Zhang, Hongbo MD, MS*; Wu, Zunyou MD, PhD†; Zheng, Yingjun MD, MS†; Wang, Jun MD*; Zhu, Junli MS*; Xu, Juan MD, MS†
Global and regional trends in the HIV/AIDS pandemic exhibit 2 distinct patterns: generalized and concentrated epidemics. In Latin America, North America, and Western Europe, concentrated epidemics of sex between men is the dominant mode of HIV transmission.1,2 Moreover, transmission has been found to spread rapidly among men who have sex with men (MSM). In Thailand alone, HIV prevalence among MSM was found to have increased 11.3% between 2003 and 2005, and as much as 21% of estimated new infections in 2005 were attributed to unprotected sex among MSM.3
In 2005, a joint assessment report by the Chinese Ministry of Health and United Nation Theme Group on AIDS estimated that HIV infections among MSM accounted for 7.3% of the total number of the 650,000 estimated HIV cases in China.4 The 2007 joint assessment report estimated that this proportion had increased to 11.0%; whereas of the estimated 50,000 HIV infections, MSM were thought to account for 12.2% of the total infections.5 Other studies have also shown rapid increases in HIV prevalence among MSM. A study found a HIV prevalence of 0.4% in 2004, 4.6% in 2005, and 5.8% in 2006 in Beijing,6 whereas another 2 studies conducted in southwestern China found prevalence rates as high as 10.6% in 20067 and 16.9% in 2007 among sampled MSM.8 The results from the above surveys indicate that HIV epidemic among MSM in China has reached crisis proportions in certain areas and that MSM are a key target populations for future prevention efforts.
MSM in China is an understudied population. Limited studies show that Chinese MSM engage in high-risk sexual behaviors, including sex with multiple and different types of sexual partners, low condom-use rates, and low rates of HIV testing. For example, a national survey of 1124 MSM in 2001 indicated that unprotected oral and anal sex were common practices, approximately 13.7% had commercial sex and 44.0% were married to women.9 A study of gay bars in Anhui Province found that in a 2-month recall period, 19.5% of respondents reported having engaged in casual, commercial, female and/or male primary sexual partners concurrently.10
Chinese MSM have also been found to have low rates of consistent condom use. A 2001 study conducted in Beijing found that 6.2% and 30.9% of MSM reported consistent condom use in oral and anal sex in the past 6 months, respectively.11 Similarly, a national study in China found the rate of condom use for last recalled oral and anal intercourse was 17.8% and 54.8%, respectively,12 and surveys conducted among MSM in Shenzhen in the southeast and Hefei in eastern China revealed similar findings.13,14
Voluntary HIV testing services have been expanded rapidly in past a few years, most MSM are not aware of their own HIV serostatus.9,10,15 In 2005, only 24.5% of MSM in Hefei reported ever being tested for HIV, and 31% of respondents were not aware of free voluntary counseling and testing services.15
Previous HIV interventions among MSM in China have largely consisted of distributing condoms and educational materials through MSM volunteers and often in MSM social venues.16-18 To date, however, there has not been a scientific evaluation of the efficacy of these intervention efforts, making it imperative that behavioral interventions targeting MSM are designed to be rigorously assessed. This peer-driven intervention is designed as a group intervention that utilizes existing peer networks and focuses on the 3 goals of increasing condom use, increasing HIV testing, and reducing the number of sexual partners among MSM.
Study Location and Participant Recruitment
The study was conducted during May to October 2006 in Hefei, Wuhu, and Fuyang, 3 cities in Anhui Province, where researchers were able to locate gay bars and contact participants through local MSM networks. Peer-driven referral was used to recruit potential study participants. Eligibility criteria included (1) age more than 18 years; (2) sex with other men in the past year; and (3) living in Hefei, Wuhu, or Fuyang during the study period.
Twelve “seed” MSM, a member of the targeted population widely respected by his peers, were recruited from our previous study to create seeds for this study.19 In addition to the above eligibility criteria, seeds also had to consent to undergo leadership training, to recruit peers to take part in the intervention study, and to lead intervention activities for their peers. Each seed was asked to refer up to 3 peers, who in turn recruited 3 of his own peers, and so on. In this manner, a total of 218 MSM participants were recruited.
