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Research Article

Internalized Sexual Minority Stigma is Associated With HIV Testing Behavior Among Chinese Men Who Have Sex With Men: A Cross-Sectional Study

Chi, Yuanyuan MSN, RN; Huang, Daoping BS; Pachankis, John PhD; Valimaki, Maritta PhD, RN; Shen, Yan MSN, RN; Li, Xianhong PhD, RN*

Author Information
Journal of the Association of Nurses in AIDS Care: September/October 2021 - Volume 32 - Issue 5 - p 578-588
doi: 10.1097/JNC.0000000000000205
  • Open

Abstract

Despite the large number of interventions developed to prevent HIV transmission globally, a high HIV prevalence among men who have sex with men (MSM) continues to contribute to the HIV epidemic in some countries (Beyrer et al., 2016; Piot et al., 2015; UNAIDS, 2016), including China. It has been reported that the HIV prevalence in China among MSM has increased from 1.77% in 2000 (Zhang et al., 2013a) to 7.75% in 2016 (Zheng, 2018). According to recent studies, of the 36,628 new infections annually, almost 30% of the new infections in China were among MSM (CDC, 2018; NCAIDS, 2018; Zhuang et al., 2018). By the end of 2018, only 58.8% of Chinese MSM knew their HIV status, and among those living with HIV only 86.5% were on antiretroviral therapy (UNAIDS, 2019). In 2010, the Chinese Center for Disease Control and Prevention (CDC) recommended MSM to obtain an HIV test every 3–6 months (CDC, 2010); however, several studies showed HIV testing rates among Chinese MSM ranged between 43.6% and 55.9% (Li et al., 2016; Liu et al., 2018a; Wei et al., 2019). In spite of the Chinese government promoting the “Four Frees and One Care” policy in 2003, which included providing free access to HIV testing, free antiretroviral drugs, free prevention of mother-to-child transmission, free schooling for HIV orphans, and economic assistance to families living with HIV (Wu et al., 2010), a serious testing gap among MSM still remains.

HIV testing is a crucial first step in preventing HIV. In other words, early detection of HIV fosters early antiretroviral therapy initiation, thereby effectively reducing HIV transmission (treatment as prevention) and HIV-related morbidity and mortality among persons living with HIV (CDC, 2016). Data from several studies suggest that MSM who were unaware of their own HIV status not only delayed treatment but also may have unintentionally participated in high-risk sexual behaviors than those who were aware of their HIV status (Caro-Vega et al., 2015; Khosropour et al., 2016; Sandfort et al., 2015). In recent years, pre-exposure prophylaxis (PrEP) has been advocated by the World Health Organization (WHO) to be another HIV preventive strategy among individuals at high risk of HIV infection, including MSM (WHO, 2014). However, in China, wide-scale implementation of PrEP has not been achieved, mainly due to two reasons. First, the Chinese health insurance system does not presently cover PrEP (Wei & Raymond, 2018). Second, there is significant concern about the side effects of the preventive medication among MSM (Liu et al., 2018c). At present, HIV prevention in China focuses on expanding HIV testing, implementing behavioral interventions, and providing continuous antiretroviral therapy for individuals who are diagnosed with HIV (Tang et al., 2016). Therefore, in China, improving HIV testing would not only benefit individuals by delivering early diagnosis and adequate treatment but also it would contribute to achieving the “90-90-90” global target (UNAIDS, 2017).

Several studies have explored the factors that influence seeking or obtaining HIV testing among MSM. These studies indicated that younger age (Noble et al., 2017), higher education (Pines et al., 2016), not engaging in unprotected insertive anal sex in the past 6 months (Li et al., 2014; Tang et al., 2016), being more acceptable about one's homosexuality (Li et al., 2016), not using drugs (Noble et al., 2017), greater community engagement in sexual health services (Zhang et al., 2017), and better knowledge of HIV (Liu et al., 2015; Pham et al., 2017) were all positively associated with HIV-testing behaviors.

