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Issue
China has made a substantial progress in tackling its HIV epidemic. The HIV epidemic in China is largely characterized by low national prevalence at 0.037% with certain regions having higher and more severe HIV prevalence rates [1]. The country has also made substantial progress with regards to funding its HIV response as 99% of funding came from domestic sources in 2015 [UNAIDS, 2016]. Despite these efforts, in December 2016 the Chinese Centre for Disease Control and Prevention (CCDC) reports 96,000 new HIV cases in the first nine months of that year. This indicated that the number of new cases in 2016 is likely to exceed 115,000, the number of new cases in 2015 [2]. HIV epidemic is still a major concern for some of the key affected populations within the country.
HIV prevalence among men who have sex with men (MSM) have been rising in China. According to Chinas Health and Family Planning Commission the MSM population has a HIV prevalence of 7.7% [2]. MSM represent over a quarter of new reported infections each year [UNAIDS,2013]. Each day of 2016, 10 Chinese university students were infected with HIV-eight of whom were MSM [3]. Unfortunately, in China, many MSM attending university first learn of HIV when they receive their HIV-positive test result. There are several factors that increase their vulnerability to HIV infection. MSM population do not feel safe in accessing public health resources due to widespread homophobia. Besides, sex education in schools is inadequate and many young people do not have basic sexual health knowledge [4]. Ignorance of HIV status is a major factor in rising epidemic amongst the MSM population.
The purpose of this paper is to investigate the gap in HIV diagnosis in MSM population in China and to identify the interventions targeted to this population to control their increasing HIV rates.
Methods
A systematic literature review was performed to collect the necessary data for this paper. Information for this paper was collected from UNAIDS & WHO websites, PubMed research papers, articles were searched using keywords-MSM HIV in China, Interventions for MSM HIV China. Information was also used from University of Pittsburgh-IDM Monday seminar presentation by Dr.Chongyi Wei.
MSM population accounted for only 0.3% of all HIV cases between 1985 and 2005 according to the Chinese ministry of health and UNAIDS statistics. This percentage however increased to 2.55 in 2006 and farther increased to 25.8% in 2014 shown in figure 1[5]. According to reports there is a prevalence of high-risk behaviors among MSM population in China. Approximately 45.7% of respondents were found to have unprotected sex with male partners and 10.9% had with female partners [5]. 22.9% of HIV infected MSM population have a blood donation history which in turn increases the likelihood transmission of HIV-1 through blood products. Apart from making the MSM population more vulnerable to infections, such high-risk behaviors also result in transmission of the disease to the uninfected general population.
The complex biology of HIV-1 virus and changes in demographic profile of Chinese MSM and pose serious challenges to prevention of HIV, development of ART and vaccines [5]. In 1997 the authorities decriminalized homosexual sex in China and in 2008 homosexual sex was erased from the official list of mental disorders [6]. However, due to cultural and economic reasons men who have sex with men often face the social stigma, abuse and tend to hide their identity from the world. Because of this stigmatization, men do not feel secure and comfortable in approaching clinics and other health resources to seek treatment or test for HIV. Thus, Chinas MSM population remain hidden from the society of China which results in rapid transmission of HIV to both homosexual and heterosexual partners. These societal pressures and cultural factors prevent a greater understanding of the HIV epidemic in China among MSM population [7].
My paper talks briefly about some of the recent research studies done for the Chinese MSM population that helps understand what factors might be preventing them from seeking help, how we can improvise more to encourage them to seek help and what measures need to be taken for a healthy sexual lifestyle in Chinas MSM population.
Findings/Results
IMPACT Project
For the control of HIV epidemic among the MSM population, community engagement as a whole is very important. Not-for-profit community-based organizations (CBOs) are responsible for providing the educational, environmental and social or public safety needs of the community in China. However, most of Chinas public-sector funded HIV programmes failed in engaging CBOs and had very limited success in preventing the countrys HIV epidemic. Also, majority of the MSM-friendly CBOs lack in providing services like HIV testing, post- HIV test counselling, notification of results and follow-up, which reduce their ability in providing comprehensive care services.
