Table IV.

Implementation themes from analyses of in-depth interviews (n = 30) and follow-up text entry responses (n = 49)

Domain	Theme	Illustrative Quotations
1. Acceptability	1.1 Participants perceived the content on anal health to be novel and professionally communicated	I think the knowledge [on physiology] was very comprehensive and in-depth. … It was brand new for me. Although I probably knew these things in the past, I didn’t know their exact structure or how they work. / 26 yo, Gay, VCT, CBO/CDC
		The approach and attitude this training adopted is all about sharing knowledge, instead of being shy about the topic or trying to hide. It made people feel that it was about knowledge. It made people feel comfortable and people benefitted a lot from it. And it was very eye-opening. / 31 yo, Bisexual, Other duties, CBO
		I think it really makes up a big blank area in China, I mean the topic of anal health. We didn’t really discuss it [before]. Or even if we did want to discuss it, we had no access to professional knowledge. / 36 yo, Gay, VCT, CBO
	1.2 Participants perceived the content on sexual pleasure as culturally relevant and necessary	The trainer talked about how to obtain pleasure from anal sex. I think this is a really good point as it comes from the needs of the community. So, the purpose of the training was to benefit community members. It's not only about “You need to be healthy, you should to this or that.” In this way, community members would really be willing to participate in the training. / 32 yo, Gay, Public health, CBO
		If you don't understand the pleasure [of anal sex], you won't be able to understand why people have anal sex. / 39 yo, Heterosexual, STI, Hospital
		I think regarding knowledge shared in the training, we always tell people how to protect themselves, but we don't know how to talk about pleasure or improving one's sex life. As far as I know, no one has done that. I understand that we are always able to tell people what they shouldn't do, and we’re not able to tell them what to do. / 33 yo, Gay, VCT, CBO
	1.3 Gradual exposure as a training approach engaged participants despite their initial reticence	It was the first time for me to participate in this kind of training, so, I was not quite at ease in the beginning, but I was able to engage. … I didn't feel it later. Basically, I felt better after the first morning and I didn’t feel ill at ease afterwards. / 26 yo, Bisexual, VCT, CBO
		Bringing up this topic and talking about it publicly made me feel both curious and embarrassed. But I think the discussion was quite open and I learned a lot. This part was really impressive. / 51 yo, Bisexual, VCT, CBO
		Even if someone was not very interested in the topic, being in the [training] environment where everyone is very active, this will affect them and make them more interested in this training … The trainer … was intentionally trying to make us not embarrassed. That is to say, he asked us to share things anonymously, asked us to exchange thoughts during small group sessions. He didn't ask us to reveal our private things. So I think there was nothing embarrassing. / 30 yo, Heterosexual, VCT, CDC
	1.4 Mixing different professional backgrounds facilitated understanding but also elevated social discomfort, serving gradual exposure for some and interfering with acceptability for others	The doctors were quite good. It's probably because they were interested in learning about this topic; they were quite good and participated in the training. This is different from CDC staff or doctors whom I have met in previous trainings. Or it's possible that it was due to the form of this training. Maybe they were a bit serious and distant in the beginning, but as we played the games and got desensitized, they felt that we could all participate in the training together. … In terms of my previous trainings with doctors, I sometimes felt awkward and could not talk freely. / 26 yo, Gay, VCT, CBO/CDC
		There was a session where we had a paper tag on the back and others came to describe it. And we were like, I mean at least for myself, we went to look for people who [also] work in CBOs or people we don't know. For officials from the CDC, I was quite embarrassed to go to them and to describe the phrase on their back. Because some of the phrases were indeed … I mean if you say it between CBO partners there is no problem at all. But it would be a little bit embarrassing if we describe it to the CDC officials. So we just avoided them intentionally. / 35 yo, Gay, VCT, CBO
		Everyone considered themselves as a student. This was very clear and also it is always hard to achieve this. For example, many people may think they are experts or very experienced, or they've studied this field. If people like this come to the training, they’d always feel they're professional and think about their status. … It didn’t happen in this training. … We were all equal and respectful to each other. / 33 yo, Gay, VCT, CBO
2. Feasibility	2.1 Information and information exchange practices are easy to use and compatible with existing approaches, but not sufficient for all client scenarios	There was not only theoretic knowledge, but also suggestions on how to relax, and different sex positions. The training also included knowledge about protection and lubrication, etc. I think this is all stuff that I might use in real life in the future. / 35 yo, Gay, VCT, Hospital/CBO/CDC
		You can only talk about this with people who are willing to talk with you. … There are people who don’t want to talk about anything with you. They just want to have the HIV testing done and leave immediately. The methods you mentioned would be limited in this scenario. Because you encounter so many different types of people when you are doing testing and counseling, it's impossible to solve all questions using one approach. … I think it can only be applied to a small portion of circumstances. / 37 yo, Gay, Public health, CBO
		I think the [elicit-provide-elicit] counseling method is great. It’s close to the audience, not complicated. You'll be able to understand it with a glance. … This is different from forcing participants with what I know. Instead, this approach is more gradual. It slowly shares the information with you with your consent and by feeding your curiosity. … It’s like slow cooking or the principle of treatment in traditional Chinese medicine. / 31 yo, Bisexual, Other duties, CBO