A growing body of research worldwide has found that HIV-related stigma is a significant barrier to HIV-testing behaviors among MSM (Bolsewicz et al., 2015; Li et al., 2014; Wei et al., 2016). HIV-related stigma refers to a variety of mechanisms that devalue people living with HIV (PLWH), including labeling, negative public attitudes, stereotyping, and negative self-image (Mahajan et al., 2008). Young et al. (2007), using an experimental design, demonstrated that HIV-related stigma reduced individuals' testing intention because they did not want to be associated with a stigmatized condition (Young et al., 2007). A systematic review by Gesesew et al. (2017) showed that individuals who perceived a high level of HIV-related stigma were twice as likely to delay HIV testing compared with those who perceived a low level of HIV-related stigma (Gesesew et al., 2017). Moreover, several studies have indicated that HIV-related stigma may be aggravated with blaming and shaming of behaviors, such as same-sex sexual activity (Arnold et al., 2014; Leluţiu-Weinberger et al., 2019). Sexual minority stigma is a term used to refer broadly to negative regard, inferior status, and relative powerlessness that society collectively accords anyone associated with nonheterosexual behaviors, identity, relationships, or communities and has also been found to be associated with lower odds of HIV testing among MSM in many countries (Andrinopoulos et al., 2015; Herek et al., 2009; Rodriguez-Hart et al., 2018; Shangani et al., 2017). In regard to sexual minority stigma, various mechanisms of action exist and include enacted, anticipated, and internalized stigma (Herek, 2007). Enacted sexual minority stigma refers to sexual minorities experiencing prejudice or discrimination from others in society (Herek, 2007). Studies have shown that those who reported experiencing enacted sexual minority stigma had more HIV risk behaviors and lower willingness to undergo HIV testing (Arnold et al., 2014; Balaji et al., 2017). Anticipated sexual minority stigma refers to anxious expectations of rejection, potentially drawn from prior stigma-related experiences (Pachankis et al., 2008), and shows associations with young gay men's HIV risk behaviors (Chaudoir et al., 2017). Internalized sexual minority stigma refers to a sexual minority individual's personal acceptance of sexual minority stigma as a part of her or his own value system (Herek et al., 2009). As a function of internalized sexual minority stigma, sexual minority individuals may suffer guilt, self-hate, low self-esteem, loss of self-worth and hold negative attitudes to their own sexual orientation (McConnell et al., 2018). Prior research has found an association between internalized sexual minority stigma and HIV risk-related sexual behaviors (Emlet et al., 2017; Zhu et al., 2018).

Although studies have examined the relationship between HIV-related stigma and HIV testing among MSM in China, there is still a lack of knowledge regarding how sexual minority stigma and HIV testing among Chinese MSM may be associated, although sexual minority stigma is prevalent among Chinese MSM (Xie & Peng, 2018). On one hand, homosexuality goes against traditional Chinese values, which favor the family tree, heterosexual marriage, and filial piety—one of the most valued virtues in Confucius's ideological system (Lum et al., 2016). Typical behavioral and psychological demonstrations of filial piety include respecting and obeying parents, taking care of parents as they grow older, striving to meet parents' expectations, and bringing honor and prosperity to the family (Hu & Ying, 2013). On the other hand, homosexual marriage is illegal in Mainland China (Wang et al., 2019). As a result of sexual minority stigma, many MSM conceal their same-sex sexual relations from their families (Steward et al., 2013) and are less likely to engage in HIV testing behaviors (Pachankis et al., 2015). Understanding factors related to HIV-related, anticipated, and internalized sexual minority stigma on HIV testing behaviors is crucial for understanding the barriers and facilitators associated with HIV testing behaviors among MSM. Therefore, based on the previous empirical studies, we hypothesized that in addition to HIV-related stigma, anticipated and internalized sexual minority stigma would also be negatively associated with HIV-testing behaviors among Chinese MSM. The insight of internalized sexual minority stigma on HIV testing behaviors will help to inform targeted interventions to expand HIV testing programs among Chinese MSM.

Methods

Study Design and Setting

A cross-sectional study was conducted among Chinese MSM from May 2016 through May 2017. The study was conducted in the Hunan Province of China. Hunan Province lies in the geographic middle of China and has a total of 689 million inhabitants (NBS, 2018). The prevalence rate of HIV in the Hunan area is similar to the nationwide HIV epidemic (Ning, 2012). As of October 2019, the reported number of PLWH in the Hunan Province exceeded 30,000, of which 25% were associated with same-sex male-homosexual contact (Dan, 2019). The data were collected in community settings with the assistance of a local gay-friendly community-based organization (CBO) called Zuo An Cai Hong (which means rainbow around the shore). The organization was established in 2008 and provides counseling, peer support, and HIV testing for MSM in the Hunan Province. This CBO has seven offices in the Hunan Province.