To address these issues, an HIV care and prevention programme was launched in China in 2008 that was sponsored by the Bill & Melinda Gates Foundation [8]. An important function of this programme was to promote collaboration between CBOs and public sector agencies in the delivery of prevention and other support services. The preventive services were targeted to high-risk groups (MSM) and aimed to lessen risk behaviors and increase HIV testing. Some of the findings of the IMPACT project in Guangzhou are discussed here. This project had different components: Online Prevention Tool- an assessment system for the risk of HIV which evaluated an individuals risk profile and then calculated an individualized HIV-risk score. This tool offered tailored guidance to promote testing of HIV and change in high-risk behaviors. HIV education was also provided online through social media. Online to Offline Service-people could choose to have a test in health facility from the online tool and they were notified about their test results by an online notification system. Service Center- in Guangzhou a one-stop service centre was built, which was coordinated by a Guangzhou CDC and a local CBO. In this centre, on-site blood sampling and HIV tests was provided by the public sector staff. The staff did several epidemiological investigations, like HIV sentinel surveillance among MSM and medical follow-up for the people who tested positive. Questions regarding sexual behaviors were also asked to the people who were tested.
As shown in figure 2 below, the project resulted in an increase in the annual number of tests from 1064 in 2008 to 7754 in 2013. By the year 2013, the project resulted in more than 80% of total HIV tests and new HIV diagnoses among men who have sex with men in Guangzhou. Right now, each day an average of 25 people make appointment and get HIV-tested through the project. Several needs of the community have been addressed by this project and it has also improved access to HIV services. Further, this project ensured continuum-of-care services, including linkage to HIV care, retention in HIV care, ART initiation and ART adherence [8].
However, one of the key limitations of this project was that it lacked a comprehensive pre-intervention data and therefore were unable to demonstrate the effect of their intervention. Also, they recruited only a subset of MSM residing in the area where the study was being done and found it difficult to recruit some of the other important subgroups like the rural or older MSM population who had poor knowledge about HIV, low education and less access to HIV health centres making them highly vulnerable to HIV [9]. The project maybe usefully adapted to other places in China and closer partnership with clinical facilities will further enhance the project.
Identifying Factors Determining MSM HIV Testing Preferences
In order to mediate proper HIV treatment and to limit its secondary transmission it is essential that HIV serostatus is diagnosed as early as possible (Charlebois, Das, Porco, & Havlir, 2011; Granich, Gilks, Dye, De Cock, & Williams, 2009). Even though there are many interventions that are working to increase the knowledge of MSM population regarding HIV serostatus, the uptake of HIV testing still remains low on a global scale (Arreola, Hebert, Makofane, Beck, & Ayala, 2012). Therefore, it is crucial to understand the modalities and factors which facilitate testing of HIV as this is the first step toward eliminating hindrance to test uptake. In order to make effective intervention strategies that can overcome the hurdles to Chinas HIV testing among the MSM population, a study was conducted by L.Han et al., in 2016 to get more information regarding HIV testing preferences among MSM.
[bookmark: _Hlk7171522][bookmark: _Hlk7171244]Two of the largest MSM CBOs were used to conduct an online survey through their respective web portals: gztz.org in Guangzhou and ManBF.net in Chongqing. The people recruited for this study were biologically men of at least 16 years of age and at least once in their lifetime had performed anal sex with men. The study noted different measures of behavioral characteristics like- the number of male partners for anal sex in the past 3 months, HIV testing history, history of sex with women, and accounts of condom less sex for the past 3 months. Options of eight different HIV testing venues were given to the participants for rating their acceptance toward the venues which were- CDC, gay mens CBO, gay bar, public hospital, private medical clinic, HIV/AIDS CBO, home, sauna. As shown in Table 1 below, the study identified that for HIV testing, the MSM population considered a guarantee of test quality (87.5%) a guarantee of confidentiality (89.7%) to be very important factors. 75.4% of men labelled the ability to test for HIV at home very important or quite important. The study also reported that MSM population find HIV testing at venues like CDCs, accept HIV testing at gay mens CBOs and public hospitals acceptable. The study results also suggested that it may be feasible to have HIV self-testing among Chinese MSM.
