HIV testing uptake and yield among sexual partners of HIV-positive men who have sex with men in Zhejiang Province, China, 2014-2016: A cross-sectional pilot study of a choice-based partner tracing and testing package

Mingyu Luo; Katrina Hann; Guomin Zhang; Xiaohong Pan; Qiaoqin Ma; Jun Jiang; Lin Chen; Shichang Xia

doi:10.1371/journal.pone.0232268

. 2020 Jun 4;15(6):e0232268. doi: 10.1371/journal.pone.0232268

HIV testing uptake and yield among sexual partners of HIV-positive men who have sex with men in Zhejiang Province, China, 2014-2016: A cross-sectional pilot study of a choice-based partner tracing and testing package

Mingyu Luo ¹, Katrina Hann ², Guomin Zhang ³, Xiaohong Pan ^1,^*, Qiaoqin Ma ^1,^*, Jun Jiang ¹, Lin Chen ¹, Shichang Xia ¹

Editor: Chongyi Wei⁴

PMCID: PMC7272034 PMID: 32497114

Abstract

Background

Measures to effectively expand tracing and testing to identify undiagnosed HIV infections are significant for the control of HIV/AIDS epidemic among men who have sex with men (MSM). We piloted a choice-based tracing and testing package aimed at improving partner tracing, uptake, and yield of HIV testing for sexual partners of newly diagnosed HIV-positive MSM.

Methods

This package was piloted in the cities of Hangzhou and Ningbo, Zhejiang province, China from June 2014 to June 2016. The package adopted four modes: couples’ HIV counseling and testing (CHCT), information assisted partner notification (IAPN), assisted HIV self-testing (HIVST) and patient referral. Data regarding sociodemographic factors and sexual behaviors between HIV-positive MSM and their sexual partners, as well as tracing and testing outcomes of each mode, were collected.

Results

Among 2,495 newly diagnosed HIV-positive MSM, 446(18%) were enrolled as index cases (ICs) through two rounds of contact tracing. The ICs disclosed a total of 4,716 sexual partners, of whom 548 (12%) were reachable. The pilot study resulted in a testing uptake of 87% (478/548), and a yield of 16% (74/478) among sexual partners. The generalized linear mixed model showed that the odds of a reachable sexual partner enrolled via IAPN taking an HIV test were 290% greater than that of a partner traced via CHCT (95% CI: 1.6, 9.3).

Conclusions

A choice-based tracing and testing package can feasibly expand HIV testing uptake and case finding among sexual partners of HIV-positive MSM. IAPN may be an acceptable option to reach sexual partners for whom limited contact information is available.

Introduction

Men who have sex with men (MSM) have a substantial risk of contracting HIV/AIDS infections in China, where newly diagnosed infection increased almost six-fold between 2010 to 2016, and where the prevalence of HIV infections in MSM was 7.75% in 2016 (similar to European countries) [1,2]. Failure to detect an infection is a significant driver of the HIV epidemic among MSM [3,4]. Globally, HIV testing rates among MSM range from 50% to 70% [5–7], indicating a large proportion of undiagnosed HIV infections.

HIV tracing and testing approaches are essential in identifying undiagnosed infections and preventing further HIV transmission among sexual partners of HIV-positive MSM [8,9]. In 2003, the Chinese government began to enforce the free voluntary counselling and testing (VCT) policy [10], which resulted in the introduction of VCT clinics, among other services [11]. The introduction of VCTs in China allowed MSM to visit testing sites and determine their infection status through passive-case finding, in which MSM initiate HIV testing, even in areas with significant NGO outreach efforts [12]. Subsequently, the rate of HIV testing among MSM increased from 50% to 65% from 2011 to 2015 [1]. However, as 25% of HIV infections among MSM remain undiagnosed [13], active case-finding approaches in which healthcare providers target this key population may be a significant step in addressing this testing gap.

Emerging evidence highlights the acceptability, feasibility, and transferability of existing intervention models as key factors in active case finding and referral. The World Health Organization lists options for assisted partner referrals, in which trained health care providers assist clients in disclosing their partners’ potential exposure to HIV infections and help refer their partners to HIV testing services (HTS).

In assisted partner notification services, information-based tracing and testing modes that utilize social network applications may provide adequate convenience and privacy protection for index cases by providing a direct line of communication line to health providers and their contacts [14,15]. By tracing sexual partners using social media account identifiers, contact between the HIV-positive MSM and their sexual partners can be avoided [16]. Social media point-to-point interventions, in which a healthcare provider communicates directly with the contact, have been shown to be feasible in reaching MSM in previous studies [14]. This approach is effective in identifying high numbers of HIV-positive individuals in need of treatment and is cost-effective in locating and contacting partners [17].

Couples’ HIV counseling and testing (CHCT) is a subtype of assisted partner notification in which couples test, share results, and receive interventions together. This also may be an acceptable approach among MSM and their sexual partners [18,19]; however, more evidence on contact-tracing of HIV-positive MSM is needed.

Assisted HIV Self-Testing (HIVST) refers to individuals who are self-testing for HIV but receive an in-person demonstration from a trained provider or peer before or during HIVST. HIVST is an acceptable strategy that can increase testing uptake among high-risk populations that are less likely to have access to testing [17,20,21]. In HIVST, oral HIV self-testing may be a complementary method for screening sexual partners who fear disclosure of HIV status, however, it has not consistently been found as acceptable [22,23].

In practice, active and passive contact tracing are complementary approaches: care providers may offer more than one testing mode for clients, which allows them to select an option that reduces each individual’s specific barriers to testing. Sharma et al. [24] explored MSM attitudes and usage preference towards six different HIV testing modes and found that MSM of different sub-groups showed low acceptability for one intervention option and had specific intervention preferences [24].

In China, there is limited data on choice-based partner tracing and testing for sexual partners of HIV-positive MSM. This type of data is essential to HIV prevention and control programs, as it provides guidelines for active case-finding strategies targeting special populations such as MSM and their sexual partners. In this study, we aimed at analyzing the uptake and infection status of HIV testing for sexual partners of newly diagnosed HIV-positive MSM. We also describe the program’s intervention components and outcomes in the Zhejiang Province of China.