Participants, Sampling, and Recruitment

The target population of the study was a wide range of gay, bisexual, and other men who self-reported having sex with men. Inclusion criteria were (a) being biologically male, (b) 18 years or older, (c) self-reported ever having sex with men, (d) having basic communication skills in Mandarin, and (e) living in the Hunan Province. Exclusion criteria were (a) cognitive impairment that limited the ability to understand and complete study questionnaires and/or (b) unwillingness to participate in the research. Because 22 predictors were put in the final logistic regression analysis and the optimal sample size was 15 to 20 respondents per predictor to ensure sufficient statistical power, the minimal sample size was estimated to be 364, allowing for a 10% to 15% rate of invalid questionnaires (Sun, 2014). In total, 687 participants were recruited into the study and 607 agreed to participate (88.4% participation rate). On reviewing the data, nine questionnaires were excluded from data analysis because they did not report same-sex sexual activity, which left us with a final total sample of 598 participants for the data analysis. A post hoc analysis showed the statistical power was 0.82, which indicated that we had enough power to detect the influencing factors (Erdfelder et al., 1996; Walters, 2009).

A nonprobability sampling method was used. Participants were recruited via flyers posted on popular gay-oriented social media and the entrances of the CBO offices. Interested participants could contact research assistants via WeChat or QQ (Chinese instant messaging program). Once participants were determined eligible, research assistants would briefly describe the study. After being informed of the details of the study (including the purpose, confidentiality procedures, possible benefits, and potential risks), both in writing and orally, eligible participants were asked their willingness to join the study. If they were willing to do so, research assistants would provide instructions to the participants on how to provide informed consent and complete the online questionnaires.

Data Collection and Ethical Considerations

The study was approved by the institutional review board of behavioral and nursing research in the School of Nursing of Central South University (permission #2016026). Permission to conduct the study was granted by the Chiefs of the CBO. The research process complied with the ethical standards of the 1975 Declaration of Helsinki, as revised in 2008: (a) written informed consent before enrollment was required, (b) participants were allowed to withdraw from the research at any stage, (c) a unique identity code linked each participant to the corresponding questionnaire, and (d) the survey was completely confidential, and all raw data were kept in a password-protected offline computer (Bădărău, 2018). Participants who showed interest toward the study received access to the online survey platform (http://www.sojump.com) by a tablet computer. In the first page of the survey, an electronic informed consent form was available to participants. Those who agreed to join the study by clicking the “Agree” button received access to the electronic survey questionnaire. To cover their time and commitment, each participant received free HIV testing (voluntary) and a gift valued at 50 RMB ($7.5 USD) for their participation as well as their transportation costs.

Instruments

Sociodemographic characteristics

Participants were asked about their age (years), ethnicity, place of residence, education level, religious beliefs, personal monthly income, marital status, self-identified sexual orientation, and whether they disclosed their sexual orientation to other people (yes/no).

History of HIV-testing behavior

HIV testing history was measured by asking: “Did you test for HIV during the last year? (yes/no).”

HIV and sexual minority stigma

The Chinese version of the HIV- and homosexuality-related stigma scale was used (Liu et al., 2009). It consisted of 25 items with three domains: “public homosexual stigma” (10-items), measuring the anticipated stigma that the society holds for sexual minority (anticipated sexual minority stigma); “self-homosexual stigma” (8-items), measuring the internalized sexual minority stigma; and “public HIV stigma” (7-items), measuring the perceived stigma society holds for PLWH (Liu et al., 2009). The participants responded how much they agreed or disagreed with each description (such as “many people unwillingly accept gay individuals,” “sometimes I think that if I were straight, I would probably be happier,andHIV infected people should be ostracized by their spouse and family members”) using a 4-point Likert scale, which ranged from 1 (strongly disagree) to 4 (strongly agree). The higher scores indicated the higher level of enacted stigma. The scales had adequate reliability as the Cronbach alpha value was 0.85 for the anticipated sexual minatory stigma subscale, whereas the Cronbach alpha was 0.78 for the internalized sexual minority stigma and 0.79 for the public HIV stigma (perceived) subscale.

