Development of the non-occupational post-exposure prophylaxis (NPEP) knowledge scale among Chinese men who have sex with men.

BACKGROUND: Nonoccupational post-exposure prophylaxis (NPEP) is a short course of medication taken to reduce the likelihood of acquiring human immunodeficiency virus (HIV) infection upon exposure. A review of the literature demonstrates an urgent need for an empirically validated instrument that measures detailed knowledge of NPEP among the key population of men who have sex with men (MSM). METHODS: Semi-structured interviews, focus groups, and a cross-sectional survey with a sample of 419 MSM was conducted in 2018 in China to develop and psychometrically evaluate the new instrument, the NPEP Knowledge Scale. Exploratory and confirmatory factor analyses, differential item functioning analyses, and structural equation modeling were conducted using Mplus 7.4. RESULTS: The NPEP Knowledge Scale demonstrated excellent reliability and validity. Cronbach's alpha was 0.903. The range of item R2 were 0.527-0.969, p's < 0.001. Model estimated inter-item correlations ranged between 0.534 and 0.968. In addition, HIV knowledge, NPEP use, and NPEP knowledge were all significantly correlated. CONCLUSIONS: The NPEP Knowledge Scale is suitable for research, program evaluation, and clinical and community services that require using NPEP to minimize the ever-present risk of new HIV infections.

HIV testing frequency and associated factors among five key populations in ten cities of China: a cross-sectional study.

BACKGROUND: Regular HIV testing is the best way to detect people living with HIV promptly, yet not much is known about the characteristics of frequent, voluntary testers. This study explores factors related to HIV testing frequency among five key populations in China including men who have sex with men (MSM), female sex workers (FSWs), people who use drugs (PWUD), men who have casual sex with women (MCSW) and sero-negative partners among sero-discordant couples (SNPs). METHODS: We conducted a cross-sectional study in ten cities of China from November 2018 to September 2019 using convenience sampling to recruit participants. Univariate and multivariate partial proportional odds models were adopted to compare socio-behavioral factors associated with HIV testing frequencies among the five key populations. RESULTS: Among the 2022 recruited participants, 36.6% reported not testing for HIV in the past year, whereas 37.0% tested once and 26.4% tested twice. Compared with MSM, FSWs (AOR = 1.97, 95% CI: 1.36-2.86) and SNPs (AOR = 3.63, 95% CI: 2.40-5.49) were more likely to test for HIV, but MCSW (AOR = 0.23, 95% CI: 0.17-0.32) were less likely. Additionally, SNPs (AOR = 4.02, 95% CI: 2.78-5.83) were more likely to be frequent HIV testers, while FSWs (AOR = 0.49, 95% CI: 0.32-0.76) and MCSW (AOR = 0.29, 95% CI: 0.20-0.41) were less likely to be frequent testers. Factors identified as barriers to HIV testing include the following: higher education level and > 5000 CNY monthly income for FSWs; elder age and a married/cohabitating status for PWUD; reported alcohol use for MCSW; and non-Han ethnicity and non-local household for SNPs. Facilitators to frequent testing included the following: higher education level for MSM and SNPs; higher AIDS knowledge score for MSM and PWUD; > 5000 CNY monthly income for FSWs and PWUD; and reporting high-risk sexual behaviors for MSM, FSW and PWUD. CONCLUSIONS: HIV testing frequencies and associated factors were not equivalent across the five key populations in China. Public health officials should take heed of the identified high-risk populations reporting high testing rates, perhaps with intensive and tailored behavioral interventions or biochemical prophylaxis.

Drug users' awareness of and willingness to use HIV non-occupational post-exposure prophylaxis (nPEP) services in China: a mixed methods study.

