Factors related to HIV testing frequency in MSM based on the 2011–2018 survey in Tianjin, China: a hint for risk reduction strategy

Men who have sex with men (MSM) have been the focus of HIV prevention in high-risk groups. According to the 2019 UNAIDS report [1], the proportion of new HIV infections amongst MSM is increasing annually. The epidemiological evidence also suggests that the greatest priority in China’s response to HIV is prevention programs targeting MSM [2]. Owing to a lack of widespread HIV testing, the majority of the infected population is not on effective antiretroviral therapy [3]. In addition, HIV testing is a key strategic tool for HIV prevention in China. It has been reported in the literature that more frequent HIV testing among MSM can reduce expenditure in the health sector [4]. Studies generally focus on comparing HIV testing strategies to analyse cost effectiveness but not on actual frequency of testing among MSM [5]. The popularization of instant messaging technologies such as WeChat and Blue D in China have gradually changed some sexual behavior of MSM but the risk of HIV transmission has also increased [6]. Although HIV testing frequency has been investigated [7], the factors related to testing frequency have not been well described in conjunction with the behavioral factors in MSM. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recommended an ambitious 95–95-95 target to end the AIDS epidemic by 2030. It states that by 2030 at least 95% of PLHIV should know their status, 95% of people diagnosed with HIV should receive sustained ART and 95% of those on ART should achieve viral suppression [8]. The Center for Disease Control (CDC, USA) has recommended that high-risk groups should be tested for HIV at least once a year [9]. However, several studies have shown that HIV testing in MSM is not as satisfactory as expected [10, 11]. In 2016, the rate of HIV testing among high-risk groups in Europe was very low, and it was estimated that 25% of people living with HIV were undiagnosed [12]. In an MSM population survey in 20 cities in the United States, more than 35% of the population did not have HIV testing within the last 1 year as recommended by the CDC [13]. The mandatory surveillance system for Sexually Transmitted Infections (STIs) in England showed that of the 37,702 HIV-negative MSM in 2013–2014, 64% were tested for HIV within the last 1 year, and only 1% were tested every quarter [14]. In China, the proportion of undetected MSM population was as high as 57.4% [15]. Furthermore, less than 20% of MSM had been tested in the past year in Jinan, China [16]. There appears to be a paucity of literature investigating the factors which influence MSM testing for HIV amongst those who have not been tested for HIV in in the last one or more years. Many people have understood the importance of HIV testing especially after decades of HIV/AIDS-related knowledge publicity. However, there still appears to be a low testing rate in MSM who also appear not to have regular testing. Therefore, the factors which influence HIV testing in MSM needs further investigation especially to implement appropriate strategies to promote regular testing in MSM.

Our study explores a range of factors which may influence HIV testing in MSM. An analysis of the demographic, sexual behavior, HIV/AIDS related knowledge and HIV testing may provide insights for recommendations to improve the testing strategy in MSM in China.

Our results demonstrate that MSM are not inclined to undergo annual HIV testing. Additionally, those MSM who are young, married, less-educated, have low-level HIV/AIDS related knowledge and those who did not accept condoms use and promotion are less likely to undergo annual HIV testing [18‐20]. MSM is a high-risk group for HIV infection and should be tested at least annually or more frequently due to their ongoing risky behaviors [21].

The HIV testing done shows that MSM may not undergoing HIV testing regularly as expected [22]. Their HIV testing results indicate that 29% of the HIV-infected MSM had never been tested for HIV before, 15% had not tested for HIV within the last 1 year, while the HIV infection rate among non-annual testers was 13.2%, the highest among the three groups. At least 44% of MSM with possible long-term HIV infection had not undergone regular testing.

The transmission rate of those who do not know their HIV status is estimated to be three times that of those who are aware of their status [23]. The lack of awareness of HIV testing, negative emotions such as the inconvenience of detection, perceived low service quality, and anxiety about HIV related stigma may cause MSM to avoid HIV testing for long periods [24].

The young MSM and those with low-education levels are main target groups for HIV testing [25]. The HIV infection rate among young MSM Chinese has been increasing [26]. Young MSM may have strong sexual desire, maybe more likely to contact MSM groups and have male sexual intercourse following online internet communication [27]. However, lack of HIV/AIDS knowledge and fear of positive results may discourage young MSM from undergoing HIV testing [28]. HIV/AIDS education was associated with significant additional reductions in sexually risky behaviors among Young MSM [29]. Low-educated MSM tend to test less for HIV, which is consistent with previous reports [30]. It is important to adopt different online and internet sites using new technologies to strengthen the HIV/AIDS related knowledge to improve HIV testing in young people [31]. Interventions amongst farmers, workers and other low-educated MSM can be implemented through easy-to-understand methods, such as using pictorial brochures to promote free HIV testing and safe sex education [32]. Therefore, when low-educated MSM seek sexual partners or engage in group sex events in the bathhouses, these interventions may reduce their risk of HIV infection.

Our results indicate that the annual testing behavior of married MSM is not as good as that of single MSM. It has been reported in China that due to parental or social pressure, nearly half (48.9%) of MSM chose to marry women, and 91% of them reported that they would practice homosexual behavior after marriage [33]. This behavior may expand the spread of HIV from MSM to the general population or even the next generation through HIV maternal transmission. It is therefore essential to increase the frequency of HIV testing in married MSM, such as making HIV testing more accessible and by promoting self-test kits. In addition, provision of frequent HIV testing to married MSM may contribute in promoting HIV testing among their sexual partners and in facilitating safer sexual practices.

The proportion of condom promotion and advanced HIV/AIDS related knowledge received in this study was about 60 to 70%, suggesting that continued expansion and strengthening of HIV-related advocacy in MSM may lead to improvements in HIV testing behaviour. In addition, the awareness of condom use is also related to frequent HIV testing [34]. Compared with MSM who always used condoms during anal sex for the past 6 months, people who never used or occasionally used condoms appeared to lack awareness of annual HIV testing. Possessing a high level of HIV/AIDS knowledge and receiving condom promotion and distribution can foster better HIV testing awareness, thereby promoting regular HIV testing behaviors among MSM [35]. Strategies to strengthen the promotion of condom use and safe sexual behaviors warrants further consideration in MSM in China to achieve the 2030 UNAIDS goal [36].

HIV/AIDS prevention and control agencies may be able to promote the benefits and implementation of HIV testing in places where MSM frequently find sexual partners such as bathhouses and the Internet. In addition, it is also necessary for the testing agency to ensure a friendly and non-discriminatory HIV testing environment for the testers [37]. Another strategy is to vigorously promote self-testing kits to ensure that potential HIV-infected MSM can safely undergo frequent HIV testing in their own homes [38].

Men who have sex with men (MSM) are a marginalized population with a high risk of HIV infection. Therefore, they need to undergo HIV testing at least once a year to prevent and control the spread of HIV, which we report may not be uniformly practiced in China. HIV/AIDS health and education interventions should accommodate the diversity of MSM with specific focus on those MSM who are young, have low education levels and are married to improve HIV testing behavior and frequency. The aim to end the AIDS epidemic by 2030 by achieving 95% diagnosed among all people living with HIV necessitates that all relevant stakeholders implement targeted publicity, HIV/AIDS health education, and promote self-test kits to encourage HIV testing among MSM in China.