Sexual behaviors

Sexual activities were assessed by a structured questionnaire. Participants were asked about their sexual practices in the past 6 months, including sexual role (e.g., “What's your sexual role for anal sex? [top/bottom/both]”) and substance use behaviors (e.g., “Have you ever used substances such as poppers, methamphetamine, marijuana in the past 6 months? [yes/no]”).

Engagement in peer education

Participants were asked two questions related to their engagement in peer education: (a) “Did you receive HIV counseling services in the MSM-friendly CBOs last year? (yes/no),” and (b) “Did you receive peer education in the MSM-friendly CBOs last year? (yes/no).

HIV transmission knowledge

HIV transmission knowledge was evaluated by an 8-item questionnaire adopted from “The China AIDS Prevention Supervision and Evaluation Framework Manual” (CDC, 2009), which was published by China CDC and widely used in the national HIV sentinel surveillance system to evaluate the HIV transmission knowledge level among the key populations. The manual provides detailed content for questionnaires on HIV transmission knowledge. The items were adopted in the form of true or false questions—one point for each correct answer. A total score of 6 or more indicated better awareness of HIV transmission. In this study, the Cronbach alpha was 0.70.

Statistical Analysis

The data were imported directly to SPSS 18.0 from sojump software, as developed by Changsha ran Xing InfoTech Ltd, a professional online survey platform. Descriptive analysis was used to examine the distributions of continuous variables, which are presented as the M and SDs. Categorical variables are presented as the frequencies and percentages. To identify the independent correlates of HIV-testing behavior among Chinese MSM (Yes = 0, No = 1), all variables that related to HIV-testing behavior in the bivariate analysis (using chi-squared tests for categorical variables or Mann–Whitney U tests for continuous variables) at p < .05 were entered in the logistic regression model. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Results

Characteristics of Participants

Of the 598 participants, the mean age was 28 years (median 28.3 years; range: 18–65 years). About 60% of participants (n = 376) had earned a bachelor's degree or above. In regard to income, 40.5% were middle-income earners (n = 242), which is defined as earning 2,001–4,000 RMB/month (289–579 USD; Liu & Xu, 2017). Most (82%, n = 491) were unmarried or divorced (Table 1). In terms of partnerships, 46.8% (n = 280) had regular male partners. In the past 6 months, 15.7% (n = 94) had unprotected vaginal sex and 31.9% (n = 191) had unprotected anal sex. About one quarter of the participants (n = 150) had used substances in the past 6 months (e.g., poppers, methamphetamine, marijuana; Table 2).

Table 1. - Sociodemographic Characteristics for MSM Who Have Tested for HIV and Those Who Have Not in the Past Year, Hunan Province, China (N = 598)
Variables N (%) Tested (%) Not Tested (%) p Value
Age (years) <.001*
 <30 461 (77.1) 384 (81.4) 77(61.1)
 30–45 119 (19.9) 78 (16.5) 41 (32.5)
 >45 18 (3.0) 10 (2.1) 8 (6.3)
Ethnicity .096
 Han 581 (97.2) 456 (96.6) 125 (99.2)
 Minority 17 (2.8) 16 (3.4) 1 (0.8)
Residence .003*
 Urban area 584 (97.7) 466 (98.7) 118 (93.7)
 Rural area 14 (2.3) 6 (1.3) 8 (6.3)
Educational background .136
 Primary school or lower 6 (1.0) 4 (0.8) 2 (1.6)
 Middle school 23 (3.8) 16 (3.4) 7 (5.6)
 High school or secondary school 193 (32.3) 164 (34.7) 29 (23.0)
 Undergraduate or above 376 (62.9) 288 (61.0) 88 (69.8)
Religion background .867
 Yes 64 (10.7) 50 (10.6) 14 (11.1)
 No 534 (89.3) 422 (89.4) 112 (88.9)
Monthly income (RMB) .719
 0 60 (10.0) 39 (8.3) 21 (16.7)
 ≤2,000 (289 USD) 46 (7.7) 35 (7.4) 11 (8.7)
 2001–4,000 (289∼579 USD) 242 (40.5) 205 (43.4) 37 (29.4)
 4,001–6,000 (579∼868 USD) 163 (27.3) 128 (27.1) 35 (27.8)
 6,001–8,000 (868∼1,157 USD) 51 (8.5) 36 (7.6) 15 (11.9)
 ≥8,001 (1,157 USD) 36 (6.0) 29 (6.1) 7 (5.6)
Marital status <.001*
 Unmarried 475 (79.4) 395 (83.7) 80 (63.5)
 Married 107 (17.9) 67 (14.2) 40 (31.7)
 Divorced 16 (2.7) 10 (2.1) 6 (4.8)
Sexual orientation <.001*
 Heterosexual 17 (2.8) 7 (1.5) 10 (7.9)
 Homosexual 444 (74.2) 370 (78.4) 74 (58.7)
 Bisexual 106 (17.7) 76 (16.1) 30 (23.8)
 Unclear 31 (5.2) 19 (4.0) 12 (9.5)
Disclosed sexual orientation .216
 Yes 214 (35.8) 163 (34.5) 51 (40.5)
 No 384 (64.2) 309 (65.5) 75 (59.5)
Note. MSM = men who have sex with men.
*p < .05.

