Abstract
The men who have sex with men (MSM) population in China has experienced a recent increase in HIV incidence. Due to the dual stigma and discrimination towards homosexuality and HIV infection, most MSM living with HIV/AIDS are hard to reach by offline intervention initiatives. We recruited HIV-positive MSM participants in Chengdu, China and assessed whether they disclosed their HIV status to partners, motivated a partner to receive testing, used condoms consistently, or initiated antiretroviral therapy. Participants were quasi-randomized to either the intervention or control arm. The intervention group was given instructions for an online program with four modules: an information exchange website, a bulletin board system, individualized online counseling with trained peer educators, and an animation game. All participants were re-assessed at 6 months. The study enrolled 202 HIV-positive MSM. The intervention group had significant increases in disclosing their HIV status to their partners (76.0% vs 61.2%, P=0.0388) and motivating partners to accept HIV testing (42.3% vs 25.5%, P=0.0156) compared with the control group, but there were no between-group differences in receiving early treatment or using condoms consistently. We found that a web-based intervention targeting HIV-positive MSM was an effective tool in increasing the uptake of HIV testing within this high-risk population.
Keywords: Antiretroviral therapy, behavioral intervention, China, condom usage, HIV/AIDS, HIV status disclosure, HIV testing, men who have sex with men
INTRODUCTION
In recent years, China has reported an increasing HIV/AIDS epidemic among the men who have sex with men (MSM) population [1, 2]. A 2005 report authored by sociologists and psychologists estimated that the MSM community in China numbered at least 30 million people, whereas public health professionals estimate a population size between 5 million and 10 million [3]. Government statistics in 2011 reported that homosexual contact was the mode of transmission for 17.4% of the estimated 780,000 HIV/AIDS infections and 29.4% of the 48,000 new infections in 2011 [4]. Furthermore, recent research indicates that the MSM population’s HIV/AIDS prevalence is approximately 5.0% and a large proportion of cases are newly diagnosed in 2008 [5, 6].
Historically, prevention efforts have primarily centered on encouraging testing and safe sex among MSM who are HIV-negative or unaware of their status. In the era of “Treatment as Prevention,” expanding treatment coverage of HIV-positive MSM has become increasingly critical. However, stigma is a significant barrier to accessing knowledge and interventions provided by health professionals [7, 8]. HIV-positive MSM experience stigma and discrimination from not only the general population but also from the MSM community [9, 10].
The national surveys among MSM in China in 2008 and 2009 found that over 70.0% of Chinese MSM meet sexual partners online [6]. Other studies have noted that MSM who meet partners online are more likely than other MSM to engage in unprotected sex [11–13]. With more universal access to the internet and widespread social pressure to keep homosexual behavior secret, MSM in China will increasingly rely on web-based platforms to establish and to maintain social connections [12].
Past research has noted different levels of risk behaviors among HIV-positive MSM and HIV-negative MSM. Several studies have found that interventions targeted at the general MSM community may not be as effective for HIV-positive MSM [14, 15]. Due to fears of stigma and discrimination, HIV-positive MSM are more likely to use the internet to meet sexual partners, and many seek partners who are also known to be HIV-positive. Delivery of a behavioral intervention over the web can cross geographical limitations and have greater success in accessing to hard-to-reach groups who are frequently missed by offline intervention measures [16]. Evaluations of web-based interventions are often difficult due to a lack of clearly defined assessment indicators and possible confounding “contamination” effects by overlaps with offline interventions. Therefore, it is important to develop an operational and assessable web-based program for delivering an intervention to hard-to-reach populations. This study aims to assess the effect of a web-based intervention on promoting safe sex behaviors and access to HIV services for MSM living with HIV/AIDS in Chengdu, China.
METHODS
Trial Design
The study was a quasi-randomized web-based intervention trial conducted in Chengdu, Sichuan, from December 2008 to September 2009. Participants were assessed at baseline and at a 6-month follow-up.
Participants
Study inclusion criteria were: 1) being male, 2) being over 18 years of age, 3) having residence or employment in Chengdu for at least the past year, 4) able and willing to provide informed consent, 5) reporting at least one sexual encounter with another male in the past year, and 6) having received confirmed HIV diagnosis (defined in China as a positive Western blot confirmatory test result).
