524434 research-article2014
APHXXX10.1177/1010539514524434Asia-Pacific Journal of Public HealthPyun et al
Original Article
Internalized Homophobia and Reduced HIV Testing Among Men Who Have Sex With Men in China
Asia-Pacific Journal of Public Health 2014, Vol. 26(2) 118–125 © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514524434 aph.sagepub.com
Thomas Pyun, MPH1, Glenn-Milo Santos, MPH2,3, Sonya Arreola, PhD4, Tri Do, MD, MPH2, Pato Hebert, MFA1, Jack Beck, BA1, Keletso Makofane, MPH1, Patrick A. Wilson, PhD5, and George Ayala, PsyD1
Abstract Although previous research has examined barriers and facilitators of HIV testing among men who have sex with men (MSM) in China, few studies have focused on social factors, including homophobia and internalized homophobia. This study utilized data from a global online survey to determine correlates of HIV testing as part of a subanalysis focused on Chinese MSM. Controlling for age, HIV knowledge, number of sexual partners, and other covariates, ever having tested for HIV was significantly correlated with lower internalized homophobia. This study suggests that stigma associated with sexual orientation may serve as a barrier to participation in HIV testing and other health-promoting behaviors. Keywords health care services, health management, health education, health promotion, epidemiology, public health, global health, men’s health
Introduction Men who have sex with men (MSM) are the fastest growing group affected by the HIV epidemic in China.1 From 2006 to 2011, it is estimated that the proportion of new infections attributed to male-to-male sexual transmission in China increased 6-fold.2 Approximately 5% of MSM in China are currently infected with HIV, with some urban centers reporting a prevalence of up to 26%.3 Given these figures, donors and the Chinese government are paying greater attention to HIV prevention initiatives that target MSM. These efforts are beginning to show some
1The
Global Forum on MSM and HIV, Oakland, CA, USA of California San Francisco, San Francisco, CA, USA 3San Francisco Department of Public Health, San Francisco, CA, USA 4RTI International, San Francisco, CA, USA 5Columbia University in the City of New York, New York, NY, USA 2University
Corresponding Author: Glenn-Milo Santos, University of California San Francisco, 185 Berry Street, San Francisco, CA 94107, USA. Email: [email protected]
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impact because research indicates that HIV testing rates among MSM have increased steadily in recent years; a systematic review estimated that rates have increased from 10.8% to 51.2% from 2002 to 2009.4 Despite these signs of improvement, however, overall testing rates among MSM in China remain relatively low, with only about half of MSM reporting ever having been tested.1,4,5 HIV testing serves as a gateway to additional HIV prevention services and to HIV care and treatment if one tests positive. Furthermore, the global AIDS field is shifting toward prevention programming that is contingent on knowing one’s HIV status (eg, prevention with positives, test and treat, and chemoprophylaxis).6 As such, any concerted effort to address the HIV epidemic among MSM in China should include initiatives to increase the rates of HIV testing among this population. Previous research has examined barriers and facilitators affecting HIV testing behavior among MSM in China. One study observed that fear of receiving a positive HIV test result and fear of discrimination that would result from a positive HIV diagnosis were significant barriers to HIV testing among MSM in China.7 Another study found that the most frequent reasons why MSM in China do not get tested for HIV include low HIV risk perception, lack of knowledge of HIV test site locations, fear that other people will learn about their sexual orientation, and concerns over confidentiality of test results.8 However, few studies have focused specifically on social factors, including homophobia (we use “homophobia” here to refer to negative attitudes and behaviors based on sexual orientation, including antigay prejudice and hostility) and internalized homophobia (ie, negative feelings about one’s own sexual orientation resulting from the internalization of antigay stigma and prejudice).9 We hypothesize that these social factors stigmatize MSM, contribute to minority stress among this population, and ultimately affect health-seeking behaviors, such as HIV testing.10 In this study, we aimed to explore social and behavioral correlates of HIV testing behavior among MSM in China. We also evaluated how levels of homophobia and internalized homophobia among MSM in China compare with levels among MSM from other countries, using a global data set of MSM. Understanding the barriers and facilitators of HIV testing can inform the design and implementation of effective HIV prevention programs targeting MSM in China.
