As a result, men who have sex with men remain largely hidden from greater Chinese Society and HIV is transmitted widely to both homosexual and heterosexual partners. This hostile environment is preventing a greater understanding of the epidemic in China among men who have sex with men [7].

Findings/Results

IMPACT Project

Community engagement is important for controlling the HIV epidemic among MSM. In China, not-for-profit community-based organizations (CBOs) are engaged with the social, educational and environmental or public safety needs of the community. However, the majority of public-sector funded HIV programmes in China have failed to engage CBOs and have had limited success to preventing HIV. Most MSM-friendly CBOs do not offer services like HIV testing, post-test counselling, result notification and follow-up, which limit their ability to provide comprehensive care services.

To address these problems, an HIV care and prevention programme sponsored by the Bill & Melinda Gates Foundation was launched in China in 2008 [8]. The programme promoted collaboration between public sector agencies and CBOs in the delivery of prevention and support services. Preventive services were directed to high-risk groups and included reducing risk behaviors and increasing HIV testing. Some of the findings of the IMPACT project in Guangzhou are discussed here. This project had different components- online prevention tool-a HIV-risk assessment system that calculates an individualized HIV-risk score by evaluating an individual’s risk profile. The system provided tailored guidance to promote HIV testing and behavioral change. HIV education was also provided online through social media. Online to offline service-from the online tool people could choose to have a test in facility and test results were made available by online notification system. Service Center- a one-stop service centre was set up in Guangzhou, which was coordinated by a local CBO and Guangzhou CDC. In this centre, public sector staff provided on-site blood sampling and testing and carried out epidemiological investigations, such as HIV sentinel surveillance among MSM and medical follow-up for people who tested positive. People who were tested were also asked questions about their sexual behavior.

As shown in figure 2 below, the annual number of tests increased from 1064 in 2008 to 7754 in 2013. By 2013, tests conducted under the project accounted for more than 80% of total HIV tests and new HIV diagnoses among MSM in Guangzhou. Currently, an average of 25 people make appointments and get tested through the project each day. This project has addressed the needs of this community and has been improving access to HIV services. The project also ensured continuum-of-care services, including linkage to care, retention in care, ART initiation and ART adherence [8]. However, one of the key limitations was that this project did not collect comprehensive pre-intervention data to demonstrate the effect of the intervention. Also, the project could recruit only a subset of MSM residing in the study area and found it difficult to reach out to some subgroups (e.g. older MSM and rural MSM).

However, one of the key limitations was that this project did not collect comprehensive pre-intervention data to demonstrate the effect of the intervention. Also, the project could recruit only a subset of MSM residing in the study area and found it difficult to reach out to some subgroups (e.g. older MSM and rural MSM). These hard-to-reach subgroups reportedly have lower levels of education, poorer HIV knowledge and fewer opportunities to access HIV-related services, making them highly vulnerable to HIV [9]. The project maybe usefully adapted to other places in China and closer partnership with clinical facilities will further enhance the project.

Identifying Factors Determining MSM HIV Testing Preferences

Early diagnosis of HIV serostatus is vital for achieving positive treatment outcomes and preventing secondary transmission (Charlebois, Das, Porco, & Havlir, 2011; Granich, Gilks, Dye, De Cock, & Williams, 2009). Despite an extensive number of interventions that seek to increase knowledge of HIV serostatus among MSM, global test uptake remains low (Arreola, Hebert, Makofane, Beck, & Ayala, 2012). An understanding of the factors and modalities that facilitate HIV testing is a first step toward eliminating barriers to test uptake. Therefore a study was conducted by L.Han et al., in 2016 to get more information regarding MSM testing preferences in order to design effective interventions that can overcome barriers to testing in China.