Materials and methods

Selection and description of participants

We defined the study population as newly diagnosed HIV-positive MSM and their sexual partners, who agreed to participate in the partner tracing and HIV testing program at VCT clinic study sites in the cities of Hangzhou and Ningbo from June 2014 through June 2016. Inclusion criteria for index cases (ICs) included the following: male, age 18 years or older, having been newly diagnosed as HIV positive within one month, having disclosed male sexual partners (including oral intercourse or anal intercourse) to VCT staff in pre- or post-testing counseling at the time of diagnosis, and having agreed to participate in the partner tracing and testing program. We excluded any potential participants with a cognitive impairment, severe AIDS complication or other illnesses requiring hospitalization, or disabilities, as determined by staff at the VCT clinics. We defined inclusion criteria for sexual partners as individuals reported to be sexual partners of ICs in post-testing counseling at the time of HIV testing, but excluded those with cognitive impairments, severe AIDS complication or other illnesses requiring hospitalization, or disabilities, as determined by staff at VCT clinics. We defined reachable sexual partners as those who could be contacted by face-to-face, official landline/telephone, social software (such as QQ, WeChat and Blued) or other communication tools. We did not include an exclusion criterion for sexual partner age in order to identify any high social risk between adult IC and minor sexual partners. However, HIV-positive sexual partners aged under 18 years were interviewed with their legal guardians’ written consent and presence.

Technical information

Study design

We used a cross-sectional design to describe a pilot choice-based partner tracing and testing program that offers a choice of four modes to analyze HIV testing uptake and identification of undiagnosed infections among sexual partners of HIV positive MSM.

Study setting

The goal of the choice-based partner tracing and testing program was to increase HIV testing uptake and yield among sexual partners of newly diagnosed HIV positive MSM, by offering choices in a partner tracing and testing package. This package targeted sexual partners of newly diagnosed HIV positive MSM, as disclosed in post-testing counseling at VCT clinics. The staff from VCT clinics introduced the package to potential participants and invited the MSM to enroll as an IC after being diagnosed within one month. ICs were introduced to a choice of four modes for partner tracing and HIV testing, and they committed to their preferred mode at enrollment. The VCT staff followed up with the ICs or their sexual partners until their sexual partners attended HTS during the three-month follow-up period.

Enrolled sexual partners proceeded to the next round if tested HIV positive and consented to be enrolled as ICs. The process ended when no positive HIV diagnosis was identified among the sexual partners, when a sexual partner was unreachable, or when no positive sexual partner consented to be enrolled as an IC.

The partner tracing and HIV testing package includes: 1) Couples’ HIV counseling and testing (CHCT): The IC is requested to return to the VCT clinic with his sexual partner at a subsequent date to receive joint HIV testing and counseling. The IC is not requested to disclose his HIV status to his sexual partner prior to the CHCT session.; 2) Information assisted partner notification (IAPN): ICs provide the social media or phone contact information of their sexual partners. The VCT staff then contact the sexual partner through these communication tools, declare their own identity, name and working facility, by official landline/telephone or social software accounts, address sexual partner’s risk of infection and encourage he/she to undertake HIV testing, communicate his/her risk of HIV infection; promote VCT; provide information of local VCT clinics; and facilitates a referral to a local VCT clinic; 3) Assisted HIV self-testing (HIVST): The VCT staff trains the ICs how to use an oral rapid HIV testing kit and provides them with testing kits; the ICs then train and provide their sexual partners with the oral rapid HIV testing kits, and return the testing kits to the clinic; 4) Patient referral: ICs are solely responsible for notifying sexual partners and encouraging them to receive HIV testing, and sexual partners come to VCT clinics by himself/herself to take HIV testing. In these modes, the VCT staff follow up to the IC or sexual partner once monthly until sexual partner attends HIV testing during the defined follow-up period of three months. S1 Fig shows this in more detail.

The partner tracing and HIV testing pilot program was implemented at all 23 Centers for Disease Control and Prevention (CDC) VCT clinic sites in the cities of Hangzhou and Ningbo from June 2014 to June 2016. The VCT staff received structured training (duration of two days) by the Zhejiang Provincial CDC. The training included information on the partner tracing and HIV testing package procedure, including how to elicit ICs and their sexual partners, and privacy concerns. All free HIV testing procedures and follow-up care followed the National Guideline for Detection of HIV/AIDS of China [25]. Participants who were tested negative will also be exposed to health education and behavior intervention during post-testing counselling. We utilized the RECORD guidelines to report this study [26].

Data sources and variables

Data on ICs and their sexual partners were collected by the VCT staff who received training on data collection and research ethics. VCT staff administered a short questionnaire on sexual partners and risk behaviors with ICs at VCT sites in addition to routine counseling after an HIV diagnosis.

The questionnaire included questions related to the IC demographics, sexual partner age and gender; the current status of their sexual relationship (currently in a relationship, not currently in a relationship, unsure); types of sexual relationships; frequency of sexual contact in the previous six months or even for stable and unstable relationships, respectively; and condom use in the previous six months. Stable relationships were defined by a report of a stable, non-commercial partner, or by having a male or female spouse. Unstable relationships were defined as either a reported commercial male partner, a casual, non-commercial male partner, or an unmarried female partner. We also collected data on the modes of the partner tracing and testing package selected by ICs (CHCT; Information assisted partner notification (IAPN); Assisted HIV-self testing (HIVST); Patient referral).

Data on sexual partners’ HIV testing uptake and testing outcome were compiled from laboratory records.

The research team extracted data from a database provided by the VCT staff every three months.

Statistics

We utilized EpiData 3.0 [Epidata.dk] for data entry and SAS 9.2 [SAS Institute Inc.] to conduct quantitative analyses. We presented ICs and sexual partners’ characteristics and compared mode participation using frequencies and proportions for categorical variables. We calculated the mode preference of ICs by assigning a preference value of one to each IC and proportionally assigning this value across his selection for each sexual partner.

We compared HIV testing uptake (Tested sexual partners/Reachable sexual partners) and yield (HIV-positive sexual partners/Tested sexual partners) of sexual partners across different modes and presented the estimated effect sizes using odds ratios from generalized linear mixed models (GLMMs). In this model, we included data on sexual partner clustering within the same IC, sexual partner age, and sexual partner gender to control for potential correlation. P-values less than 0.05 were considered statistically significant.

Ethics approval and consent to participate

This study was reviewed and approved by the Zhejiang Provincial Center for Disease Control and Prevention Ethics Review board (2013–001, 2018–038). Written informed consent forms were obtained from all participants in this study.

