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Original Studies

Out of the Closet, Into the Clinic: Opportunities for Expanding Men Who Have Sex With Men–Competent Services in China

Watson, Julia BA*†‡; Tang, Weiming PhD*†‡§; Pan, Stephen PhD†¶; Wu, Dan PhD*†‡; Zhao, Peipei MS*†∥; Cao, Bolin PhD†**; Liu, Chuncheng BA*†††; Bien, Cedric MD*†; Huang, Wenting MS*†; Luo, Zhenzhou MS; Tucker, Joseph D. MD*†‡‡‡

Author Information
Sexually Transmitted Diseases: August 2018 - Volume 45 - Issue 8 - p 527-533
doi: 10.1097/OLQ.0000000000000808

Human immunodeficiency virus (HIV) services, especially services for key populations, have substantially decentralized in the past 5 years. Many men who have sex with men (MSM) can receive HIV testing at a wide range of sites.1 Although some aspects of decentralization are simple, configuring many diverse services to be responsive to the unique needs and preferences of young MSM will likely be challenging. This situation has contributed to MSM having difficulty finding local physicians who deliver MSM-competent services, defined as services meeting evidence-based standards for serving MSM.2 Yet all MSM need MSM-competent physicians who can sensitively elicit sexual histories, tactfully safeguard dignity, and provide evidence-based care.1,2 The MSM-competent services have been associated with sexual orientation disclosure, greater HIV testing, and antiretroviral adherence and retention within the HIV care continuum.3,4 The difficulty that MSM face in finding local physicians likely contributes to the substantial MSM disparities in HIV outcomes and overall mortality.5,6

Men who have sex with men in China have a high burden of HIV. The HIV prevalence among MSM in China has increased from 6.0% in 2010 to 8.0% in 2015.7 The HIV incidence among Chinese MSM was 8.9/100 person-years in a recent study.8 Although free HIV testing is provided in many government and community-based settings in China, MSM still have suboptimal HIV testing and delayed antiretroviral therapy initiation.9 Persistent discrimination against MSM makes it challenging to reach and engage MSM in China.10,11 Few MSM regularly disclosure their sexual orientation to physicians.12 Expanded MSM-competent services are needed in China.

The integration of HIV and primary care services has been shown to enhance MSM-competent services in high-income countries,13 but China and many low- and middle-income countries (LMICs) have less well-developed primary care.14 Although the Chinese government has been working since 2006 to reinstate a strong primary care system in China, the utilization of primary care services by Chinese people remains poor.15–17 The first point of contact for most people with illness is still tertiary care centers that have few primary care physicians (PCPs).15 Health reform has gradually expanded the system of primary care in China over the last decade, providing an opportunity for enhancing MSM-competent care.18

Few studies have evaluated MSM-competent services outside high-income countries.19,20 The limited research on MSM services in low- and middle-income countries focuses on physician self-report and administrative data.21 Moreover, qualitative research among MSM suggests that many physicians discriminate against MSM and perceived discrimination can deter MSM from seeking or continuing care.22 The purpose of this study was to evaluate MSM-competent services and determine the frequency of health care discrimination among a nationwide online sample of young MSM in China.

MATERIALS AND METHODS

Study Design and Sampling Methods

We conducted a national, cross-sectional online survey from May 27 through May 30, 2017. The survey was closed when the necessary sample size was reached. We recruited men using 2 large gay websites and an HIV organization's WeChat account. WeChat, a free multi-functional social media platform based in China, reported 938 million monthly active users as of May 2017.16 The entire survey instrument was field tested among 20 MSM, and feedback was incorporated into the finalized survey instrument. The link to the survey was first listed at the end of an HIV-related article posted on Blued's WeChat platform. Blued is the world's largest sex-seeking gay app. As of 2016, 27 million MSM have used Blued. Next, a short advertisement about the online survey was posted on the HIV organization's official WeChat account and then shared on the official WeChat account of an MSM organization headquartered in Qingdao, a city in China's eastern Shandong Province. This MSM organization provides health counseling, outreach, education, and online support for MSM and people living with HIV. This organization typically posts online articles about MSM to attract readers. We chose an HIV-related article because we wanted to recruit MSM at risk for and living with HIV. Recruitment was tracked using Sojump, an online questionnaire management software, and stopped on May 30th after the prespecified sample of 500 was reached. Assuming 60% of MSM who saw an MSM-competent doctor have a PCP and 40% of MSM who saw an MSM-competent doctor do not have a PCP, a sample size of 500 allows for detection of a statistically significant difference between these 2 groups with 95% confidence. The values of 60% and 40% were chosen based on data from field testing.

