Providing HIV-related services in China for men who have sex with men

Bull World Health Organ 2016;94:222–227 | doi: http://dx.doi.org/10.2471/BLT.15.156406 Lessons from the field 222 Providing HIV-related services in China for men who have sex with men Weibin Cheng,a Yanshan Cai,a Weiming Tang,b Fei Zhong,a Gang Meng,c Jing Gu,d Chun Hao,d Zhigang Han,a Jingyan Li,c Aritra Das,e Jinkou Zhao,f Huifang Xu,a Joseph D Tuckerb & Ming Wanga Introduction Community engagement is important for controlling the human immunodeficiency virus (HIV) epidemic among men who have sex with men (MSM).1–3 In China, not-for-profit community- based organizations (CBOs) are engaged with the social, educa- tional, environmental or public safety needs of the community. However, the majority of public sector-funded HIV programmes in China have failed to engage CBOs4,5 and have had limited suc- cess in preventing HIV.6 Furthermore, the lack of endorsement for CBOs from the public sector has hampered the work of CBOs on HIV control and delivery of related services. Most MSM-friendly CBOs do not offer services like HIV testing, post-test counsel- ling, result notification and follow-up, which limit their ability to provide comprehensive care services. To address these problems, an HIV care and prevention pro- gramme sponsored by the Bill & Melinda Gates Foundation was launched in China in 2008. The programme promoted collaboration between public sector agencies and CBOs in the delivery of prevention and support services. Preventive services were directed to high-risk groups and included reducing risk behaviours and increasing HIV testing. Support services focused on increasing access to care and improving the quality of services for people living with HIV. During the programme, the responsibility for some HIV-targeted interven- tions began to shift from the public sector to CBOs.7 Here we describe a project collaboration called IMPACT (integration minimum package of prevention in accelerating case finding and treatment) in Guangzhou. Local setting In China, basic HIV control and prevention measures are implemented primarily through the public health system organized by the Chinese Center for Disease Control and Pre- vention (CCDC). These measures include HIV-testing cam- paigns, condom promotion, behavioural change interventions, follow-up care for people living with HIV and implementa- tion of free antiretroviral therapy (ART).4,5 Due to stigma and discrimination against homosexuality and people living with HIV, MSM are usually hard to reach. Most of the CBOs working with MSM are newly-established organizations that know the community very well. However, a large proportion of CBOs have not been well supported by the public health sector due to policy barriers and a perceived lack of expertise in HIV prevention in these organizations. Many CBOs have not survived due to lack of funds. In 2011, MSM constituted almost one-third of the 48 000 new HIV infections.5 The HIV prevalence among MSM has increased from 2.5% in 2006 to 7.4% in 2009.8,9 Furthermore, it is estimated that in 2011, 50% of MSM who were HIV-positive did not know their status.5 Guangzhou is a city in southern China with over 12 million inhabitants. In 2008, it was estimated that 44 593 sexually active MSM were living in the city. HIV prevalence among MSM has increased significantly from 5.0% (19/379) in 2008 to 11.4% (72/633) in 2013.10 Problem In China, human immunodeficiency virus (HIV) care provided by community-based organizations and the public sector are not well integrated. Approach A community-based organization and experts from the Guangzhou Center for Disease Control and Prevention developed internet-based services for men who have sex with men, in Guangzhou, China. The internet services were linked to clinical services offering HIV testing and care. Local setting The expanding HIV epidemic among men who have sex with men is a public health problem in China. HIV control and prevention measures are implemented primarily through the public system. Only a limited number of community organizations are involved in