An Integrated Peer Intervention Trial To Decrease Hiv Risky Sexual Behavior Among Men Who Have Sex With Men

Objectives To describe the prevalence of HIV related risky behavior among men who have sex with men (MSM) both in Mianyan and Yibin, Sicuan province, evaluate the efficacy of an integrated peer intervention in reducing HIV high-risk sexual behaviors among MSM, build and prove the theoretical framework of HIV related factors of high risky behavior among MSM.Method We conducted our study in two cities, Mianyang and Yibin, Sichuan province, China. Mianyang city is located in northern area of Sichuan province while Yibin in the southern, there are distance of 400 miles between them. The geographic isolation can limit the possibility of target population crossover or experimental contamination. AIDS intervention targeting MSM had not been conducted in two cities before. Both Mianyang and Yinbin city are similarity in population size, HIV-prevention polices, HIV counseling and testing services, and socio-cultural factors. In two cities we could get help from municipal and provincial Center for Disease Control and Prevention in HIV counseling and testing, as well as MSM volunteers in recruiting participants during our study.With help of MSM volunteers, the participants were recruited by peer referring chain. First of all, we recruited 20 participants from MSM venues according to criterion of participants, then, they referring their peers to participate in our survey, one of them could refer up to three peers, and these were eligible peers could refer up to three peers in same way. The eligibility of participants included (1) male who were at least eighteen years old, (2) had anal sex or oral sex with men in the previous twelve months, (3) living in the study areas during our study period and (4) providing written informed consent. The recruitment ended when the participants reached 200 in two cities respectively.We assigned Mianyang city to be intervention site while Yibin city to be control site randomly. In Yibin, the control city, we just did HIV-related health education and Voluntary HIV counseling and testing service according to national HIV-prevention policies. In Mianyang, the intervention city, we conducted MSM community level intervention with integrated peer intervention consisting of advocating safe sexual behaviors, distributing HIV-education materials and condoms in MSM venues and providing HIV-related information on local gay website by Peer Health Educators (PHEs) of MSM.Every three months during one year intervention, we selected 20 PHEs, totally 80, from MSM community and trained them with four sessions of advocating safe sexual behaviors in every two weeks. The PHEs attended four 1.5~2h group training sessions consisting of 1) HIV-risk and safe sexual behavior, 2) understanding unsafe sexual behavior occurring in MSM community, 3) communication skills of advocating safe sexual behaviors with MSM peers, and 4) How to overcome difficulties in advocating safe sexual behaviors with MSM peers. We used the standard protocol for all training sessions and trained PHEs with using modeling, game, role play, discussion and debating. These PHEs, who received each training session every two weeks, required to communicate with their MSM peers to endorse the safe sexual behaviors during daily life during one year intervention. PHEs gathered at tenth month during intervention to discuss difficulties and to be encountered to share their experiences and skills of advocating safe sexual behaviors.We evaluated the efficacy of the intervention by comparing the pre- and post-intervention indicators both in intervention and control city. We carried out the pre- and post-intervention surveys which were designed cross-sectional surveys, in intervention city and control city at pre-intervention, and after intervention respectively. In the surveys, we investigated socio-demographic information including age, level of education, sexual orientation and marital status. The survey assessed AIDS/STDs knowledge, self-efficacy of condom use and asked participants to report whether they had male sexual partner including regular partner, commercial partner and casual sexual partner in the previous six months, as well as condom use in sexual intercourse with these sexual partners above.Studied the relation between AIDS/STDs related knowledge, stigma and the self-efficacy of condom use as well as high risky sexual behavior and male sexual partners among MSM in pre- and post-intervention in intervention city through the path analysis, built and proved the theoretical framework of HIV related factors of high risky behavior among MSM.Results A total of 200 MSM participated in pre- and post-intervention surveys in intervention city and control city respectively in the same way. The age of participants were 18 to 57 years old in intervention city; The sexual identity of participants with homosexual, bisexual, heterosexual and undecided were 76.0%, 13.0%, 1.0% and 10.0% respectively; The score of knowledge related AIDS/STDs were 12.37±3.27, and the score of self-efficacy of condom use were 10.30±4.76; 54 MSM with depressive symptoms, accounted of 27.0% of participants; 78.0% of participants found sexual partners