Methods Data are from the 2010 Global Men’s Health and Rights Survey (2010 GMHR), a multilingual online survey conducted from June 24, 2010, to August 17, 2010, by the Global Forum on MSM & HIV (MSMGF). Offered in English, Spanish, French, Russian, and Chinese, the survey targeted MSM and their health care providers worldwide. Participants were recruited through intensive outreach via social media platforms, relevant professional e-mail listservs, and the MSMGF’s global networks of advocates and service providers. The Committee on Human Research at RTI International approved secondary analyses of the data and considered the anonymous study to be low risk. The goal of the 2010 GMHR was to assess the following: access to and participation in HIV prevention strategies; knowledge of emerging HIV prevention technologies; perceived homophobia; and internalized homophobia. The survey utilized existing scales, including the Rosenberg self-esteem scale.11 The survey also used versions of existing scales that were adapted to fit the survey’s goals, including the 2010 GMHR’s Sexual Stigma Scale and Internalized Homophobia Scale.11-13 For example, the 2010 GMHR’s Sexual Stigma Scale included 5 items that were adapted from a measure used to obtain perceptions of perceived discrimination.13 The Sexual Stigma Scale included items such as, “In the country I live in, most people believe that a person who is gay/MSM cannot be
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trusted.” Participant responses to this item corresponded to a 4-point Likert scale, with responses ranging from “strongly agree” to “strongly disagree.” Perceptions of sexual stigma had high reliability; Cronbach’s α for Chinese language participants for this scale was 0.85, which was comparable to the reliability of this measure in the overall sample.14 The Internalized Homophobia Scale included 7 items used to gauge levels of internalized stigma around homosexuality and same sex behavior among MSM. Items were adapted from existing measures.12,15 Responses corresponded to a 4-point Likert scale, with responses ranging from “often” to “never.” For internalized homophobia, internal reliability assessment yielded a Cronbach’s α of 0.79 for Chinese language participants, which was comparable to the reliability of this measure in the overall sample.14 For this analysis, the binary dependent variable was defined as reporting ever having been tested for HIV. Once a full draft version of the 2010 GMHR was complete, the MSMGF gathered feedback on the survey from members of its Steering Committee, which comprises leaders in MSM sexual health and human rights from 18 different countries representing every major world region. This feedback was integrated into the final measure, which was then pilot tested for acceptability and completion time by members of the target population. The survey was found to take 8 to 12 minutes to complete. Once the final version of the survey was completed in English, it was translated into Spanish, French, Russian, and Chinese for broader implementation globally. A professional translation service was used by the MSMGF, and each language translation involved 2 translators: one native in the target language and fluent in English and the other native in English and fluent in the target language. Both translators worked in tandem to ensure the highest-quality translation possible. Once the survey was translated, they were reviewed by local advocates focused on MSM health who were native speakers of the target language but also fluent in English. The survey was administered through Survey Monkey. This current study is a subgroup analysis of survey results focused specifically on Chinese MSM. Inclusion criteria for this analysis were as follows: (a) self-identifying as a male who has ever had sex with a male, (b) stating country of residence as China, and (c) not identifying as a health care provider. Respondents for whom HIV testing data were missing or not reported were excluded from the analysis because HIV testing was the primary focus of this study. Because the subanalysis is focused on ever having been tested for HIV, respondents living with HIV were included in this sample. We used logistic regression models in bivariate analyses that examined sociodemographic differences, psychosocial differences, and differences in knowledge, attitude, and behavior between Chinese MSM who had ever been tested for HIV and those who had not. Unadjusted odds ratios and 95% confidence intervals (CIs) were calculated for bivariate point estimates. To assess independent correlates of HIV testing behavior, we conducted a multivariable logistic regression analysis. We used a stepwise, backward elimination approach (ie, all the initial independent variables were entered, then eliminated one at a time in a stepwise fashion) to develop the final multivariate regression model, using a significant cutoff level of P < .05. For the stepwise procedure, ever having been tested for HIV served as the dependent variable, whereas age and sociodemographic factors as well as key measures that were significant (at the .05 level) in the bivariate analysis served as the initial independent variables. Once the final model was obtained, we calculated adjusted odds ratios (AORs) and respective 95% CIs. For continuous independent variables, we verified that there were no departures from linearity. In exploratory comparative analyses, we evaluated how levels of homophobia and internalized homophobia among MSM in China compared with MSM elsewhere using Wilcoxon rank-sum tests. We also compared levels of HIV testing among MSM in China with those among MSM outside of China using Fisher’s exact tests. All analyses were conducted using IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp).
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Results Sample Characteristics A total of 5066 respondents accessed and completed the survey over the 8-week period, 318 of whom were Chinese MSM who met the criteria for inclusion in the subanalysis. The average age of the sample was 30 years. The majority of respondents in this sample were in the middle- to high-income group (70%) and had at least some postsecondary education (87%). In terms of sexual behavior, 68% had had 2 or more sexual partners in the past year. Of the men who reported having had sex in the past year, 87% had sexual relations with men only and 85% self-identified as “gay.” Of the sample, 60% reported ever having been tested for HIV—a lower figure in comparison to the overall global survey sample (76%, N = 5066). Of those who responded to questions regarding HIV serostatus (n = 173), 45% reported being HIV negative. In exploratory comparative analyses, we found that MSM in China had reported higher levels of homophobia compared with MSM from outside China (P < .001); MSM in China reported a mean homophobia score of 2.72 (standard deviation [SD] = 0.73), whereas MSM from outside China reported a mean homophobia scored of 2.38 (SD = 0.75). Moreover, we found that MSM in China have significantly higher levels of internalized homophobia compared with MSM from outside China (P < .001); the mean internalized homophobia score among MSM in China and MSM outside of China were 2.04 (SD = 0.66) and 1.77 (SD = 0.67), respectively. In our sample, 40% of MSM from China reported not having had an HIV test, compared with 23% of MSM outside of China. Chinese MSM were significantly less likely to have reported an HIV test compared with the rest of our sample (P < .001).
Correlates of HIV Testing Logistic regression analysis yielded bivariate and multivariable estimates, which are presented in Table 1. Bivariate analysis revealed several significant correlates of ever having been tested for HIV, including older age, lower internalized homophobia, greater knowledge of HIV prevention strategies, higher perceived access to basic HIV prevention services, higher income, having had 2 or more sexual partners in the past year, gay sexual identification, exposure to billboards or signs about HIV prevention, and obtaining free condoms or safer sex materials from communitybased organizations, nightclubs/bars, and the office of a doctor or health care provider. Some correlates were significant in the bivariate analysis but not the multivariate analysis. These included perceived availability of HIV services in the community, income, and obtaining free condoms at nightclubs/bars and obtaining free condoms at the office of a doctor or health care provider. However, the magnitude of the point estimates for the correlates that remained significant in the multivariable model changed little from the bivariate analyses. In the final multivariable model, ever having tested for HIV was significantly correlated with older age (AOR = 1.07; CI = 1.03, 1.12), lower internalized homophobia (AOR = 0.60; CI = 0.38, 0.94), greater knowledge of HIV prevention strategies (AOR = 1.79; CI = 1.10, 2.91), having 2 or more sexual partners in the past year (AOR = 2.33; CI = 1.26, 4.32), gay sexual identification (AOR = 3.38; CI = 1.48, 7.70), exposure to billboards or signs about HIV prevention (AOR = 1.80; CI = 1.03, 3.32), and having previously obtained condoms or safer sex materials from a community-based organization (AOR = 2.53; CI = 1.32, 4.86).