Some of the other previous studies in similar fields have reported that many men do not prefer to test at facilities due to stigma associated with HIV testing (Myers et al., 2013; Tucker et al., 2013), inconvenience , confidentiality, lack of privacy and confidentiality, and stigma associated with HIV testing. Therefore, this studies identified that we need to improvise on the confidentialities and qualities of HIV tests at Chinas MSM friendly CBOs and at the different HIV testing venues. Steps need to be taken to make the different testing venue MSM friendly so that they do not face any negative environment or discomfort. Further this study showed us that HIV-self testing can be a big solution to these societal problems.
HIVST (HIV Self-Testing)
HIV self-testing is a method in which people can conduct a rapid point-of care test with their own oral fluid or blood specimen at a convenient location of their own choice. This may help Chinese MSM overcome some of these barriers to HIV testing since it does not lead to disclosure of their sexual minority status [10]. According to reports, there is a high level of unrecognized HIV infection in China as a significant proportion of the countrys MSM population have either not been HIV tested or do not take routine testing. Studies in different countries have identified that acceptance/preference of HIV self-testing is very high among the MSM [11].
In Jiangsus MSM population, a cross-sectional study was conducted by H.Yan et al, in 2015 where questions about HIV self-testing were asked to the participants. It was found that 26.2% of the total 522 participants had ever self-tested. Most of the participants said performing HIV self-testing was very easy or somewhat easy and 86.1% reported that the most common self-testing modality was finger stick. 85% of the participants said they would routinely continue to use HIVST and 82% were willing to HIV self-testing with their partners [12]. Therefore, in China we need to utilize different platforms like campaigns, advertisement and posters across street and health clinics, social media, dating apps to spread the awareness of HIV self-testing intervention package in order to increase the frequency of HIVST uptake among the MSM population.
PrEP
A major reason for the increasing burden of HIV in MSM population of China could be the lack of integration of PrEP into the portfolio of HIV prevention strategies and the unavailability of PrEP in China. PrEP involves daily intake of oral ART by HIV-negative individuals and is a very effective biomedical intervention.
A study was done by Lei Zhang et al. in 2018 that evaluated the epidemiological impact of implementing PrEP for over the next two decades in Chinese MSM. The study reported that lack of PrEP in China could result in 1.13.0 million new HIV infections and 0.72.3 million HIV related deaths in the next two decades. Approximately 0.170.32 million new HIV infections could be prevented by moderate coverage of PrEP (50%) [13]. The study demonstrated that there could be major epidemiological benefits if PrEP is integrated into Chinas national HIV prevention program as it estimates if PrRP is used for an average of 5 years each by 1.2 million high-risk MSM then 256,000 new infections would be averted over a twenty-year [13].
However, a drawback to the implementation of PrEP in China is that it might not be cost effective at the current annual price rate of US $3,500. Therefore, government in China need to take steps to cut down the cost of Truvada by about 50% to make ART more accessible to the MSM population. This could be achieved probably by negotiating with Gilead to reduce the price of Truvada in Chinese market by bulk purchase. However, despite the lack of cost-effectiveness the government must take measures to immediately implement PrEP in its HIV prevention strategy since delaying the implementation even by 5 years could result in tens of thousands of infections in MSM that could be averted by PrEP. Further, China also needs to think about how to reach out and deliver PrEP to the high-risk population. PrEP delivery needs to be initiated via multiple prevention service delivery systems like CDC that works in collaboration with local community-based organizations (CBOs), primary care practices, sexual health clinics to find out which system works best for MSM population in different regions of China [13].
Discussion
Chinas MSM population accounts for one-third of new HIV infections in the country and there has been a rising burden of HIV epidemic in Chinese MSM population [14]. Many of these affected individuals either do not reach out to or cannot be reached by HIV prevention services. In support of this, a meta-analysis reported that in the past 12 months just 38% and 47% of Chinese MSM received HIV counseling and testing in their lifetime, respectively [15]. Although same-sex behavior is not illegal in China, MSM population has significant negative social and cultural consequences, like loss of employment and family rejection. As a result of this fear, most of the MSM do not reveal their same-sex behavior to their health-care providers. Also, in order to not encounter any discrimination or stigma and they do not access HIV prevention services [6]. Therefore, the above studies were critical to understand the different ways/strategies that can facilitate increased uptake of HIV testing among the MSM population of China and also prevent new incidence of HIV in them.