through Internet; the percentage of participants who had female sexual partners was 13.0% in past 6 months; the participants who had one or more male commercial and casual sexual partners were 16.5% and 38.0% respectively; 23.0% of participants had more than one male regular sexual partners in past 6 months; the self-report rate of unprotected sexual intercourses of participants with male commercial, casual and regular sexual partners in last 3 anal sexual intercourses in past 6 months were 62.5%, 67.8% and 64.1% respectively; the self-report rate of condom use of participants with female, male commercial , male casual, male regular sexual partners in the last instance in past 6 months were 61.5%,53.6%,65.2% and 51.7%.The age of participants were 18 to 63 years old in control city; The sexual identity of participants with homosexual, bisexual, heterosexual and undecided were 60.5%, 31.0%, 0.5% and 8.0% respectively; The score of knowledge related AIDS/STDs were 11.64±3.64, and the score of self-efficacy of condom use were 10.89±4.31; 56 MSM with depressive symptoms, accounted of 28.0% of participants; 92.5% of participants found sexual partners through bar/clubs/tea rooms; the rate of participants who never use condoms with female, male commercial, male casual and male regular sexual partners in last 3 anal sexual intercourses in past 6 months were 52.8%, 25.0%,16.9% and 24.6% respectively; the self-report rate of condom use of participants with female, male commercial , male casual, male regular sexual partners in the last instance in past 6 months were 31.7%, 61.4%,70.7% and 58.5%.We evaluated the efficacy of the intervention by comparing the pre- and post-intervention indicators both in intervention and control city. Used the General Liner Model to compare the score of knowledge related AIDS/STDs in pre- and post-intervention both in intervention and control city respectively. The results showed that the mean score of knowledge related AIDS/STDs was 15.1±2.3 in post-intervention, which was higher than that of pre-intervention mean score of 12.4±3.3(P﹤0.05) in intervention city; the results of GLM showed that the mean score of knowledge related AIDS/STDs was 9.9±3.0 in post-intervention, which was lower than in pre-intervention which was 11.6±3.6(P﹤0.05) in control city; The results from data analysis showed that the mean score of self-efficacy of condom use in intervention city was 12.2±3.8 in post-intervention, higher significantly than in pre-intervention which was 10.3±4.8 (P﹤0.05). In control city, the mean score of self-efficacy of condom use was 8.4±5.5 in post-intervention, lower than that in pre-intervention which was 10.9±4.3(P﹤0.05); the proportion of unprotected anal intercourse of participants with male casual and commercial sexual partners in past 6 months was 40.3% at post-intervention lower than 67.1% at pre-intervention significantly (P﹤0.05) in intervention city; a significant difference of those was not observed in Yibin; The rate of unprotected sexual intercourse with male regular sexual partners in past 6 months was 57.5% at post-intervention, also lower than 76.3% at pre-intervention in intervention city, while the change in control city was not significant; 64.1% of participants reported unprotected anal intercourse with male regular sexual partners in the last 3 instances in the past 6 months in pre-intervention in intervention city and the rate was decreased significantly to 37.2%( P﹤0.05) at post-intervention; while the rate of unprotected anal intercourse was 71.1% at post-intervention and 62.7% at pre-intervention (P﹥0.05) in control city; Of participants 65.3% reported unprotected anal intercourse with male casual and commercial sexual partners in the last 3 instances in the past 6 months in intervention city, the rate significantly decreased to 22.9%( P﹤0.05), while the change in control city was not significant; the percentage of participants who reported condom use with male commercial and casual sexual partners in the last instance was increased from 64.6% at pre-intervention decrease significantly to 87.0% at post-intervention (P﹤0.05) in intervention city; with male regular sexual partners in the last instance, 51.7% of participants reported condom use at pre-intervention in intervention city increased significantly to 78.0% at post-intervention (P﹤0.05); while a significant difference of those was not observed in control city.The theoretical framework of HIV related factors of high risky behavior among MSM was built and proved. The AIDS/STDs related knowledge and stigma situation could influence the high risky sexual behavior and male sexual partners of MSM directly, also could influence the behavior and sexual partners through the self-efficacy of condom use indirectly.Conclusions The integrated intervention can increase the AIDS/STDs related knowledge and the self-efficacy of condom use, decrease high risk sexual behavior with regular and casual male partners. It can supply experience to similar cities which will conduct HIV interventions among MSM in China. The theoretical framework of HIV related factors of high risky behavior give us clues about the future intervention direction towards to increase the self-efficacy of condom use among MSM.