Social stigma and discrimination, based on and directed at an individual's behavioral characteristics or identity (eg, same-sex behavior; gay or bisexual identity) and HIV-positive status, are major barriers to accessing HIV prevention and care services, including HIV testing and counseling, among men who have sex with men (MSM) worldwide.1–4 The HIV epidemic in China is now largely concentrated among MSM, who account for a third of new HIV infections.5 Many of these men do not access or cannot be reached by HIV prevention services. For instance, a meta-analysis reported that just 47% and 38% of Chinese MSM received HIV testing and counseling in their lifetime and in the past 12 months, respectively.6
Although same-sex behavior is not illegal in China, being MSM has significant negative social and cultural ramifications, which may include rejection by family and loss of employment.7 As a result, most MSM do not disclose their same-sex behavior to others including health care providers. They also do not access HIV prevention services in fear that their sexual minority status would be exposed or they would encounter discrimination from health care workers.4,8 A global online survey reported that internalized homophobia was negatively associated with having ever tested for HIV among Chinese MSM.9 In addition to identity and/or behavior-related stigma, HIV-related stigma also discourages Chinese MSM from accessing HIV prevention and care services. Although anti-HIV stigma campaigns have been implemented nationally, HIV stigma and discrimination are still highly prevalent among the general public and also within MSM communities.10,11 A recent study found that higher levels of HIV-related stigmatizing and discriminatory attitudes were independently associated with lower uptake of recent HIV testing among MSM in Beijing.12 Although it is important to document the effects of social stigma and discrimination on negative health outcomes, intervening at the level of stigma and discrimination may be the most difficult one. Interventions usually require significant social actions, structural changes, and cultural shifts, all of which can be incremental. For example, a US study found that MSM living in more stigmatizing environments had decreased use of antiretroviral-based HIV prevention strategies compared with those in less stigmatizing environments, suggesting that legal reforms protecting sexual minorities might be necessary to reduce HIV risk among MSM.13 In the context of an expanding HIV epidemic among Chinese MSM, it is critical to identify modifiable factors that mediate the relationships between social stigma and discrimination and HIV risk and/or protective behaviors on which short-term and medium-term interventions can be developed.
Increasing HIV testing uptake among MSM is a priority in the Chinese national HIV/AIDS strategic plan, and there is a growing body of literature on this topic; however, few studies of Chinese MSM have assessed the effects of multiple psychosocial conditions on HIV testing or examined the impact of stigma on HIV testing through mediation models.9,14,15 A study of MSM in Hong Kong reported that subjective norms and perceived control were independently associated with lifetime and 12-month uptake of testing.15 In this paper, we examined the associations among experiences of homophobia, HIV stigma, and recent HIV testing among MSM in Jiangsu Province, China. In addition, we assessed whether depression and subjective norms toward HIV testing mediated hypothesized associations. Specifically, we examined whether (1) experiences of homophobia, HIV stigma, depression, and lack of subjective norms would each be negatively associated with recent HIV testing; (2) depression would mediate the association between experiences of homophobia and recent HIV testing; and (3) subjective norms would mediate the association between HIV stigma and recent HIV testing.
Study Design and Recruitment
This is an analysis of baseline data of a longitudinal cohort study designed to evaluate the effects of an intervention in increasing HIV testing uptake among MSM in Jiangsu province, China. We conducted a cross-sectional survey study of MSM between November 2013 and January 2014. To be eligible to participate in the study, participants had to (1) be biologically male, (2) age 18 or older, (3) be a resident in Jiangsu province, (4) have had oral or anal sex with another male in the past year, and (5) self-report being HIV uninfected or unknown HIV status. Furthermore, in order to track participants for follow-up surveys, we asked eligible participants to provide their contact information. As the intervention was implemented at MSM venues and on the Internet, we used time–location sampling (TLS) and online convenience sampling to recruit a diverse sample of participants.
TLS methodology has been described in detail elsewhere.16 It is used to sample MSM populations through creation of a sampling frame that comprises the universe of venues- day-time (VDT) periods where and when the population can be found to congregate. First, a formative phase constructed an up-to-date sampling frame of venues frequented by MSM and the days and time periods of attendance in Nanjing. From the roster of all possible VDT periods, a random sample of VDT was drawn. At the randomly selected VDT, the attendance of all potentially eligible subjects was counted and men entering or exiting the venue or crossing a predetermined line are intercepted, assessed for eligibility, and invited to participate.