providing HIV services. Relevant changes The programme integrated community and public sector HIV services including health education, online HIV risk assessment, on-site HIV counselling and testing, partner notification, psychosocial care and support, counting of CD4+ T-lymphocytes and treatment guidance. Lessons learnt The internet can facilitate HIV prevention among a subset of men who have sex with men by enhancing awareness, service uptake, retention in care and adherence to treatment. Collaboration between the public sector and the community group promoted acceptance by the target population. Task sharing by community groups can increase access of this high-risk group to available HIV-related services. a Department of AIDS/STD Control and Prevention, Guangzhou Center for Disease Control and Prevention, No. 1 Qide Road, Jiahe, Guangzhou, Guangdong,510440, China. b University of North Carolina Project-China, Guangzhou, China. c Lingnan Partners Community Support Center (GZTZ.ORG), Guangzhou, China. d School of Public Health, Sun Yat-sen University, Guangzhou, China. e Fielding School of Public Health, University of California Los Angeles, Los Angeles, United States of America. f Global Fund to fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland. Correspondence to Huifang Xu (email: gzxuhuifang@hotmail.com). (Submitted: 3 April 2015 – Revised version received: 28 September 2015 – Accepted: 16 November 2015 – Published online: 22 January 2016 ) L sons from the field Bull World Health Organ 2016;94:222–227| doi: http://dx.doi.org/10.2471/BLT.15.156406 223 Lessons from the field HIV care in ChinaWeibin Cheng et al. Relevant changes Previously CBOs were restricted to car- rying out programme implementation only. Here, the Guangzhou CDC and the Lingnan Partners Community Support Center worked together to design an integrated service including HIV health education, online HIV-risk assessment, on-site HIV counselling and testing, partner notification, psychosocial care and support, CD4+ T-lymphocyte count testing and guidance on clinical treat- ment. Each component of the project was designed with a specific goal and relevant HIV care service (Table 1). We describe these components below. Project components Online prevention tools We developed two internet tools: a scenario-based application and an HIV risk self-assessment system. The scenario- based application is an interactive inter- net application that simulates real-life HIV risk scenarios. The objective of this application is to encourage HIV testing and reduce high-risk behaviours. The online HIV risk self-assessment system calculates an individualized HIV- risk score by evaluating an individual’s risk profile. Based on the results, this system also provides tailored guidance to promote HIV testing and behavioural change. These two online tools reach a wide user base via the internet and provide tailored interventions to meet specific needs. HIV education was also provided online and by public service broadcasting via a social media applica- tion (WeChat). Online-to-offline service This component linked virtual interven- tions for increasing HIV testing to actual HIV testing and facilitated HIV care. The online prevention tools described above were linked to an online appointment sys- tem for HIV testing. People could choose to have a test at one of three facilities in the area and test results were made avail- able via an online notification system. A person who made an online appointment could also choose that the notification system (Easy Tell®) informed their partner anonymously about a positive result by clicking a consent button and providing the partner’s mobile phone number or email address.11 If the result was positive, a system message which contained a veri- fication code was sent automatically to the partner. Notified partners could retrieve the information through the platform using the verification code and then be linked to HIV testing from the platform. Service centre We set up a one-stop service centre in Guangzhou, which was coordinated by a local CBO and Guangzhou CDC. In