BACKGROUND: Drug users are regarded as a high-risk population for HIV infection. Non-occupational post-exposure prophylaxis (nPEP) is internationally regarded as an effective biomedical prevention against HIV but still a small-scale pilot project in China at present. The aim of this study was to understand drug users' awareness of and willingness to use nPEP service in China. METHODS: This mixed methods study consisting of a qualitative study and a cross-sectional survey was conducted in two cities of China from 2018 to 2019. The in-depth interviews were audio-taped, transcribed verbatim and analyzed using thematic framework analysis. Univariate and multivariate logistic regressions were used to examine factors associated with drug users' awareness of and willingness to use nPEP. RESULTS: There were 401 and 19 participants included in quantitative and qualitative study respectively. Among participants in quantitative study, 30.2% had heard of nPEP and 56.7% reported willingness to use nPEP in future HIV exposure. In multivariate analyses, nPEP awareness was associated with age, sex, education level, AIDS knowledge score and HIV risk perception. nPEP willingness was associated with AIDS knowledge score, HIV risk perception, alcohol use, monthly income and awareness of nPEP. The qualitative results showed the barriers to nPEP willingness included the fatigue after taking drugs, high cost and side effects of nPEP medication, long nPEP course, and fear of privacy disclosure. CONCLUSION: Drug users had low nPEP awareness and only about half participants reported willingness to use nPEP. It is essential to promote nPEP education campaigns among drug users, especially for elders, women and those with lower education level. Simultaneously, price regulation, side effect management, psychological support and privacy protection need to be managed well when nPEP is routinized.

HIV non-occupational postexposure prophylaxis (nPEP) usage among five key populations in China.

OBJECTIVES: To examine the feasibility of non-occupational postexposure prophylaxis (nPEP) as a national strategy for HIV prevention in China, we investigated nPEP usage and related sociodemographic and behavioural factors among five key populations at high risk of contracting HIV. METHODS: We conducted a cross-sectional study among five key populations from November 2018 to September 2019 in China using convenience sampling to recruit participants aged ≥18 years, self-reporting HIV status as either negative or unknown and providing written informed consent. Univariable and multivariable logistic regression models were fitted. RESULTS: Our analysis included data from 2022 participants with a mean age of 35 years (SD=11.62). Only 57 (2.82%) participants had ever used nPEP. Sociodemographic and behavioural factors related to nPEP usage included populations (p<0.0001), age (p<0.05), education (p<0.05), nPEP knowledge (p<0.01), receiving conventional HIV prevention services (p<0.05) and HIV testing (p<0.05). A significant percentage (26%) of nPEP users used nPEP medication more than once. Challenges and concerns, such as multiple use of nPEP and syndemic conditions, were emerging. CONCLUSIONS: Key populations in China had low nPEP usage rates. Female sex workers, people who use drugs, older and illiterate individuals with poor nPEP knowledge, not using HIV prevention services or never tested for HIV should be emphasised. Implementing nPEP services would be an important way to access high-risk individuals for intensive and tailored HIV prevention and intervention. Challenges of providing nPEP services and future study foci are highlighted.

Examining potential effects of non-occupational post-exposure prophylaxis (nPEP) on sexual behaviors of Chinese men who have sex with men: a cross-sectional study.

BACKGROUND: In China, non-occupational post-exposure prophylaxis (nPEP) is not a conventional service yet and nPEP related studies are very few. Recently, China's 13th Five Year Action Plan for HIV/AIDS Containment and Prevention examines the feasibility of including nPEP as one of the national strategies for HIV prevention. However, there is a concern that nPEP use might exacerbate high-risk sexual activities. In order to facilitate a research-based policy making of routinizing nPEP services, the current study examined potential effects of nPEP use on condom use and number of sexual partners among Chinese men who have sex with men (MSM) . METHODS: A cross-sectional survey was conducted in two cities of China in November and December 2018. Descriptive analyses of participants' sociodemographic and behavioral characteristics were conducted using SPSS 24.0. Mplus 7.4 was used to conduct confirmatory factor analysis and structural equation modeling. RESULTS: The sample included 419 Chinese MSM with a mean age of 28.04 (SD = 9.71). Participants reported more positive anticipation of their own behaviors than other MSM's behaviors regarding condom use and number of sexual partners if nPEP were to be routinized in China. About 60% of participants reported discrepancies between anticipated individual and population behaviors as a potential result of routinization of nPEP services. Anticipated individual behavioral change was positively related to age and duration of residence in the current city, and negatively related to education. Anticipated population behavioral change was positively related to age. Anticipated behavioral discrepancy was positively related to being ethnic minority and never married. CONCLUSIONS: These findings identify a high-risk subgroup of MSM, who reported they would use condoms less and/or have more sexual partners when nPEP becomes available. This subgroup of MSM might benefit from targeted health interventions. Moreover, there is a clear discrepancy between anticipated individual and population behavioral changes regarding future routinization of nPEP services, suggesting incorporating nPEP services as a means of community development for MSM.