To better understand the target population in this setting, ten key informants in Chengdu were invited to a focus group discussion. These individuals were actively involved in the local gay community, HIV-positive MSM who were very familiar with local healthcare services, or volunteers involved in counseling and outreach activities targeting MSM. The discussion focused on the HIV epidemic in the local community, and their views on high-risk behaviors, feedback on how to improve the study design, and suggestions on how to reach and follow the target population. Lessons learned from this discussion resulted in modifications of the study protocol and questionnaire. A pilot study was then conducted in Beijing among 30 participants to examine the protocol and questionnaire, after which the operational manual was finalized and training materials were standardized.
The Chengdu Tongle Counseling and Health Care Center (hereafter referred to as “Tongle”), a local gay community organization, helped with participant recruitment and acted as an implementing agency for the study. Tongle has been involved in past HIV/AIDS related studies and has an established network of connections within the local MSM community and the government health sector. The Sichuan Center for Disease Control and Prevention (CDC) monitored the project and conducted laboratory-based CD4 cell count testing. The Chengdu Municipal Hospital for Infectious Diseases provided technical support on patient counseling skills and participant recruitment and delivered antiretroviral therapy (ART) to patients eligible for treatment,
Recruitment was conducted via a joint effort by Tongle and the Chengdu Municipal Hospital for Infectious Diseases. Participants were recruited over the phone or over Tencent QQ (Tencent Holdings Limited, China), an instant messaging software program available for computers and mobile phones that is popular throughout China. Tongle used multiple recruitment methods to increase representativeness of the study population, including outreach work by peer educators and web-based recruitment. The Chengdu Municipal Hospital for Infectious Diseases recruited HIV/AIDS patients who received medical services in the hospital.
Study Setting
The study was conducted at the ART clinic of Chengdu Municipal Hospital for Infectious Diseases from December 2008 to September 2009. Chengdu is the capital of Sichuan province and the largest city in Southwest China with a population of 14.3 million.
In the Chengdu municipal region, the estimated MSM population size surpasses 40,000. Chengdu public health officials were among the first in China to set up a sentinel surveillance system specifically for MSM and HIV/AIDS. Sentinel surveillance data showed the HIV prevalence sharply increased from 0.5% in 2005 to approximately 6.0% in 2010 [17]. As of the end of 2008, 351 HIV-positive MSM living in Chengdu were registered in the National HIV/AIDS Case Reporting System.
Interventions
Two Tongle coordinators were responsible for study oversight, and eight HIV-positive MSM peer educators conducted the interviews at both baseline and follow-up. All peer educators received 25 hours of training on study procedures. Baseline and six-month follow-up assessments were conducted by interviewer-administered confidential questionnaires. The baseline questionnaire was intended to collect demographic, behavioral, and HIV treatment-related data. The six-month follow-up questionnaire focused on measuring disclosure of HIV status to partner, motivating partners to receive HIV testing, changes in risk behavior, and earlier initiation of treatment. Each respondent who finished an assessment was paid 50 RMB (~8 USD) for local transportation.
Following the baseline survey, each participant in the intervention group was given a unique authorization code for an internet-based program. The program consisted of four complementary modules: an information exchange website, a bulletin board program, individualized one-on-one online counseling, and an animated game. The information exchange website offered information and clinical advice on early initiation of ART. It also linked to outside Chinese websites that provide up-to-date information on HIV/AIDS. The bulletin board program included four sessions of online discussion focusing on four topics corresponding to the four main outcomes. The individualized one-on-one online counseling was conducted by eight peer educators through Tencent QQ every evening during the study period. In addition, peer educators summarized and posted answers to frequently asked questions on the information exchange website. The animated game was designed to promote safe sexual behaviors. After the game concluded, a feedback letter was generated automatically by the system to provide personalized safe sex advice based on the participant’s decisions in the game. The control arm followed standard-of-care procedures and did not receive an intervention.
Outcomes
The primary outcomes of this study were differences between the intervention and control groups on earlier initiation of ART, disclosure of HIV status to partners, motivating partners to receive HIV testing, and consistent condom use within the past 3 months. Earlier initiation of ART was defined as starting ART at CD4 counts higher than 350 cells/mm3. At the time, the National Guidelines for ART recommended initiating treatment at CD4 counts less than 200 cells/mm3.
Randomization
Two Tongle coordinators recorded the birth year of each eligible participant and then quasi-randomized participants to intervention or control arms based on an odd or even birth year.
Measures and Data Analysis
Primary outcomes were measured and compared between the intervention and control arms. Categorical variables were reported as numbers and percentages, and continuous variables as means and standard deviations (SD). Bivariate analyses were performed to assess differences between and within the intervention and control groups. T test and χ2 test were used for continuous variables and categorical variables, respectively. Under intent-to-treat analysis principles, participants who were lost to follow-up were not excluded, and missing data, if any, were analyzed by the randomization scheme. P-values of < 0.05 were considered statistically significant. All analyses were conducted using SAS Software (Cary, NC, USA).