An online survey was conducted with two of the largest MSM CBOs through their respective web portals: gztz.org in Guangzhou and ManBF.net in Chongqing. The survey recruited people who were biologically men and had anal sex with men at least once in their lifetime and were at least 16 years of age. Measures of behavioral characteristics like history of HIV testing, number of male anal sex partners in the past 3 months, history of sex with women, and condom less sex in the past 3 months were taken. Participants rated their acceptance toward eight different HIV testing venues: public hospital, CDC, private medical clinic, gay men’s CBO, HIV/AIDS CBO, gay bar, sauna, home. As shown in Table 1 below, the study identified that a guarantee of confidentiality (89.7%) and a guarantee of test quality (87.5%) were very important factors considered MSM when testing for HIV. The ability to test for HIV at home was labelled very important or quite important by 75.4% of men. The study also demonstrated that MSM accept HIV testing at gay men’s CBOs, CDCs, and public hospitals. Their data suggested that HIV self-testing may be feasible among MSM in China. Many individuals choose not to test at facilities due to inconvenience (Song et al., 2011), lack of privacy and confidentiality (Krause et al., 2013), and stigma associated with HIV testing (Myers et al., 2013; Tucker et al., 2013).

HIVST

HIV self-testing, in which an individual collects his or her own oral fluid or blood specimen and conducts a rapid point-of-care test at a convenient location of his or her own choice, may help Chinese MSM overcome some of these barriers (e.g., self-testing does not entail disclosure of sexual minority status) [10]. Significant proportion of the MSM population in China have not been tested for HIV or do not seek routine testing which results in high levels of unrecognized infections. From studies in many other countries it has been identified that the acceptance of and the preference for HIV self-testing was very high [11]. In a study by H.Yan et al, in 2015, a cross-sectional survey was conducted among MSM population in Jiangsu where participants were asked questions regarding HIV self-testing uptake. Of 522 participants, 26.2% had ever self-tested. Finger stick was the most common self-testing modality (86.1 %). A majority of participants reported that it was “very easy” (43.1 %) or “somewhat easy” (34.3 %) to perform self-testing. The study reported that 85% of the participants would continue to use HIVST routinely and 82% expressed willingness to use HIVST with a partner [12]. From this study we can conclude that spreading the awareness of HIVST intervention package through different platforms like social media, dating apps, campaigns in China can highly increase the uptake and frequency of testing in MSM population.

PrEP

A big reason for the increasing burden of HIV in MSM population of China could be the fact that the country has not yet integrated PrEP into its portfolio of HIV preventions interventions and PrEP is not available in China. PrEP is a highly effective biomedical intervention that involves people who are HIV-negative taking daily oral ARTs to prevent HIV acquisition. In 2018, a study was done by Lei Zhang et al., to evaluate the epidemiological impact of implementing PrEP in Chinese MSM over the next two decades. The study reported that without PrEP, there will be 1.1–3.0 million new infections and 0.7–2.3 million HIV-related deaths in the next two decades. Moderate PrEP coverage (50%) would prevent 0.17–0.32 million new HIV infections in China [13]. The study demonstrates that the integration of PrEP into China’s national HIV prevention program could yield significant epidemiological benefts as the study estimates 256,000 new infections would be averted over a twenty-year horizon if PrEP is used by 1.2 million high-risk MSM (50% PrEP coverage) for an average of 5 years each [13]. However, a limitation of PrEP implementation in China could be the fact that it will not be cost effective at the current annual price rate of US $3,500 in China. Despite the lack of cost-effectiveness, immediate widespread implementation of oral PrEP should be recommended as it has the potential to prevent hundreds of thousands of MSMs from becoming infected with HIV.

Discussion

The HIV epidemic in China is now largely concentrated among MSM, who account for a third of new HIV infections [14]. Many of these men do not access or cannot be reached by HIV prevention services. For instance, a meta-analysis reported that just 47% and 38% of Chinese MSM received HIV testing and counseling in their lifetime and in the past 12 months, respectively [15]. Although same-sex behavior is not illegal in China, being MSM has significant negative social and cultural ramifications, which may include rejection by family and loss of employment. As a result, a majority of MSM do not disclose their same-sex behavior to others including health care providers. They also do not access HIV prevention services in fear that their sexual minority status would be exposed, or they would encounter discrimination from health care workers [6]. Therefore, the above studies were critical to understand the different ways/strategies that can facilitate increased uptake of HIV testing among the MSM population of China and also prevent HIV new incidence in them.

