Reasons for boosting HIV testing and association with risky sexual behaviors in MSM population: evidence from China

doi:10.21203/rs.3.rs-4609668/v1

Background: A regular human immunodeficiency virus (HIV) testing with a safe sexual behavior is an important preventive strategy in the control of HIV especially among men who have sex with men (MSM), who are in risk of HIV infection. Therefore, we aim to explore the reasons boosting HIV testing among MSM and the risky sexual behaviors behind.

Methods: An institutional based investigationwas conducted to collect data from MSM in January and December 2022in Zhejiang Coastal Public Welfare Center which is a non-government organization (NGO). The risky sexual behaviors included commercial sexual behaviors, unprotected sexual behaviors, multiple sexual partners, drug using and using sexual stimulant. The reasons for boosting MSM to have HIV testing included prevention before/after exposure, regular habit testing high risk post testing, peer driven testing, publicity and education testing and others. The factors influencing the unprotected sex, multiple sexual partners, using drugs and sexual stimulants of MSM were explored based on multivariate logistic regression.

Results:In total, 7266 MSM were incorporated in the analysis. The most important reason for boosting MSM to have an HIV testing were their regular habit testing(51.73%) followed by high risk post test (15.99%), publicity and education testing(12.72%). The population who had high risk post HIV test had the highest percentage of unprotected sex(78.83%), commercial sex(0.84%), using drugs(4.22%) and sexual stimulant(42.0%), multiple sexual partners(30.98%) and symptoms or diagnosis of sexual transmitted diseases (6.11%) compared with MSM with other HIV testing reasons respectively. Compared with the reasons for HIV testing of prevention before/after exposure, people with high-risk post testing had a higher probability of having unprotected sex (P<0.001, OR=5.804) and multiple sexual partners (P=0.041, OR=1.476). Publicity and education testing had a lower probability of having unprotected sex (P<0.001, OR=0.432) and multiple sexual partners (P=0.006, OR=0.575).

Conclusions: Reasons for boosting HIV testing among MSM were different with different risky sexual behaviors, and the rate of having risky sexual behaviors among MSM with regular HIV testing habits was lower. However, most MSM have not developed the habit of regular HIV testing. Therefore, improving the HIV testing among MSM is still important to reduce the transmission of HIV.

HIV testing

Risky sexual behavior

MSM

China

By the end of 2021, 38.4 million people living with human immunodeficiency virus (HIV) / acquired immunodeficiency syndrome (AIDS) (PLWHA) were reported globally and the number of AIDS-related deaths was up to 650,000 in 2021[1]. Amongst 23% of new adult HIV infections were MSM[2]. However, the HIV epidemic among young MSM is not well defined considering limited data on the number of MSM globally. Some studies reported that the lifetime prevalence of sex between males in some low- and middle-income countries ranged from

3–20%.[3] A study from Canada showed that 1.7% of the boys reported being attracted exclusively to the same sex based on 11000 secondary-school students. [4] In New Zealand, it was reported 0.9% of secondary-school students reported exclusive attraction to the same sex. [5] In China, the HIV prevalence among MSM was as high as 6.9% and has continued to increase significantly in recent years.[6, 7] The timely identification of HIV infection through HIV testing is an important way to prevent the HIV transmission and to achieving UNAIDS 95% of people living with HIV know their HIV status. HIV testing is also a critical entry to early HIV treatment services and is the basic for achieving 95% of those initiate HIV antiretroviral therapy.[8]

The rate of HIV testing showed an increase trend in the last decade. However, there were still some risky sexual behaviors populations especially MSM never to have an HIV testing. [9, 10] Some studies had explored the barriers for HIV testing and regular HIV testing and they also found associations between no lifetime history of HIV testing and risky sexual behaviors including condomless anal intercourse[11–13]. To promote HIV testing especially among MSM, several ways were developed including prevention before exposure, regular habit testing high risk post testing, peer driven testing, and publicity and education testing in China. In addition, HIV testing with a safe sexual behavior is an important preventive strategy in the control of HIV. However, limited studies explored the association between reasons boosting HIV testing and risky sexual behaviors, which may provide evidence for the precise interventions of reducing risky sexual behaviors among MSM.