Results

From June 2014 through June 2016, 2,495 newly diagnosed HIV-positive MSM from VCT clinics in Hangzhou and Ningbo were invited to participate in the study. 435 consented and enrolled as ICs, resulting in an enrollment of 17%. Following the program guidelines, the pilot resulted in two rounds of contact tracing and 4,176 disclosed sexual partners. Of those disclosed, 548 (13%) were reachable. The first-round ICs disclosed 4,116 sexual partners in total; 537 were reachable. Of those reached, 467 accepted HIV testing, 65 tested positive, and 11 consented to enroll as second-round ICs. These second-round ICs disclosed 60 sexual partners in total; 11 of these were reachable and accepted HIV testing. All reachable second-round partners accepted HIV testing, which resulted in nine HIV-positive test results. S2 Fig shows this in more detail.

There were 367 ICs who reached 1 sexual partner, 61 ICs who reached 2 sexual partners, 14 ICs who reached 3 sexual partners, 3 ICs who reached 4 sexual partners, and 1 IC who reached 5 sexual partners. Overall, the proportion of HIV testing among reachable sexual partner for HIV testing was 87%, and HIV testing yield among tested sexual partners was 16%.

In total, 446 first- and second-round ICs enrolled in the pilot, with a mean age of 31.5 (SD = 9.6) years old. Around half of ICs had a college education or above (212, 48%), lived in the local county of the VCT (225, 52%), and disclosed six or more sexual partners (239, 54%). The two rounds of tracing and testing in the pilot resulted in 4,176 disclosed sexual partners (1,014 in recent 6 months), and 548 reached sexual partners (Fig 1). The mean age of sexual partners was 30.7 (SD = 8.9) years old, and most were male (460, 84%). Nearly half of the reachable sexual partners (267, 49%) were currently in a sexual relationship with ICs. Among reachable sexual partners in a stable relationship with an IC, over half (179, 60%) had sex with ICs less than once per week. Among those in casual relationships, almost half (110, 45%) had sex with ICs a total of two to five times. Only approximately one-third of reachable sexual partners (34.7%) reporting consistently using condoms with ICs over the past six months (Table 1).

Table 1. Newly diagnosed HIV-positive men who have sex with men enrolled in a partner tracing and HIV testing program, from June 2014 through June 2016 in the cities of Hangzhou and Ningbo, China.

Characteristics	N	%
Index cases of newly diagnosed men who have sex with men (MSM)	446	100.0
Index cases recruited through self-testing at VCT sites	435	97.5
Index cases recruited through partner tracing and HIV testing program	11	2.5
Age of index case, years
18–24	108	24.2
25–34	200	44.8
35–44	78	17.5
45 and above	48	10.8
Missing	12	2.7
Education level completed by index case
Primary school or below	31	7.0
Junior middle school	87	19.5
Senior high school	104	23.3
College or above	212	47.5
Missing	12	2.7
Residence of index case
local county	225	51.8
outside local county	209	48.2
Number of sexual partners disclosed by index case
1	39	8.7
2–5	168	37.7
6–10	119	26.7
11 and above	120	26.9
Number of sexual partners disclosed by index case in recent 6 months
0–1	206	46.2
2–5	212	47.5
6–10	21	4.7
11 and above	7	1.6
Mode preference of index case, weighted^a
CHCT	160	35.9
IAPN	126	28.3
HIVST	13	2.9
Patient referral	139	31.2

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MSM: men who have sex with men; CHCT: couples’ HIV testing and counseling; IAPN: information assisted partner notification; HIVST: assisted HIV self-testing

^a Weighted by assigning a preference value of one to each IC and proportionally assigning this value across his selection for each sexual partner

ICs selected the patient referral and CHCT mode most frequently (163, 37%) and the HIVST mode the least (13, 3%) (Table 2).

Table 2. Sexual partners of newly diagnosed HIV-positive men who have sex with men enrolled in a partner tracing and HIV testing program from June 2014 through June 2016, in the cities of Hangzhou and Ningbo, China.

Characteristics	N	%
Reachable sexual partners reported by index cases	548
No enrollment as index case in partner tracing and HIV testing program	537	98.0
Subsequent enrollment as index case in partner tracing and HIV testing program	11	2.0
Age of sexual partners, years
17–24	125	22.8
25–34	272	49.6
35–44	105	19.2
45 and above	46	8.4
Gender of sexual partners
Male	460	83.9
Female	85	15.5
Missing	3	0.6
Current relationship status with sexual partners, as disclosed by index case*
Currently in a relationship	267	48.7
Not sure	11	2.0
No current relationship	267	48.7
Missing	3	0.6
Type(s) of sexual relationship with sexual partners, as disclosed by index case cases
Stable relationship with sexual partner
Stable, non-commercial same-sex relationship	219	40.0
opposite-sex spouse	78	14.2
Non-Stable relationship with sexual partner
Commercial same-sex relationship	1	0.2
Casual, non-commercial same-sex relationship	236	43.1
Unmarried opposite-sex relationship	7	1.3
Other	7	1.3
Frequency of sex as disclosed by index cases
Stable relationship with sexual partner: times per week in the past 6 months	297
<1	176	59.3
1–2	95	32.0
3–4	12	4.0
5 and above	0	0
Non-Stable relationship with sexual partner: total sexual partner	244
1	76	31.1
2	70	28.7
3–4	40	16.4
5 and above	33	13.5
Condom use between index case and sexual partner in the past 6 months, as disclosed by index case
Never	91	16.6
Inconsistent	256	46.7
Consistent	190	34.7
Missing	11	2.0

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HIV testing uptake among all reachable sexual partners was 87% and varied between 82–94% across the selected modes. Sexual partners reached through the IAPN mode showed the highest testing uptake (94%).

HIV testing yield among all tested sexual partners was 16%. Among the selected testing and tracing modes, patient referral yielded 18%, CHCT 17%, and IDAPN 7% (Table 2).

We found the odds of a reachable sexual partner taking an HIV test were 290% greater for contacts who were traced and tested through IAPN compared to those traced through CHCT (95% CI: 1.6, 9.3). The odds of a reachable sexual partner testing HIV-positive were 90% lower for contacts who were traced and tested in IAPN compared to those traced through CHCT (95% CI: 0.0, 0.6) (Table 3).

Table 3. HIV testing uptake and yield by modes of partner tracing and testing package among reachable sexual partners of newly diagnosed HIV positive MSM in June 2014 through June 2016, in the cities of Hangzhou and Ningbo, China.

