HIV and syphilis prevalence among men who have sex with men: a cross-sectional survey of 61 cities in China
TL;DR: HIV and syphilis prevalences among MSM in China are high and the 2 epidemics are largely separate geographically, but three segments of the Chinese MSM population each have different demographic and sexual risk "profiles" that suggest high potential for bridging infection across geographies, generations, and sexes.
Abstract: Background. Human immunodeficiency virus (HIV) has rapidly spread among men who have sex with men (MSM) in China in recent years; the magnitude of the epidemic is unclear. We sought to test 3 hypotheses: (1) The prevalence of both HIV and syphilis among MSM in China is high, (2) the 2 epidemics each have unique geographical distributions, and (3) demographic and sexual behavior characteristics are different among segments of the MSM population in China.
Methods. A total of 47 231 MSM from 61 cities in China participated in a cross-sectional survey conducted from February 2008 to September 2009. Demographic and behavioral data were collected and analyzed and blood samples tested for HIV and syphilis. Three subgroups among the broader MSM sample were described. Main outcome measures were HIV and syphilis prevalence.
Results. An overall prevalence of 4.9% (2314/47 231; 95% confidence interval [CI], 4.7%–5.1%) for HIV and 11.8% (5552/47 231; 95% CI, 11.5%–12.0%) for syphilis was found. Syphilis-positive MSM had the highest HIV prevalence, 12.5% (693/5552; 95% CI, 11.6%–13.4%). However, correlations between HIV and syphilis prevalence were found in only 3 of 6 geographical regions (Northwest: r = 0.82, P = .0253; East: r = 0.78, P = .0004; and South-central: r = 0.63, P = .0276). Three subgroups—nonlocal MSM, Internet-using MSM, and female-partnering MSM—were found to have different profiles of characteristics and behaviors.
Conclusions. HIV and syphilis prevalences among MSM in China are high and the 2 epidemics are largely separate geographically. Three segments of the Chinese MSM population each have different demographic and sexual risk “profiles” that suggest high potential for bridging infection across geographies, generations, and sexes.
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TL;DR: Addressing the expanding epidemics of HIV in MSM will require continued research, increased resources, political will, policy change, structural reform, community engagement, and strategic planning and programming, but it can and must be done.
Abstract: Epidemics of HIV in MSM continue to expand in most low, middle, and upper income countries in 2013 and rates of new infection have been consistently high among young MSM. Current prevention and treatment strategies are insufficient for this next wave of HIV spread. We conducted a series of comprehensive reviews of HIV prevalence and incidence, risks for HIV, prevention and care, stigma and discrimination, and policy and advocacy options. The high per act transmission probability of receptive anal intercourse, sex role versatility among MSM, network level effects, and social and structural determinants play central roles in disproportionate disease burdens. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiologic data show marked clustering of HIV in MSM networks, and high proportions of infections due to transmission from recent infections. Prevention strategies that lower biological risks, including those using antiretrovirals, offer promise for epidemic control, but are limited by structural factors including, discrimination, criminalization, and barriers to healthcare. Subepidemics, including among racial and ethnic minority MSM in the United States and UK, are particularly severe and will require culturally tailored efforts. For the promise of new and combined bio-behavioral interventions to be realized, clinically competent healthcare is necessary and community leadership, engagement, and empowerment are likely to be key. Addressing the expanding epidemics of HIV in MSM will require continued research, increased resources, political will, policy change, structural reform, community engagement, and strategic planning and programming, but it can and must be done.
289 citations
TL;DR: The authors' analysis provided reliable estimates of China’s HIV burden among MSM, which appears to present an increasing national public health challenge and effective government responses are needed to address this challenge.