Increasing HIV testing uptake among MSM is a priority in the Chinese national HIV/AIDS strategic plan and there is a growing body of literature on this topic. Even with limitations such as lower sensitivity and not being able to detect HIV infection during the “window period”, HIV self-testing can have significant public health impact in terms of reducing transmission among MSM if it can reach more never-tested individuals and increase testing frequency among self-testers. To do so strategies are needed to encourage and expand adoption. Over-the counter availability of self-tests can increase the frequency of testing in this population.

Pre-exposure prophylaxis (PrEP) has been considered the most promising biomedical HIV prevention strategy so far. The antiviral drug tenofovir (TDF) used in PrEP and combined therapy with TDF and emtricitabine (TDF-FTC) have been approved by the USFDA as preventive drugs for the MSM population [15]. Condom use and ART were implemented from 2003 to 2013 in the Chaoyang district of Beijing. Compared with 2012, HIV incidence among MSM was found to have declined and reached the target of the National AIDS Comprehensive Prevention and Control Demonstration Area (HIV incidence rates reduced by 20-25%). Condom use also resulted in a decrease in the relative risk of HIV infections from 0 to 31.53% [18].

Challenges & Recommendations

At the policy level: Although China’s State Council approved the ‘Regulation on the Prevention and Treatment of HIV-1/AIDS’ in 2006 which outlined recommendations to eliminate legal and public prejudices against infected individuals, it currently does not carry any specific legal consequences. New legislation is necessary which would provide clear legal requirements and enforcement policies, and should also be expanded to criminalize the intentional exposure of others to HIV-1 and require both physician and partner notification of an individual’s HIV-1 positive status

At the program level: Increasing public education on and awareness of HIV-1/AIDS has shown to positively affect behavioral changes, and these campaigns need to be substantially targeted at Chinese MSM population. Studies have shown that a majority of MSM prefer connecting via internet, mobile phones and other modern social media [5]. Health campaigns should therefore utilize these new technologies and target the online chat rooms and resources frequently accessed by this population. The context of these programs should focus on promoting condom use and those proven effective preventive measures, as well as encouraging individuals and communities take responsibility for safe decisions. To raise awareness for these programs, popular regional and local figures affected by HIV-1/AIDS should be encouraged to take on leadership positions and act as role models for behavioral change. In particular, MSM population as a whole must recognize the seriousness and consequence of the situation should the status quo remains the same and has to lead the way to make drastic behavior change to minimize the further spread of HIV-1 in the population.

At the research and clinical care level: Epidemiological research has increased in recent years; however, data need to be improved and applied to public health ends rather than held purely for surveillance and analysis. Proactive, voluntary testing and counseling services should be extended into outreach campaigns that specifically target MSM population, in order to ensure individuals know their status and receive clinical treatment and care in a timely manner. Vaccine strategies should also be targeted to the HIV-1 strains that are dominant in MSM population.

Population health: Treatment as Prevention (TasP) is a promising strategy for HIV prevention and intervention as it can reduce the risk of HIV secondary transmission by preventing viral replication. This strategy has been expanded to the MSM population in China. However, a major challenge to this strategy is to maintain a good adherence to ART. Depression and anxiety are expected to be more common among HIV-infected Chinese MSM and mental health may interrupt a patient’s ability to adhere to treatment [5].

Some other recommendations would be to have sex education classes in schools where students will learn basic knowledge about sex safety, condom use etc. Initiatives should also be taken in schools where students should be advised to treat every individual with respect irrespective of their gender bias, so as to reduce the homophobic stigma in society.

Limitations

The paper is a review of some of the interesting strategies and research works that are being done to decrease HIV prevalence in MSM population in China. I did not carry out any of above research studies. There are a lot of current research studies going on regarding this topic. My paper probably does not cover all the current intervention strategies.