Characteristics			Tested		Not tested		OR	(95%	CI)	Neg		Pos		OR	(95%	CI)
	N	(%)	n	(%)	n	(%)				n	(%)	n	(%)
Reachable sexual partners	548	((100.0)	478	((87.2)	70	((12.8)				404	(85.6)	74	((15.5)
Modes
CHCT	197	((35.9)	162	((82.2)	35	((17.8)	1.0			128	((79.0)	34	((21.0)	1.0
IAPN	155	((28.3)	146	((94.2)	9	((5.8)	3.9	(1.6,	9.3)	136	((93.2)	10	((6.8)	0.1	(0.0,	0.6)
HIVST	16	((2.9)	15	((93.8)	1	((6.3)	3.4	(0.4,	30.0)	15	((100.0)	0	((0.0)	-
Patient Referral	171	((31.2)	153	((89.5)	18	((10.5)	1.8	(0.9,	3.6)	123	((80.4)	30	((19.6)	0.9	(0.4,	2.1)
Unknown	9	((1.6)	2	((22.2)	7	((77.8)	-			2	((100.0)	0	((0.0)	-

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OR: Odds Ratio; CI: Confidence Interval; Neg: negative HIV test; Pos: positive HIV test; CHCT: couples’ HIV testing and counseling; IAPN: Information assisted partner notification; HIVST: assisted HIV self-testing

Regarding different types of sexual relationship with sexual partners, 43% (93/219) of stable same-sex contacts and 55.1% (43/78) opposite-sex spouses were designated to CHCT; 40% (95/236) of casual same-sex partners were designated to IAPN. In casual, non-commercial same-sex relationships, individuals traced and tested through IAPN who received HIV testing were present in higher proportions than individuals traced and tested through CHCT who received HIV testing. S1 Table shows this in more detail.

Discussion

We presented results from a pilot program on combination partner tracing and HIV testing to expand HIV testing uptake for sexual partners of HIV-positive MSM. Our results showed that this package is a feasible approach in this setting, which may help target and locate high-risk populations.

We found that a high proportion (87%) of reachable, sexual partners were successfully tested, which was higher than a previous study in eastern China (23%), but similar to a study in Hangzhou and Kunming (85%) in the Yunnan province southwest of China [27,28]. This suggests that a potential advantage of this partner tracing and testing package may be the ability to expand HIV testing uptake among reachable sexual partners of HIV-positive MSM, and highlight that further research on the effectiveness of testing uptake is needed.

We found a higher HIV testing yield (16%) among tested sexual partners of HIV-positive MSM compared to the HIV prevalence of the Zhejiang province general population (estimated at 0.04%) [13] and general population passive tracing (VCT) testing yield of its cities (1.30% in Hangzhou) [29]. These results were not unexpected, given the higher risk behaviors of MSM [7,30,31]. Our testing yield result was also higher than that of MSM in a city in Zhejiang province who were contacted through passive tracing (VCT; 4.19% in Lishui, 2008–2015) [32]. A previous study also found that partner tracing and testing may be more effective than other HIV testing policies in identifying undiagnosed infections [28]. These findings suggest that a higher efficiency of integrating active case-finding strategies with passive strategies is necessary to target MSM contacts in this setting.

Our results showed variability in the testing uptake and yield across different tracing and testing modes. In the CHCT mode, reachable sexual partners presented the lowest rate of HIV testing uptake, and less odds of uptake than those in the IAPN mode. As CHCT requires that couples take HIV testing and counseling together [18], fear of disclosure or discrimination may be barriers to selection of this mode [33]. Our results on CHCT uptake (82%) are similar to those of a previous study in China that showed high willingness to receive CHCT (86%) [34]. However, this mode resulted in effective case finding compared to other modes, which indicates that it may be more acceptable for same-sex couples who are in or seeking committed relationships [35]. Our results also showed that CHCT is more acceptable among stable sexual partners. These individuals are more likely to engage in unprotected anal sex, and are thus at higher risk of HIV transmission [36], which may contribute to our high-yield results for those who received testing using this mode. Therefore, CHCT may be feasible to identify undiagnosed infections in stable sexual partners.

The information assisted partner notification presented the highest HIV testing uptake. It is in-line with previous studies that showed acceptability of similar methods [15]. Because this mode did not require direct contact between ICs and sexual partners, it may be effective in targeting sexual partners with limited contact information (such as those with social media contact information only) and protect the privacy of both sides. Information assisted partner notification may result in high testing uptake when ICs do not have the intention or ability to notify sexual partners [21]. However, in our study, case finding in the information assisted partner notification was not as effective as that for CHCT and patient referral. This may reflect the fact that the choice of information assisted mode may indicate a less intimate relationship between ICs and their sexual partners, resulting in the difficulty for ICs to reach their sexual partners.

Previous studies showed that oral HIV self-testing can be feasible and effective for MSM and their sexual partners [37]. However, our results indicated that fewer participants chose this mode for their sexual partners. As ICs needed to learn how to use oral HIV self-testing kits and teach this skill to their sexual partners, the overly complex instructional materials and procedure may have restricted ICs’ intention to bring kits to their partners [38]. Further studies and practical applications are needed to identify whether oral HIV self-testing is feasible for expanding HIV testing in the sexual partners of HIV-positive MSM in this setting. Results showed that patient referral is still an important component in expanding HIV testing and case-identification among MSM and should continue to be an option among multi-modal HIV testing uptake programs.

There are some limitations to this research. We utilized self-reported data from ICs, which could have caused information bias in the characteristics of sexual behavior between ICs and sexual partners. In addition, enrollment in the study was limited, as only 435 of 2508 total newly diagnosed HIV positive MSM agreed to participate, and only 18% (548/4,116) of disclosed sexual partners were traceable. The rate of participation as index cases varied among different types of HIV positive populations, and the rate of participation in our study might be lower, compared to results of other studies [39, 40]. However, the number of sexual partners in recent six months (1,014) was much less than the number of sexual partners in their whole life (4,116), which is also need to be considered, as we assume that those reachable sexual partners may mostly come from those who are still in touch with ICs in recent six months. We have compared those HIV positive MSM who enrolled to those who did not, and have found that those who settled in the detection place vs. those outside (28.5% vs. 12.3%), those with education level of college or above vs. those with lower education level (20.5% vs. 16.0%) would be more likely to be enrolled to the program, and there was no statistical difference for the variables of age and marital status. The demographic characteristics of HIV positive MSM might be associate with their participation in this pilot study. Previous studies showed that fear of disclosure of infection status, lack of contact information of sexual partners, and other limitations still play important roles in the gap between numbers of total newly diagnosed HIV positive MSM and enrolled as ICs, and the gap between numbers of self-disclosed sexual partners and reachable sexual partners [28, 41]. However, this pilot package is feasible for identifying undiagnosed infections among reachable sexual partners of HIV-positive MSM. Therefore, our findings are still significant as they provide insight into future approaches.