Discussion The proportion of Chinese MSM who had ever been tested for HIV in our study was comparable to that in previous research focused on MSM in China.3,16,17 One study that targeted migrant Chinese MSM yielded a higher lifetime prevalence: 72% of its sample had ever been tested for
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Table 1. Results of Univariate, Bivariate, and Multivariate Analyses of Correlates of HIV Testing.a
Variable Age (years), mean External sexual stigma (range = 1-4) Internalized homophobia (range = 1-4) Self-esteem (range = 1-4) Reported access to basic HIV prevention services in community (range = 1-5) Reported access to emerging HIV prevention services in community (range = 1-5) Knowledge of HIV prevention strategies (range = 1-4) Desire to learn more about HIV prevention (range = 1-4) Income Low Middle High Education Secondary and below Postsecondary and above Number of sexual partners ≤2 In past year ≥2 In past year Type of sexual partners Men only Men and women No sexual partner Sexual identification Bisexual or heterosexual Gay Relationship status Single Attached Seen radio announcement about HIV prevention Seen television commercials about HIV prevention Seen advertisements on the Internet about HIV prevention Seen advertisements in newspapers or magazines about HIV prevention Seen billboards or signs in your community about HIV prevention Obtained free condoms or safer sex materials from a community organization Obtained free condoms or safer sex materials from a nightclub/bar or other public place Obtained free condoms or safer sex materials from a doctor or health care provider Obtained free condoms or safer sex materials from a religious institution Agreed that if condoms or safer sex materials were made available, would take them Reported access to HIV counseling Reported access to testing for sexually transmitted diseases (STDs) Reported access to free condoms Reported access to free water-based lubricants Reported access to free HIV testing Reported access to media campaigns to reduce HIV Reported access to HIV education materials Ever been tested for HIV Yes No
Bivariate
Multivariate
N (Percentage) Mean (SD)
OR
95% CI
OR
95% CI
29.8 (8.0) 2.7 (0.7) 2.0 (0.7) 3.6 (0.4) 2.6 (0.9)
1.09 0.90 0.50 1.00 1.55
(1.04, 1.12)b (0.71, 1.34) (0.35, 0.72)b (0.60, 1.66) (1.19, 2.02)b
1.07 — 0.60 — —
(1.03, 1.12)b — (0.38, 0.94)b — —
2.2 (1.0)
1.11
(0.87, 1.41)
—
—
2.0 (0.7) 3.8 (0.5)
1.77 0.63
(1.19, 2.49)b (0.37, 1.07)
1.79 —
64 (20.1) 127 (39.9) 97 (30.2)
Reference 1.35 2.46
Reference (0.74, 2.47) (1.28, 4.38)b
14 (4.4) 276 (86.8)
Reference 1.46
Reference (0.50, 4.29)
75 (23.6) 215 (67.6)
Reference 2.12
Reference (1.24, 3.61)b
252 (79.2) 31 (9.7) 6 (1.9)
Reference 0.45 0.31
Reference (0.21, 0.96)b (0.06, 1.74)
43 (13.5) 248 (78.0)
Reference 3.17
Reference (1.61, 6.24)b
181 (56.9) 106 (33.3) 168 (52.8) 198 (62.3) 256 (80.5) 225 (70.8)
Reference 1.05 1.02 0.94 1.27 1.39
Reference (0.65, 1.72) (0.65, 1.62) (0.58, 1.51) (0.70, 2.29) (0.84, 2.30)
170 (53.5)
2.17
(1.36, 3.46)b
1.80
(1.03, 3.14)b
111 (34.9)
3.05
(1.82, 5.21)b
2.53
(1.32, 4.86)b
119 (37.4)
2.43
(1.48, 3.98)b
—
—
107 (33.6)
2.00
(1.21, 3.29)b
—
—
37 (11.6)
1.08
(0.53, 2.19)
—
—
311 (97.8)
0.38
(0.04, 3.41)
—
—
78 (24.5) 82 (25.8)
— —
— —
— —
— —
64 (20.1) 23 (7.2) 75 (23.6) 59 (18.6) 47 (14.8)
— — — — —
— — — — —
— — — — —
192 (60.4) 126 (39.6)
— —
— —
— —
— — — — — — —
(1.10, 2.91)b — — — — — — — — — — — — — — 2.33 (1.26, 4.32)b — — — — — — Reference Reference 3.38 (1.48, 7.70)b — — — — — — — — — — — —
(continued)
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Pyun et al Table 1. (continued)
Variable Self-reported HIV status Negative Positive Do not know Decline to answer
Bivariate
Multivariate
N (Percentage) Mean (SD)
OR
95% CI
OR
95% CI
143 (45.0) 17 (5.3) 11 (3.5) 2 (0.6)
— — — —
— — — —
— — — —
— — — —
Abbreviations: SD, standard deviation; OR, odds ratio; CI, confidence interval. may not add to 100% because of missing data. bDenotes significance at α level of 0.05. aPercentage
HIV.3 However, that study focused specifically on MSM in Beijing, and the higher prevalence could potentially be attributed to the study’s highly urban setting, where HIV testing coverage and access to services is greater.16 Conversely, 2 meta-analyses of HIV testing estimated that 51% and 47% of MSM in China had ever been tested in 2009—figures somewhat lower than our result.4,17 Our finding—in conjunction with results from other studies—highlights the fact that HIV testing rates are low, both in comparison to other countries and also in light of the high prevalence of HIV among MSM in China.4,18-20 Our study also yielded an association between HIV testing behavior and knowledge of HIV prevention strategies. This finding is supported by a recent meta-analysis of 34 studies, which found that HIV risk reduction interventions in China are efficacious in increasing uptake of HIV testing as well as in improving HIV knowledge and reducing HIV-related risk behaviors among Chinese MSM.21 Indeed, these results are corroborated by other research on Chinese MSM that also found a statistically significant association between higher knowledge of prevention strategies and likelihood of testing.3,4 Another study finding was the significant link between exposure to community billboards and/or signs about HIV prevention and testing behavior. To our knowledge, there is currently no research that