The top priority of the Chinese national HIV/AIDS strategic plan is to promote HIV testing uptake among MSM and there has been a growing body of literature on this topic. Even though HIVST has some limitations such as low sensitivity and failing to detect infection during the window period , there can be significant public health impact of this method. It can result in highly reduced transmission of the virus among MSM population if there is an increase in the uptake among self-testers and if it reaches never-tested people. Therefore, strategies are needed to encourage and expand adoption. HIVST kits should be made available over-the counter in order to increase the frequency of testing among the high-risk MSM population.
The most promising biomedical intervention for HIV prevention so far is Pre-exposure prophylaxis or PrEP. USFDA has approved a combined therapy of the antiviral drug tenofovir (TDF) and emtricitabine (TDF-FTC) as preventive drugs for MSM [15]. From 2003 to 2013 there was implementation of condom use and ART Condom use and ART in the Chaoyang district of Beijing. This resulted in 20-25% reduction of HIV incidence among MSM and it also reached the target of the National AIDS Comprehensive Prevention and Control Demonstration Area. There was also a decline in the relative risk of HIV infections from 0 to 31.53% because of condom use among the high-risk groups [18].
Challenges & Recommendations
Policy level: The Regulation on the Prevention and Treatment of HIV-1/AIDS established rules in 2006 to erase public and legal prejudices against HIV infected individuals. Even though these recommendations have been approved by China’s State Council, breach of these recommendations currently do not entail any legal consequences. Therefore, China needs strict legislations with clearly defined legal consequences and enforcement policies. There should be proper MSM support/help centres where men facing any kind of prejudice or breach of confidentiality regarding their HIV status should be able to go in order to take legal actions. New policies need to be formed where intentional exposure of others to HIV could result in criminalization.
A challenge in the implementation of PrEP in Chinas HIV prevention regimen is the high cost of Truvada. Therefore, government needs to make new policies so that these drugs could be made affordable for the high-risk MSM groups.
Program level: There needs to HIV-1 awareness programmes and campaigns targeted at MSM population in China to encourage people not to indulge in high-risk behaviors and encourage positive changes in behaviors. Studies have reported that majority of MSM population interact or connect via various social media platforms. [5] Blued is a very popular gay dating app in China with around 40 million registered users. Therefore, measures should be taken to promote safe-sex methods like advertisement of condom use, campaigns on PrEP uptake benefits, importance of routine HIV testing both on self and their partners through these dating app platforms and other technologies. There needs to organizations set up in China targeted at MSM population that will offer free advice on safe-sex methods, demonstrations on condom use, where to get HIV tested, how to seek medical help if an individual got positive results for HIVST. Popular regional figures affected by HIV should also be encouraged to act as role models for the minority population and raise awareness programs.
Research and clinical care level: Even though there have been a recent increase in epidemiological research, there needs to be a shift in focus of the utilization of the data for improved and applied public health measures and needs rather than data use only for analysis and surveillance. MSM population should be encouraged to participate in more clinical studies to identify proper therapeutic and vaccine strategies targeted for this highly vulnerable group. More research should be done in China to identify what results in the high susceptibility of HIV among men who have anal sex with men. Government should encourage more research studies that are targeting at MSM population and trying to develop therapeutics that can lessen HIV incidence in cases of anal sex among MSM population.
Population health: A potential intervention to prevent secondary transmission cases of HIV is treatment as prevention (TasP)which acts by preventing viral replication and this strategy has now been implemented in the Chinese MSM population.
However, a major challenge to this strategy is maintaining a good adherence to ART. There are reports which indicate that anxiety and depression are very common among HIV infected Chinese MSMs as they lack proper resources and face societal stigma due to which they cannot disclose their problems openly. This interrupts their ability to adhere to ART treatment regimens [5]. Therefore, there needs to some MSM counseling centres set up in China that can provide help to men who are suffering from low self-esteem or depression during their illness and motivate them to adhere to their treatment plans.
Some other recommendations would be to have sex education classes in schools where students will learn basic knowledge about sex safety, condom use etc. Initiatives should also be taken in schools where students should be advised to treat every individual with respect irrespective of their gender bias, so as to reduce the homophobic stigma in society.
Limitations
The paper is a review of some of the interesting strategies and research works that are being done to decrease HIV prevalence in MSM population in China. I did not carry out any of above research studies. There are a lot of current research studies going on regarding this topic. My paper probably does not cover all the current intervention strategies.
References
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