During assessment, recruiters briefly described the study to men and asked if they were willing to participate. Men who had not previously participated were referred to an interviewer who administered the eligibility screener. Eligibility screening occurred in a private area of the venue or in a designated interviewing space near the venue. In addition to the above eligibility criteria, participants recruited through TLS also had to be consecutively approached by the staff at the randomly selected VDT (ie, they could not approach the staff on their own or at a later time). Once participants were determined eligible, staff reviewed informed consent with them using a tablet computer and addressed questions. To consent to the study, participants had to click the “Agree” button on the electronic informed consent. Staff then oriented participants to the tablet computer-assisted interview. Once participants were familiar with the operation of the tablet computer, they completed the self-administered survey and received an incentive for their participation. From November 2013 to December 2013, participants were recruited during 23 randomly selected VTD periods. Staff enumerated 777 men from 10 venues, consecutively approached 478, screened 342 (71.5% eligibility determination), found 290 to be eligible (84.8% eligibility), and 261 (90.0% participation) consented to the study.
In addition to recruiting men from venues, we also posted our study advertisement on a popular provincial gay-oriented Web site to invite participation in our survey. By clicking on the advertisement, interested MSM were taken to the Internet-based survey Web page. The same eligibility screening and informed consent procedures were implemented for the online survey as the TLS. To prevent duplicate participation, a feature within the survey software program (www.qualtrics.com), which would not allow potential participants to access the survey more than once from the same IP address, was enabled. Furthermore, our staff double-checked the contact information provided by participants before giving out incentives for completing the survey. From mid November 2013 to mid January 2014, 985 potential participants clicked on our online survey advertisement or link. Of these, 941 entered the eligibility screening page, 823 answered all eligibility questions (87.5% eligibility determination), 592 met the eligibility criteria (71.9% eligibility), and 271 (45.8% participation) consented to the study.
The study was approved by the University of California—San Francisco's Committee on Human Research and Jiangsu Provincial Center for Disease Control and Prevention's Institutional Review Board.
Participants were asked about their age, educational level, legal marital status, if they were cohabiting with a man or woman, official residential status (hukou), if they were living in the Nanjing Metropolitan Area (capital of the province), employment status, monthly gross income (1 USD ≈ 6 RMB), and sexual orientation.
Participants reported the number of male anal sex partners in the past 6 months, and whether condoms were used consistently with these male partners when engaging in insertive and/or receptive anal sex.
History of HIV Testing
Participants were asked whether they have ever been tested for HIV. Those who responded “Yes” were further asked about the number of HIV tests they had in the past year (“None,” “Once,” and “Twice or more”). In the analysis, we dichotomized this outcome variable into having had vs. having not had an HIV test in the past year. Participants who reported having never been tested were categorized as having not had an HIV test in the past year.
Experiences of Homophobia
A 9-item scale was adapted to measure experiences of homophobia that happened to participants when they were growing up and during their adulthood because they were, or were thought to be, gay or bisexual (eg, “Have you lost friends because of your sexual orientation?” “Have you been rejected by your family due to your sexual orientation?”).17 Response options were either “Yes” or “No.” Scores of the 9-item scale ranged from 0 to 9, with higher scores indicating greater experiences of homophobia (Cronbach's α = 0.766).
Depression (CES-D 10)
A 10-item short form of the original CES-D scale was translated and adapted to screen for depressive symptomatology within the past week.18 Scores of CES-D 10 ranged from 0 to 30, with higher scores indicating more depressive symptoms (Cronbach's α = 0.811).
The AIDS-related Stigma Scale was adapted to measure HIV stigma.19 The scale consists of 9 items that tap a broad range of stigmatizing beliefs including beliefs about negative qualities of people living with HIV/AIDS (eg, dirty and cursed). In addition, based on our formative work with Chinese MSM, we added 2 items: “HIV-infected individuals must have been promiscuous,” and “I would distant myself from a friend who became infected with HIV.” Scores of this 11-item scale ranged from 0 to 11, with higher scores indicating more stigmatizing beliefs (Cronbach's α = 0.805).