has specifically examined the impact of social marketing on HIV testing behavior among MSM in China. However, according to other research assessing the effect of social marketing on HIV testing behavior globally, there is evidence—albeit limited—that social marketing can significantly increase uptake of HIV testing in low-, middle-, and high-income countries.22,23 Other research on Chinese MSM has shown the potentially deleterious effects of homophobia and its association with unprotected anal intercourse.8 Our study did not find an association between homophobia and HIV testing behavior. However, having access to the Internet may provide a venue for MSM to disclose sexual orientation without stigma, build community, and/ or develop a sense of belonging, which in turn may offset the negative effects of homophobia.24 Thus, because this sample was recruited online, the impact of homophobia on men in this sample may have been different from what would have been found if they had been recruited by other means. Consistent with and related to our finding that internalized homophobia is correlated with never having been tested for HIV, a previous cross-sectional study showed that “fear of people learning about [one’s] homosexuality” is a barrier to HIV testing uptake among MSM.8 This same study also revealed a positive association between “being out” and having ever tested for HIV. These past study findings underscore that indicators of and/or proxies for internalized homophobia are associated with HIV testing behavior. To our knowledge, our study is the first to utilize an inventory to measure internalized homophobia among Chinese MSM and its subsequent relationship with HIV testing behavior. Furthermore, we note that this measure for internalized homophobia exhibited high internal validity.
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There are several limitations to our study that are important to highlight. Our use of convenience sampling via the MSMGF’s online network may have created a selection bias for MSM who are connected to gay and HIV-related organizations and communities as well as for those who have access to the Internet. There may also be selection bias for MSM who are particularly motivated to participate. However, this bias is likely to overestimate access and underestimate sexual stigma. In addition, our study did not collect information on other structural barriers that may affect HIV testing such as HIV stigma, cost of testing, and difficulties arranging time off to get tested. Furthermore, we did not assess other dimensions of health that may also play a role in getting tested for HIV, including views on health and illness, potential impact of illness, and concerns over privacy of one’s sexual orientation.7,8 Nonetheless, this study is one of the first to examine correlates of HIV testing behavior among Chinese MSM using a series of social and behavioral scales, including homophobia and internalized homophobia. Many of our findings validate and corroborate findings from other research examining the relationship between social or structural factors and HIV prevention behaviors among MSM.25,26 The results of this study have several important implications for future programs to prevent HIV among MSM in China. First, HIV prevention efforts targeting Chinese MSM should be comprehensive and include social marketing and other behavioral change communication components in conjunction with HIV testing and treatment. Social marketing efforts to promote HIV testing among MSM in low- and middle-income countries are rare or relatively nascent; more funding support should be directed toward these efforts, and additional research will be needed to determine its efficacy.23 Second, future efforts to address homophobia should include a focus on internalized homophobia in both programmatic design and public health policy initiatives. Although China decriminalized homosexuality in 1997, interventions are urgently needed that promote education countering stigmatization and discrimination of gay men and other sexual minorities in daily life. Social discrimination and stigma associated with sexual orientation, identity, and behavior may make it difficult for MSM to engage in health promoting behaviors.27 From both a policy and programmatic standpoint, prevention efforts targeting MSM in China should focus on community engagement, outreach, reduction of homophobia and internalized homophobia, and the provision of culturally sensitive services, including HIV testing and counseling, to improve the safety and accessibility of services for MSM clients. Reducing internalized homophobia and stigma related to homosexuality and HIV is essential for optimizing access to HIV prevention services for MSM. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research was funded by a grant from the Bill and Melinda Gates Foundation.
References 1. Li X, Lu H, Raymond HF, et al. Untested and undiagnosed: barriers to HIV testing among men who have sex with men, Beijing, China. Sex Transm Infect. 2012;88:187-193. 2. Ministry of Health, People’s Republic of China. China AIDS Response Progress Report. Beijing, China: Ministry of Health, People’s Republic of China; 2012. 3. Song D, Zhang H, Wang J, et al. Prevalence and correlates of HIV infection and unrecognized HIV status among men who have sex with men and women in Chengdu and Guangzhou, China. AIDS Behav. 2013;17:2395-2404.