Abstract: The prevalence of HIV among men who have sex with men (MSM) has become a significant public health challenge. The aim was to comprehensively estimate the national prevalence of HIV among MSM and its time trends through a large-scale systematic analysis. Systematic search of Cochrane Library, PubMed, EMBASE, CNKI, VIP, and Wanfang Data databases without language restriction for studies on the prevalence of HIV among MSM published before Dec.31, 2018. Studies were eligible for inclusion if they were published in the peer-reviewed literature and used validated assessment methods to assess the prevalence of HIV among MSM. Estimates were pooled using random-effects analysis. Data were extracted from 355 cross-sectional studies (571,328 individuals) covered 59 cities from 30 provinces and municipalities of China. The overall national prevalence of HIV among MSM from 2001 to 2018 was estimated to be 5.7% (95% CI: 5.4–6.1%), with high between-study heterogeneity (I2 = 98.0%, P < 0.001). Our study showed an increased tendency in the HIV prevalence as time progressed by meta-regression analysis (I2 = 95.9%, P < 0.0001). HIV prevalence was the highest in those aged 50 years and older with HIV prevalence of 19.3% (95%CI: 13.1-27.4%, N = 13). HIV was more prevalent in the illiterate population (16.8%), than in those who had received an education. Although the internet was a major venue for Chinese MSM seeking male sex partners (35.6, 95%CI: 32.3-39.9%, N = 101), seeking MSM in bathhouses/saunas had the highest associated prevalence of HIV (13.4, 95%CI: 10.3-17.1%, N = 22). The HIV prevalence among MSM varied by location: compared with other regions in China, HIV was highly prevalent among MSM in the southwest (10.7, 95%CI: 9.3-12.2%, N = 91). Compared to participants who sometimes or always used condoms, participants who had never used a condom in the past 6 months had a higher risk of HIV infection, with odds ratios of 0.1 (95%CI: 0.08-0.14). Our analysis provided reliable estimates of China’s HIV burden among MSM, which appears to present an increasing national public health challenge. Effective government responses are needed to address this challenge and include the implementation of HIV prevention.
108 citations
TL;DR: It is demonstrated that crowdsourcing may be an effective tool for improving HIV testing messaging campaigns and could increase community engagement in health campaigns.
Abstract: BACKGROUND: Crowdsourcing, the process of shifting individual tasks to a large group, may enhance human immunodeficiency virus (HIV) testing interventions. We conducted a noninferiority, randomized controlled trial to compare first-time HIV testing rates among men who have sex with men (MSM) and transgender individuals who received a crowdsourced or a health marketing HIV test promotion video. METHODS: Seven hundred twenty-one MSM and transgender participants (≥16 years old, never before tested for HIV) were recruited through 3 Chinese MSM Web portals and randomly assigned to 1 of 2 videos. The crowdsourced video was developed using an open contest and formal transparent judging while the evidence-based health marketing video was designed by experts. Study objectives were to measure HIV test uptake within 3 weeks of watching either HIV test promotion video and cost per new HIV test and diagnosis. RESULTS: Overall, 624 of 721 (87%) participants from 31 provinces in 217 Chinese cities completed the study. HIV test uptake was similar between the crowdsourced arm (37% [114/307]) and the health marketing arm (35% [111/317]). The estimated difference between the interventions was 2.1% (95% confidence interval, -5.4% to 9.7%). Among those tested, 31% (69/225) reported a new HIV diagnosis. The crowdsourced intervention cost substantially less than the health marketing intervention per first-time HIV test (US$131 vs US$238 per person) and per new HIV diagnosis (US$415 vs US$799 per person). CONCLUSIONS: Our nationwide study demonstrates that crowdsourcing may be an effective tool for improving HIV testing messaging campaigns and could increase community engagement in health campaigns. CLINICAL TRIALS REGISTRATION: NCT02248558.
107 citations
Cites background from "HIV and syphilis prevalence among m..."
...Our nationwide study spanned 31 provinces and 217 cities in China, identifying MSM with sociodemographic and risk behaviors similar to that of a nationwide survey of >40 000 MSM [17]....
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...Second, given the need to expand HIV testing among MSM in China [17], there would be ethical concerns associated with withholding an evidence-based intervention from untested MSM [18]....
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TL;DR: Compared to non-app users, app users were more likely to be younger, better educated, “out” about their sexual orientation, and single, and there was no difference in condomless sex between the two groups.
Abstract: Anti-gay stigma and harsh local environments in many low and middle-income countries (LMIC) encourage men who have sex with men (MSM) partner-seeking mobile application (gay app) use. To investigate the sexual risk profiles of gay app users and guide future HIV prevention programs, we conducted a cross-sectional online survey among 1,342 MSM in China examining associations between gay app use and sexual behaviors, including HIV and sexually transmitted disease testing. Compared to non-app users, app users were more likely to be younger, better educated, “out” about their sexual orientation, and single. They were also more likely to report multiple recent sex partners and HIV testing, but there was no difference in condomless sex between the two groups. Future research among MSM in LMIC is needed to characterize gay app use and explore its potential for future public health interventions.