Growth Trajectories of Peer Norms, Self-efficacy and Condom Use Behavior Among Sexually Active Chinese Men Who Have Sex with Men: Latent Class Analysis and Growth Mixture Modeling.

Data from a randomized controlled trial in 2015 were used to estimate the growth trajectories of peer norms, self-efficacy, and condom use behavior, and to identify associated sociodemographic and behavioral factors among a sample of 804 Chinese men who have sex with men (MSM). Latent class analysis and growth mixture modeling were conducted using Mplus. Two growth trajectories were estimated for each outcome variable with good model fit. The growth trajectories of peer norms were related to age (ß = - 0.066, p < 0.05). The growth trajectories of self-efficacy were related to age (ß = 0.057, p < 0.01) and using a condom during first sexual encounter with another man (ß = 0.777, p < 0.001). The growth trajectories of condom use behavior were related to income (ß = 0.366, p < 0.01) and having casual male partners (ß = - 1.016, p < 0.001). Predictors for the growth factors within each latent class were also estimated. For subsets of MSM who are older, richer, used a condom during their first sexual encounter with another man, and do not have a casual male partner, condom videos may not have sufficient efficacy and other interventions may be necessary.

Mediation Analysis of Peer Norms, Self-Efficacy, and Condom Use Among Chinese Men Who Have Sex with Men: A Parallel Process Latent Growth Curve Model.

The objective of this study was to examine direct and indirect relationships among peer norms, self-efficacy, and condom use among Chinese men who have sex with men (MSM). A longitudinal study determined the effectiveness of a condom use video promotion among Chinese MSM in 2015. In this analysis, 804 Chinese MSM were recruited at baseline and then followed at 3 weeks and 3 months after the intervention. Parallel process latent growth curve modeling (LGM) with multiple indicators and bootstrapping was conducted using Mplus 7.4. The LGM model fit indexes were good with RMSEA = 0.046, 90% CI (0.044, 0.048), CFI = 0.956, TLI = 0.955. Our results showed that the initial measure of peer norms affected the initial measure of condom use indirectly through the initial measure of self-efficacy (αß = 0.414, 95% CI 0.260-0.759). The rate of change in peer norms over time also significantly affected the rate of change in condom use through the rate of change in self-efficacy (αß = 0.101, 95% CI 0.014-0.262). Self-efficacy mediated the association between peer norms and condom use, indicating a strong potential of causal relationship between peer norms and self-efficacy among Chinese MSM.

Crowdsourcing to expand HIV testing among men who have sex with men in China: A closed cohort stepped wedge cluster randomized controlled trial.