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4. Chow EPF, Wilson DP, Zhang L. The rate of HIV testing is increasing among men who have sex with men in China. HIV Med. 2012;13:255-263. 5. Wei C, Ruan S, Zhao J, Yang H, Zhu Y, Raymond HF. Which Chinese men who have sex with men miss out on HIV testing? Sex Transm Infect. 2011;87:225-228. 6. Cohen MS, Smith MK, Muessig KE, Hallett TB, Powers KA, Kashuba AD. Antiretroviral treatment of HIV-1 prevents transmission of HIV-1: where do we go from here? Lancet. 2013;382:1515-1524. 7. Zhang L, Xiao Y, Lu R, et al. Predictors of HIV testing among men who have sex with men in a large Chinese city. Sex Transm Dis. 2013;40:235-240. 8. Choi KH, Lui H, Guo Y, Han L, Mandel JS. Lack of HIV testing and awareness of HIV infection among men who have sex with men, Beijing, China. AIDS Educ Prev. 2006;18:33-43. 9. Herek GM. Beyond homophobia: thinking about sexual prejudice and stigma in the twenty-first century. Sex Res Soc Policy. 2004;1:6-24. 10. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129:674-697. 11. Rosenberg M. Society and the Adolescent Self-image. Rev ed. Princeton, NJ: Wesleyan University Press; 1989. 12. Herek GM, Glunt EK. Identity and community among gay and bisexual men in the AIDS era: preliminary findings from the Sacramento Men’s Health Study. In: Herek GM, Green B, eds. AIDS, Identity, and Community: The HIV Epidemic and Lesbians and Gay Men. 1995:55-84. Newbury Park, CA: Sage. 13. Kessler RC, Mickelson KD, Williams DR. The prevalence, distribution, and mental health correlates of perceived discrimination in the United States. J Health Soc Behav. 1999;40:208-230. 14. Wilson P, Santos GM, Hebert P, Ayala G. Access to HIV Prevention Services and Attitudes About Emerging Strategies: A Global Survey of Men Who Have Sex With Men (MSM) and Their Health Care Providers. Oakland, CA: Global Forum on MSM and HIV (MSMGF); 2011. 15. Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav. 1995;36:38-56. 16. Gill B, Chang J, Palmer S. China’s HIV crisis. Foreign Aff. 2002:96-110. 17. Zou H, Hu N, Xin Q, Beck J. HIV testing among men who have sex with men in China: a systematic review and meta-analysis. AIDS Behav. 2012;16:1717-1728. 18. Gao L, Zhang L, Jin Q. Meta-analysis: prevalence of HIV infection and syphilis among MSM in China. Sex Transm Infect. 2009;85:354-358. 19. Kerr LRFS, Mota RS, Kendall C, et al. HIV among MSM in a large middle-income country. AIDS. 2013;27(3):427-35. 20. Lyons A, Pitts M, Grierson J, Smith A, McNally S, Couch M. Sexual behavior and HIV testing among bisexual men: a nationwide comparison of Australian bisexual-identifying and gay-identifying men. AIDS Behav. 2012;16:1943-1943. 21. Lu H, Liu Y, Dahiya K, et al. Effectiveness of HIV risk reduction interventions among men who have sex with men in China: a systematic review and meta-analysis. PLoS One. 2013;8:e72747. 22. Pettifor AE, Rees HV, Kleinschmidt I, et al. Young people’s sexual health in South Africa: HIV prevalence and sexual behaviors from a nationally representative household survey. AIDS. 2005;19: 1525-1534. 23. Wei C, Herrick A, Raymond HF, Anglemyer A, Gerbase A, Noar SM. Social marketing interventions to increase HIV/STI testing uptake among men who have sex with men and male-to-female transgender women. Cochrane Database Syst Rev. 2011;(9):CD009337. 24. Feng Y, Wu Z, Detels R. Evolution of MSM community and experienced stigma among MSM in Chengdu, China. J Acquir Immune Defic Syndr. 2010;53(suppl 1):S98-S103. 25. Beyrer C, Baral SD, van Griensven F, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet. 2012;380:367-377. 26. Cahill S, Valadez R, Ibarrola S. Community-based HIV prevention interventions that combat antigay stigma for men who have sex with men and for transgender women. J Public Health Policy. 2012;34:69-81. 27. Knox J, Sandfort T, Yi H, Reddy V, Maimane S. Social vulnerability and HIV testing among South African men who have sex with men. Int J STD AIDS. 2011;22:709-713.