Eligible participants were born biologically male, 16 to 30 years of age, had ever engaged in anal or oral sex with another man, and had seen a physician in the last 24 months. Participants read a consent form and selected “agree” to acknowledge understanding and willingness to participate in the survey. Eligible participants received a small (~US $7.50) phone credit for participating.

Measures

The online survey was anonymous and measured sociodemographic information, HIV testing, recent experiences seeing a physician, and lifetime experiences of health care discrimination. Most survey items were from a population-based survey of sexual behaviors in China.23 Sociodemographic information included age (as a continuous variable), geographical location (city and province), residence (urban or rural), migrant status (migrant or local resident), occupation, marital status, education level (high school or below, some college, college and above), annual income (≤ US $5400, US $5401–9000, > US $9000), and ethnic affiliation. For reference, the average household net income in 2012 in China was approximately US $7000.24 Participants' province of origin was categorized based on 8 geographical regions in China: eastern, southern, central, northern, northwestern, northeastern, southwestern, and other (Taiwan, Hong Kong, and Macau). Participants were asked whether they currently have a PCP. We defined a PCP as a community level, nonspecialist physician who men trusted and saw on a regular basis.25 Participants were asked to report their self-identified sexual orientation (gay, bisexual, heterosexual, or unsure/other) and their current self-identified gender (man, woman, transgender, or unsure/other). For self-identified gender, we combined the categories of women and male-to-female transgender.12 Participants were asked if they had ever tested for HIV. Among those who tested for HIV infection, participants were asked their most recent HIV test result. The full survey instrument is included as supplemental material.

More detailed information was collected on the last physician visit. Men were asked about whether the physician asked about the following: having sex with other men (yes or no), anal sex (yes or no), condom use (yes or no), HIV testing (yes or no), and recommended HIV testing (yes or no). The MSM-competent physicians were defined as physicians who asked about having sex with other men, asked about anal sex, and either asked about or recommended HIV testing. This operational definition was based on MSM evidence-based guidelines from the US Centers for Disease Control,26 the World Health Organization (1), and the Fenway Institute (2).

Physician discrimination against MSM was examined using 9 survey items (Table 2) that were adapted from existing survey instruments.18,27,28 These survey items were used among young MSM in other settings27,28 and young sexual minorities.18 Men responded to each of the 9 items, and then we dichotomized the variable to denote whether the man had experienced any health care discrimination in their lifetime.

Statistical Analysis

For the descriptive analyses, we stratified the sociodemographic and health seeking behaviors by whether man reported last seeing an MSM-competent physician. We also performed t tests (for means) and χ2 tests to evaluate whether the 2 groups were different. We further evaluated the factors associated with seeing an MSM-competent physician by conducting a bivariate logistic regression analysis (odds ratio [OR], 95% confidence intervals [CI]). Finally, we performed multivariable analyses to obtain the adjusted association between different variables and seeing an MSM-competent physician. Variables with P values of less than 0.2 in the bivariate models were included in the final multivariate analysis.29 All data analyses were completed using IBM SPSS Statistics 19 (IBM, Armonk, NY). We used similar methods to evaluate factors correlated with reported lifetime experiences of health care discrimination. Specifically, we conducted bivariate logistic regressions and multivariable logistic regressions, and variables with P values of less than 0.2 in the bivariate models were included in the multivariate regression models.

Ethical Statement

Ethical approval was obtained from the ethics review committees at the Guangdong Provincial Center for Skin Diseases and STI Control (Guangzhou, China) and the University of North Carolina at Chapel Hill (Chapel Hill, NC).

RESULTS

Of 1689 people who clicked on the survey link, 1084 were determined ineligible. Approximately half of those ineligible were excluded because they had not seen a physician in the last 24 months. Of the 605 eligible respondents, 503 completed the survey, yielding a completion rate of 83.1%.