BACKGROUND: HIV testing rates are suboptimal among at-risk men. Crowdsourcing may be a useful tool for designing innovative, community-based HIV testing strategies to increase HIV testing. The purpose of this study was to use a stepped wedge cluster randomized controlled trial (RCT) to evaluate the effect of a crowdsourced HIV intervention on HIV testing uptake among men who have sex with men (MSM) in eight Chinese cities. METHODS AND FINDINGS: An HIV testing intervention was developed through a national image contest, a regional strategy designathon, and local message contests. The final intervention included a multimedia HIV testing campaign, an online HIV testing service, and local testing promotion campaigns tailored for MSM. This intervention was evaluated using a closed cohort stepped wedge cluster RCT in eight Chinese cities (Guangzhou, Shenzhen, Zhuhai, and Jiangmen in Guangdong province; Jinan, Qingdao, Yantai, and Jining in Shandong province) from August 2016 to August 2017. MSM were recruited through Blued, a social networking mobile application for MSM, from July 29 to August 21 of 2016. The primary outcome was self-reported HIV testing in the past 3 months. Secondary outcomes included HIV self-testing, facility-based HIV testing, condom use, and syphilis testing. Generalized linear mixed models (GLMMs) were used to analyze primary and secondary outcomes. We enrolled a total of 1,381 MSM. Most were ≤30 years old (82%), unmarried (86%), and had a college degree or higher (65%). The proportion of individuals receiving an HIV test during the intervention periods within a city was 8.9% (95% confidence interval [CI] 2.2-15.5) greater than during the control periods. In addition, the intention-to-treat analysis showed a higher probability of receiving an HIV test during the intervention periods as compared to the control periods (estimated risk ratio [RR] = 1.43, 95% CI 1.19-1.73). The intervention also increased HIV self-testing (RR = 1.89, 95% CI 1.50-2.38). There was no effect on facility-based HIV testing (RR = 1.00, 95% CI 0.79-1.26), condom use (RR = 1.00, 95% CI 0.86-1.17), or syphilis testing (RR = 0.92, 95% CI 0.70-1.21). A total of 48.6% (593/1,219) of participants reported that they received HIV self-testing. Among men who received two HIV tests, 32 individuals seroconverted during the 1-year study period. Study limitations include the use of self-reported HIV testing data among a subset of men and non-completion of the final survey by 23% of participants. Our study population was a young online group in urban China and the relevance of our findings to other populations will require further investigation. CONCLUSIONS: In this setting, crowdsourcing was effective for developing and strengthening community-based HIV testing services for MSM. Crowdsourced interventions may be an important tool for the scale-up of HIV testing services among MSM in low- and middle-income countries (LMIC). TRIAL REGISTRATION: ClinicalTrials.gov NCT02796963.

Benefits and Potential Harms of Human Immunodeficiency Virus Self-Testing Among Men Who Have Sex With Men in China: An Implementation Perspective.

BACKGROUND: Human immunodeficiency virus self-testing (HIVST) holds great promise for reaching high-risk key populations who do not access facility-based services. We sought to characterize unsupervised HIVST implementation among men who have sex with men in China. METHODS: We conducted a nationwide online survey in China. Eligible men were at least 16 years, had anal sex with a man, and had recent condomless sex. We assessed benefits (first-time testing, increased testing frequency, confirmatory testing) and potential harms (coercion, violence, suicidality) of HIVST. Among men who have sex with men who reported ever testing for human immunodeficiency virus (HIV), we identified correlates of HIVST as first-time HIV test being a self-test using multivariable logistic regression. RESULTS: Among 1610 men who met the eligibility criteria and started the survey, 1189 (74%) completed it. Three hundred forty-one (29%) of 1189 reported ever self-testing for HIV. Human immunodeficiency virus prevalence was 7% (24/341) among self-testers and 5% (15/306) among non-self-testers. Two hundred (59%) of 341 men who self-tested reported HIVST as a first-time HIV test. Thirty-one (9%) men experienced coercion with HIVST. Thirty-one (78%) of 40 men with positive HIV self-tests sought confirmation. Multivariable analysis revealed that HIVST as first-time HIV test was associated with younger age (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.92-0.99), not being "out" (OR, 2.28; 95% CI, 1.60-3.28), not using the internet to meet sex partners (OR, 0.39; 95% CI, 0.22-0.69), and group sex (OR, 1.74; 95% CI, 1.02-2.9). CONCLUSIONS: Human immunodeficiency virus self-testing reached high-risk individuals that had never received facility-based testing. Further implementation research is needed to better understand HIVST outside of research programs.

The Role of ARV Associated Adverse Drug Reactions in Influencing Adherence Among HIV-Infected Individuals: A Systematic Review and Qualitative Meta-Synthesis.