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APHXXX10.1177/1010539514524434Asia-Pacific Journal of Public HealthPyun et al
Original Article
Internalized Homophobia and Reduced HIV Testing Among Men Who Have Sex With Men in China
Asia-Pacific Journal of Public Health 2014, Vol. 26(2) 118–125 © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514524434 aph.sagepub.com
Thomas Pyun, MPH1, Glenn-Milo Santos, MPH2,3, Sonya Arreola, PhD4, Tri Do, MD, MPH2, Pato Hebert, MFA1, Jack Beck, BA1, Keletso Makofane, MPH1, Patrick A. Wilson, PhD5, and George Ayala, PsyD1
Abstract Although previous research has examined barriers and facilitators of HIV testing among men who have sex with men (MSM) in China, few studies have focused on social factors, including homophobia and internalized homophobia. This study utilized data from a global online survey to determine correlates of HIV testing as part of a subanalysis focused on Chinese MSM. Controlling for age, HIV knowledge, number of sexual partners, and other covariates, ever having tested for HIV was significantly correlated with lower internalized homophobia. This study suggests that stigma associated with sexual orientation may serve as a barrier to participation in HIV testing and other health-promoting behaviors. Keywords health care services, health management, health education, health promotion, epidemiology, public health, global health, men’s health
Introduction Men who have sex with men (MSM) are the fastest growing group affected by the HIV epidemic in China.1 From 2006 to 2011, it is estimated that the proportion of new infections attributed to male-to-male sexual transmission in China increased 6-fold.2 Approximately 5% of MSM in China are currently infected with HIV, with some urban centers reporting a prevalence of up to 26%.3 Given these figures, donors and the Chinese government are paying greater attention to HIV prevention initiatives that target MSM. These efforts are beginning to show some
1The
Global Forum on MSM and HIV, Oakland, CA, USA of California San Francisco, San Francisco, CA, USA 3San Francisco Department of Public Health, San Francisco, CA, USA 4RTI International, San Francisco, CA, USA 5Columbia University in the City of New York, New York, NY, USA 2University
Corresponding Author: Glenn-Milo Santos, University of California San Francisco, 185 Berry Street, San Francisco, CA 94107, USA. Email: [email protected]
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impact because research indicates that HIV testing rates among MSM have increased steadily in recent years; a systematic review estimated that rates have increased from 10.8% to 51.2% from 2002 to 2009.4 Despite these signs of improvement, however, overall testing rates among MSM in China remain relatively low, with only about half of MSM reporting ever having been tested.1,4,5 HIV testing serves as a gateway to additional HIV prevention services and to HIV care and treatment if one tests positive. Furthermore, the global AIDS field is shifting toward prevention programming that is contingent on knowing one’s HIV status (eg, prevention with positives, test and treat, and chemoprophylaxis).6 As such, any concerted effort to address the HIV epidemic among MSM in China should include initiatives to increase the rates of HIV testing among this population. Previous research has examined barriers and facilitators affecting HIV testing behavior among MSM in China. One study observed that fear of receiving a positive HIV test result and fear of discrimination that would result from a positive HIV diagnosis were significant barriers to HIV testing among MSM in China.7 Another study found that the most frequent reasons why MSM in China do not get tested for HIV include low HIV risk perception, lack of knowledge of HIV test site locations, fear that other people will learn about their sexual orientation, and concerns over confidentiality of test results.8 However, few studies have focused specifically on social factors, including homophobia (we use “homophobia” here to refer to negative attitudes and behaviors based on sexual orientation, including antigay prejudice and hostility) and internalized homophobia (ie, negative feelings about one’s own sexual orientation resulting from the internalization of antigay stigma and prejudice).9 We hypothesize that these social factors stigmatize MSM, contribute to minority stress among this population, and ultimately affect health-seeking behaviors, such as HIV testing.10 In this study, we aimed to explore social and behavioral correlates of HIV testing behavior among MSM in China. We also evaluated how levels of homophobia and internalized homophobia among MSM in China compare with levels among MSM from other countries, using a global data set of MSM. Understanding the barriers and facilitators of HIV testing can inform the design and implementation of effective HIV prevention programs targeting MSM in China.
Methods Data are from the 2010 Global Men’s Health and Rights Survey (2010 GMHR), a multilingual online survey conducted from June 24, 2010, to August 17, 2010, by the Global Forum on MSM & HIV (MSMGF). Offered in English, Spanish, French, Russian, and Chinese, the survey targeted MSM and their health care providers worldwide. Participants were recruited through intensive outreach via social media platforms, relevant professional e-mail listservs, and the MSMGF’s global networks of advocates and service providers. The Committee on Human Research at RTI International approved secondary analyses of the data and considered the anonymous study to be low risk. The goal of the 2010 GMHR was to assess the following: access to and participation in HIV prevention strategies; knowledge of emerging HIV prevention technologies; perceived homophobia; and internalized homophobia. The survey utilized existing scales, including the Rosenberg self-esteem scale.11 The survey also used versions of existing scales that were adapted to fit the survey’s goals, including the 2010 GMHR’s Sexual Stigma Scale and Internalized Homophobia Scale.11-13 For example, the 2010 GMHR’s Sexual Stigma Scale included 5 items that were adapted from a measure used to obtain perceptions of perceived discrimination.13 The Sexual Stigma Scale included items such as, “In the country I live in, most people believe that a person who is gay/MSM cannot be
