Methods
Intervention
Our study evaluates an MSM peer-led, CBO-based, mobile rapid HIV testing programme on the outcomes of reaching previously untested MSM, linkage to care of those confirmed HIV positive, and, for Jiangsu residents, retention in care to 6 months.
For the purpose of this pilot intervention, the Jiangsu provincial CDC authorised MSM community members be trained to provide counselling with HIV rapid testing at gay-oriented venues in three cities. The programme required the CBO to refer MSM initially screened HIV positive to the local CDC for repeat and confirmatory testing by western blot. The programme also provided social support and case management up to the point of initiating their enrolment in HIV care with the CDC if a Jiangsu resident or to referral if their residence is elsewhere.
The study was conducted from 1 January to 30 June 2012. Seven teams were established in three cities, consisting of 28 MSM peer volunteers trained for 2 days on HIV knowledge, administering rapid testing, pretest and post-test counselling, maintaining confidentiality and procedures for referral and follow-up for HIV-positive individuals according to national guidelines. The programme's services were publicised to the MSM community through gay-oriented websites, posters and leaflets distributed at venues, mobile phone messages and word of mouth along social networks.
Study Subjects
Men who ever engaged in anal or oral sex with a man, 18 years or older, but never tested for HIV were eligible. Participants were recruited through snowball sampling by peers at venues frequented by the community, including gay bars, clubs, bathhouses, cruising areas and hotels. Working with owners and managers, the team conducted HIV testing in a private room within the venue, a room at a venue nearby or in a mobile van. Peers approached men at venues, screened for eligibility, explained the procedures and offered rapid HIV testing. Those interested provided verbal consent. Subsequent participants were referred at the venues by previous participants. A target of 512 MSM was set for the study.
HIV Counselling, Testing, Referral and Linkage
MSM peers were trained and certified in HIV counselling for pretest and post-test sessions according to national standards. After discussing the means of acquiring and preventing HIV infection and the clients' behaviour, individualised risk reduction counselling was done. Clients were screened for their readiness for receiving results and plans if positive. The window period and the need for repeat testing for recent risk and periodic testing with on-going risk were explained as well as the potential for false positive test results and the need for further repeat testing and follow-up by the CDC. Following pretest counselling, a finger-prick rapid HIV test was performed by the peer in the private room or van and screening test results were disclosed with post-test counselling. Participants with negative results were informed by the peer counsellors directly and no further follow-up was required, apart from encouraging repeat testing if risk was recent (ie, potential window period) in 6 weeks and future regular testing if risk continued. For MSM screening positive, the peer counsellors made a referral to the local CDC for repeat and confirmatory testing and an appointment to accompany the participant to the site. During the period of waiting for confirmatory results, typically 2–7 days, at least one contact method (phone, face-to-face or website chat) was offered by peers to help reduce participants' anxiety, answer questions related to HIV, and provide behavioural change education. In the study, no false positives were observed; however, if they were to occur participants would be given the negative results by CDC and recommended to take another HIV test in 6 weeks. For MSM confirmed HIV positive, an additional 1 month of contacts were offered by the CBO to those who were willing to disclose their confirmed seropositive status. These sessions addressed the concerns of those newly diagnosed and helped navigate the CDC system. These contacts also included further HIV-related information, psychological and social support, suicide prevention and STD referrals. CDC staff undertook follow-up care thereafter, including free CD4 testing and when appropriate ART. Figure 2 describes the procedures of the rapid HIV test, referral and follow-up care provided by the CBO.
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Figure 2.
Operational model for a peer community-based organisation intervention, including rapid HIV screening, linkage to care and case management for men who have sex with men, Jiangsu province, China, 2012.
Measures
Prior to pretest counselling, a brief standardised questionnaire was administered to participants face-to-face to collect demographics, condom use in the last 6 months, and history of STD in the past year. For HIV-positive men engaging peer case management, a quick survey including follow-up by the CDC and CD4 testing were collected by the CBO at 6 months. Participants did not receive incentives.
Comparison Population
Although the study was not designed as a randomised control trial or quasi experiment, HIV serological surveys of the MSM population conducted for the purpose of surveillance provided a comparison group to see differences in which MSM were reached, which were detected as positive, and subsequent linkage outcomes. These 'sentinel surveillance surveys' were conducted by provincial and local CDC staff between April and June 2012 at 14 sites in Jiangsu. The surveillance surveys followed a uniform protocol across China. In brief, sampling and procedures resembled the CBO rapid HIV testing pilot programme in several aspects. MSM were recruited at diverse gay-identified venues using snowball sampling. Eligibility criteria were men who have ever engaged in anal or oral sex with a man and age 18 years or older. Newly diagnosed HIV-positive MSM in the surveillance surveys were referred and reported to the central HIV case reporting and management system where data on their linkage to care and retention at 6 months were available. In the surveillance surveys, no previously diagnosed HIV-positive MSM were noted. Beyond in the procedures of the surveillance surveys, the CBO pilot study used peer rather than CDC staff counsellors, accompanied MSM personally to confirmatory testing, and provided social support and case management facilitation through engagement in HIV care.
Laboratory Methods
Initial HIV fingerprick rapid testing was performed using the Diagnostic Kit for Antibody to Human Immunodeficiency Virus (1+2) assay (Colloidal Gold, NewScen Coast Bio-pharmaceutical Co. Ltd, Tianjin, China). An ELISA (Beijing Wantai Biological Pharmacy Enterprise Co., Ltd) was used for repeat HIV antibody testing. Confirmatory testing was performed by western blot (MP Biomedicals Asia Pacific., Ltd, Singapore).
Analysis
Questionnaire-based data and laboratory results were recorded, double entered and compiled with Epi Data (The Epi Data Association Odense, Denmark). SPSS V.16.0 (SPSS Inc) was used for statistical analysis. χ tests were conducted to compare characteristics of MSM in the intervention study to those in the surveillance surveys.