Ethics Statement
This study was reviewed and approved by the Institutional Review Board of the National Center for AIDS/STD Control and Prevention, China CDC. Written informed consent was obtained from all participants. The consent form notified respondents that their national identification number would be collected and only used to check their HIV status in the National Case Reporting System. De-identified data were used whenever possible.
RESULTS
Screening, Quasi-Randomization, and Assessment of the Study Participants
A total of 262 HIV-positive MSM (accounting for 74.6% of total 351 reported cases as of December 2008 in Chengdu city) were recruited between December 2008 and March 2009. Follow-up completion rates were 100% in the intervention arm and 98.0% in the control arm.
Baseline Characteristics
An overview of key demographic and behavioral characteristics is presented in Table 1. The majority of participants were 26–35 years old, and the mean age was 30.9 years with a range from 18–52 years. Nearly 56% had completed a college education or above. Approximately 85% had resided in Chengdu for more than 24 months, and 49.0% reported that their monthly income was between 1000 to 3000 RMB (~161 to 482 USD).
Table 1.
Baseline characteristics of the study participants and comparison of the intervention and control groups.
| Characteristic | Total Participants N (%) | Intervention Group N (%) | Control Group N (%) | p-Value |
|---|---|---|---|---|
| Age (years) | ||||
| Mean (SD) | 30.9 ± 8.2 | 30.6 ± 8.4 | 31.1 ± 8.0 | 0.6657 |
| Educational attainment | ||||
| < Middle school | 7 (3.5) | 4 (3.8) | 3 (3.1) | 0.9191 |
| Middle school | 82 (40.6) | 43 (41.4) | 39 (39.8) | |
| > Middle school | 113 (55.9) | 57 (54.8) | 56 (57.1) | |
| Duration residing in Chengdu (months) | ||||
| < 24 | 31 (15.3) | 17 (16.3) | 14 (14.3) | 0.6847 |
| ≥ 24 | 171 (84.7) | 87 (83.7) | 84 (85.7) | |
| Monthly income (CNY) | ||||
| < 1,000 | 69 (34.2) | 34 (32.7) | 35 (35.7) | 0.8195 |
| 1,000−2,999 | 99 (49.0) | 51 (49.0) | 48 (49.0) | |
| ≥ 3,000 | 34 (16.8) | 19 (18.3) | 15 (15.3) | |
| Self-reported syphilis infection in past 12 months | ||||
| Positive | 28 (13.8) | 14 (13.5) | 14 (14.3) | 0.8655 |
| Negative | 174 (86.2) | 90 (86.5) | 84 (85.7) | |
| Time since initial HIV-positive test (months) | ||||
| < 3 | 41 (20.3) | 21 (20.2) | 20 (20.4) | 0.6785 |
| 3−11 | 78 (38.6) | 43 (41.3) | 35 (35.7) | |
| ≥ 12 | 83 (41.1) | 40 (38.5) | 43 (43.9) | |
| CD4 testing in the past year | ||||
| Yes | 179 (88.6) | 91 (87.5) | 88 (89.8) | 0.6076 |
| No | 23 (11.4) | 13 (12.5) | 10 (10.2) | |
| Received ART | ||||
| Yes | 60 (29.7) | 27 (26.0) | 33 (33.7) | 0.4777 |
| No | 106 (52.5) | 58 (55.7) | 48 (49.0) | |
| Not eligible | 36(17.8) | 19(18.3) | 17(17.3) | |
| Disclosure of HIV status to partners | ||||
| Yes | 122 (60.4) | 63 (60.6) | 59 (60.2) | 0.9568 |
| No | 80 (39.6) | 41 (39.4) | 39 (39.8) | |
| Motivating partners to receive HIV testing | ||||
| Yes | 45 (22.3) | 22 (20.4) | 23 (23.5) | 0.6926 |
| No | 157 (77.7) | 82 (79.6) | 75 (76.5) | |
| HIV status of partners | ||||
| Unknown or never tested | 87 (43.1) | 44 (42.3) | 43 (43.8) | 0.0759 |
| Positive | 31 (15.3) | 13 (12.5) | 18 (18.4) | |
| Negative | 32 (15.8) | 15 (14.4) | 17 (17.4) | |
| ≥ 2 partners with different statuses | 10 (5.0) | 3 (2.9) | 7 (7.1) | |
| No sex | 42(20.8) | 29(27.9) | 13(13.3) | |
| Used condoms consistently† | ||||
| Yes | 109 (54.0) | 47 (45.2) | 62 (63.2) | 0.0144 |
| No | 51 (25.2) | 28 (26.9) | 23 (23.5) | |
| No sex | 42(20.8) | 29(27.9) | 13(13.3) | |
| Overall | 202 (100) | 104 (100) | 98 (100) | - |
SD: standard deviation. CNY: Chinese Yuan (1 CNY ~ 0.16 USD). ART: antiretroviral treatment.