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trusted.” Participant responses to this item corresponded to a 4-point Likert scale, with responses ranging from “strongly agree” to “strongly disagree.” Perceptions of sexual stigma had high reliability; Cronbach’s α for Chinese language participants for this scale was 0.85, which was comparable to the reliability of this measure in the overall sample.14 The Internalized Homophobia Scale included 7 items used to gauge levels of internalized stigma around homosexuality and same sex behavior among MSM. Items were adapted from existing measures.12,15 Responses corresponded to a 4-point Likert scale, with responses ranging from “often” to “never.” For internalized homophobia, internal reliability assessment yielded a Cronbach’s α of 0.79 for Chinese language participants, which was comparable to the reliability of this measure in the overall sample.14 For this analysis, the binary dependent variable was defined as reporting ever having been tested for HIV. Once a full draft version of the 2010 GMHR was complete, the MSMGF gathered feedback on the survey from members of its Steering Committee, which comprises leaders in MSM sexual health and human rights from 18 different countries representing every major world region. This feedback was integrated into the final measure, which was then pilot tested for acceptability and completion time by members of the target population. The survey was found to take 8 to 12 minutes to complete. Once the final version of the survey was completed in English, it was translated into Spanish, French, Russian, and Chinese for broader implementation globally. A professional translation service was used by the MSMGF, and each language translation involved 2 translators: one native in the target language and fluent in English and the other native in English and fluent in the target language. Both translators worked in tandem to ensure the highest-quality translation possible. Once the survey was translated, they were reviewed by local advocates focused on MSM health who were native speakers of the target language but also fluent in English. The survey was administered through Survey Monkey. This current study is a subgroup analysis of survey results focused specifically on Chinese MSM. Inclusion criteria for this analysis were as follows: (a) self-identifying as a male who has ever had sex with a male, (b) stating country of residence as China, and (c) not identifying as a health care provider. Respondents for whom HIV testing data were missing or not reported were excluded from the analysis because HIV testing was the primary focus of this study. Because the subanalysis is focused on ever having been tested for HIV, respondents living with HIV were included in this sample. We used logistic regression models in bivariate analyses that examined sociodemographic differences, psychosocial differences, and differences in knowledge, attitude, and behavior between Chinese MSM who had ever been tested for HIV and those who had not. Unadjusted odds ratios and 95% confidence intervals (CIs) were calculated for bivariate point estimates. To assess independent correlates of HIV testing behavior, we conducted a multivariable logistic regression analysis. We used a stepwise, backward elimination approach (ie, all the initial independent variables were entered, then eliminated one at a time in a stepwise fashion) to develop the final multivariate regression model, using a significant cutoff level of P < .05. For the stepwise procedure, ever having been tested for HIV served as the dependent variable, whereas age and sociodemographic factors as well as key measures that were significant (at the .05 level) in the bivariate analysis served as the initial independent variables. Once the final model was obtained, we calculated adjusted odds ratios (AORs) and respective 95% CIs. For continuous independent variables, we verified that there were no departures from linearity. In exploratory comparative analyses, we evaluated how levels of homophobia and internalized homophobia among MSM in China compared with MSM elsewhere using Wilcoxon rank-sum tests. We also compared levels of HIV testing among MSM in China with those among MSM outside of China using Fisher’s exact tests. All analyses were conducted using IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp).
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Results Sample Characteristics A total of 5066 respondents accessed and completed the survey over the 8-week period, 318 of whom were Chinese MSM who met the criteria for inclusion in the subanalysis. The average age of the sample was 30 years. The majority of respondents in this sample were in the middle- to high-income group (70%) and had at least some postsecondary education (87%). In terms of sexual behavior, 68% had had 2 or more sexual partners in the past year. Of the men who reported having had sex in the past year, 87% had sexual relations with men only and 85% self-identified as “gay.” Of the sample, 60% reported ever having been tested for HIV—a lower figure in comparison to the overall global survey sample (76%, N = 5066). Of those who responded to questions regarding HIV serostatus (n = 173), 45% reported being HIV negative. In exploratory comparative analyses, we found that MSM in China had reported higher levels of homophobia compared with MSM from outside China (P < .001); MSM in China reported a mean homophobia score of 2.72 (standard deviation [SD] = 0.73), whereas MSM from outside China reported a mean homophobia scored of 2.38 (SD = 0.75). Moreover, we found that MSM in China have significantly higher levels of internalized homophobia compared with MSM from outside China (P < .001); the mean internalized homophobia score among MSM in China and MSM outside of China were 2.04 (SD = 0.66) and 1.77 (SD = 0.67), respectively. In our sample, 40% of MSM from China reported not having had an HIV test, compared with 23% of MSM outside of China. Chinese MSM were significantly less likely to have reported an HIV test compared with the rest of our sample (P < .001).
Correlates of HIV Testing Logistic regression analysis yielded bivariate and multivariable estimates, which are presented in Table 1. Bivariate analysis revealed several significant correlates of ever having been tested for HIV, including older age, lower internalized homophobia, greater knowledge of HIV prevention strategies, higher perceived access to basic HIV prevention services, higher income, having had 2 or more sexual partners in the past year, gay sexual identification, exposure to billboards or signs about HIV prevention, and obtaining free condoms or safer sex materials from communitybased organizations, nightclubs/bars, and the office of a doctor or health care provider. Some correlates were significant in the bivariate analysis but not the multivariate analysis. These included perceived availability of HIV services in the community, income, and obtaining free condoms at nightclubs/bars and obtaining free condoms at the office of a doctor or health care provider. However, the magnitude of the point estimates for the correlates that remained significant in the multivariable model changed little from the bivariate analyses. In the final multivariable model, ever having tested for HIV was significantly correlated with older age (AOR = 1.07; CI = 1.03, 1.12), lower internalized homophobia (AOR = 0.60; CI = 0.38, 0.94), greater knowledge of HIV prevention strategies (AOR = 1.79; CI = 1.10, 2.91), having 2 or more sexual partners in the past year (AOR = 2.33; CI = 1.26, 4.32), gay sexual identification (AOR = 3.38; CI = 1.48, 7.70), exposure to billboards or signs about HIV prevention (AOR = 1.80; CI = 1.03, 3.32), and having previously obtained condoms or safer sex materials from a community-based organization (AOR = 2.53; CI = 1.32, 4.86).