Table 2. - Testing Behaviors Influenced by Sexual Characteristics and Counseling Seeking Behaviors Among MSM in Hunan, China (N = 598)
Variables N (%) Tested (%) Not Tested (%) p Value
Regular female partner .023*
 Yes 161 (26.9) 117 (24.8) 44 (34.9)
 No 437 (73.1) 355 (75.2) 82 (65.1)
Had unprotected vaginal sex with female partner (past 6 months) .001*
 Yes 94 (15.7) 62 (13.1) 32 (25.4)
 No 504 (84.3) 410 (86.9) 94 (74.6)
Regular male partner <.001*
 Yes 280 (46.8) 242 (51.3) 38 (30.2)
 No 318 (53.2) 230 (48.7) 88 (69.8)
Sexual role .546
 Top 171 (28.6) 137 (29.0) 34 (27.0)
 Bottom 110 (18.4) 90 (19.1) 20 (15.9)
 Both 317 (53.0) 245 (51.9) 72 (57.1)
Had unprotected anal sex with male partner (past 6 months) .006*
 Yes 191 (31.9) 138 (29.2) 53 (42.1)
 No 407 (68.1) 334 (70.8) 73 (57.9)
Substance use (e.g., poppers, methamphetamine, marijuana) in the past 6 months .432
 Yes 150 (25.1) 115 (24.4) 35 (27.8)
 No 448 (74.9) 357 (75.6) 91 (72.2)
Diagnosed with STI (excluding HIV) .293
 Yes 24 (4.0) 21 (4.4) 3 (2.4)
 No 574 (96.0) 451 (95.6) 123 (97.6)
Received HIV counseling services at MSM-friendly CBOs <.001*
 Yes 443 (74.1) 406 (86.0) 37 (29.4)
 No 155 (25.9) 66 (14.0) 89 (70.6)
Received peer education at MSM-friendly CBOs <.001*
 Yes 423 (70.7) 372 (78.8) 51 (40.5)
 No 175 (29.3) 100 (21.2) 75 (59.5)
Note. CBO = community-based organization; MSM = men who have sex with men; STI = sexually transmitted illness.
*p < .05.

HIV-Testing Behavior and Community Engagement

Overall, 78.9% (n = 472) of MSM had had an HIV test in the past year. Approximately 4% (n = 24) reported they had been diagnosed with a sexually transmitted illness in the previous year. More than two-thirds reported ever receiving HIV counseling services (74.1%, n = 443) or peer education at MSM-friendly CBOs (70.7%, n = 423; Table 2). Gay-oriented social media, friend outreach, and gay-initiated QQ groups (a Chinese instant-messaging program) were the main channels for MSM to access HIV testing information.

HIV Transmission Knowledge, HIV, and Sexual Minority Stigma

The mean score of HIV transmission knowledge was 7.27 (SD = 0.21, possible range: 0–8), with 93.7% of the participants scoring at least 6 or higher, indicating a high knowledge level. However, about one-third (31.4%) responded incorrectly to the item, “People who have been infected with HIV can be identified from his appearance.” The average scores of anticipated and internalized sexual minority stigmas and public HIV stigma were 2.78 (SD = 0.58), 2.36 (SD = 0.64), and 1.82 (SD = 0.63), respectively (possible range: 0–4; Table 3).