Poor adherence remains a major barrier to achieving the clinical and public health benefits of antiretroviral drugs (ARVs). A systematic review and qualitative meta-synthesis was conduct to evaluate how ARV adverse drug reactions may influence ARV adherence. Thirty-nine articles were identified, and 33 reported that ARV adverse drug reactions decreased adherence and six studies found no influence. Visually noticeable adverse drug reactions and psychological adverse reactions were reported as more likely to cause non-adherence compared to other adverse drug reactions. Six studies reported a range of adverse reactions associated with EFV-containing regimens contributing to decreased adherence. Informing HIV-infected individuals about ARV adverse drug reactions prior to initiation, counselling about coping mechanisms, and experiencing the effectiveness of ARVs on wellbeing may improve ARV adherence.

Suicidal Ideation, Resilience, and Healthcare Implications for Newly Diagnosed HIV-Positive Men Who Have Sex with Men in China: A Qualitative Study.

Globally, suicidal ideation and behavior have been widely reported among people living with human immunodeficiency virus (HIV). Knowledge gaps exist regarding the longer life and resilience-related experiences of people living with HIV (PLWH). Specifically, there is a dearth of data about the interaction of perceived risk and resilient factors resulting in a wide spectrum of intentional suicidal ideation outcomes in a Chinese cultural context. This qualitative research drew from a larger ethnographic study of newly diagnosed HIV-positive men who have sex with men (MSM) in Mainland China. Interviews were conducted with 31 MSM within 6 months of diagnosis of HIV infection. Initial suicidal ideation was commonly reported with participants subsequently feeling more resilient to these thoughts through gaining a greater understanding of their prognosis and treatment. Post-HIV diagnosis, some participants reported forming new relationships and receiving increased support from their partners, friends, peers, families, and community-based organizations. At follow-up, these participants generally reported suicidal ideation had declined. However, participants who continued to express suicidal ideation perceived extended pressure from their families' expectations for them to engage in heterosexual marriages and parenthood. Furthermore, these men reported ongoing hardships in their daily life, unemployment, lack of social support, and isolation. Among this Mainland Chinese cohort of HIV-positive MSM, suicidal ideation may be a transient phenomenon experienced initially following HIV diagnosis that resolves with increased and specific familial, social, and service-based support. It is crucial to identify the causes of stress and social suffering associated with HIV diagnosis in order to reduce suicidal ideation. In China, action is needed to develop routine mental health screening and to increase services that support PLWH. Important services mechanism to accomplish this are promoting resilience through intentional activities as well as continued public health campaigns to reduce stigma toward HIV-positive MSM.

Condom use peer norms and self-efficacy as mediators between community engagement and condom use among Chinese men who have sex with men.

BACKGROUND: Community engagement strategies are often integrated in public health interventions designed to promote condom use among men who have sex with men (MSM), a key population for HIV prevention. However, the ways in which condom use peer norms and self-efficacy play a role in the association between community engagement and condom use is unclear. This study examines the potential mediating roles of peer norms and self-efficacy in this association. METHODS: A nationwide cross-sectional online survey was conducted among Chinese MSM in 2015. Recruitment criteria included being born biologically male, being older than 16 years, having had anal sex with a man at least once during their lifetime, and having had condomless anal or vaginal sex in the past three months. Mplus 6.11 was used to conduct confirmatory factor analysis and path modeling analysis to examine the structural relationships between HIV/sexual health community engagement (e.g., joining social media and community events related to HIV and sexual health services), condom use peer norms, condom use self-efficacy, and frequency of condom use. RESULTS: The study found that HIV/sexual health community engagement, condom use peer norms, condom use self-efficacy, and frequency of condom use were mutually correlated. A good data model was achieved with fit index: CFI = 0.988, TLI = 0.987, RMSEA = 0.032, 90% CI (0.028, 0.036). HIV/sexual health community engagement was associated with frequency of condom use, which was directly mediated by condom use peer norms and indirectly through self-efficacy. CONCLUSION: The study suggests that condom use peer norms and self-efficacy may be mediators in the pathway between community engagement and condom use, and suggests the importance of peer-based interventions to improve condom use.

Barriers and facilitators of linkage to HIV care among HIV-infected young Chinese men who have sex with men: a qualitative study.