101 citations
Cites background from "HIV and syphilis prevalence among m..."
...A recent cross-sectional study of nearly 50,000 MSM across 61 Chinese cities found that 45 % of MSM use the internet to find sex partners [3]....
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TL;DR: Data from two randomized controlled trials suggests that crowdsourcing contests can increase HIV testing, creating demand for services while engaging communities, and improving HIV surveillance and expanding HIV interventions for Chinese MSM and TG individuals are essential.
Abstract: Despite global efforts to control HIV among key populations, new infections among men who have sex with men (MSM) and transgender (TG) individuals are still increasing. The increasing HIV epidemic among MSM/TG in China indicates that more effective services are urgently needed. However, policymakers and program managers must have a clear understanding of MSM/TG sexual health in China to improve service delivery. To meet this need, we undertook a scoping review to summarize HIV epidemiology and responses among MSM and TG individuals in China. We searched MEDLINE, EMBASE and the Cochrane Library for recent studies on MSM/TG HIV epidemiology and responses. We also included supplemental articles, grey literature, government reports, policy documents, and best practice guidelines. Overall, HIV prevalence among Chinese MSM was approximately 8 % in 2015 with a higher prevalence observed in Southwest China. TG are not captured in national HIV, STD, or other sexual health surveillance systems. There is limited data sharing between the public health authorities and community-based organizations (CBOs). Like other low and middle income countries, China is challenged by low rates of HIV testing, linkage, and retention. Several pilot interventions have been shown to be effective to increase HIV testing among MSM and TG individuals, but have not been widely scaled up. Data from two randomized controlled trials suggests that crowdsourcing contests can increase HIV testing, creating demand for services while engaging communities. Improving HIV surveillance and expanding HIV interventions for Chinese MSM and TG individuals are essential. Further implementation research is needed to ensure high-quality HIV services for MSM and TG individuals in China.
90 citations
Cites background from "HIV and syphilis prevalence among m..."
...Large numbers of MSM in China routinely use the Internet [20], especially smart-phone based partner-seeking mobile applications [49]....
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...Since 2008, the China MOH carried out comprehensive AIDS responses with MSM populations in 61 cities across China, including expanding MSM surveillance, increasing HIV testing, case finding, and promoting linkage to care [20]....
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...In addition, municipalities and provincial capitals also have higher HIV prevalence, compared to other cities [20]....
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...Internet-based and social media interventions A few internet-based interventions have been conducted to improve accessibility to HIV services and care [55, 58, 59]....
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References
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TL;DR: A systematic review of studies published from January 1, 1950, through November 31, 2008 using PubMed, EMBASE, Web of Knowledge, CINAHL, and all Evidence-Based Medicine Reviews found that randomized clinical trials and prospective studies of RRTs that reported data on changes in the primary outcome of hospital mortality or the secondary outcome of cardiopulmonary arrest cases were included.
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TL;DR: This chapter discusses the differences between meta-analysis of randomised controlled trials and observational studies, introduces methods forMeta-analysis in this unique setting, and illustrates the issues involved using a real example from a meta- analysis in the field of diet and cancer.
Abstract: Observational studies such as those used to investigate lifecourse epidemiology present particular challenges for meta-analysis. This chapter discusses the differences between meta-analysis of randomised controlled trials and observational studies, introduces methods for meta-analysis in this unique setting, and illustrates the issues involved using a real example from a meta-analysis in the field of diet and cancer. Emphasis is placed on practicalities of how to conduct meta-analyses of observational studies where the information presented in the articles reviewed may be limited.
856 citations
TL;DR: Targeted STD detection and treatment should have a central role in HIV prevention in these emerging epidemics, especially in China, eastern Europe and Russia.