p-values were generated using T test for continuous variables and χ2 test for categorical variables
Self-reported using condoms consistently over the past 3 months.
Less than half of the participants (43.1%) stated they had had sexual contact with partners whose HIV status was unknown or who had never been tested. A quarter (25.2%) had engaged in unsafe sex in past 3 months, and 13.8% self-reported syphilis infection.
About two in five respondents had known their HIV-positive status for more than 12 months. Nearly 90% of the study participants had received CD4 testing in the past 12 months, but only 29.7% were currently engaged in ART. Approximately 40% had never disclosed their HIV status to sex partners, and 77.7% had never encouraged their partners to be tested.
Participation rates for the Online Intervention
For the 104 participants assigned to intervention arm, the attendance rates for the bulletin boards for discussions on earlier treatment promotion, disclosure of HIV-positive status to partners, motivating partners to seek HIV or sexually transmitted infection (STI) testing, and promoting safe sex were 91.3%, 89.4%, 90.4% and 88.4%, respectively. According to the information exchange website page view statistics, there were 96,703 page views during the intervention period. In the 6-month follow-up assessment, 98.1% of the 104 participants reported they had logged onto the website to obtain knowledge on HIV and to share experiences. A total of 203 online counseling sessions were provided by the eight peer educators, who also posted answers to 47 frequently asked questions on the information exchange website. Nearly 75% of the 104 participants played the animation game and received feedback letters with tailored advice for safer sex.
Changes in Primary Outcome Indicators Following the Intervention
Primary outcomes are shown in Table 2. The participants in the intervention group performed significantly better than those in the control group on disclosing HIV status to partners (P=0.0388) and encouraging partners to be tested (P=0.0156), but there were no between-group differences on receiving ART and consistent condom use (P>0.05).
Table 2.
Primary outcomes comparison by study group.
| Main Outcomes | Intervention Group N (%) | Control Group N (%) | p-Value* |
|---|---|---|---|
| Earlier initiation of ART | |||
| Yes | 31 (29.8) | 37 (37.8) | 0.3684 |
| No | 59 (56.7) | 46 (46.9) | |
| Not eligible | 14(13.5) | 13(13.2) | |
| Disclosure of HIV status to partners | |||
| Yes | 79 (76.0) | 60 (61.2) | 0.0388 |
| No | 25 (24.0) | 36 (36.8) | |
| Motivating partners to receive HIV testing | |||
| Yes | 44 (42.3) | 25 (25.5) | 0.0156 |
| No | 60 (57.7) | 71 (72.5) | |
| Used condoms consistently† | |||
| Yes | 49 (47.1) | 53 (54.2) | 0.1992 |
| No | 10 (9.6) | 14 (14.2) | |
| No sex | 45(43.3) | 31(31.6) | |
| Overall | 104 (100) | 98 (100) | - |
p-values were generated using χ2 test
Self-reported using condoms consistently over the past 3 months.
DISCUSSION
This quasi-randomized intervention in Chengdu, China assessed the effect of a web-based intervention on increasing safe sex behaviors and access to ART among HIV-positive MSM. After six months, the intervention group that participated in the online program demonstrated behavioral changes that were significantly different from the control group. Specifically, participants in the intervention group were more likely to disclose their HIV-positive status to partners and to encourage partners to be tested for HIV. To our knowledge, this was the first web-based intervention targeted at MSM living with HIV/AIDS in China.
Our study demonstrated that a tailored web-based intervention program can be effective in motivating HIV-positive MSM to disclose their infection status to sexual partners. A range of factors are known to be associated with HIV disclosure [18]. Some studies have found that regret can be associated with serostatus disclosure [19], and an intervention trial focused on regret was successful in encouraging participants to disclose their HIV-positive status and sexual orientation [20]. Some researchers suggest that perceptions of the probable consequences of disclosure are the most significant predictor of disclosure behavior [21]. A study conducted among Australian MSM showed that having recently had sex with a male partner outside of a long-term relationship and expecting HIV-negative and HIV-positive men to disclose before sex were predictors of HIV disclosure [22]. We took these factors into account while developing the online counseling module of our intervention program.