Participants

An institutional based investigation was conducted to collect data from MSM in January and December 2022. Zhejiang Coastal Public Welfare Center which is a non-government organization (NGO) was the study setting, which provides health publicity and education for sexual minorities especially MSM. It has established a comprehensive prevention and control system for HIV prevention, testing, and treatment based on the Internet, such as HIV online appointment testing and personalized HIV prevention services. The inclusion criteria for the participants were the physiological gender is male; males who have ever sex with men and those who made an appointment for HIV testing including application for HIV self-testing reagents and the facility-based HIV testing based on the system of Zhejiang Coastal Public Welfare Center in January and December 2022. All these participants were invited to participant in the survey and informed consent was given before starting the filling out the questionnaire.

In the survey system, it was set to allow each MSM to fill out the questionnaire only once to prevent the repeated filling. In addition, to ensure the quality of the survey, first, the number of questions was minimized to less than 20 to reduce MSM dropout or random filling out; second, to prevent MSM from missing a certain question, the system will remind the missing questions to ensure that all questions are filled out before submitting the questionnaire; third, informed consent was provided to ensure that that research does not involve any information that can identify personal characteristics; fourth, we conducted logical verification on the collected data (e.g., gender, sexual behaviors and sexual partners) and found that the logical accuracy of the data was up to 100%. Finally,7266 MSMs participated in the survey and incorporated in the data analysis.

Data collection

The following information was collected including social-demographics (i.e., gender, age, marital status and employment), risky sexual behaviors in the past 3 months, symptoms of sexually transmitted diseases or whether they have been diagnosed as sexually transmitted diseases in the past 3 months. The gender in our study was measured by self-reported gender rather than physiological gender. Age were measured by 15–19, 20–24, 25–29, 30–39, 40 − 39 and ≥ 50. Marital status included married, cohabitation, divorced and widow. Employment was measured by employed, unemployed, students, farmers and others. The risky sexual behaviors in our study were measured if the MSM had commercial sexual behaviors or unprotected sexual behaviors or multiple sexual partners or drug using or using sexual stimulant in the past 3 months. The reasons for boosting MSM to have an HIV testing included prevention before/after exposure, regular habit testing high risk post testing, peer driven testing, publicity and education testing and others.

Statistical analysis

The basic characteristics of MSM, the reasons for boosting HIV testing and sexually related behaviors among MSM were analyzed using descriptive statistics with frequency and percentage. Moreover, multivariate logistic regression was used to explore the influencing factors of risky sexual behaviors including unprotected sex, multiple sexual partners, using drugs and sexual stimulants[14]. All statistical analyses were performed using SPSS 24.0 with statistical significance of p < 0.05.

Characteristics of MSM

Table 1 showed the basic characteristics of MSM in our study. Among the total MSM, 99.72% (7246) reported they were male. 37.39% (2717) were 20–24 years old followed by 25–29(28.24%, 2052) and 30–39(18.59%, 1351). Regarding marital status, most MSM were unmarried(82.80%, 6016). For the occupation, more than half of them (63.94%, 4646) were employed followed by 24.92%(1811) students. Regarding the education, 45.20% of MSM were undergraduate or above, and 2.16% were illiteracy or primary school.

Table 1

The basic characteristics of MSM
Items		Frequency	Percentage(%)
Self-reported gender	Male	7246	99.72
Self-reported gender	Other	20	0.28
Age	15–19	685	9.43
	20–24	2717	37.39
	25–29	2052	28.24
	30–39	1351	18.59
	40–49	368	5.06
	≥ 50	93	1.28
Marital status	Unmarried	6016	82.80
	Married	790	10.87
	Cohabitation	281	3.87
	Divorced	170	2.34
	Widow	9	0.12
Occupation	Employed	4646	63.94
	Unemployed	71	0.98
	Students	1811	24.92
	Farmers	49	0.67
	Others	689	9.48
Education level	Illiteracy	82	1.13
	Primary school	75	1.03
	Junior high school	585	8.05
	High school or technical secondary school	1363	18.76
	Junior college	1877	25.83
	Undergraduate	2787	38.36
	Master or above	497	6.84

HIV testing reasons and risky sexual behaviors

The most important reason for boosting MSM to have an HIV testing were their regular habit testing (51.73%) followed by high risk post test (15.99%), publicity and education testing (12.72%). The rate of peer driven testing accounting for 7.5%, and 2.35% for prevention before/after exposure (Fig. 1).