		I think in terms of feasibility, there is no problem. It’s easy to use. The critical point is when to use it. You cannot just copy the training materials. That is to say, we can't just repeat what's said in the textbook. It's just a recommendation. Everyone has different counselling skills. The important thing is when during the counseling to apply which method. I don't think there will be any problem or barriers for me to apply it in my practice. / 46 yo, Heterosexual, STI, CDC/Other setting
	2.2 Recommended practices suit existing practices, but adaptation and dissemination is unreliable	I’ve been talking to people briefly since I came back from the training, about knowledge of anal sex, etc. But I don’t think I could do the counseling as thoroughly as the trainer. … I believe it is necessary to receive concrete training in a classroom, to feel, and to summarize and come up with your own model for counseling. However … even if I repeat exactly what I learned, we probably couldn't achieve what the trainer modeled. / 29 yo, Gay, Other duties, Other setting
		When I returned from the training, the next day, I trained other counselors and staff in our clinic. But during my training … I compressed the training into a two-hour session and just provided a brief training. During this process, I could feel that people there were embarrassed. … They have many years of working experience. I think this embarrassment came from the fact that I didn’t help them get desensitized enough nor did I conduct the ice-breaking activities well. It was probably also due to my training skills. But I still think they have the capability to accept this. But you just need to give them more time to accept it. / 33 yo, Heterosexual, Public health, Hospital
3. Appropriateness	3.1 Information learned will help engage MSM	We need to better understand our body not only to have better anal sex, but also to protect it. We need to first understand it before doing it. / 26 yo, Gay, VCT, CBO/CDC
		If the training is open to the general public, I think gay men in general would be interested as well. This is very relevant to them. I mean gay men who are not working in health-related field, who are not CBO volunteers, nor participated in HIV-related work. I am saying that, just as a regular gay guy, they would be interested. / 30 yo, Heterosexual, VCT, CDC
		Everyone could see that CBO people were very interested in the training. So I believe that my patients should be interested in this content as well. / 41 yo, Heterosexual, VCT, CDC
	3.2 Information was linked to health and prevention	I think when people know more about this, it would be helpful for our future work on prevention and intervention. This is beneficial. Because anal sex is not simply about sex, it requires skills and knowledge. The point is how to have anal sex in a safer and healthier way. / 37 yo, Gay, VCT, Hospital/CBO
		The trainer didn't need to explicitly talk about HIV and STI prevention…I mean he didn’t need to specifically explain how to prevent these diseases. Instead, he achieved this through talking about anal health…If he exclusively talked about the negative consequences of HIV or STIs, it might have had some negative impact. So what he did is not specifically talk about HIV or STIs, but by educating everyone [about anal health] … we learned how to prevent diseases. This also achieved the outcome of disease prevention. / 36 yo, Bisexual, VCT, Hospital
		Clients rarely come for testing and ask us how to obtain more pleasure. This is rare, not many people. … I think pleasure is a less important point during counseling [than HIV]. … [But] if you couldn't open the conversation or they wouldn't share with you some critical information, maybe you could try to talk about pleasure to overcome the barriers, so that it would be easier to continue your counseling [about safety from HIV]. / 23 yo, Gay, VCT, CBO
	3.3 How to share information with clients is nuanced	It may make them have some negative reactions, they may think that you are trying to pry into his personal life. By the way, during the training, you could consider including this scenario: you are very eager to share this knowledge with a client, but the environment at that time makes it difficult to do so. In this situation, you are having difficulties and you don’t know how to start the discussion on this topic. In the training, you can teach participants skills on how to guide and elicit – how to gradually guide the conversation to this topic, so that you could better communicate the knowledge. / 28 yo, Heterosexual, Public health, CDC
		If a client comes to me and directly asks, I wouldn't feel any pressure … But if a client didn’t ask about questions related to this topic, and I need to initiate discussion about anal health or anal pleasure … it feels a little bit like sexual harassment. … I think it’s really hard actually to distinguish. … It wouldn't be any problem to talk about it in a group setting, but if it's one-one-one … It could be difficult to find the right tone to talk about anal sex in a one-on-one setting. If you talk gently, they may think you’re flirting. If you try to distance yourself and use a serious tone – which is very hard, to talk in this tone – even if you did it, it’d sound strange. / 29 yo, Gay, Other duties, Other setting
		I think the topic of HIV/AIDS is more difficult than this. I'm able to talk about that with my clients, why wouldn't I be confident about discussing this? … I haven’t tried to discuss this topic in this way yet. I don’t know if people will feel embarrassed at that moment, or don't know what to say, or they'd think it's too much and you're harassing them. I don’t know what will happen. … I don’t know if people will think it’s weird if I bring up this topic, like “Why would you talk about it?’ / 39 yo, Heterosexual, STI treatment, Hospital

VCT: voluntary HIV counseling and testing; STI: sexually transmitted infection treatment; CBO: community-based organization; CDC: Chinese Centers for Disease Control and Prevention