this centre, public sector staff provided on-site blood sampling and testing and carried out epidemiological investigations, such as HIV sentinel surveillance among MSM and medical follow-up for people who tested positive. People who were tested were also asked questions about their sexual behaviour. Meanwhile, CBO peers delivered high-quality and timely pre- and post-test counselling, psychosocial support services, guidance on retention in care and ART adherence support ser- vices. The quality of these processes was ensured by following a stringent selection process. Peer workers were trained by staff from Guangzhou CDC and the CBO for about three months in the one-stop ser- vice centre. All peer counsellors signed a confidentiality agreement. Project outcome Between 2008 and 2013, the project gave 22 282 HIV antibody tests, of which 999 tests were positive. The annual number of tests increased from 1064 in 2008 to 7754 in 2013. By 2013, tests conducted under the project accounted for more than 80% of total HIV tests (22 282/26 884) and new HIV diagnoses (999/1218) among MSM in Guangzhou (Fig. 1). Currently, an average of 25 people make appointments and get tested through the project each day. This project has addressed the needs of this Table 1. HIV-related services for men who have sex with men provided by collaboration between the public sector and a community- based organization in Guangzhou, China, 2008–2013 Type of service Goal Content Service package (year available) Related information Internet- based prevention services To assist MSM in generating, reinforcing, and validating awareness of HIV risk and safe sex behaviour HIV health education and HIV testing mobilization Online HIV knowledge dissemination (2008) http://www.gztz.org Scenario-based application (2010) http://www.gztz.org Only open for registered users Online HIV risk self-assessment system (2012) http://pink.gztz.org Only for registered users Health-related online broadcasting for the gay community (2013) WeChat, a free social media application. WeChat ID: Lingnan-station Online-to-off line service linkage To increase connectivity between online and offline services and promote HIV testing among partners of newly diagnosed HIV individuals HIV testing and counselling booking and result notification and counselling Online HIV testing appointment system (2010) http://lingnan.gztz.org Online testing-results-notification system (2010) http://www.gztellthem.org Anonymous partner notification system (Easy Tell®, 2009) http://www.gztellthem.org Offline one- stop shop service To boost the confidence among MSM in receiving the service and to keep the person in care On-site HIV counselling and testing, psychosocial care and support for HIV, ART support HIV rapid testing (2011) http://lingnan.gztz.org/May/UserStory CD4+ T-lymphocyte count and viral load testing, ART support (2010) NA One-on-one care support for newly diagnosed individuals (2009) NA ART: antiretroviral therapy; CD4: cluster of differentiation 4; HIV: human immunodeficiency virus; MSM: men who have sex with men; NA: not applicable. Bull World Health Organ 2016;94:222–227| doi: http://dx.doi.org/10.2471/BLT.15.156406224 Lessons from the field HIV care in China Weibin Cheng et al. community and has been improving ac- cess to HIV services. The project also ensured continuum- of-care services, including linkage to care, retention in care, ART initiation and ART adherence. Of the 999 HIV-positive people, it was possible to link 948 (95%) to care services, while 891 (94%) of those linked were successfully retained in care. Among those who were retained in care and met the criteria for receiving free ART (CD4+ count < 350 cells/μL), over 85% (353/415) initiated ART. Based on the percentage of people on ART, we as- sumed that approximately 75% of these people achieved viral suppression (less than 50 copies/mL). Challenges and lessons learnt The project had several limitations and faced several challenges (Box 1). One of the key limitations is that this project did not collect comprehensive pre-interven- tion data to demonstrate the effect