Figure 2 showed that among MSM with different gender, age, marital status, occupation and education level, the major reason for having HIV testing was regular habit testing except for the widow and illiteracy, which publicity and education, high risk post testing were the major reason.

Figure 3 showed the risky sexual behaviors under boosting HIV testing reasons among MSM. The population who had HIV test after high risk exposure had the highest percentage of unprotected sex(78.83%), commercial sex(0.84%), using drugs(4.22%) and sexual stimulant(42.0%), multiple sexual partners(30.98%) and symptoms or diagnosis of sexual transmitted diseases (6.11%) compared with MSM with other HIV testing reasons respectively. MSM with publicity and education testing, and regular habit HIV testing had a relatively lower percentage on unprotected sex, commercial sex, using drugs and sexual stimulant, multiple sexual partners and symptoms or diagnosis of sexual transmitted diseases respectively.

Factors influencing risky sexual behaviors of MSM

Table 2 showed the influencing factors of having unprotected sex and multiple sexual partners among MSM. Compared with the reasons for HIV testing of prevention before/after exposure, people with high risk post testing had a higher probability of having unprotected sex (P < 0.001, OR = 5.804) and multiple sexual partners (P = 0.041, OR = 1.476). Publicity and education testing had a lower probability of having unprotected sex (P < 0.001, OR = 0.432) and multiple sexual partners (P = 0.006, OR = 0.575). However, Table 3 showed that there were no statistical differences on the drug and sexual stimulant using among different HIV testing reasons(P > 0.05).

Table 2

Influencing factors of having unprotected sex and multiple sexual partners among MSM
Items	Unprotected sex				Multiple sexual partners
	P-value	OR	95%CI		P-value	OR	95% CI
	P-value	OR	Lower limit	Upper limit	P-value	OR	Lower limit	Upper limit
Gender
Other	0.362	1.373	0.694	0.143	0.611	0.835	0.416	0.991
Male(ref)
Age
15–19(ref)
20–24	0.229	0.880	0.715	0.248	0.737	1.042	0.819	0.023
25–29	0.553	0.930	0.733	0.208	0.081	1.272	0.971	0.009
30–39	0.588	0.932	0.721	0.558	0.010	1.454	1.093	0.001
40–49	0.648	1.082	0.771	0.464	0.002	1.765	1.237	0.079
≥ 50	0.780	0.928	0.548	0.431	0.010	1.938	1.172	0.514
Marital status
Unmarried(ref)
Married	0.532	1.068	0.869	0.001	< 0.001	1.542	1.262	0.091
Cohabitation	< 0.001	1.907	1.486	0.238	0.567	1.085	0.821	0.027
Divorced	0.232	1.227	0.877	0.329	0.007	1.572	1.131	0.200
Widow	0.200	0.260	0.033	0.999	0.003	5.915	1.850	0.403
Occupation
Employed(ref)
Unemployed	0.310	0.787	0.496	0.529	0.099	0.632	0.366	0.391
Farmers	0.050	0.479	0.230	0.112	0.458	0.783	0.410	0.153
Students	0.620	0.961	0.823	0.904	0.027	0.819	0.687	0.067
Others	0.858	0.984	0.824	0.777	0.979	1.002	0.833	0.342
Education level
Illiteracy(ref)
Primary school	0.019	0.421	0.204	< 0.001	0.081	2.027	0.917	0.005
Junior high school	0.432	0.801	0.461	< 0.001	0.039	2.035	1.038	< 0.001
High school or technical secondary school	0.405	0.798	0.468	< 0.001	0.034	2.040	1.056	< 0.001
Junior college	0.080	0.622	0.366	< 0.001	0.083	1.789	0.927	< 0.001
Undergraduate	0.036	0.568	0.335	< 0.001	0.060	1.875	0.974	< 0.001
Master or above	0.001	0.397	0.227	< 0.001	0.013	2.367	1.202	< 0.001
Regular test
Yes	0.303	1.055	0.953	0.617	0.508	1.038	0.929	0.454
No(ref)
Reasons for HIV testing
Prevention before/after exposure(ref)
Regular habit testing	0.004	0.626	0.454	< 0.001	0.246	0.807	0.561	0.016
High risk post testing	< 0.001	5.804	4.101	0.417	0.041	1.476	1.015	0.995
Peer driven testing	0.064	0.712	0.497	0.153	0.579	0.891	0.594	0.296
Publicity and education testing	< 0.001	0.432	0.305	0.004	0.006	0.575	0.388	0.014
Others	< 0.001	0.489	0.343	0.016	0.016	0.609	0.406	0.024

