Background

In 2015 the WHO launched a comprehensive revision of the 2013 consolidated ARV guidelines, recommending immediate treatment for all people living with HIV and pre-exposure prophylaxis (PrEP) for people at high risk of HIV infection [1, 2]. At the same time, UNAIDS declared that the world should end the AIDS epidemic by 2030, with the goal of achieving the 90-90-90 diagnosis and treatment targets by 2020 [3]. Given these goals, it is imperative that we have a better understanding of key populations, including men who have sex with men (MSM) and transgender individuals (TG).

Globally, MSM are 19 times more likely to be living with HIV than the general population [4]. Despite global efforts to control HIV among key populations, new infections among MSM are still increasing [5–7]. High HIV prevalence was consistently observed among MSM in many regions around the world. For example in 2012, the HIV prevalence among MSM in the Caribbean was as high as 25 % [8]. Similar patterns have also been observed in Asia [8]. TG individuals are also an important, but often neglected, key population [9, 10].

The Chinese government has increased policy attention to HIV in recent years, providing an opportunity to enhance service delivery for MSM and TG individuals [11]. The purpose of this sco** review was to summarize HIV epidemiology and responses among MSM and TG individuals in China.

Methods

We undertook a sco** review to summarize the MSM/TG HIV epidemics in China, sexual health services across the HIV care continuum, and interventions for Chinese MSM/TG. In addition, based on the literature review, we summarized several policy points for consideration.

We used Arksey and O’Malley’s framework for conducting this sco** study. Sco** studies summarize key evidence on a topic, but do not go through the process of a formal systematic review [12]. We identified studies published between January 2009 and October 2015 that reported on Chinese MSM HIV epidemiology, sexual health services across the HIV care continuum, and sexual health interventions. Studies were identified using keyword searches in electronic databases. We searched the following databases: MEDLINE (OVID interface, 1946 onwards), EMBASE (OVID interface, 1947 onwards) and the Cochrane Library. The search string used synonyms and variations of the following terms: MSM, TG, meta-analysis, review and China.

We included studies that had the following elements: 1) Study designs were systematic reviews; 2) Study participants were MSM or TG in China; and 3) Outcomes included data on health services across the HIV care continuum or interventions targeting Chinese MSM or TG. If data of interest were not available in systematic reviews, supplemental articles, grey literature, government reports, policy documents, and best practice guidelines were also included. We also contacted experts at the Chinese CDC, WHO, Gates Foundation and UNAIDS to provide reports, policy documents, and guidelines. Our preliminary report was reviewed by civil society organizations, UN organizations, the WHO China office, and two external reviewers.

Results

HIV epidemiology and surveillance

Population size estimation and data sharing

The WHO estimated 2–10 million MSM in China in 2009 [13]. China reported that about 2–4 % adult male population in urban areas and 1–2 % adult male population in rural areas are MSM, and estimated that the number of MSM in China may range from 3.1 to 6.3 million in 2009 [14]. Another study in China estimated that there were 5–10 million MSM in China [15].

Collected data is shared among some public health organizations and community-based organizations (CBOs). However, most of the MSM CBOs that work closely with local CDC have limited access to MSM health surveillance and related data [16–18].

HIV prevalence among Chinese MSM

The HIV prevalence was estimated to be 6.0 % in 2010 [16], and it has gradually increased to 8.0 % in 2015 (Fig. 1) [19]. Regional disparity is an important feature of the HIV epidemic among Chinese MSM. Based on a systematic review, HIV prevalence is increasing across all regions of China, particularly in the southwest region, made up of five provinces [16]. The average HIV prevalence in this region was three times the overall Chinese average. In addition, municipalities and provincial capitals also have higher HIV prevalence, compared to other cities [40, 48].

Interventions ongoing and completed

Prevention and behavioral interventions at individual and group-level

Since 2005, the Chinese government has expanded its intervention efforts to MSM [49]. Various programs have been conducted to promote condom use, counseling and testing, peer education, and follow-up outreach. A meta-analysis that summarized 22 MSM intervention studies suggested that behavioral interventions have been efficacious in increasing HIV knowledge, HIV testing, and condom use, and in reducing sexual risk behaviors. However, the study also indicated that interventions have not reduced the incidence of HIV among Chinese MSM [50].

Interventions for promoting HIV Self-testing (HIVST) in China

HIVST is not illegal in China, and more than 20 HIVST kits have been approved by the Chinese Food and Drug Administration [51] and are available in China [52]. There is currently no national program of HIVST among MSM in China, however around one quarter of Chinese MSM have self-tested for HIV [52, 53]. Several pilot programs have shown that HIVST is an additional HIV testing method that could increase first-time HIV testing [53, 54]. Many pilot interventions have been conducted to examine the efficacy of hybrid CBO-clinic models in promoting HIV testing and linkage to care (Table 1). These interventions primarily focus on improving cooperation among CDC system, hospital and MSM CBOs in China [46, 55]. For example, by collaborating with a local CBO, the Guangzhou CDC built a social entrepreneurship model to promote HIVST among MSM [56]. Overall, 198 (52.1 %) MSM purchased self-testing kits, and 192 (97.0 %) participants used kits and returned the testing results [57].