of the intervention. Also, the project could re- cruit only a subset of MSM residing in the study area and found it difficult to reach out to some subgroups (e.g. older MSM and rural MSM). These hard-to-reach subgroups reportedly have lower levels of education, poorer HIV knowledge and fewer opportunities to access HIV-related services, making them highly vulnerable to HIV.10 Despite the expanding scope of HIV services arising from collaboration be- tween the public sector and the CBO, the relative absence of formal partnerships with treatment facilities limited the extent to which this intervention impacted clini- cal management and retention. Closer partnerships with clinical facilities may further enhance the project. Our annual HIV sentinel surveillance face-to-face survey showed that 80% (2081/2603) of respondents received some form of HIV- related service during the past year, HIV testing coverage remained relatively low (47%; 1227/2603) among MSM.12,13 This disparity indicates the need to strengthen the promotion of HIV testing. Other challenges included instability of peer workforce, lack of sustained funding and intervention information fatigue. Despite the limitations, the high percentage of people who were retained in HIV care suggests that collaboration between the public sector and CBOs can be successful in providing high-quality HIV-related services. Internationally, task-shifting from health professionals to CBOs has proven to be effective in the provision of counselling, testing, care and treatment services for HIV.7,14 In the cur- rent project, the CBO engaged with the MSM community and the public sector agencies contributed technical profi- ciency and worked together to improve the quality of services offered. The key to this successful collaboration was the mutual trust between the public sector and the CBO. The role of the CBO was not restricted to programme implemen- tation; it was also involved in the project development phases.15 The one-stop shop concept of providing a range of HIV services from a single location increased retention in HIV care. The project may be usefully adapted to other places in China and perhaps other low- and middle-income countries, where opportunities for community en- gagement are limited. Finally, experience gained from the project can also inform decision-making in other public health domains, which is likely to benefit from increased collaboration between the public sector and community groups. ■ Acknowledgements We thank Wen Fang, Liu Jiewei, Xie Muqun and Tang Chen from the Depart- ment of AIDS/STD Control and Preven- tion, Guangzhou Center for Disease Control and Prevention and Liu Qi, Lu Yongheng and Xue Kunyu from Lingnan Partners Community Support Center. Funding: The study was supported by the China-Gates HIV Prevention Program (2008-2012), the Medical Scientific Pro- gram of Guangzhou (20131A011114, 2013A011090012, 20141A011061) and the Science and Technology Program of Guangzhou (2012Y2–00021). WT and JT were supported by grants from the US NIH (NIAID 1R01AI114310–02, 1D43TW009532–03). Competing interests: None declared. Fig. 1. HIV testing of men who have sex with men through a project linking internet- based HIV services to testing, in Guangzhou, China, 2008–2013 No . o f p er so ns te st ed 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 Pr op or tio n of d ia gn os es th ro ug h pr oj ec t ( % ) 100 90 80 70 60 50 40 30 20 10 0 Year Diagnoses identified through projectTested through project Tested outside project 2008 2009 2010 2011 2012 2013 448 1064 625 2490 933 2338 994 3247 1137 5389 465 7754 92.8 82.8 75.5 60.2 89.1 70.4 HIV: human immunodeficiency virus. Box 1. Summary of main lessons learnt • The internet can facilitate human immunodeficiency virus (HIV) prevention among a subset of men who have sex with men by enhancing awareness, service uptake, retention in care and adherence to treatment. • Collaboration between the public sector and the community group promoted acceptance by the target population. • Task sharing by community groups can increase access of this high-risk group to available HIV-related services. Bull World Health Organ 2016;94:222–227| doi: http://dx.doi.org/10.2471/BLT.15.156406 225 Lessons from the field HIV care in ChinaWeibin Cheng et al. صخلم ينصلا في ةيلثم ةيسنج تاقلاع نوميقي نيذلا لاجرلل يشربلا يعانلما زوعلا سويرفب ةطبترلما تامدلخا يرفوت زوعلا سويرف ضىرلم ينصلا في ةمدقلما ةياعرلا نأ ظحول ةلكشلما ةلماكتم يرغ ماعلا عاطقلاو ةيعمتجلما تماظنلما نم يشربلا يعانلما .