Discussion
A government-supported pilot project that authorised, trained and mobilised CBOs to recruit MSM for rapid HIV testing in China reached a large number of never-tested MSM and increased linkage to HIV care for those newly diagnosed. The intervention informed over 500 MSM of their HIV serostatus, ensured confirmatory results were received for all but one and linked over 90% of new diagnoses to care. Our data support the operational model for the effective expansion of HIV testing and linkage to care for Chinese MSM.
We perceive other advantages of the programme. Peers providing convenient, fast services in a MSM-friendly manner in familiar community settings reduced many barriers. The approach may particularly lessen anxiety for MSM who have never tested before, easing the current test and subsequent tests sought elsewhere. Satisfied clients were willing to refer peers, reaching several hundred untested MSM. Thus, the intervention was able to circumvent several important barriers to HIV testing among Chinese MSM, including lack of awareness where to test, the perceived stigma and discrimination associated with government-supported clinics and inconveniences such as longer wait time for standard blood test results and limited after work hours. The peer-based strategy also reached demographically different populations, including younger and migrant MSM, and MSM less likely to use condoms compared with those accessed through surveillance surveys.
In addition to convenience and trust placed in MSM peers to test, we believe positive effects on linkage to services can be attributed to the social support provided throughout the critical period following initial test through CDC confirmation and engagement in care. Unlike conventional testing programmes, the CBO provided instant referral and accompanying to the CDC after positive rapid screening, social support while awaiting confirmatory results, and a 1-month period of support to assist case management by the CDC system. Receiving social support at the early stage following diagnosis can reduce individuals' stress and anxiety and better prepare them for entry into care. Within the Chinese context, peer counsellors might be the only immediate support MSM are able to access and willing to accept, particularly if they are reluctant to disclose HIV and MSM status to family, friends or health providers for fear of rejection and discrimination. A lesson from our pilot project is that support needs to be continuously available to newly diagnosed MSM until they are fully engaged in care.
Our data also reveal potential weaknesses in the cascade of engagement in HIV care for MSM in China. While the CBO programme linked a higher proportion of newly diagnosed men to care, once in care the CBO intervention may not improve subsequent retention as compared with MSM entering through the surveillance surveys. Further peer support or alternative interventions, such as HIV-positive peer groups, are needed. By analogy, peer interventions may also be needed to help locate and encourage defaulters to return to care and to maximise ART adherence. Another potential weakness is the linkage to care of non-Jiangsu residents. While we cannot verify if referrals to out-of-province jurisdictions were completed, returning to areas that may be at great distance from Jiangsu and disruption of employment are likely to be substantial barriers. Loss to follow-up is also likely to occur before ART prescription. The CD4 criterion for ART initiation at the time of the study was ≤350 cell/mm. While the criterion was subsequently raised to ≤500 cell/mm, losses may occur in comparison to offering treatment to all persons with HIV as in the USA. As of writing, several cities of China, including Nanjing in Jiangsu province, are pilot testing the offering of ART to MSM regardless of CD4 count.
We recognise limitations of our data. While MSM recruited through the surveillance surveys were used for comparison to assess characteristics of the community reached and outcomes for linkage to care through an alternate approach, the design did not have a random or truly comparable control group. Rather, the outcomes highlight that different MSM are reached by different approaches. Moreover, we have no gold standard for generalisation to the wider population of MSM. The focus of this demonstration pilot was on reaching MSM who have never previously tested. While this group is a priority, MSM and other persons at risk are recommended to test more frequently, such as annually, in order to achieve the earliest possible diagnosis and the maximum benefits of treatment.
Despite limitations, our pilot project provides evidence in favour of a commonsensical approach to expanding HIV testing among MSM in China: place the tools in the hands of trusted community members who can efficiently bring the technology to them and individually walk HIV-positive persons through the early steps of their lifelong engagement in care. The CBO-based rapid testing and case management approach operationalises key components of the HIV response strategy of 'Five Expand, Six Strengthen' and is consistent with the established Chinese stance of national government leading policy, local health departments implementing policy and the full participation of society to maximise benefits. Community-based, non-judgemental, gay-positive rapid HIV test services have been accepted by MSM in other parts of the world. The present study translates and quantifies the contribution of such a programme in the Chinese context.