References

1. China Health and Family Planning Commission (2015)
2. Zhang, A. (2016, December 01). Increase in number of HIV cases in China raises concerns. Retrieved from https://www.ft.com/content/586c3526-b795-11e6-ba85-95d1533d9a62
3. Sohu NewsVoice from the National People’s Congress and the Chinese People’s Political Consultative Conference 2017.http://www.sohu.com/a/128715460_464387 Date: 2017
4. Burki, T. (2016). Sex education in China leaves young vulnerable to infection. The Lancet Infectious Diseases,16(1), 26. doi:10.1016/s1473-3099(15)00494-6
5. Shang, H., & Zhang, L. (2015). MSM and HIV-1 infection in China. National Science Review,2(4), 388-391. doi:10.1093/nsr/nwv060
6. Anonymous. (2014, December 02). China: The Legal Position and Status of Lesbian, Gay, Bisexual and Transgender People in the People’s Republic of China. Retrieved from https://www.outrightinternational.org/content/china-legal-position-and-status-lesbian-gay-bisexual-and-transgender-people-people’s
7. Chow, E., Wilson, D., & Zhang, L. (2012). The rate of HIV testing is increasing among men who have sex with men in China. HIV Medicine,13(5), 255-263. doi:10.1111/j.1468-1293.2011.00974.x
8. Cheng, W., Cai, Y., Tang, W., Zhong, F., Meng, G., Gu, J., . . . Wang, M. (2016). Providing HIV-related services in China for men who have sex with men. Bulletin of the World Health Organization,94(3), 222-227. doi:10.2471/blt.15.156406
9. [bookmark: R10]Zhong F, Liang B, Xu H, Cheng W, Fan L, Han Z, et al. Increasing HIV and decreasing syphilis prevalence in a context of persistently high unprotected anal intercourse, six consecutive annual surveys among men who have sex with men in Guangzhou, China, 2008 to 2013. PLoS ONE. 2014;9(7):e103136.http://dx.doi.org/10.1371/journal.pone.0103136 pmid: 25061936
10. Tucker JD, Bien CH, Peeling RW. Point-of-care testing for sexually transmitted infections: recent advances and implications for disease control. Curr Opin Infect Dis. 2013;26:73–9
11. Pant Pai N, Sharma J, Shivkumar S, et al. Supervised and unsupervised self-testing for HIV in high- and low-risk populations: a systematic review. PLoS Med. 2013;10:e1001414
12. Yan, H., Yang, H., Raymond, H. F., Li, J., Shi, L., Huan, X., & Wei, C. (2014). Experiences and Correlates of HIV Self-Testing Among Men Who Have Sex with Men in Jiangsu Province, China. AIDS and Behavior,19(3), 485-491. doi:10.1007/s10461-014-0968-8
13. Zhang, L., Peng, P., Wu, Y., Ma, X., Soe, N. N., Huang, X., . . . Meyers, K. (2018). Modelling the Epidemiological Impact and Cost-Effectiveness of PrEP for HIV Transmission in MSM in China. AIDS and Behavior,23(2), 523-533. doi:10.1007/s10461-018-2205-3
14. China Ministry of Healht, UNAIDS, World Health Organization (WHO). 2009 estimates for the HIV/AIDS epidemic in China. Beijing, China: China Ministry of Health; 2010.
15. Zou H, Hu N, Xin Q, et al. HIV testing among men who have sex with men in China: A systematic review and meta-analysis. AIDS Behav. 2012; 16:1717–1728. [PubMed: 22677975]
16. Wei C, Yan H, Yang C, et al. Accessing HIV testing and treatment among men who have sex with men in China: a qualitative study. AIDS Care. 2014; 26:372–378. [PubMed: 23909807]
17. Holmes D. FDA paves the way for pre-exposure HIV prophylaxis. Lancet. 2012;380(9839):325
18. Tao, L., Liu, M., Li, S., Liu, J., & Wang, N. (2018). Condom use in combination with ART can reduce HIV incidence and mortality of PLWHA among MSM: A study from Beijing, China. BMC Infectious Diseases,18(1). doi:10.1186/s12879-018-3026-8

Appendices

• MSM- Men who have sex with men
• ART-Anti-retro viral
• PreP-Pre-Exposure prophylaxis
• HIVST-HIV Self-testing
• IMPACT- Integration minimum package of prevention in accelerating case finding and treatment
• CBO-Community based organizations