Table 1 Project IMPACT: A Model for Increasing the Collaboration between Community-based Organizations and the Public Sector in China
Full size table

Internet-based and social media interventions

A few internet-based interventions have been conducted to improve accessibility to HIV services and care [55, 58, 59]. For example, the Guangzhou CDC developed two internet-based interventions: ‘scenario experiencing intervention application’ and ‘online HIV risk self-assessment system’ [58]. Compared to the control group, participants in the intervention arm of HIV risk-assessment system had reduced CAI in the last anal sex by 44 %, and CAI with regular and casual partners within the last three months by 26 and 25 % respectively [58].

Various social media techniques have been applied to HIV educational interventions as well as to testing mobilization and partner services interventions targeted towards MSM in China. Danlan Gongyi, an LGBT online web portal and CBO, used Wechat to provide rapid and anonymous HIV testing services as well as offline services such as psychological counseling and support [3]. Other social media platforms, such as QQ, Jack’d and microblogging, have been also used in carrying out HIV/AIDS interventions among Chinese MSM [60, 61].

Crowdsourcing HIV test promotion interventions

Crowdsourcing is “the practice of obtaining needed services, ideas, or content by soliciting contributions from a large group of people and especially from the online community [62].” Crowdsourcing can be used to solicit concepts, images, and videos to promote HIV testing (Table 2). Several crowdsourcing contests have been implemented in South China. One randomized controlled trial (RCT) in China aimed at promoting HIV testing showed that crowdsourcing methods were both effective and cost saving when compared to a health marketing intervention. HIV test uptake was similar between the crowdsourced arm (37 %, 114/307) and the health marketing arm (35 %, 111/317) [52]. Another RCT in China found that a crowdsourced intervention was non-equivalent to a social marketing intervention, also noting cost savings [63].

Table 2 SESH and crowdsourcing contests to create demand for HIV testing and other services
Full size table

Interventions for improving linkage and retention in care

In 2012, the China CDC initiated a pilot intervention project to demonstrate a ‘one-stop’ service model for individuals with HIV infection [

Abbreviations

ART:

Antiretroviral therapy

ARV:

Antiretroviral(s)

CAI:

Condomless anal intercourse

CBOs:

Community based organization(s)

CDC:

Centers for disease control and prevention

HIVST:

HIV self-testing

HTS:

HIV testing service

ISR:

Implementation science research

KP:

Key population(s)

LGBT:

Lesbian, gay, bisexual and transgender

MSM:

Men who have sex with men

PLHIV:

People living with HIV

PrEP:

Pre-exposure prophylaxis

PS:

Partner services

RNA:

Ribonucleic acid

STDs:

Sexually transmitted diseases(s)

STIs:

Sexually transmitted infection(s)

UNAIDS:

Joint United Nations Programme on HIV/AIDS

VCT:

Voluntary counselling and testing

VL:

Viral load

WHO:

World Health Organization

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Acknowledgement

Sincere thanks are given to Colin Shepard, MD, and Zhijun Li, MD from Division of Global HIV/AIDS in China, China office of U.S. Centers for Disease Control & Prevention (CDC); Dr. James Yang from UNDP and Mr. John Shen from Bei**g LGBT center for their strong support during the data collection process. Thanks are also given to two excellent young scholars, Jessica Mao and Wei Zhang, for their contributions in process of literature collection and report editing. We also would like to thank the staff at Social Entrepreneurship for Sexual Health (SESH) Global, Danlan Gongyi (淡蓝公益), Lingnan Partner (岭南伙伴), Guangzhou CDC, and Guangdong Provincial Center for Skin Diseases and STI Control, who contributed to our work.

Funding

This work was supported by the WHO-China office; National Institutes of Health [National Institute of Allergy and Infectious Diseases 1R01AI114310 to JT]; and UNC-South China STD Research Training Centre [Fogarty International Centre 1D43TW009532 to JT].

Availability of data and materials

The dataset supporting the conclusions of this article is included within the article’s Additional file 1.

Authors’ contributions

All authors have read and approved the final manuscript. This sco** review was prepared by Drs. Songyuan Tang, Weiming Tang, Kathrine Meyers, and Joseph Tucker. Drs. Polin Chan made significant contribution in process of literature collection. Drs. Polin Chan, and Zhongdan Chen reviewed the manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable.

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Author notes

    Authors and Affiliations

    1. University of North Carolina Project-China, No. 2 Lu**g Road, Guangzhou, 510095, China

      Songyuan Tang, Weiming Tang & Joseph D. Tucker

    2. Guangdong Provincial Center for Skin Diseases and STI Control, Guangzhou, China

      Songyuan Tang, Weiming Tang & Joseph D. Tucker

    3. SESH Global, Guangzhou, China

      Songyuan Tang, Weiming Tang & Joseph D. Tucker

    4. Kunming Medical University, Kunming, China

      Songyuan Tang

    5. Aaron Diamond Aids Research Center, New York, USA

      Kathrine Meyers

    6. WHO China Office, Bei**g, China

      Polin Chan

    7. UNAIDS China Office, Bei**g, China

      Zhongdan Chen

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    Correspondence to Joseph D. Tucker.

    Additional information

    Songyuan Tang and Weiming Tang are co-first authors.

    Additional file

    Additional file 1:

    Annex: Summary of ongoing and completed interventions focus on the HIV care continuum among MSM in China (DOCX 137 kb)

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    Tang, S., Tang, W., Meyers, K. et al. HIV epidemiology and responses among men who have sex with men and transgender individuals in China: a sco** review. BMC Infect Dis 16, 588 (2016). https://doi.org/10.1186/s12879-016-1904-5

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