لثملأا وحنلا لىع ءابرخو ةيعمتجلما تماظنلما ىدحإ في نولوؤسم ماق بولسلأا دادعإب اهنم ةياقولاو ضارملأا ةحفاكلم ”وشتغناوق“ زكرم نم نوميقي نيذلا لاجرلل تنترنلإا ةكبش لىع ةزكترلما تامدلخا تامدخ طبر متو .ينصلا في ”وشتغناوق“ ةيلثم ةيسنج تاقلاع سويرف صحف رفوت يتلا ةيريسرلا تامدلخاب تنترنلإا ةكبش .هب ينباصلما ةياعرو يشربلا يعانلما زوعلا ينب شرتنلما يشربلا يعانلما زوعلا سويرف ءابو نإ ةيلحلما عقاولما ةيحص ةلكشم وه ةيلثم ةيسنج تاقلاع نوميقي نيذلا لاجرلا يعانلما زوعلا سويرف ةحفاكم يربادت ذيفنت متي .ينصلا في ةماع دجوي لا .ماعلا ماظنلا للاخ نم ساسلأا في هنم ةياقولاو يشربلا ميدقتب ةينعلما ةيعمتجلما تماظنلما نم طقف دودمح ددع ىوس .يشربلا يعانلما زوعلا سويرف تامدخ زوعلا سويرف تامدخ جمدب جمانبرلا ماق ةلصلا تاذ تا ّريرغتلا كلذ في ماب ماعلا عاطقلاو عمتجلما نم ةمدقلما يشربلا يعانلما يشربلا يعانلما زوعلا سويرف رطامخ مييقتو ،يحصلا فيقثتلا يعانلما زوعلا سويرف نع تاراشتسا ميدقتو ،تنترنلإا ةكبش لىع فرطلا غلابإو ،هفاشتكلا صحفلا ءارجإو عقولما في يشربلا ددع ءاصحإو ،يعمتجلماو سيفنلا معدلاو ةياعرلا يرفوتو ،رخلآا .جلاعلل تاداشرإ ميدقتو ،CD4+ ةيئاتلا تايوافمللا ايلاخ ةياقولا ليهست في ةهماسلما تنترنلإا ةكبشل نكمي ةدافتسلما سوردلا لاجرلا نم ةيعرف ةعوممج ينب يشربلا يعانلما زوعلا سويرف نم ،يعولا ةدايز للاخ نم ةيلثم ةيسنج تاقلاعب نوموقي نيذلا ىدأو .جلاعلاب مازتللااو ،ةياعرلا ءاقبتساو ،تامدلخا باعيتساو لوبق عيجشت لىإ ةيعمتجلما ةعومجلماو ماعلا عاطقلا ينب نواعتلا نم ماهلما ةكراشم نإ .ينفدهتسلما ناكسلا عاطق بناج نم ضىرلما هذه لوصح ةبسن نم ديزي نأ نكمي ةيعمتجلما تاعمالجا بناج سويرفب ةطبترلما ةرفوتلما تامدلخا لىع رطخلل ةضرعلما ةعومجلما .يشربلا يعانلما زوعلا 摘要 中国境内为男男性行为者提供 HIV 相关服务 问题 在中国，社区组织和政府机构提供的人体免疫缺 陷病毒 (HIV) 预防和关怀服务未充分整合。 方法 广州的社区组织和广州市疾病预防控制中心的专 家为男男性行为者创建了基于互联网的 HIV 服务。互 联网的服务与现场 HIV 检测和关怀服务形成无缝连 接。 当地状况 男男性行为者群体 HIV 的疫情逐渐上升是 中国当前面临的一大公共卫生问题。HIV 防控措施主 要通过政府系统实施，仅有少数社区组织参与提供 HIV 服务。 相关变化 该计划将社区组织与政府机构的 HIV 服务 结合起来。这些服务包括健康教育、在线 HIV 风险评 估、HIV 现场咨询与检测、性伴通知、社会心理关怀 和支持、CD4+ T 淋巴细胞计数监测和抗病毒治疗指 导。 经验教训 通过互联网提高人群风险意识、服务渗透率、 随访维持率和治疗依从性，能够在部分男男性行为者 中促进 HIV 预防。政府机构和社区组织之间的合作提 升了目标人群的接受度。社区组织的参与让高风险群 体能够更加方便地接受现有的 HIV 相关服务。 Résumé Offre de services relatifs au VIH en Chine pour les hommes ayant des rapports sexuels avec d’autres hommes Problème En Chine, la prise en charge du virus de l’immunodéficience humaine (VIH) par des organismes communautaires et par le secteur public n’est pas bien intégrée. Approche Un organisme communautaire et des experts du Centre de contrôle et de prévention des maladies de Guangzhou ont mis au point des services sur internet pour les hommes ayant des rapports sexuels avec d’autres hommes, à Guangzhou, en Chine. Ces services internet étaient rattachés à des services cliniques proposant un dépistage et un traitement du VIH. Environnement local La propagation de l’épidémie de VIH chez les hommes ayant des rapports sexuels avec d’autres hommes est un problème de santé publique en Chine. Les mesures de lutte et de prévention du VIH sont principalement mises en œuvre par le système public. Seul un petit nombre d’organismes communautaires offrent des services en lien avec le VIH. Changements significatifs Le programme a intégré des services relatifs au VIH de la communauté et du secteur public, notamment des services d’éducation à la santé, l’évaluation en ligne des risques liés au VIH, le dépistage du VIH sur site et des conseils associés, l’information des partenaires, des soins et un soutien dans le domaine psychosocial, la numération des lymphocytes T CD4+ et des recommandations en matière de traitement. Leçons tirées Internet peut faciliter la prévention du VIH chez une partie des hommes ayant des rapports sexuels avec d’autres hommes en renforçant la sensibilisation, l’utilisation de services, le maintien des soins et le respect du traitement. La collaboration