Conclusions

In conclusion, a partner tracing and testing package program that includes CHCT and information assisted partner notifications may have the potential to play an important role in expanding HIV testing uptake among sexual partners of HIV-positive MSM. This package is also a feasible approach for case finding in high-risk populations. An information assisted partner notification may be an acceptable option to reach sexual partners for whom limited contact information is available. However, further study on the feasibility of oral HIV self-testing among sexual partners of MSM is needed.

Supporting information

S1 Fig. Introduction for modes in the partner tracing and HIV testing package among sexual partners of newly diagnosed HIV positive men who have sex with men, Zhejiang Province, China.

(PDF)

Click here for additional data file.^{(135.9KB, pdf)}

S2 Fig. Two round procedure of partner tracing and HIV testing package among sexual partners of newly diagnosed HIV positive men who have sex with men June 2014 through June 2016 in Hangzhou and Ningbo, China.

(PDF)

Click here for additional data file.^{(39.7KB, pdf)}

S1 Table. HIV testing uptake by modes in different types of sexual relationship among reachable sexual partners of newly diagnosed HIV positive MSM in June 2014 through June 2016, in Hangzhou and Ningbo Cities, China.

(PDF)

Click here for additional data file.^{(113.9KB, pdf)}

S1 File

(DOCX)

Click here for additional data file.^{(18.1KB, docx)}

S2 File

(DOCX)

Click here for additional data file.^{(17.4KB, docx)}

Acknowledgments

This research was conducted through the Structured Operational Research and Training Initiative (SORT-IT), a global partnership coordinated by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization (WHO/TDR). The training model is based on a course developed jointly by the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF). The Specific SORT-IT programme which resulted in this publication was implemented by: Médecins Sans Frontières, Brussels Operational Centre, Luxembourg and the China Centre for Disease Control & Prevention. Mentorship and the coordination/facilitation of this SORT-IT workshop were provided through the University of Washington, Department of Global Health, USA; AMPATH, Eldoret, Kenya; Sustainable Health Systems, Sierra Leone; Universidad Pontificia Bolivariana, Columbia; Global AIDS Interfaith Alliance, USA; Centre for Operational Research, The Union, Paris, France; and the China Centre for Disease Control & Prevention. Thanks to all CDC staff in Hangzhou and Ningbo cities.

Data Availability

The data underlying this study cannot be publicly shared because the database contains personal and sexual information of HIV positive persons, which is sensitive, confidential and under restrict management by Chinese Law. The anonymized data will be available upon request to the Zhejiang Provincial Center for Disease Control and Prevention Ethics Review board. Zhejiang Provincial Center for Disease Control and Prevention Ethics Review Board: Address: NO.3399, Binsheng Road, Binjiang District, Hangzhou City, Zhejiang Province, China Please contact: Mr. Zhenggang Jiang Email: zhgjiang@cdc.zj.cn, TEL:+86 571-87115105.

Funding Statement

This study was supported by Key Project on Social Development among S&T Major Project of Zhejiang Province, China (2013C03047-1), Zhejiang Provincial Medicine Science and Technology Plan (2015PYA004), National Science and Technology Major Project of China (2017ZX10201101), The Training Project of Young Scientific and Technological Innovative Talents of Zhejiang Provincial Center of Disease Control and Prevention. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0232268.r001

Decision Letter 0

Chongyi Wei

12 Dec 2019

PONE-D-19-30003

HIV testing uptake and yield among sexual contacts of HIV-positive men who have sex with men in Zhejiang Province, China, 2014-2016: a cross-sectional pilot study of a choice-based partner tracing and testing package

PLOS ONE

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Reviewer #1: Yes

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Reviewer #3: Yes

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Reviewer #1: Yes

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Reviewer #1: Yes

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Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Congratulations on a fascinating project. This paper articulates the study design and the relevant findings. Also, the methods are sound. You could however explain a little more fully and in detail the different methods of partner tracing (i.e. not all readers will understand patient referral without an explanation).

My greatest concern with this paper is the written English. The paper needs to be revised by a native English speaker/writer which will allow these important findings to be understood more clearly and easily by the relevant audience.

Reviewer #2: This study used routinely collected data to evaluate a contact tracing and testing intervention for partners of men who have sex with men in Zhejiang province, China conducted over two years. Overall, the manuscript read well, but I have concerns about the analysis, intervention description, and the interpretation.

1. The authors conclude that the partner tracing and testing package was “effective for case-finding among a high-risk population.” However, it is unclear what criteria were used to determine “effectiveness”, as there were no outcomes measures for a comparison group that did not receive the intervention. Moreover, the authors’ optimistic appraisal does not seem very strongly supported by the data. The arguably low participation in the intervention (18%) and arguably low proportion of reachable contacts (12%), would lead many readers to conclude that the intervention was in fact not very effective. What if the participation rate and proportion of reachable contacts were only 5%? What was the cut-off point defining effectiveness, if any? Would the authors still conclude that the intervention was “effective”, as long as a relatively high proportion of reachable contacts of completed testing? Please provide stronger justification for why the intervention should be considered “effective”, or modify the appraisal regarding the effectiveness of the intervention. In addition, further discussion is needed about why the participation and reachable contact rates were so low, and what can be done to improve greater uptake.

2. In the interest of implementation and replication, much more detail about the intervention (each mode) is needed. For example, for the “information-driven assisted partner notification” mode of intervention, how did staff introduce themselves when reaching out to contacts of the indexes? What was their training? How were they able to ensure confidentiality? Who covered the cost of testing of partners? For the “patient referral” intervention mode, how did study investigators ascertain the HIV test results of their contacts?

3. In the abstract and text, it appears that the authors did not meaningfully differentiate in their presentation of statistically significant and non-statistically significant results. For example, in the abstract: “odds of a reachable sexual contact enrolled in 28 information-driven mode taking an HIV test were 90% more than that of one enrolled in 29 patient referral (95%CI:0.8, 4.4).” Why conduct significance tests and state “We assigned statistical significance at p-values less than 0.05”, if the presentation of significant results are basically the same as non-significant results?

4. Given the fact that partner contacts were clustered within indexes, I am concerned that the analytic approach did not control for correlated data. Please reanalyze the data using an analytic approach that controls for clustering of observations within indexes (e.g., GEE or random effects), or provide strong justification for why such an analysis is unnecessary.

5. Numerous grammatical errors need to be corrected. For example, “We defined reachable sexual contacts as those can be contacted…” (pg 7).