Table 3

Influencing factors of injecting drug and using sexual stimulant among MSM
Items	Inject drug using				Using sexual stimulant
	P-value	OR	95% CI		P-value	OR	95% CI
	P-value	OR	Lower limit	Upper limit	P-value	OR	Lower limit	Upper limit
Gender
Other	0.880	0.831	0.074	9.335	0.019	0.419	0.202	0.867
Male(ref)
Age
15–19(ref)
20–24	0.019	0.486	0.267	0.887	0.029	0.806	0.664	0.978
25–29	0.032	0.424	0.194	0.929	0.464	1.085	0.871	1.352
30–39	0.109	0.502	0.217	1.165	0.439	0.911	0.719	1.154
40–49	0.937	0.959	0.346	2.662	0.484	0.893	0.650	1.226
≥ 50	0.263	1.924	0.611	6.056	0.006	0.481	0.284	0.814
Marital status
Unmarried(ref)
Married	0.010	2.522	1.244	5.112	0.389	1.087	0.899	1.312
Cohabitation	0.003	3.028	1.476	6.212	0.435	1.099	0.867	1.394
Divorced	0.830	1.154	0.312	4.273	0.317	1.176	0.856	1.615
Widow	0.999	0	0	.	0.259	0.411	0.088	1.922
Occupation
Employed(ref)
Unemployed	0.693	1.359	0.297	6.221	0.670	0.912	0.598	1.391
Farmers	0.625	0.654	0.119	3.598	0.092	0.561	0.286	1.099
Students	0.202	1.471	0.814	2.658	< 0.001	0.765	0.660	0.886
Others	0.384	1.331	0.700	2.531	0.814	0.981	0.833	1.154
Education level
Illiteracy(ref)
Primary school	< 0.001	0.056	0.018	0.174	0.135	0.634	0.349	1.152
Junior high school	< 0.001	0.040	0.019	0.088	< 0.001	0.350	0.220	0.557
High school or technical secondary school	< 0.001	0.027	0.014	0.053	0.001	0.458	0.294	0.714
Junior college	< 0.001	0.028	0.014	0.054	< 0.001	0.429	0.276	0.667
Undergraduate	< 0.001	0.017	0.008	0.034	< 0.001	0.410	0.265	0.636
Master or above	< 0.001	0.022	0.008	0.061	< 0.001	0.327	0.205	0.524
Regular test
Yes	0.768	1.059	0.722	1.553	0.846	1.010	0.918	1.110
No(ref)
Reasons for boosting testing
Prevention before/after exposure(ref)
Regular habit testing	0.434	0.593	0.161	2.193	0.949	1.011	0.733	1.393
High risk post testing	0.322	1.927	0.526	7.065	0.075	1.353	0.970	1.888
Peer driven testing	0.504	1.588	0.409	6.168	0.887	0.974	0.681	1.394
Publicity and education testing	0.623	0.704	0.174	2.851	0.277	0.827	0.588	1.165
Others	0.181	0.361	0.081	1.607	0.006	0.604	0.423	0.862

This is the first research to analyze the reasons boosting HIV testing of MSM and the risky sexual behaviors behind the reasons. The results from this research showed almost 50% of MSM did not develop a habit of regular HIV testing including institutional HIV testing and self-testing. In addition, we found that MSM who have regular HIV testing had a relatively lower rate in unprotected sex and multiple sexual partners.

In our study, most MSM were young people, with 75.06% were under 30 years old and unmarried people. These were consistent with previous studies[6, 10]. There are several reasons influencing this phenomenon. With the development of society and internationalization, more and more people have learned about the lesbians, gays, bisexuals, transgender (LGBT) through different channels (such as European and American movies and TV works), which has gradually led people to accept homosexuality[15, 16]. At the same time, it may also lead to more and more young people viewing homosexuality as a trend, especially some young adults who are even still in adolescence and have immature thoughts. In addition, homosexual groups were in a highly stigmatized state of the whole society, and they had to hide themselves more deeply in the past, so we could see very few homosexual groups. But more young homosexuals dare to admit their homosexual orientation currently.