BACKGROUND: The Four Free and One Care Policy (HIV/AIDS-related free services) has been in place in China since 2004. However, linkage to human immunodeficiency virus (HIV) care is not yet achieved very well among people living with HIV. We conducted a qualitative study to explore individual and contextual factors that may influence a linkage to HIV care from the perspective of young HIV-infected men who have sex with men (MSM) in a highly centralized HIV care context of China. METHODS: Purposive sampling was used to recruit 21 HIV-infected MSM in Shandong Province, with in-depth interviews conducted between March and July 2015. Thematic content analysis was subsequently used for data analysis. RESULTS: Key barriers and facilitators related to a linkage to HIV care emerged from participants' narratives. The barriers included perceived healthy status, low health literacy, and stigma associated with receiving HIV care. The facilitators included an awareness of responsibility, knowledge associated with health literacy, social support, and trusting and relying on services provided by the Center for Disease Control and Prevention (CDC) and the government. These were related to the quality of current HIV counselling and testing, service promotion, and the cost and placement of these HIV services. CONCLUSIONS: In order to improve the MSM linkage to HIV care in China, it is imperative to improve the quality of the current on-going counselling and testing. Further critical linkage support includes increasing supportive services among local CDC systems, designated hospitals and community-based organizations (CBOs), and more financial support for HIV/AIDS related testing, medical checkups and treatments.

Disclosure appraisal mediating the association between perceived stigma and HIV disclosure to casual sex partners among HIV+ MSM: a path model analysis.

HIV stigma is widely believed to be related to HIV disclosure. However, there is a dearth of studies examining the mechanisms that link stigma to disclosure. This is a specific study to assess the relationship between perceived stigma and HIV disclosure to casual sex partners based on a social cognitive theory. HIV+ men who have sex with men (MSM) from two US cities (N = 297) completed questionnaires administered using audio computer-assisted self-interviewing. Path modeling analysis was used to assess the theory-based structural relationships. Perceived stigma was negatively associated with attitudes, intention and behavior of HIV disclosure to casual sex partners. The association was fully mediated by disclosure appraisal, including disclosure outcome expectations, costs and self-efficacy. Findings of this study add new knowledge regarding HIV stigma and disclosure, and provide timely data supporting more effective behavioral interventions to encourage HIV disclosure among MSM.

HIV non-occupational post-exposure prophylaxis (nPEP) awareness and promotion among five key populations in China: A cross-sectional study.

BACKGROUND: This study investigated HIV non-occupational post-exposure prophylaxis (nPEP) awareness and promotion, and related sociodemographic and behavioural factors among five key populations in China. METHODS: From November 2018 to September 2019, we adopted convenience sampling to recruit participants who were age ≥ 18, self-reported HIV status as either negative or unknown and provided informed consent from five key populations cross-sectionally in 10 Chinese cities. Univariable and multivariable logistic regressions were adopted. FINDINGS: Our analysis included data from 2022 participants with a mean age of 35 years (SD = 11·62). Approximately 60% of participants reported non-consistent condom use in the past month, and 37% had not been tested for HIV in the past 12 months. There were 857 (42%) participants hearing about nPEP before the study, and 1728 (86%) endorsing nPEP promotion after learning about nPEP. Sociodemographic and behavioural factors related to both nPEP awareness and endorsement of nPEP promotion included the key population indicator, age, HIV knowledge score, and HIV testing over life course. INTERPRETATION: The key populations in China generally had low nPEP awareness, particularly people who use drugs and female sex workers, while seronegative partners had the lowest endorsement of nPEP promotion. nPEP education and promotion campaigns should be integrated into conventional HIV services, and tailored to sexually active young individuals, people with poor HIV knowledge, and people never tested for HIV. FUNDING: China National Key Research and Development Program and National Science and Technology Major Project, and the i Guardian Platform of the People's Medical Publishing House.

Sociocultural facilitators and barriers to condom use during anal sex among men who have sex with men in Guangzhou, China: an ethnographic study.