Intervention Design and Outcome Indicators
A peer-driven behavioral intervention was chosen to influence the MSM peer networks. Each intervention group consists of a seed and his referral chain made up of his peers. Confidentiality and informed consent were strictly observed in this study. Investigators explained the aims, significance, benefits, and potential risks of the study to all eligible MSM, and willing participants provided written consent before study commencement.
The intervention was based on the AIDS Risk Reduction Model20 and consisted of 4 1.5-hour sessions with activities such as role playing, games, group discussions, brain-storming, and competitions to test knowledge. The first session focused on behavior labeling, (ie, identifying HIV high-risk behaviors, including assessing knowledge of HIV transmission and prevention) and evaluating individual high-risk behaviors. Participants were assessed on their knowledge of HIV transmission, prevention, and correct condom use. Evaluation of individual high-risk behaviors was comprised of discussions of usual MSM behaviors, ways to evaluate the risk of HIV infection and transmission, and methods to protecting themselves. In session 2, participants develop individualized plan to make a commitment to changing their high-risk behaviors. During this session, open discussions about happiness and well-being were encouraged to improve the desire of MSM to change their behaviors. Additionally, identifying obstacles and finding solutions were discussed for the intent of planning changes in behavior. This session also included training on communication skills about sexual topics. Session 3 emphasized taking action to change high-risk behaviors. This session discussed the obstacles to safe sex and the solutions to overcome these obstacles. Participants were given an opportunity to communicate personal experiences and provide mutual support. Each participant continued to work on his own behavior change plan. The final session addressed ways to deal with barriers to practicing safe sex. Participants shared their experiences of having safe sex and discussed any difficulties encountered. They described situations in which they failed to engage in safe sex and then discussed the factors related to the situation and provided suggestions. Through role-play, participants also learned skills about having safe sex. These include practicing how to put a condom on a penis (using a banana); practice negotiating the use of different types of condoms and discussing which ones were more stimulating (eg, flavored, ribbed, colored, etc.); and discussing the feelings of happiness and the sense of well-being experienced by engaging in safe sex between lovers.
Intervention efficacy and feasibility was evaluated comparing pretest and posttest indicators, including sexual behaviors, HIV-related knowledge, condom use, and HIV testing history. Self-reported condom use was measured as use in the last 3 episodes of anal intercourse with another man. Recall period for other behaviors at posttest is for the past 2 months. Information was collected through self-administered questionnaires administered at baseline and in the third month after the intervention.
EpiData 3.0 (The EpiData Association, Odense, Denmark) software was used to input the original data and Statistical Product and Service Solution 10.01 (SPSS Inc. Chicago, IL) was used to analyze the data. χ2 tests were used to compare preintervention and postintervention indicators, including rate of HIV testing, condom use in male anal sex, and the number of male sexual partners and to compare different patterns of condom use between sex with males and sex with females. Rates of HIV testing, condom-use habits, and sexual partnering behaviors were analyzed using paired χ2 tests to determine behavior change since baseline among the 170 participants who were followed up 3 months after the end of the intervention program.
Study Subject Characteristics
A total of 218 eligible MSM participated in this intervention. The mean age was 25.5 (median 24.0; SD: 6.8; range: 18-61), and 64.2% reported homosexual orientation, whereas 22.5% reported bisexual orientation. Heterosexual and undecided sexual orientations accounted for 0.9% and 12.4%, respectively. The majority had completed at least tertiary education (65.6%), and current students (university or vocational school) accounted for 35.3% of participants. Migrants from other areas of China comprised 9.6% of participants (Table 1).
All participants took part in the first and second intervention activities, 75.2% (164 of 218) attended the third and the fourth intervention activities, and 77.9% (170 of 218) participants were followed up for assessment in the third month after completion of the intervention. Comparing participants who dropped out of the study (n = 48) versus those who were followed up after the study (n = 170), 3 variables of age (26.3 ± 8.9 vs. 25.2 ± 6.0), education level at least college (51.1% vs. 69.6%), and condom use in anal sex last 3 times (59.5% vs. 55.6%), no significant differences were found between the 2 groups at the baseline.
