HIV Infection And High-risk Behaviors In Men Who Have Sex With Men In Shandong Province Under COVID-19 Pandemic

BackgroundAcquired Immune Deficiency Syndrome(AIDS)is a serious and chronic infectious disease caused by human immunodeficiency virus(HIV)that attacks the human immune system.It is still a major global public health problem.By the end of 2020,about 37.7 million people were living with HIV,1.5 million people were newly infected with HIV worldwide in 2020,and 680,000 people died of AIDS-related diseases.Moreover,the phased anti-AIDS target set for 2020 has not been achieved as scheduled,and the global AIDS situation is still very serious.Men who have sex with men(MSM)have the characteristics of complex social network,multiple sexual roles and multiple sexual partners due to their special identity,and are prone to unprotected anal sex,group sex and other high-risk behaviors.MSM has become the group with the highest risk of infection and transmission of HIV.In Shandong province,the rate of HIV transmission through homosexual sex has increased significantly in recent years.By the end of 2020,67.7%of the existing HIV/AIDS cases in Shandong province were transmitted through MSM.Of the new cases reported in 2020,99.5 percent were sexually transmitted,and 69.3 percent were homosexual.In recent years,MSM’s awareness of AIDS-related knowledge has reached a high level,but the HIV infection rate of MSM is still rising,because they have the phenomenon of "separation of knowledge and practice",that is,when having sex,they are inconsistent with their cognition and cannot insist on using condoms.Corona Virus Disease 2019(COVID-19)is a newly emerging acute respiratory infectious disease.At present,COVID-19 continues to exist in the world and has become a major global public health event.By the end of January 2022,more than 370 million confirmed COVID-19 cases and 5.6 million deaths had been reported globally.China’s 31 provinces(autonomous regions and municipalities directly under the Central Government)and Xinjiang Production and Construction Corps have reported a total of 106,139 confirmed COVID-19 cases,including 1,884 confirmed cases,99,619 cured and discharged from hospital,and 4,636 deaths.In order to prevent and control COVID-19,a series of measures taken in Shandong province,including isolation and crowd gathering reduction,not only affected the discovery and reporting of new HIV/AIDS cases,but also affected the activities and behaviors of MSM.The reduction of HIV testing in MSM due to COVID-19 pandemic,difficulties in implementing pre-exposure prophylaxis(PrEP),and delays and discontinuations of antiviral therapy(ART)for HIV infected people may increase the risk of HIV infection in MSM.ObjectivesIn this study,a cross-sectional survey among MSM in Shandong province was conducted to understand the basic characteristics of MSM in Shandong Province,to analyze the changes of HIV infection and high-risk behaviors among MSM in Shandong province under the COVID-19 pandemic,and to explore the influencing factors of the separation of knowledge and practice in condom use among MSM.This study also aimed to provide a theoretical basis for the development of appropriate interventions to increase condom use,to reduce high-risk behaviors,to reduce separation of knowledge and practice and to control HIV transmission in MSM.MethodsA cross-sectional study was conducted in 11 cities in Shandong province from April to September in 2020.With the assistance of the local CDC and gay community-based organizations,four non-probabilistic sampling methods were used to recruit 400 subjects who met the inclusion criteria in each city for questionnaire survey and laboratory examination.For comparison,this study also used survey data from April to June in 2019.EpiData 3.1 was used to establish the database.SPSS 24.0 and R 4.1.2 were used for statistical analysis,and Origin and Visio were used to draw statistical graphs.Chi-square test was used to compare the HIV infection rate of MSM in Shandong province in 2020 and 2019.Univariate logistic regression analysis was used to compare the differences between HIVnegative and HIV-positive participants,and multivariate logistic regression analysis was used to further analyze the factors associated with HIV infection.Chi-square test was used to compare the differences of high-risk behaviors of MSM in 2020 and 2019,and to analyze the impact of COVID-19 pandemic on high-risk behaviors of MSM.Univariate and multivariate logistic regression analysis and random forest model were used to analyze the influencing factors of the separation of knowledge and practice in condom use among MSM.Results1.A total of 4246 subjects were recruited in this study,all of whom completed questionnaires and laboratory examinations.Participants’ age ranged from 15 to 87 years,with a median age of 30(25,36)years.58.8%of MSM were unmarried,34.6%of MSM were married or cohabiting with women;32.4%of MSM had high school or technical secondary school education,47.1%of MSM had college education or above;92.7%of MSM knew AIDS knowledge;87.4%of MSM had anal sex with men in the last 6 months;23.3%of MSM had sex with women in the last six months;25.2%of MSM had taken drugs;91.0%of MSM had received condom promotion and distribution/AIDS counseling and testing in the last year;66.9%of MSM had received peer education in the last year.2.The HIV infection rate of MSM in this study was 3.7%,and that of MSM in Shandong Province in 2019 was 3.5%.The difference was not statistically significant(P=0.712).Multivariate analysis showed that age over 40 years was positively related to HIV infection in MSM(P=0.039).Peer education,HIV testing and volunteer work in clinics or institutions providing HIV testing services for gay men were negatively related to HIV infection in MSM(P<0.05).3.Compared with 2019,the number of MSM who had anal sex with men decreased by 3.7%in the last six months of 2020,and the number of MSM who received,liked,followed,discussed,shared or replied to information about HIV testing on Weibo,wechat,QQ or mobile phone software increased by 4.9%in the past three months,both of which were statistically significant(P<0.05).In 2020,the number of MSM who had anal sex with men in the last week decreased by 0.7%,the number of MSM who had group sex in the last six months decreased by 1.3%,the number of MSM who had commercial sex with men in the last six months decreased by 1.3%,and the number of MSM who had sex with women in the last six months increased by 1.9%,with no statistical significance.4.In this study,42.5%of MSM had separation of knowledge and practice in condom use.Multivariate analysis showed that cohabitation with women,divorced or widowed,high school or technical secondary education level,drug use,sexually transmitted diseases in the last year,received peer education in the last year,HIV positive,accompanied friends or sexual partners to a regular testing site for HIV testing,forced to have sexual behavior were positively related to the separation of knowledge and practice in MSM.Having sex with women in the last 6 months and having an HIV test in the last 12 months were negatively related to the separation of knowledge and practice in MSM(P<0.05).According to the random forest model,the top three factors of importance were having been forced to have sexual behavior,educational level,and peer education.Conclusions1.The MSM in Shandong Province has a high proportion of marriage or cohabitation with women,a low rate of receiving peer education,a high proportion of receiving HIV testing,but there is still a gap between the target of 90%,and the HIV positive rate is relatively stable.Peer education should be vigorously carried out to publicize the knowledge of AIDS prevention and treatment with the help of peers,to improve the awareness rate of AIDS knowledge among MSM,and to promote HIV detection and health intervention.2.Under COVID-19 pandemic,the HIV infection rate of MSM in Shandong province has not changed significantly.The homosexual behavior among MSM during the isolation period decreased,and the proportion of MSM who followed HIV testing information on the Internet increased.The publicity of HIV self-testing should be increased to meet the needs of MSM for HIV testing while carrying out COVID-19 prevention and control,so that more HIV infected people can be diagnosed and treated as soon as possible.3.The level of separation of knowledge and action in condom use among MSM was high.More attention should be paid to MSM who have or have been married to women,have drug addiction,or have been forced to have sexual behavior.The MSM should be informed of the importance of condom use and the dangers of unprotected sexual behavior.The availability of condoms should be increased to increase condom use during sex among MSM and to reduce the separation between knowledge and practice.