A 4-item scale measured subjective norms toward HIV testing: “Most of your MSM friends think it is important to get tested for HIV”; “Most of your MSM friends get tested for HIV after having had unprotected sex”; “Most of your MSM friends get tested for HIV when they have new boyfriends or sex partners”; and “Most of your MSM friends think it is important to receive routine HIV testing.” Response options were measured using 4-point Likert scale, from “Strongly agree” to “Strongly disagree”. Scores ranged from 4 to 16, with higher scores indicating stronger norms toward testing (Cronbach's α = 0.881).
After cross-checking contact information provided by TLS and online participants, 7 duplicate records were excluded from analysis. In addition, 9 participants did not respond to questions regarding history of HIV testing, leaving a final sample size of 523 MSM participants. We conducted all analyses in STATA/SE 11 (College Station, TX) with level of significance set at a 0.05 P value. The univariate distribution of each variable on HIV testing behavior was assessed using χ2 tests for categorical variables or Mann–Whitney U tests for continuous variables. To assess the conditional effects of variables on recent HIV testing, we fitted 3 separate multivariable logistic regression models, where inclusion of covariates was guided by Poundstone et al's socioepidemiologic framework, literature review, and causal diagrams (Fig. 1).20–22 The first model assessed sociodemographic correlates of HIV testing behavior, variables with a P value higher than 0.3 and did not have a priori research interest were excluded in subsequent models. Then a second model, restricted to those who reported ever having anal sex with a man, was fitted to assess the conditional effects of sexual behavioral risk factors associated with recent HIV testing. A third model was fitted to assess psychosocial factors associated with recent HIV testing. Before modeling, we multiplied and imputed the missing values (n = 188, 35%) on subjective norm toward HIV testing, otherwise complete-case analyses were used for all other variables and models.
To assess whether depression would mediate the association between experiences of homophobia and recent HIV testing, and whether subjective norms would mediate the relationship between HIV stigma and recent HIV testing, we conducted causal mediation parametric analysis with a counterfactual framework, which is robust against more modeling misspecifications such as interaction and nonlinearity.23 Using the STATA command (paramed) developed by Valeri and VanderWeele,23 we estimated the natural direct effect (NDE) and the natural indirect effect (NIE) by fitting a logistic regression for HIV testing conditional on experiences of homophobia and a set of covariates including age, marital status, employment status, hukou, place of residence, and reported condomless receptive anal sex. We then fitted a linear regression model for depression conditional on experiences of homophobia and the same set of covariates.23 The same procedure was used for subjective norms and HIV stigma. However, since imputation procedures do not support the mediation analysis, we used complete case analysis and conducted sensitivity analyses on each imputed data set to evaluate deviation of effect estimates across the complete-case and imputed data sets.
Of 523 participants, almost a third (156/523, 29.8%) had not been tested for HIV in the past year. Compared with participants who had been recently tested, those who had not been were significantly more likely to be married (17.2% vs. 28.2%, P = 0.001) and resided outside Nanjing metropolitan area (32.7% vs. 43.6%, P = 0.018) (Table 1). Condomless receptive anal sex was more prevalent among those who reported no recent HIV testing compared with those who did (35.3% vs. 23.7%, P = 0.007). Stronger subjective norm toward testing was significantly and positively associated with recent testing (13.5 vs. 12.4, P = 0.005), whereas higher levels of HIV stigma and depressive symptoms were significantly and negatively associated with recent testing (2.5 vs. 1.9, P = 0.012; and 11.7 vs. 10.1, P = 0.012, respectively) (Table 2).
Table 3 presents factors independently associated with recent HIV testing in 3 separate models. Model 1 included sociodemographic factors associated with recent testing. Compared with MSM who were between the ages of 18 and 25 and those who lived outside Nanjing metropolitan area, MSM who were 36 or older and those who lived within Nanjing metropolitan area had higher odds of being recently tested (adjusted odds ratio [AOR]: 2.00, 95% confidence interval [CI]: 1.10 to 3.67; and AOR: 1.71, 95% CI: 1.12 to 2.61, respectively). After including sexual risk behaviors in model 2, only those who reported condomless anal sex had lower odds of recent HIV testing compared with those who did not have any condomless anal sex (AOR: 0.56, 95% CI: 0.34 to 0.93). Model 3 included psychosocial factors, where stronger subjective norm toward testing was associated with higher odds of recent HIV testing (AOR: 1.10, 95% CI: 1.01 to 1.21), whereas increasing levels of depression and HIV stigma were both associated with lower odds of recent HIV testing (AOR: 0.96, 95% CI: 0.92 to 0.99; and AOR: 0.91, 95% CI: 0.84 to 0.99, respectively).