This ethnographic study explored how cultural belief systems shaped sexual risk practices among men who have sex with men (MSM) in Guangzhou, China. A specific focus was on how these men's sexual practices varied across sexual venues and among different partners in order to better understand sociocultural facilitators and barriers to condom use in the Guangzhou community. Qualitative data were obtained through semi-structured in-depth interviews with MSM and ethnographic observations in MSM sexual venues in the city. The thematic analysis focused specifically on the accounts of unprotected sex occasions. We found that an erotic idea of "rouyu" (desire of physical flesh) embedded in a subculture of MSM and a metaphor for condom use as being inferior and promoting distance posed a considerable barrier to condom use among these MSM. Some men reported gaining a positive self-concept related to same-sex identity through unprotected sex. These MSM's subjective evaluations of HIV risk were closely tied to the perceived characteristics of sex partners and sexual venues. We conclude by advocating specific sociocultural interventions in emerging risk venues, such as saunas/bathhouses, to better meet the needs of the MSM community in Guangzhou.

Negotiating homosexual identities: the experiences of men who have sex with men in Guangzhou.

This paper reports on an ethnographic study of male homosexuality in contemporary Chinese society. The study focused on how men negotiated with the mainstream Chinese heterosexual society and in so doing constructed their sexual identities. The factors found to inform sexual identity were: the cultural imperative of heterosexual marriage, normative family obligations, desired gender roles, emotional experiences and a need for social belonging. The four types of sexual identities constructed included: establishing a deliberate non-homosexual identity, accumulating an individual homosexual identity, forming a collective homosexual identity and adopting a flexible sexual identity. For the men interviewed, sexual identity was both fluid and fragmented, derived from highly personalised negotiations between individualised needs and social and cultural constructs. The analysis is set against the background of China's rapid and recent economic development, shifting national and international social environments and improved access to the Internet.

Safer sex practices among newly diagnosed HIV-positive men who have sex with men in China: results from an ethnographic study.

The study reported here sought to understand the rationales of safer sex practices adopted by newly diagnosed HIV-positive men who have sex with men (MSM). Guided by a socio-ecological framework, an ethnography was conducted among newly diagnosed HIV-positive MSM. In-depth interviews and participant observation were employed to produce an account of the social and cultural settings that was faithful to the perspectives of participants. A total of 31 participants with diverse backgrounds were recruited in a southern city of China. Participant observation was conducted in local healthcare settings, MSM venues, and NGO offices. Most participants (24/31) reported stopping unprotected anal intercourse (UAI) immediately after being diagnosed as HIV-positive. Factors associated with safer sex practices were identified at both individual and environmental levels, including self-protection, establishment of self-esteem, dignity, altruism and reciprocity, disease experience as a source of personal growth, and organizational culture and values. Newly diagnosed HIV-positive MSM navigate their sexual practices within the context of multiple competing factors. Implications for sustained behaviour change enabling safer sex practices include stimulating survival instinct, facilitating safer sex decision making, motivating and facilitating personal growth, and encouraging volunteerism to promote intentional activities for safer sex practices.

Enhancing Public Health HIV Interventions: A Qualitative Meta-Synthesis and Systematic Review of Studies to Improve Linkage to Care, Adherence, and Retention.

Although HIV services are expanding, few have reached the scale necessary to support universal viral suppression of individuals living with HIV. The purpose of this systematic review was to summarize the qualitative evidence evaluating public health HIV interventions to enhance linkage to care, antiretroviral drug (ARV) adherence, and retention in care. We searched 19 databases without language restrictions. The review collated data from three separate qualitative evidence reviews addressing each of the three outcomes along the care continuum. 21,738 citations were identified and 24 studies were included in the evidence review. Among low and middle-income countries in Africa, men living with HIV had decreased engagement in interventions compared to women and this lack of engagement among men also influenced the willingness of their partners to engage in services. Four structural issues (poverty, unstable housing, food insecurity, lack of transportation) mediated the feasibility and acceptability of public health HIV interventions. Individuals living with HIV identified unmet mental health needs that interfered with their ability to access HIV services. Persistent social and cultural factors contribute to disparities in HIV outcomes across the continuum of care, shaping the context of service delivery among important subpopulations.