Reviewer #3: This paper was well conceptualized, however, there are instances where the writing does not follow standard English grammatical conventions. It may be prudent of the authors to have a proof reader who can ensure that sentence structure and the usage of punctuation are sound.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PLoS One. 2020 Jun 4;15(6):e0232268. doi: 10.1371/journal.pone.0232268.r002

Author response to Decision Letter 0

6 Mar 2020

Dear editor and reviewers,

We appreciate it for your efforts to review this manuscript.

Thank you for the reviewers’ comments. We have revised the manuscript and especially paid attention to your comments and suggestions.

We have changed “sexual contact” to “sexual partner” in this revised manuscript as we think this description is much more accurate to define a person who had sex with IC.

In this revised version. Mr. Qiaoqin Ma has helped a lot with improving the description and related analysis. We authors have agreed that he should be listed as co-corresponding author.

Answers to reviewers’ comments are as follows:

Reviewer #1:

Congratulations on a fascinating project. This paper articulates the study design and the relevant findings. Also, the methods are sound. You could however explain a little more fully and in detail the different methods of partner tracing (i.e. not all readers will understand patient referral without an explanation).

Answer: Thanks for the reviewer’s comments. We have revised the method section, and provided details about different modes of partner tracing and HIV testing package.

About the written English, we have asked a native English speaker to help revise the manuscript and edit the language. We also have searched for language editing service from www.editage.cn.

Reviewer #2:

Answer: Thanks for reviewer’s comments. We have seriously taken this comment into consideration. One important reason for overall low uptake might be that the number of self-disclosed sexual partners was the number of total sexual partners during one IC’s life. We consider that those reachable sexual partners may mostly come from those who are still in touch with ICs in recent period of time, thus we analyze the number of sexual partners in recent 6 months disclosed by index case, and to reflect the real gap between disclosed sexual partners and reachable sexual partners in the limitation part of discussion section. The participation rate of index cases varied among different types of HIV positive populations.

In this revised manuscript, we have used “feasible” in place of “effective” (lines 343-366).

Answer: Many thanks.

We have revised the method section. All the details about introduction process, confidentiality, training, cost of testing, ascertaining testing results have been provided in the method section (lines 146-165), and we have updated the supplemental figure 1 to show this in detail.

All our co-authors have agreed that the English translation for “information-driven assisted partner notification” mode is redundant, and have decided to use “information assisted partner notification” to describe this mode.

Answer: We have revised related section, changed reference group in this categorical variable (modes), and changed the description, in related sections (lines 28-30, 265-269) based on reviewer’s comments.

Answer: Thanks, we have seriously considered this comment.

Now, we used univariate logistic regression to compare HIV testing uptake and yield of sexual contacts across different modes. In this study, we found that 18% (79/446) ICs have more than 1 reachable sexual partners, therefore we agree that potential correlation within clustered sexual partners should be considered in analysis process.

The estimated effect size now is produced and represented using odds ratios through generalized linear mixed models (GLMMs). In this model, whether or not sexual partners were clustered with the same IC, sexual partners’ age, and sexual partners’ gender are included to control potential correlation. We have revised related sections (lines 28-30, 205-211).

5. Numerous grammatical errors need to be corrected. For example, “We defined reachable sexual contacts as those can be contacted…” (pg 7).

Answer: Thanks, we have revised the whole manuscript to correct these grammatical errors, and we have searched for language editing service from www.editage.cn to improve the description.

Reviewer #3:

This paper was well conceptualized, however, there are instances where the writing does not follow standard English grammatical conventions. It may be prudent of the authors to have a proof reader who can ensure that sentence structure and the usage of punctuation are sound.

Answer: Thanks for the reviewer’s comments. We have revised the written English through the whole manuscript. We also ask a native English speaker to help revise the manuscript, and we have searched for language editing service from www.editage.cn to improve the description.

Methods

• Please explicitly state the time frame (e.g., past month, past 2 months, etc.) in which someone would be considered “newly diagnosed as HIV positive”.

Answer: Thanks for the reviewers’ comments. Now we explicitly state the time frame as being diagnosed in one month in which someone would be considered “newly diagnosed as HIV positive”. We have revised the method section to make the description clearer, in lines 108, 137-138.

• The sentence in lines 109-111 is a bit hard to understand.

Answer: This sentence was to state the definition of “reachable sexual contacts”. We have revised this sentence to make the expression clearer. The revised version is “We defined reachable sexual contacts as those who could be contacted by face-to-face, official landline/telephone, social software (such as QQ, WeChat and Blued) or other communication tools.” In lines 117-119 now.

• Were sexual contacts of IC who were under the age of 18 and who were HIV-negative also included in this study? You explicitly mentioned sexual contacts under 18 who were HIV-positive.

Answer: Yes, there was one male sexual partner of IC, who was 17 years old, and HIV negative, was included in this study.

We provide standard post-testing counselling, and all participants tested negative would be exposed to health education and behavior intervention. We have made it clear in lines 173-175.

• Given the nature of this study, it may be important to include the IC’s viral load data in this analysis, since this metric is often used to estimate potential risk of forward transmission.

Answer: In China, ARV and viral load testing is provided to HIV positive patients free of charge by the government. We couldn’t collect viral load data of all newly diagnosed IC because viral load testing for free is not required to be done at the moment when a patient is newly diagnosed, just required to be provided once a year to the patients.

• What type of regression did you use? You presented odds ratios, which makes me assume logistic regressions were used.

Answer: Yes, we used univariate logistic regression to compare HIV testing uptake and yield of sexual partners across different modes.

In this revised manuscript, we have updated the analysis through generalized linear mixed models (GLMMs) to control potential correlation within clustered sexual partners (lines 205-211).

• It may be worthwhile to examine if sexual contacts who are in different types of relationships prefer certain methods of contact. For example, if the sexual contact is in a relationship with someone of the opposite sex, the sexual contact may be hesitant to appear with his male sexual partner in public.

Answer: Yes, we agree that sexual partners who are in different types of relationships prefer certain methods of contact. In this study, four modes for partner tracing and HIV testing were introduced to each IC, who then choose a mode which who think that this is the best and appropriate to him and his sexual partners.

On the other hand, unlike the western, two Chinese men may not hesitate to appear together in public because it won’t bring any suspicions that they are MSM or sex partners in Chinese culture as long as they don't act intimately even though one of them is in a relationship with someone of the opposite sex.