Table 4 presents estimated natural direct, indirect, and total effects of the respective mediation pathways. Consistent with model 3 in Table 3, there was no evidence of a direct relationship (NDE) between increasing level of experienced homophobia and recent HIV testing (OR NDE: 0.96, 95% CI: 0.79 to 1.00); however, there was evidence of an indirect relationship (NIE) of experienced homophobia on recent testing (OR NIE: 0.96, 95% CI: 0.93 to 0.98) mediated (35.0%) through depression. In addition, there was evidence of a direct relationship between increasing level of HIV stigma and recent testing (ORNDE: 0.92, 95% CI: 0.83 to 0.99) and an indirect relationship (ORNIE: 0.98, 95% CI: 0.95 to 0.99) mediated (19.2%) through subjective norm toward testing. Sensitivity analyses did not reveal any notable differences in effect estimates across each imputed copy.
Consistent with findings from previous studies,4,12 our study found that HIV stigma was a significant barrier to HIV testing among Chinese MSM. Although internalized homophobia has been found to deter Chinese MSM from seeking HIV testing,9 our results showed that experiences of homophobia was not significantly associated with recent HIV testing among MSM participants. This finding suggests that experiences of homophobia, which occurred during adolescence and early adulthood and were not directly related to encounters with health professionals, may be too distal to have an effect on recent health-seeking behaviors. However, the role of homophobia in negatively affecting sexual minorities' HIV and non–HIV-related health outcomes has been widely documented.24–26
Our study, more importantly, has demonstrated that not only did depression and community norms directly affect HIV testing uptake among Chinese MSM, they also mediated the effects of experienced homophobia and HIV stigma, respectively, on HIV testing behavior among this population. Depression has been consistently linked to HIV risks and HIV infection in the MSM literature.24,27,28 As the social environment for gays, bisexuals, and other MSM in China is not likely to improve drastically in the near future, one can reasonably expect that mental health problems such as depression may play a key role in the HIV epidemic among Chinese MSM. Lessons learned from the West suggest that comprehensive HIV prevention for MSM should adopt a holistic approach to addressing these men's overall health including mental health.29,30 However, at present, HIV programming for MSM in China is heavily focused on promoting condom use and HIV testing. But in order to improve these behavioral outcomes and ultimately reduce HIV infections, HIV prevention programs should strengthen their efforts in screening depressive symptoms among Chinese MSM and referring men with depression to appropriate mental health services.
In addition to individual-focused screening and treatment of depression, community-level interventions that are designed to change community norms toward HIV testing also need to be strengthened and scaled up. First, this will require continued and expanded support for community-based organizations to conduct outreach activities and peer-led education. Second, health communication campaigns that appeal to and resonate with the MSM communities should be implemented at larger scales. Existing and emerging models (eg, social marketing and crowdsourcing) of health communication and marketing can guide the development of such campaigns.31,32 Finally, innovative strategies to harness the power of technologies should be developed and used to reach members of the virtual communities, whom otherwise would not be reached through traditional outreach efforts.
This study has several limitations. First, our findings may not be generalizable to MSM who did not frequent MSM venues and those who did not visit the recruitment Web site. These men might be more “hidden” and less “out.” However, using both TLS and online sampling, we believe that our sample of participants was more diverse than a single sampling strategy could have achieved. Furthermore, the demographic and risk profiles of our online MSM sample were similar to those recruited through other methods such as respondent-driven sampling.33 Second, our data were cross-sectional and therefore causal inferences could not be made. In particular, depression was measured within the past week while HIV testing behavior measured within the past year. Hence, the depression measure was likely serving as a proxy for previous depression. However, results from the mediation analysis are similar to findings from a few longitudinal cohort studies.34,35 Third, participants' responses were subject to recall and social desirability biases, although the mode of survey administration might have mitigated these biases.
In summary, our study showed that depression and community norms are important mediators of HIV testing uptake among stigmatized MSM in China. Therefore, HIV prevention programs should address mental health issues and incorporate community-based approaches to changing social norms toward HIV testing. Finally, MSM community-based advocacy efforts and government-enforced policies that address overarching social-level stigma and discrimination against sexual minorities and MSM living with HIV should be supported and implemented.
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