Demographic Characteristics of Total MSM Participants

Table 1 shows the total demographic characteristics of the sample. Overall, the average age of participants was 23.9 ± 3.5 years old. 93.2% (n = 469) identified as men, 5.4% (n = 27) identified as male-to-female transgender, and 1.4% (n = 7) identified as unsure/other. In terms of sexual orientation, 83.5% (n = 420) self-identified as gay, 11.9% (60) self-identified as bisexual and 4.6% (n = 23) self-identified as either heterosexual or unsure/other. Most respondents had never been married (94.4%, n = 475). Most participants were Han Chinese (94.2%, n = 474), and the survey included men from every province in China except Tibet. Participants were from, in descending order of frequency: eastern China (33.2%, n = 167), southern China (19.1%, n = 96), northern China (14.9%, n = 75), southwestern China (12.1%, n = 61), central China (10.5%, n = 53), northeastern China (6.2%, n = 31), northwestern China (3.6%, n = 18), and other (0.4%, n = 2). Most respondents lived in urban areas (85.9%, n = 432), and about half (50.1%, n = 252) were migrants. Most participants were employed (57.1%, n = 287), and about one-third (34.4%, n = 173) were students. Annual income distribution among participants was 45.1% (n = 227), 34.4% (n = 173), and 20.5% (n = 103) earning US $5400 or less, US $5401 to 9000, more than US $9000, respectively. Overall, 14.3% (n = 72) of participants had never been tested for HIV. Among those tested, HIV prevalence was approximately 14.5% (n = 73). Seventy-four (14.7%) of the participants had an established PCP.

TABLE 1
TABLE 1:
Demographic Characteristics of the Survey Participants in China, 2017 (N = 503)

Comparison of Sociodemographics Between MSM Who Saw an MSM-Competent Physician and MSM Who Did Not

Table 2 shows the comparison of sociodemographics between MSM who saw an MSM-competent physician and MSM who did not. The average age of MSM who saw an MSM-competent physician at their last visit was 23.2 (±3.4) versus 24.3 (±3.6) for MSM who did not see an MSM-competent physician (P < 0.001, Table 2). Southwestern China had the highest proportion of respondents who saw an MSM-competent physician (52.5%, n = 32), followed by northwestern China (38.9%, n = 7), southern China (38.5%, n = 37), northern China (34.7%, n = 26), eastern China (31.7%, n = 53), central China (28.3%, n = 15), and northeastern China (19.4%, n = 6) (P for group difference = 0.034). In terms of HIV status, 54.8% (n = 40) of participants living with HIV saw an MSM-competent physician at their last visit while 66% (n = 231) of participants with HIV did not see an MSM-competent physician at their last visit (P < 0.001). Regarding primary care, 59.5% (n = 44) of participants, who reported having a PCP, saw an MSM-competent physician at their last visit, whereas 30.8% (n = 132) of the participants without a PCP saw an MSM-competent physician at their last visit (P < 0.001).

TABLE 2
TABLE 2:
Comparison of Sociodemographics Between MSM Who Saw an MSM-Competent Doctor and MSM Who Did Not in China, 2017 (N = 503)

Factors Associated With Seeing an MSM-Competent Physician

Correlates of seeing an MSM-competent physician are presented in Table 3. Overall, 35.0% (n = 176) of men saw an MSM-competent physician at their last visit. The MSM who saw an MSM-competent physician at their last visit were more likely to be younger (adjusted OR [AOR], 0.87; 95% CI, 0.81–0.94) and have a PCP (AOR, 3.24; 95% CI, 1.85–5.67). Those who were living with HIV were more likely than others to report seeing an MSM-competent physician at their last visit (AOR, 2.01; 95% CI, 1.13–3.56). In the crude model, people living in southwestern China had an increased odds of seeing an MSM-competent physician at their last visit compared to other regions (crude OR, 2.37; 95% CI, 1.30–4.32). No association was detected between self-identified gender, sexual orientation, residency, migrant status, occupation, marital status, education, annual income, or ethnic affiliation.