• Were there processes in place to make sure that sexual contacts were not duplicated? For example, if two different ICs identified the same sexual contact, this may affect the validity of the post estimates.

Answer: Thanks for your comment.

This study was conducted at 23 VCT clinics of 23 local CDCs in Hangzhou and Ningbo, 2 big cities in Zhejiang Province, China. Standardized VCT service is provided to each VCT seeker at VCT clinics, which is professional, confidential, free of charge and client friendly. Theoretically, one partner in this study is less likely to go to another VCT clinics again after he/she visited one clinic requested by the study staff. Further, we didn’t find duplicated sexual partners who is HIV negative using IC’s partners information such as social software accounts, phone numbers to match each other.

All HIV positive person must be reported to China national HIV/AIDS reporting system. Verification of duplicate case reporting is done when one case is reported. Thus, duplicate IC or IC’s HIV positive partner in this study could not be an issue to be noticed.

• It may be important to explain exactly why those with severe AIDS complications were excluded. If the authors considered high viral load/low cd4 count as a severe complication, those at highest risk for forward transmission may be excluded from this study.

Answer: In inclusion and exclusion section, we have revised this section into “severe AIDS complication or other illnesses requiring hospitalization”, in lines 112-113, to make it much clearer.

Results

• The first three 95% Cis presented in lines 222-226 all cross the null, however, they are presented as if they were statistically significant.

Answer: Based on the reviewers’ comment, we changed reference group in this categorical variable (modes), reanalyzed the dada and have made revision in related sections (lines 275-281).

Discussion

• You mention that only a small proportion of potential participants enrolled in this study. Would it be possible to compare those who enrolled to those who did not to identify if there are certain characteristics that differ between the two groups?

Answer: Thanks for your comment.

We couldn’t collect the characteristics about IC’s sexual partners who are not reachable. Therefore, we were not able to compare the differences between those IC who enrolled and those who did not.

We could just collect social-demographics for IC, such as age, education status, marital status and residence. We have compared those HIV positive MSM who enrolled to those who did not, and have found that those who settled in the detection place vs. those outside ( 28.5% vs. 12.3%) , those with education level of college or above vs. those with lower education level ( 20.5% vs. 16.0%) would be more likely to be enrolled to the program, and there was no statistical difference and there was no statistical difference for the variables of age and marital status. This comparison has also been stated in the discussion section as a limitation. (lines 353-358)

Minor

Line 186 – Change 4176 to 4,176

Line 187 – please add a space between 548 and (13%)

Line 195 – please add a space between 31.5 and (SD=9.6)

Line 198 – please add a space between 30.7 and (SD=8.9)

It may be worthwhile for the authors to go through the manuscript to identify additional grammatical errors.

Answer: Thanks for your advices, we have revised related sections and go through the manuscript to revise other grammatical errors.

Additional requirements

Answer: Thank you for your advice. We have downloaded these files and checked the format.

Answer: We have uploaded two copies of the questionnaire, one in Chinese and the other one in English, as supporting files.

Pre-investigation was conducted among 20 HIV positive MSM in Hangzhou city to improve the quality of questionnaire, mainly in questions related to sexual contacts with their sexual partners.

Answer: Consent was informed and written informed consent forms were obtained from HIV positive minor participants and their guardians (lines 121-123). We make it clear in the method section.

4. Thank you for stating the following in the Acknowledgments Section of your manuscript:

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

Answer: Thanks. We have removed details of funding information from the manuscript to the online submission form.

The funding statement will be updated as follows:

“This study was supported by Key Project on Social Development among S&T Major Project of Zhejiang Province, China (2013C03047-1), Zhejiang Provincial Medicine Science and Technology Plan (2015PYA004), National Science and Technology Major Project of China (2017ZX10201101), The Training Project of Young Scientific and Technological Innovative Talents of Zhejiang Provincial Center of Disease Control and Prevention.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

In your revised cover letter, please address the following prompts:

We will update your Data Availability statement on your behalf to reflect the information you provide.

Answer: We are sorry we couldn’t upload the database in the system because this database contains personal and sexual information of HIV positive persons, which is sensitive, confidential and under restrict management by Chinese Law. Please contact our ethics committee if having any question about this.

Contact information of Zhejiang Provincial Center for Disease Control and Prevention Ethics Review board:

Address: NO.3399, Binsheng Road, Binjiang District, Hangzhou City, Zhejiang Province, China.

Please contact: Mr. Zhenggang Jiang

Email: zhgjiang@cdc.zj.cn，TEL：+86 571-87115105

Answer: We have checked and moved ethics statement to the methods section, and deleted ethics statement in any other sections.

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PLoS One. doi: 10.1371/journal.pone.0232268.r003

Decision Letter 1

Chongyi Wei

16 Mar 2020

PONE-D-19-30003R1

HIV testing uptake and yield among sexual partners of HIV-positive men who have sex with men in Zhejiang Province, China, 2014-2016: a cross-sectional pilot study of a choice-based partner tracing and testing package

PLOS ONE

Dear Mrs Pan,

==============================

Please address Reviewer# 2's additional comments.

==============================

We would appreciate receiving your revised manuscript by Apr 30 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Chongyi Wei, DrPH

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: The authors have addressed most points satisfactorily, but there are a few outstanding issues.

1. The authors state: “The Chinese government has advocated for an increase in HIV

51 testing among high-risk populations since 2012.” However, it is clear that testing among high-risk populations was advocated much earlier than 2012. See http://data.unaids.org/una-docs/china_joint_assessment_2003_en.pdf

2. Line 135. Change “HIV men” to men living with HIV, or something else.

3. Lines 142-145. “Enrolled participants proceeded to the next round if tested…” What do you mean by “the next round if tested”? Please restructure/reword this paragraph, which I found to be somewhat confusing.

4. Line 234. “to identify a positive.” Please reword.

5. There are still typos/grammatical issues in the manuscript. For example, “sexual partner” on lines 243 and 245 and Table 2 (Frequency of sexual partner) should be changed to “sex”. And “mod” is misspelled on line 254.

6. Lines 291-292. “The mean number of successfully recruiting a reachable

292 sexual partner for HIV testing was 1.1.” Please rephrase for clarity.

7. Lines 329-331. “This may reflect the fact that the choice of information assisted mode may indicate a less intimate relationship.” Please elaborate on the connection between an intimate relationship and lower effectiveness in case finding. That connection may not be intuitive to the reader.

