BackgroundHIV testing rates are suboptimal among at-risk men. Crowdsourcing may be a useful tool for designing innovative, community-based HIV testing strategies to increase HIV testing. The purpose of this study was to use a stepped wedge cluster randomized controlled trial (RCT) to evaluate the effect of a crowdsourced HIV intervention on HIV testing uptake among men who have sex with men (MSM) in eight Chinese cities.Methods and findingsAn HIV testing intervention was developed through a national image contest, a regional strategy designathon, and local message contests. The final intervention included a multimedia HIV testing campaign, an online HIV testing service, and local testing promotion campaigns tailored for MSM. This intervention was evaluated using a closed cohort stepped wedge cluster RCT in eight Chinese cities (Guangzhou, Shenzhen, Zhuhai, and Jiangmen in Guangdong province; Jinan, Qingdao, Yantai, and Jining in Shandong province) from August 2016 to August 2017. MSM were recruited through Blued, a social networking mobile application for MSM, from July 29 to August 21 of 2016. The primary outcome was self-reported HIV testing in the past 3 months. Secondary outcomes included HIV self-testing, facility-based HIV testing, condom use, and syphilis testing. Generalized linear mixed models (GLMMs) were used to analyze primary and secondary outcomes. We enrolled a total of 1,381 MSM. Most were ≤30 years old (82%), unmarried (86%), and had a college degree or higher (65%). The proportion of individuals receiving an HIV test during the intervention periods within a city was 8.9% (95% confidence interval [CI] 2.2–15.5) greater than during the control periods. In addition, the intention-to-treat analysis showed a higher probability of receiving an HIV test during the intervention periods as compared to the control periods (estimated risk ratio [RR] = 1.43, 95% CI 1.19–1.73). The intervention also increased HIV self-testing (RR = 1.89, 95% CI 1.50–2.38). There was no effect on facility-based HIV testing (RR = 1.00, 95% CI 0.79–1.26), condom use (RR = 1.00, 95% CI 0.86–1.17), or syphilis testing (RR = 0.92, 95% CI 0.70–1.21). A total of 48.6% (593/1,219) of participants reported that they received HIV self-testing. Among men who received two HIV tests, 32 individuals seroconverted during the 1-year study period. Study limitations include the use of self-reported HIV testing data among a subset of men and non-completion of the final survey by 23% of participants. Our study population was a young online group in urban China and the relevance of our findings to other populations will require further investigation.ConclusionsIn this setting, crowdsourcing was effective for developing and strengthening community-based HIV testing services for MSM. Crowdsourced interventions may be an important tool for the scale-up of HIV testing services among MSM in low- and middle-income countries (LMIC).Trial registrationClinicalTrials.gov NCT02796963

Objective Female injection drug users who are also sex workers (FSW-IDUs) occupy a pivotal population in HIV transmission, whereas their mental health problems are largely overlooked. We aimed to investigate prevalence and associated socio-ecological factors of depression, suicidal ideation and suicidal attempts among FSW-IDUs in China. Methods Using snowball sampling methods, 200 FSW-IDUs were recruited from communities in Liuzhou, China. Anonymous face-to-face interviews were administered by trained doctors. Results Thirty-nine percent of participants had severe or extremely severe depression, 44.7% had suicidal ideation in the last six months and 26.8% had suicidal attempts in the last six months. After adjusting for background variables, self-stigma was significantly associated with severe or extremely severe depression (OR=1.18, 95% CI: 1.07–1.31). Self-stigma (OR=1.08, 95% CI: 1.01–1.15), depression (OR=1.11, 95% CI: 1.05–1.18), having completely broken up with family (OR=2.60, 95% CI: 1.35–5.02) and having been abused by clients or gatekeepers (OR=2.15, 95% CI: 1.32–3.50) were associated with suicidal ideation in the last six months, while self-stigma (OR=1.03, 95% CI: 1.10–1.16), depression (OR=1.12, 95% CI: 1.04–1.20) and being abused by clients or gatekeepers (OR=2.15, 95% CI: 1.09–4.24) were associated with suicidal attempt in the last six months. In mediation analyses, the associations between self-stigma and the two suicidal outcomes were fully mediated by depression. Conclusions There are unmet mental health needs of FSW-IDUs. Screening of mental health problems should be integrated into current HIV-related services. Psychological intervention efforts should include components such as self-stigma, family support and abuse.

Background HIV self-testing (HIVST) holds great promise for reaching high-risk key populations who do not access facility-based services. We sought to characterize unsupervised HIVST implementation among men who have sex with men (MSM) in China. Methods We conducted a nationwide online survey in China. Eligible men were at least 16 years, had anal sex with a man, and had recent condomless sex. We assessed benefits (first-time testing, increased testing frequency, confirmatory testing) and potential harms (coercion, violence, suicidality) of HIVST. Among MSM who reported ever testing for HIV, we identified correlates of HIVST as first-time HIV test being a self-test using multivariable logistic regression. Results Among 1,610 men who met the eligibility criteria and started the survey, 1,189 (74%) completed it. 29% (341/1189) reported ever self-testing for HIV. HIV prevalence was 7% (24/341) among self-testers and 5% (15/306) among non-self-testers. 59% (200/341) of men who self-tested reported HIVST as a first-time HIV test. 31 men (9.1%) experienced coercion with HIVST. 78% (31/40) of men with positive HIV self-tests sought confirmation. Multivariable analysis revealed that HIVST as first-time HIV test was associated with younger age (OR=0.95, 95% CI 0.92, 0.99), not being “out” (OR = 2.28; 95% CI 1.60, 3.28), not using the internet to meet sex partners (OR=0.39, 95% CI 0.22, 0.69), and group sex (OR = 1.74; 95% CI 1.02, 2.9). Conclusions HIVST reached high-risk individuals that had never received facility-based testing. Further implementation research is needed to better understand HIVST outside of research programs.

IntroductionQualitative research on antiretroviral therapy (ART) adherence interventions can provide a deeper understanding of intervention facilitators and barriers. This systematic review aims to synthesize qualitative evidence of interventions for improving ART adherence and to inform patient-centred policymaking.MethodsWe searched 19 databases to identify studies presenting primary qualitative data on the experiences, attitudes and acceptability of interventions to improve ART adherence among PLHIV and treatment providers. We used thematic synthesis to synthesize qualitative evidence and the CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess the confidence of review findings.ResultsOf 2982 references identified, a total of 31 studies from 17 countries were included. Twelve studies were conducted in high-income countries, 13 in middle-income countries and six in low-income countries. Study populations focused on adults living with HIV (21 studies, n=1025), children living with HIV (two studies, n=46), adolescents living with HIV (four studies, n=70) and pregnant women living with HIV (one study, n=79). Twenty-three studies examined PLHIV perspectives and 13 studies examined healthcare provider perspectives. We identified six themes related to types of interventions, including task shifting, education, mobile phone text messaging, directly observed therapy, medical professional outreach and complex interventions. We also identified five cross-cutting themes, including strengthening social relationships, ensuring confidentiality, empowerment of PLHIV, compensation and integrating religious beliefs into interventions. Our qualitative evidence suggests that strengthening PLHIV social relationships, PLHIV empowerment and developing culturally appropriate interventions may facilitate adherence interventions. Our study indicates that potential barriers are inadequate training and compensation for lay health workers and inadvertent disclosure of serostatus by participating in the intervention.ConclusionsOur study evaluated adherence interventions based on qualitative data from PLHIV and health providers. The study underlines the importance of incorporating social and cultural factors into the design and implementation of interventions. Further qualitative research is needed to evaluate ART adherence interventions.