Table 3. - The Association Between HIV Transmission Knowledge, HIV-Related and Sexual Minority-Related Stigma With HIV Test Behaviors Among MSM, Hunan Province, China (N = 598)
Dimensions Cronbach α M ± SD Tested Not Tested p Value
HIV transmission knowledge 0.60 7.27 ± 0.21 7.42 ± 0.94 6.70 ± 1.37 <.001*
HIV and homosexuality related stigma
 (1) Anticipated sexual minority stigma 0.91 2.78 ± 0.58 2.76 ± 0.58 2.87 ± 0.56 .003*
 (2) Internalized sexual minority stigma 0.91 2.36 ± 0.64 2.28 ± 0.63 2.64 ± 0.61 <.001*
 (3) Public HIV stigma 0.93 1.82 ± 0.63 1.77 ± 0.64 2.02 ± 0.57 <.001*
Note. MSM = men who have sex with men.
*p < .05.

Factors Associated With HIV Testing

Based on bivariate analyses (Tables 1–3), MSM who were younger, unmarried, living in an urban area, self-identified as gay, having regular male partners, and receiving HIV counseling services or peer education in the MSM-friendly CBOs were more likely to have an HIV test in the previous year. Conversely, MSM who had regular female partners, had unprotected vaginal sex with a female partner in the past 6 months, and had unprotected anal sex with a male partner in the past 6 months reported higher levels of anticipated and internalized sexual minority stigmas and public HIV stigma and were more likely not to have had an HIV test in the previous year.

After controlling for all the demographic and behavior-related characteristics, the logistic regression analysis demonstrated that those who were older in age (OR: 1.84, 95% CI: 1.11–2.84, p = .016), did not receive counseling services in the MSM-friendly CBOs in the past year (OR: 0.064, 95% CI: 0.04–0.11, p < .001), did not have regular male partners (OR: 0.570, 95% CI: 0.34–0.97, p = .036), had lower HIV transmission knowledge (OR: 0.71, 95% CI: 0.58–0.87, p = .001), and had higher levels of internalized sexual minority stigma (OR: 1.94, 95% CI: 1.27–2.96, p = .002) had higher odds of not undergoing an HIV test in the previous year (Table 4).

Table 4. - Summary Model of Factors Associated With HIV Testing Among MSM in the Past Year, Hunan Province, China (N = 598)
Variables B SE p-Value Exp (B) (Adjusted OR) 95% CI for Exp(B)
Lower Upper
Age 0.58 0.24 .016* 1.84 1.11 2.84
Received HIV counseling services at MSM-friendly CBOs −2.76 0.27 .000** 0.064 0.04 0.11
Regular male partner −0.56 0.27 .036* 0.570 0.34 0.97
HIV transmission knowledge −0.34 0.10 .001** 0.710 0.58 0.87
Internalized sexual minority stigma 0.66 0.22 .002** 1.94 1.27 2.96
Note. The probability for stepwise: entry: 0.05, removal: 0.10. Model adjusted for residence, marital status, sexual characteristics, sexual orientation, community engagement (peer education), anticipated sexual minority stigma, and public HIV stigma. CBO = community-based organization; CI = confidence interval; MSM = men who have sex with men; OR = odds ratio.
*p < .05, **p < .01.

Discussion

Our study indicated that internalized sexual minority stigma was independently associated with HIV-testing behavior for Chinese MSM after controlling for other characteristics, including HIV-related and anticipated sexual minority stigmas. Most studies in China found that HIV-related stigma and discrimination can affect HIV-testing behaviors among MSM (Knight et al., 2016; Wei et al., 2016); however, when we consider HIV-related and sexual minority stigmas together, only the latter—internalized sexual minority stigma—affects the HIV-testing behaviors for MSM.