entre le secteur public et le groupe communautaire a favorisé l’acceptation du projet par la population cible. Le partage des tâches entre groupes communautaires peut améliorer l’accès de ce groupe à haut risque aux services disponibles en matière de VIH. Bull World Health Organ 2016;94:222–227| doi: http://dx.doi.org/10.2471/BLT.15.156406226 Lessons from the field HIV care in China Weibin Cheng et al. Резюме Оказание услуг, связанных с ВИЧ, мужчинам, практикующим секс с мужчинами, в Китае Проблема В Китае существует проблема недостаточной интеграции медицинских услуг, оказываемых местными общественными организациями и государственным сектором, для лиц, зараженных вирусом иммунодефицита человека (ВИЧ). Подход Организацией на уровне общин и специалистами Центра по борьбе с болезнями и их профилактике г. Гуанчжоу были разработаны интернет-службы для мужчин, практикующих секс с мужчинами, в г. Гуанчжоу, Китай. Интернет-службы были привязаны к медицинским услугам, предполагающим проведение тестирования на ВИЧ и предоставление связанного с этим вирусом лечения. Местные условия Растущая эпидемия ВИЧ среди мужчин, практикующих секс с мужчинами, представляет собой проблему общественного здравоохранения в Китае. Меры по борьбе с ВИЧ и его профилактике реализуются в основном через государственную систему. Местные общественные организации вовлечены в оказание услуг по ВИЧ лишь в ограниченном количестве. Осуществленные перемены С помощью программы была осуществлена интеграция услуг, связанных с ВИЧ, предоставляемых местными общественными организациями и государством, включая медико-санитарное просвещение, оценку риска заражения ВИЧ в онлайн-режиме, консультирование и тестирование на ВИЧ на месте, уведомление партнера, психосоциологическую помощь и поддержку, определение количества T-лимфоцитов с фенотипом CD4+ и консультации по лечению. Выводы С помощью Интернета можно упростить профилактику ВИЧ среди подгруппы мужчин, практикующих секс с мужчинами, за счет повышенной информированности, увеличенного количества оказываемых услуг и более строгого соблюдения больными предписаний врачей, в том числе больничного режима. Благодаря взаимодействию государственного сектора и общин вырос показатель использования услуг целевой группой населения. Распределение обязанностей между местными общественными группами может поспособствовать увеличению доступности имеющихся услуг, связанных с ВИЧ, для данной группы повышенного риска. Resumen Proporcionar servicios relacionados con el VIH en China para hombres que mantienen relaciones sexuales con otros hombres Situación En China, el cuidado contra el virus de inmunodeficiencia humana (VIH) proporcionado por organizaciones de ámbito comunitario no está bien integrado con el sector público. Enfoque Una organización de ámbito comunitario y expertos del Centro para el Control y la Prevención de Enfermedades de Guangzhou han desarrollado servicios en línea para hombres que mantienen relaciones sexuales con otros hombres en Guangzhou (China). Los servicios en línea estaban vinculados con servicios clínicos que ofrecían pruebas y tratamiento del VIH. Marco regional La epidemia de VIH en expansión entre hombres que mantienen relaciones sexuales con otros hombres es un problema de salud pública en China. Las medidas de control y prevención del VIH se implementan principalmente a través del sistema público. Únicamente un pequeño número de organizaciones comunitarias proporcionan servicios para el VIH. Cambios importantes El programa integró servicios comunitarios y del sector público para combatir el VIH, incluyendo educación sanitaria, evaluación de riesgos del VIH en línea, asesoramiento y pruebas del VIH in situ, notificación a la pareja, cuidado y apoyo psicosocial, recuento de linfocitos T CD4+ y guía de tratamiento. Lecciones aprendidas Internet puede facilitar la prevención del VIH entre un subgrupo de hombres que mantienen relaciones sexuales con otros hombres mediante el aumento de la toma de conciencia, el uso de los servicios, la recepción de atención y el cumplimiento del tratamiento. 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