Abstract: Factors that increase transmission
Factors that increase susceptibility
STDs and HIV transmission
STDs and community-based studies
More than 42 million people worldwide are now infected with HIV, in spite of sustained prevention activities. Although the spread of HIV has been primarily sexual, epidemiological studies have indicated that the efficiency of the spread of HIV is poor, perhaps as infrequently as 1 in every 1,000 episodes of sexual intercourse. However, sexually transmitted diseases (STDs) that cause ulcers or inflammation greatly increase the efficiency of HIV transmission — by increasing both the infectiousness of, and the susceptibility to HIV infection. STDs might be particularly important in the early stages of a localized HIV epidemic, when people with risky sexual behaviour are most likely to become infected. In China, eastern Europe and Russia, there has been a remarkable increase in the incidence of STDs in recent years, and this is reflected in the rapid increase in the spread of HIV in these areas. Targeted STD detection and treatment should have a central role in HIV prevention in these emerging epidemics.
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"HIV and syphilis prevalence among m..." refers background in this paper
...Because sexually transmitted infections such as syphilis are thought to increase the sexual transmission efficiency of the HIV virus [4], one could speculate that syphilis had an impact in facilitating the spread of HIV only after sexual transmission became more dominant, and that by that time, the HIV epidemic was already well established in southwestern China....
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...As HIV susceptibility and/or infectiousness is associated with the presence of other sexually transmitted infections such as syphilis [4], it is not surprising that syphilis is also a major public health issue among MSM in developing Asian nations—4....
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TL;DR: In this paper, a comprehensive review of HIV studies among MSM in low and middle-income countries and performed a meta-analysis of reported MSM and reproductive-age adult HIV prevalence data.
Abstract: Funding: Publication costs were offset by a Center for Public Health and Human Rights (CPHHR) operating grant. The source of funding did not play a role in the design of the study, analysis of the data, writing of the manuscript, or the decision to submit for publication. ABSTRACT Background Recent reports of high HIV infection rates among men who have sex with men (MSM) from Asia, Africa, Latin America, and the former Soviet Union (FSU) suggest high levels of HIV transmission among MSM in low- and middle-income countries. To investigate the global epidemic of HIV among MSM and the relationship of MSM outbreaks to general populations, we conducted a comprehensive review of HIV studies among MSM in low- and middle-income countries and performed a meta-analysis of reported MSM and reproductive-age adult HIV prevalence data. Methods and Findings A comprehensive review of the literature was conducted using systematic methodology. Data regarding HIV prevalence and total sample size was sequestered from each of the studies that met inclusion criteria and aggregate values for each country were calculated. Pooled odds ratio (OR) estimates were stratified by factors including HIV prevalence of the country, Joint United Nations Programme on HIV/AIDS (UNAIDS)-classified level of HIV epidemic, geographic region, and whether or not injection drug users (IDUs) played a significant role in given epidemic. Pooled ORs were stratified by prevalence level; very low-prevalence countries had an overall MSM OR of 58.4 (95% CI 56.3-60.6); low-prevalence countries, 14.4 (95% CI 13.8-14.9); and medium- to high-prevalence countries, 9.6 (95% CI 9.0-10.2). Significant differences in ORs for HIV infection among MSM in were seen when comparing low- and middle-income countries; low-income countries had an OR of 7.8 (95% CI 7.2-8.4), whereas middle-income countries had an OR of 23.4 (95% CI 22.8-24.0). Stratifying the pooled ORs by whether the country had a substantial component of IDU spread resulted in an OR of 12.8 (95% CI 12.3- 13.4) in countries where IDU transmission was prevalent, and 24.4 (95% CI 23.7-25.2) where it was not. By region, the OR for MSM in the Americas was 33.3 (95% CI 32.3-34.2); 18.7 (95% CI 17.7-19.7) for Asia; 3.8 (95% CI 3.3-4.3) for Africa; and 1.3 (95% CI 1.1-1.6) for the low- and middle-income countries of Europe.
706 citations
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...6% in Thailand [1]....
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TL;DR: A national campaign for detection and treatment of syphilis, and a credible prevention strategy, are urgently needed, and the results suggest that a range of unique biological and social forces are driving the spread ofSyphilis in China.
275 citations
"HIV and syphilis prevalence among m..." refers background in this paper
...Although syphilis was nearly eradicated in China during the 1960s, it was still present in small pockets in remote areas of northern China [15], and began spreading rapidly beginning in 1993 [16]....
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