As far as we are aware, our study is the first to document that internalized sexual minority stigma is a significant barrier for HIV testing for MSM in China. This finding is similar to other studies in other social–cultural settings that have documented the higher the level of internalized sexual minority stigma MSM perceived, the more sexual risk behaviors they exhibited (Emlet et al., 2017; Zhu et al., 2018) and the higher level of anxiety and depression they had (Xu et al., 2017), the lower their HIV prevention and care-seeking behaviors were (Li et al., 2014; Wang et al., 2018). Although homosexuality was removed from the China Psychiatrics Classification and Diagnostic Criteria (Wu, 2003) in 2001, homosexuality is still widely unacceptable in Mainland China among members of mainstream Chinese society. A national survey conducted in Mainland China in 2017 revealed that almost 97% of MSM had heard someone state “homosexuality is not normal”; in this same study, 68.7% had pretended to be heterosexual for social acceptance (Sun et al., 2020). The reason for the higher stigma level toward the gay population lies in that homosexuality is against traditional Chinese values, which are dominated by familism and filial piety (Liu et al., 2018b). The combination of anticipated discrimination and negative experiences aggravated the internalization of the sexual minority stigma by the men themselves (Masuch et al., 2019), especially for those who experienced intense familial and cultural pressure to conceal sexuality and enter heterosexual marriage.

In comparison with other areas of Mainland China, the participants in this study had taken at least one HIV test during the past year at higher rates—78.9% in Hunan—compared with those reported rates in Chongqing (58%; Zhang et al., 2013b) and Nanjing (46%; Yan et al., 2016); our rates were comparable with those in Guangzhou (81%; Cheng et al., 2019). Compared with a cross-sectional study carried out in Hunan 3 years ago, the HIV testing proportion, based on our results, has increased from 62.3% (Zhou et al., 2018) to 79% because the local CDC has actively collaborated with gay-friendly CBOs—who can offer nonjudgmental, friendly health-related services to MSM—to offer HIV testing services. However, there is still a gap in achieving the “90-90-90” goal proposed by the Joint United Nations Programme on HIV and AIDS (UNAIDS, 2017).

Our study has several limitations that are important to note. First, the participants were recruited from only one gay-friendly CBO, which limits the generalization of our study results to other parts of China or international CBOs. Second, nonprobability sampling methods were used, which may create a selection bias for MSM. For example, the study results may represent mostly men who were easy to access, visible, and not worried about their personal reputation of being a homosexual. Thus, the external validity of our findings may be limited. Third, the self-reported data may lead to recall bias or socially desirable responses due to the sensitivity of homosexuality in China. Fourth, this study lacks a theoretical framework; however, we proposed a hypothesis based on the literature and examined it. Fifth, we only have several items to evaluate the covariates of the sexual behavior and engagement in peer education, which limit the validity of the instrument. However, other main validated instruments for independent and outcome variables were used. Last, the data were cross-sectional, which limited the ability to make causal inferences.

Despite these limitations, our findings have implications for the future. First, our results indicate the need to design culturally sensitive and relevant programs to address internalized sexual minority stigma to scale up HIV testing among Chinese MSM. These programs for Chinese MSM should be sensitive to individual-based psychological challenges and provide MSM with specific mental health services, which can help them accept their sexual identities and offset feelings of inferiority. Second, service providers should be trained to improve their skills and attitude toward homosexuality so that they can create a nonhomophobic, respectful environment for MSM, where confidentiality and responsible follow-up are normative. Third, public health education should improve tolerance toward sexual minorities and reduce the risk of sexual minority men with HIV infection. Finally, at the societal and policy levels, policymakers should note that addressing stigma against sexual minorities plays a significant role in HIV prevention, which requires attitude changes not only in individuals of sexual minority groups but also in all parts of China's society.

Conclusion

Compared with HIV-related stigma, internalized sexual minority stigma is a more severe barrier for HIV testing among MSM in China. Addressing internalized sexual minority stigma at a cultural level should be emphasized in HIV clinical settings, which not only can improve the mental health of sexual minorities but can also increase HIV testing among MSM in China.

Key Considerations

  • Internalized sexual minority stigma is perhaps a stronger obstacle than HIV-related stigma to seeking HIV testing for Chinese MSM.
  • Reducing internalized sexual minority stigma and improving sexual minority men's psychological health represent important factors to consider in encouraging MSM to seek HIV testing.
  • Addressing internalized sexual minority stigma and establishing a nonjudgmental environment in clinical health settings is urgently needed to expand HIV testing among MSM in China.

Disclosures

The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest.

Acknowledgments

This study was funded by Central South University Innovation-driven Project (Grant Number: 1053320184158; PI: Yuanyuan Chi). The authors would like to thank all the participants who completed the study questionnaire and the staff of the community-based organization, Zuo An Cai Hong, for their facilitation in participant recruitment.

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Keywords:

China; HIV testing; men who have sex with men; stigma

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