Recruitment Chains and Number of Recruitment Waves
Twelve MSM from gay venues (gay bars, public parks, and toilets) were recruited as seeds. From the first recruitment wave to the fifth, 16.5% (36 of 218), 34.8% (76 of 218), 32.6% (71 of 218), 12.4% (27 of 218), and 3.7% (8 of 218) of participants, respectively, were recruited. Of the 12 seeds' recruitment chains, 7 reached 5 waves (Table 2).
Effects of the Intervention
χ2 tests comparing baseline and postintervention indicators found that the rate of HIV testing in the last 2 months increased significantly from 15.1% (33 of 218) to 52.4% (89 of 170) (P < 0.01). Reported condom-use rates also improved, with the percentage of subjects who never used condoms during sex with men in the last 2 months decreased from 25.0% (34 of 136) to 9.4% (12 of 128) (P < 0.01) and the percentage of subjects reporting consistent use in last 3 instances of anal intercourse with a man increased from 49.8% (326 to 654) to 59.8% (305 to 510) (P < 0.01). No change was found in the number of male sexual partners reported by study subjects over the course of the intervention (Table 3).
The rate of HIV testing increased from 10.0% at the baseline to 52.4% at the follow-up (P < 0.01). There were improved rates of condom use in the last 3 instances of anal intercourse (from 55.3% to 65.2%, P < 0.05), with a similar improvement in condom-use rates with casual male sexual partners (from 43.2% to 52.2%; P < 0.05) and regular sexual partners (from 41.9% to 60.9%; P < 0.01). Meanwhile, the rate of having female sexual partners in the last 2 months decreased significantly from 17.6% to 11.2% (P < 0.01). No changes in the rates of having 1 or more male casual sexual partners and having 2 or more male sexual partners in the last 2 months were found (Table 4).
With the increase of HIV infection among MSM in China, there is an urgent need to develop interventions to promote condom use and HIV testing.5-7,21 The primary aim of this study was to test the feasibility and effectiveness of a peer-driven behavioral intervention to reduce HIV-related risk behaviors among MSM in China. The results of this study may have important implications for future HIV prevention efforts among MSM in mainland, China.
Regarding feasibility, this study found that “seeds” played a crucial role in assisting researchers by leading intervention sessions and to maintain contact with participants throughout the study. These are important findings in light of results of a recent study in Shanghai which found that many Chinese MSM still experience social discrimination from family members, peers, colleagues, and employers even in large metropolitan cities.22 Such environments lead many MSM to hide their sexual orientation and drive their risk behaviors underground where public health officials cannot perform effective interventions.19 Nor have MSM been a traditional target group of public health authorities in China, although this is slowly changing.
Results of this study suggest that our intervention is effective in promoting HIV testing and increase condom use and may also decrease the number of female partners among MSM in China. Based on our findings, public health authorities could incorporate the peer-driven behavioral intervention model to conduct a multilocation trial to test the feasibility of a nation-wide scale up of HIV control and prevention programs targeting MSM. This is particularly applicable in China where MSM often seek out sexual partners via the internet, in discreet gay venues (bars frequented by MSM, bathhouses, parks, and public restrooms, etc), or through personal social networks.19 In light of Chinese social and cultural norms, MSM intervention efforts must consider how to access MSM in a discreet manner that respects their privacy. Intervention programs must also work with members of the target community to identify acceptable ways of effecting sustainable behavior change.
A limitation of this study is that it is a preintervention and postintervention comparison design and uses self-reported behaviors as indicators of intervention efficacy rather than measuring new cases of HIV or sexually transmitted infections. A long-term objective therefore is the need to more accurately determine whether the peer-driven behavioral intervention model actually does reduce the incidence of HIV infection. Future studies will need to consider using randomized controlled trial designs to effectively measure the effectiveness of an MSM-targeted intervention.
Our study has found that peer-driven behavioral interventions are culturally and socially acceptable to Chinese MSM, can increase condom use and HIV testing among MSM in China, and can decrease the number of female sexual partners. Decreasing the numbers of male sexual partners may be more difficult than increasing condom use among MSM in China.
The authors would like to thank Naomi Juniper and Adrian Liau for editing the article and Kumi Smith for her comments.
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