Reasons for boosting HIV testing among MSM were different and almost 50% of them did not develop a habit of regular HIV testing. A high percentage of MSM only chosen to have HIV testing after high-risk sexual behaviors, which is consistent with a published study with 24.60% of MSM had a test due to a high-risk sexual behavior[17]. Moreover, the rate of peer driven testing was also low (7.5%), which presents it is still important to improve the peer education among MSM to increase the uptake of HIV testing. In addition, evidences have proved that peer education has a good effect on boosting HIV testing and reduce the risk of HIV infections [18–21].

The rate of having risky sexual behaviors under reasons for boosting HIV testing were also different. MSM who have regular HIV testing had a relatively lower rate in unprotected sex and multiple sexual partners. However, MSM who had high risk post HIV test had the highest percentage of unprotected sex(78.83%), commercial sex(0.84%), using drugs(4.22%) and sexual stimulant(42.0%), having multiple sexual partners(30.98%) and symptoms or diagnosis of sexual transmitted diseases (6.11%) compared with MSM with other HIV testing reasons respectively. In addition. it was showed MSM who had high risk post HIV test were more likely had a higher risky sexual behavior compared with other MSM (P < 0.05). Correspondingly, strengthening regular HIV testing among MSM is important for early detection of HIV status, promoting early use of antiviral treatment drugs, and preventing further transmission of HIV, which have significant health benefits both for MSM individuals and others. Moreover, as we move forward in the effort to reach the UNAIDS 95–95–95 targets, effective measures to promoting HIV testing are vital. First, more context-based health education campaigns are still needed to reduce self-perceived luck for MSM not uptake HIV testing after high-risk sexual behavior[22, 23]. Second, offering testing to MSM through effective strategies is necessary to discover the HIV positive MSM. For example, promoting HIV testing to MSM through trusted key opinion leaders or peers, which can reduce the fear and mistrust of MSM under a discriminatory social context [24]. Moreover, with the development of internet and internet is widely accessed, web-based AI chatbot is reported as a personalized, engaging, and effective way to promote HIV testing, which can learn from previous human-machine interactions to increase the accuracy and quality of HIV related intervention [25].

Limitations

Our study was subject to some limitations. First, considering the significant number of MSM and the cultural differences, this study may not be able to represent the whole MSM population in China. Second, considering the investigation was conducted online based on the NGOs, the results may subject to the limitations of online survey. Moreover, considering our study was based on some institution, which may subjective to the potential for selection bias.

Ethics approval and consent to participate

The study protocol and consent procedure were approved by Medical Ethics Committee of Public health school of Zhejiang University (Project No. ZGL202306-9). The confidentiality of individuals was properly protected in the management of the investigation and the processing of the data.
Consent for publication

All authors have agreed with the content and approved the submission of the manuscript. Availability of data and material

All of the main data have been included in the results. Additional materials with details may be obtained from the corresponding author. Competing interests

All authors declare that they have no competing interests.
Funding

This work was supported by China Medical Board (Project No. 20-391), Special Research Program of Pharmacoeconomics and Health Technology Assessment Committee of Zhejiang Pharmaceutical Association (Project NO. 2023ZYJ02, 2022ZYJ06)and Zhejiang Provincial Medical and Health General Project (Project No. 2020KY777).

Authors' contributions

XZ conducted the literature review and drafted the paper. SW analyzed the data. KX, and JX contributed to the interpretation of the data, and critical revisions of the paper. The authors all approved the final versions for submission.
Acknowledgements

We are grateful to all study participants for their valuable participation.

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No competing interests reported.

Reasons for boosting HIV testing and association with risky sexual behaviors in MSM population: evidence from China

Status:

Version 1

Abstract

Figures

Background

Methods

Participants

Data collection

Statistical analysis

Results

Characteristics of MSM

HIV testing reasons and risky sexual behaviors

Factors influencing risky sexual behaviors of MSM

Discussion

Limitations

Declarations

References

Additional Declarations

Status:

Version 1