Our results also showed the online intervention was effective in motivating HIV-positive MSM to encourage HIV testing for their partners. Testing is considered the entry threshold to the cascade of HIV/AIDS care and prevention [23]. Many factors negatively affect the implementation of HIV testing, such as low perceptions of infection risk, fear of positive results, lack of psychological support, and low coverage or quality of medical services as well as stigma and discrimination [24–26]. Empowerment is crucial in order for participants to persuade their partners to accept testing. By providing information on testing and HIV/AIDS on the bulletin board system and individualized one-on-one online counseling, we incorporated the previous research findings on disclosure and empowered participants to make decisions based on their personal needs.
A high self-reported syphilis infection rate among the study participants suggests that they experienced a high frequency of unprotected sex. The syphilis rate was much higher in our study than in a previous study, which showed 6.4% of 398 HIV-positive MSM tested positive for syphilis [15]. A cross-sectional study in Italy showed that many HIV-positive MSM who were aware of their status continued to engage in at-risk behaviors: 25.0% of the study population did not use a condom during STI episodes which can increase transmission rates of HIV and other STIs [14].
Consistent condom use significantly increased during the study period both in the intervention and control groups, but there was not a significant between-group difference. Another web-based randomized clinical trial with a 3-month follow-up period showed that an intervention focusing on cognitive behavioral skills training and motivational enhancement was effective in reducing sexual risk behaviors, particularly during sex with partners with a positive or unknown HIV status [27]. The impact of structural factors on the effectiveness of HIV interventions must be considered when implementing and evaluating behavioral interventions [28]. The use of seroadaptation strategies, including serosorting, in MSM communities should be also considered during the assessment of unprotected intercourse frequencies [29, 30]. Additional significant predictors of consistent condom use include low levels of psychotropic drug use, high satisfaction with sexuality, and previous behavioral change after their HIV diagnosis [31]. Consistent condom use increased among our study participants in the intervention and control groups; we are unable to identify causes of these changes. It is possible that the increases are due to study participation itself (i.e., the Hawthorne effect) or a response bias.
Early ART initiation has a significant impact on both HIV-positive individuals and their partners [32–35]. Although we intentionally designed our web-based program to include promoting ART initiation, we failed to observe any significant difference between the two study arms. This may be due to an study insufficient observation time. Another possible reason may be that because our peer educators were not health professionals, they could not provide extensively detailed medical or academic information to the participants.
Some study limitations should be addressed. First, the presented results are restricted to initial efficacy; the study population was not assessed as the 6-month study follow-up period, so we cannot conclude any long-term effects. Second, we recognize that not all individuals in our target population (HIV-positive MSM) regularly use the internet, although a large and growing percentage does so. However, we cannot generalize the findings to all HIV-positive MSM. Third, given the nature of a behavior-based intervention and logistical limitations, the study did not include blinding. As mentioned above, participants were aware of their study arm assignments. Finally, although the intervention is novel, it was conducted in 2009, and the significance of our findings may be weakened in part. Despite these limitations, we believe our findings are significant due to the randomized controlled study structure and the high follow-up rate.
In conclusion, a web-based intervention targeted towards HIV-positive MSM can increase the frequency of disclosing a HIV-positive status and encouraging sexual partners to accept HIV testing. Online interventions for HIV-positive MSM should be considered for further research and inclusion in HIV prevention and sexual risk reduction intervention strategies.
Fig. (1).
Flow chart for the screening, quasi-randomization, and assessment of study participants.
ACKNOWLEDGEMENTS
The authors thank all the participants in Chengdu as well as Feng Tian and Feng Ye for their work in conducting participant interviews and data entry. The authors would also like to thank Kaveh Khoshnood for his valuable comments and suggestions on developing the manuscript.
Funding
The project was partly supported by the United States National Institutes of Health (Grant # U2RTW06918, funded by the Fogarty International Center and National Institute on Drug Abuse), and partly funded by the National Health and Family Planning Commission of the People’s Republic of China (Grant# 131-13-000-105-01).
Biography
Zunyou Wu
Footnotes
CONFLICT OF INTEREST
The authors confirm that this article content has no conflict of interest.
Publisher's Disclaimer: DISCLAIMER
The opinions expressed herein reflect the collective views of the co-authors and do not necessarily represent the official position of the National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention. Funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
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