TABLE 3
TABLE 3:
Factors Associated With MSM Who Saw an MSM-Competent Doctor in China, 2017 (N = 503)

Factors Associated With Health Care Discrimination

Table 4 displays young MSM participant experiences of discrimination from physicians. Three hundred eight (61.2%) of the participants reported ever experiencing perceived discrimination by a physician. Overall, 40% (n = 199) of participants reported having ever refrained from a necessary examination or treatment because they were afraid of being discriminated against because of their sexual orientation. One hundred eighty-seven (37.2%) of the participants reported having felt that their physician should know about their sexual orientation prior to an examination or treatment, but did not disclose it for fear of negative consequences. Thirty percent (n = 151) of respondents had perceived that their physician was uncomfortable discussing sexuality or sexual history. Another 20.7% (n = 104) of respondents reported having felt discriminated against by physicians because of their sexual orientation. We analyzed correlates of health care discrimination in a multivariate analysis and found that no correlates were associated (Supplemental Table 1 http://links.lww.com/OLQ/A248).

TABLE 4
TABLE 4:
Young MSM (n = 503) Experiences of Discrimination from Physicians in China, 2017

DISCUSSION

In this study, we evaluated several elements of MSM-competent services among an online, cross-sectional sample of MSM in China. We found that approximately one third of men saw an MSM-competent physician at their last physician visit. Men with a PCP were more likely to report seeing an MSM-competent physician. This study expands the literature by asking about 3 important aspects of MSM-competent services, evaluating MSM-competent services in a middle-income context, and reporting frequencies of MSM experiences of health care discrimination in China.

We found only one half of respondents reported being recommended HIV testing at their last physician visit. This level of HIV test offer likely represents an improvement from a 2012 study among patients seen by sexually transmitted infection providers in China.21 Among men who are not living with HIV in our study, over one third were recommended HIV testing at their last physician visit. This proportion of HIV test offer is higher than reported in a 2009 study among non–HIV-infected MSM in the United States.13

We found that men with PCPs were more likely to receive MSM-competent care. This is consistent with data from Australia and United States.13,30 We were not able to identify similar data on the frequency of MSM-competent services in China. Primary care physicians may be more competent in managing MSM health themselves or could facilitate referral to HIV or sexually transmitted infection specialists. Although there has been a growing primary care movement in China in the last decade, most people see specialists first and primary care services are underutilized.16,17 All physicians need to have the skills, knowledge, and experience to serve MSM in the clinic, but this need is particularly prominent in infectious diseases and primary care settings where MSM represent a larger portion of patients seen.

We found substantial discrimination experienced by MSM in health care settings. Nearly two thirds of participants experienced some form of lifetime health care discrimination. Men in our sample reported being ignored, mistreated, and refused health care by physicians at rates similar to 2 studies in the United States.27,28 Rates of refraining from an examination or treatment or disclosure of sexual orientation for fear of discrimination were higher than that among sexual minorities in Germany.18 Homophobic attitudes among physicians are common and may prevent MSM from seeking the health services.31,32 Training and related interventions for physicians may help to decrease MSM health care discrimination.33

Our data have implications for research and policy. From a research perspective, additional studies are needed to evaluate the extent to which physicians provide MSM-competent services. Earlier research has used administrative data to understand the quality of physician sexual health services in China.21 The MSM-focused evaluation of physician services through online platforms may be another option, given the high rates of internet use among MSM in China.34 From a policy perspective, more detailed guidelines for serving MSM in China may be useful for clinicians. Although global World Health Organization guidelines exist,1,35 these have not been adapted or widely implemented in China.

Our study has several limitations. First, our definition of MSM competence was relatively narrow and did not incorporate all of the needs of MSM. Second, this is a cross-sectional study, and no causal relationships can be inferred. We recruited a young, online sample of mostly urban MSM who may be different from the general MSM population.36 Third, we only asked about MSM-competent services at the last physician visit. Fourth, our measures of health care discrimination evaluated lifetime experiences, introducing the possibility of recall bias. However, similar measures have been used in other contexts.37 Fifth, discrimination survey items and a few other items were not validated in China. At the same time, we did adapt them based on field testing, and this preliminary data are important for subsequent behavioral research on this topic.

Despite these limitations, this study provides important information for further research and suggests that there is an urgent need to continue to evaluate and expand MSM-competent services in China. Our data suggest that there is already a subset of MSM-competent physicians, laying the foundation for subsequent MSM service improvements.

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