8. Grammar. Line 350. “However, the gap between total disclosed sexual partners (4116) and

351 those in recent six months (1014) is also need to be considered, as…”

9. Line 358. Given the stated study population, I don’t quite understand the issue with selection bias. The stated study population on lines 103-106 is MSM who agreed to participate in the program. This would suggest that MSM who did not agree to participate were NOT in the study population of interest. Perhaps the authors meant the study sample were MSM who tested positive and agreed to participate and that the study population was all MSM who tested positive?

10. The wording of the stated aim could be clearer. “In this study, we describe a pilot study of a choice-based partner tracing and testing program aimed at analyzing the uptake and infection status of HIV testing for sexual partners of newly diagnosed HIV-positive MSM.” Is it the study that is aiming to analyze the uptake and infection status? Or is it the program itself that aimed to analyze the uptake and infection status?

Recommendation: MINOR REVISION

Reviewer #3: Thank you for taking the time to make revisions on your manuscript. I believe that the paper now reads significantly better and conveys your findings in a clear way.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

PLoS One. 2020 Jun 4;15(6):e0232268. doi: 10.1371/journal.pone.0232268.r004

Author response to Decision Letter 1

10 Apr 2020

Dear editor and reviewers，

We appreciate a lot for your comments which are critical to help us improve this manuscript. We take these comments into account carefully, and have revised this manuscript accordingly. All authors of this manuscript would like to express our sincere thanks for your consideration of this resubmission.

The reviewers’ comments are responded as follows point by point.

Reviewer #2: The authors have addressed most points satisfactorily, but there are a few outstanding issues.

1. The authors state: “The Chinese government has advocated for an increase in HIV

testing among high-risk populations since 2012.” However, it is clear that testing among high-risk populations was advocated much earlier than 2012. See http://data.unaids.org/una-docs/china_joint_assessment_2003_en.pdf

� Thanks a lot for your comment. We have checked this assessment and related polices，and read the document A Joint Assessment of HIV/AIDS Prevention, Treatment and Care in China provide by the reviewer. In 2003, Chinese government issued the national policy of "Four Free and One Care", which included free HIV counselling and testing (VCT), free antiviral treatment, free prevention of transmission from mother to child, free education for HIV affected children, and care for people living with HIV. We have revised this sentence into “In 2003, the Chinese government began to enforce the free voluntary counselling and testing (VCT) policy.” In lines 51-53. The relevant reference was also changed.

2. Line 135. Change “HIV men” to men living with HIV, or something else.

� We have revised “HIV men” into “HIV positive MSM”, in lines 134.

� This sentence has been revised as “Enrolled sexual partners proceeded to the next round if tested HIV positive and consented to be enrolled as ICs.” In lines 141-142.

4. Line 234. “to identify a positive.” Please reword.

� We have revised the whole sentence into “Overall, the proportion of HIV testing among reachable sexual partner for HIV testing was 87%, and HIV testing yield among tested sexual partners was 16%.” In lines 231-233.

� We have checked and revised these grammatical or spelling mistakes.

6. Lines 291-292. “The mean number of successfully recruiting a reachable

292 sexual partner for HIV testing was 1.1.” Please rephrase for clarity.

� We think this sentence may be a little redundant and not clear, and removed this sentence.

� This sentence has been revised in lines 329-330 to clarify that less intimate relationship may result in the difficulty for ICs to reach their sexual partners.

8. Grammar. Line 350. “However, the gap between total disclosed sexual partners (4116) and

351 those in recent six months (1014) is also need to be considered, as…”

� This sentence has been revised as “However, the number of sexual partners in recent six months (1,014) was much less than the number of sexual partners in their whole life (4,116), which is also need to be considered, as…” in lines 349-350.

� As descripted in lines 102-105, we defined the study population as newly diagnosed HIV-positive MSM and their sexual partners, who agreed to participate in the partner tracing and HIV testing program at VCT clinic study sites in the cities of Hangzhou and Ningbo from June 2014 through June 2016. We agree that it may not be suitable to name this as selection bias. This sentence is revised into “The demographic characteristics of HIV positive MSM might be associate with their participation in this pilot study” 357-359.

� This study aims to analyze the uptake and the infection status. We have revised this sentence into “In this study, we aimed at analyzing the uptake and infection status of HIV testing for sexual partners of newly diagnosed HIV-positive MSM.” In lines 95-97.

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PLoS One. doi: 10.1371/journal.pone.0232268.r005

Decision Letter 2

Chongyi Wei

13 Apr 2020

PONE-D-19-30003R2

Dear Dr. Pan,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

Chongyi Wei, DrPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0232268.r006

Acceptance letter

Chongyi Wei

24 Apr 2020

PONE-D-19-30003R2

Dear Dr. Pan:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Chongyi Wei

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Fig. Introduction for modes in the partner tracing and HIV testing package among sexual partners of newly diagnosed HIV positive men who have sex with men, Zhejiang Province, China.

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S1 File

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S2 File

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Data Availability Statement

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PERMALINK

HIV testing uptake and yield among sexual partners of HIV-positive men who have sex with men in Zhejiang Province, China, 2014-2016: A cross-sectional pilot study of a choice-based partner tracing and testing package

Mingyu Luo

Katrina Hann

Guomin Zhang

Xiaohong Pan

Qiaoqin Ma

Jun Jiang

Lin Chen

Shichang Xia

Roles

Abstract

Background

Methods

Results

Conclusions

Introduction

Materials and methods

Selection and description of participants

Technical information

Study design

Study setting

Data sources and variables

Statistics

Ethics approval and consent to participate

Results

Fig 1. Cascade of partner tracing and HIV testing package among sexual partners of newly diagnosed HIV positive men who have sex with men June 2014 through June 2016 in Hangzhou and Ningbo, China.

Table 1. Newly diagnosed HIV-positive men who have sex with men enrolled in a partner tracing and HIV testing program, from June 2014 through June 2016 in the cities of Hangzhou and Ningbo, China.

Table 2. Sexual partners of newly diagnosed HIV-positive men who have sex with men enrolled in a partner tracing and HIV testing program from June 2014 through June 2016, in the cities of Hangzhou and Ningbo, China.

Table 3. HIV testing uptake and yield by modes of partner tracing and testing package among reachable sexual partners of newly diagnosed HIV positive MSM in June 2014 through June 2016, in the cities of Hangzhou and Ningbo, China.

Discussion

Conclusions

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Chongyi Wei

Roles

Author response to Decision Letter 0

Decision Letter 1

Chongyi Wei

Roles

Author response to Decision Letter 1

Decision Letter 2

Chongyi Wei

Roles

Acceptance letter

Chongyi Wei

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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