Discussion The proportion of Chinese MSM who had ever been tested for HIV in our study was comparable to that in previous research focused on MSM in China.3,16,17 One study that targeted migrant Chinese MSM yielded a higher lifetime prevalence: 72% of its sample had ever been tested for
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Table 1. Results of Univariate, Bivariate, and Multivariate Analyses of Correlates of HIV Testing.a
Variable Age (years), mean External sexual stigma (range = 1-4) Internalized homophobia (range = 1-4) Self-esteem (range = 1-4) Reported access to basic HIV prevention services in community (range = 1-5) Reported access to emerging HIV prevention services in community (range = 1-5) Knowledge of HIV prevention strategies (range = 1-4) Desire to learn more about HIV prevention (range = 1-4) Income Low Middle High Education Secondary and below Postsecondary and above Number of sexual partners ≤2 In past year ≥2 In past year Type of sexual partners Men only Men and women No sexual partner Sexual identification Bisexual or heterosexual Gay Relationship status Single Attached Seen radio announcement about HIV prevention Seen television commercials about HIV prevention Seen advertisements on the Internet about HIV prevention Seen advertisements in newspapers or magazines about HIV prevention Seen billboards or signs in your community about HIV prevention Obtained free condoms or safer sex materials from a community organization Obtained free condoms or safer sex materials from a nightclub/bar or other public place Obtained free condoms or safer sex materials from a doctor or health care provider Obtained free condoms or safer sex materials from a religious institution Agreed that if condoms or safer sex materials were made available, would take them Reported access to HIV counseling Reported access to testing for sexually transmitted diseases (STDs) Reported access to free condoms Reported access to free water-based lubricants Reported access to free HIV testing Reported access to media campaigns to reduce HIV Reported access to HIV education materials Ever been tested for HIV Yes No
Bivariate
Multivariate
N (Percentage) Mean (SD)
OR
95% CI
OR
95% CI
29.8 (8.0) 2.7 (0.7) 2.0 (0.7) 3.6 (0.4) 2.6 (0.9)
1.09 0.90 0.50 1.00 1.55
(1.04, 1.12)b (0.71, 1.34) (0.35, 0.72)b (0.60, 1.66) (1.19, 2.02)b
1.07 — 0.60 — —
(1.03, 1.12)b — (0.38, 0.94)b — —
2.2 (1.0)
1.11
(0.87, 1.41)
—
—
2.0 (0.7) 3.8 (0.5)
1.77 0.63
(1.19, 2.49)b (0.37, 1.07)
1.79 —
64 (20.1) 127 (39.9) 97 (30.2)
Reference 1.35 2.46
Reference (0.74, 2.47) (1.28, 4.38)b
14 (4.4) 276 (86.8)
Reference 1.46
Reference (0.50, 4.29)
75 (23.6) 215 (67.6)
Reference 2.12
Reference (1.24, 3.61)b
252 (79.2) 31 (9.7) 6 (1.9)
Reference 0.45 0.31
Reference (0.21, 0.96)b (0.06, 1.74)
43 (13.5) 248 (78.0)
Reference 3.17
Reference (1.61, 6.24)b
181 (56.9) 106 (33.3) 168 (52.8) 198 (62.3) 256 (80.5) 225 (70.8)
Reference 1.05 1.02 0.94 1.27 1.39
Reference (0.65, 1.72) (0.65, 1.62) (0.58, 1.51) (0.70, 2.29) (0.84, 2.30)
170 (53.5)
2.17
(1.36, 3.46)b
1.80
(1.03, 3.14)b
111 (34.9)
3.05
(1.82, 5.21)b
2.53
(1.32, 4.86)b
119 (37.4)
2.43
(1.48, 3.98)b
—
—
107 (33.6)
2.00
(1.21, 3.29)b
—
—
37 (11.6)
1.08
(0.53, 2.19)
—
—
311 (97.8)
0.38
(0.04, 3.41)
—
—
78 (24.5) 82 (25.8)
— —
— —
— —
— —
64 (20.1) 23 (7.2) 75 (23.6) 59 (18.6) 47 (14.8)
— — — — —
— — — — —
— — — — —
192 (60.4) 126 (39.6)
— —
— —
— —
— — — — — — —
(1.10, 2.91)b — — — — — — — — — — — — — — 2.33 (1.26, 4.32)b — — — — — — Reference Reference 3.38 (1.48, 7.70)b — — — — — — — — — — — —
(continued)
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Variable Self-reported HIV status Negative Positive Do not know Decline to answer
Bivariate
Multivariate
N (Percentage) Mean (SD)
OR
95% CI
OR
95% CI
143 (45.0) 17 (5.3) 11 (3.5) 2 (0.6)
— — — —
— — — —
— — — —
— — — —
Abbreviations: SD, standard deviation; OR, odds ratio; CI, confidence interval. may not add to 100% because of missing data. bDenotes significance at α level of 0.05. aPercentage
HIV.3 However, that study focused specifically on MSM in Beijing, and the higher prevalence could potentially be attributed to the study’s highly urban setting, where HIV testing coverage and access to services is greater.16 Conversely, 2 meta-analyses of HIV testing estimated that 51% and 47% of MSM in China had ever been tested in 2009—figures somewhat lower than our result.4,17 Our finding—in conjunction with results from other studies—highlights the fact that HIV testing rates are low, both in comparison to other countries and also in light of the high prevalence of HIV among MSM in China.4,18-20 Our study also yielded an association between HIV testing behavior and knowledge of HIV prevention strategies. This finding is supported by a recent meta-analysis of 34 studies, which found that HIV risk reduction interventions in China are efficacious in increasing uptake of HIV testing as well as in improving HIV knowledge and reducing HIV-related risk behaviors among Chinese MSM.21 Indeed, these results are corroborated by other research on Chinese MSM that also found a statistically significant association between higher knowledge of prevention strategies and likelihood of testing.3,4 Another study finding was the significant link between exposure to community billboards and/or signs about HIV prevention and testing behavior. To our knowledge, there is currently no research that has specifically examined the impact of social marketing on HIV testing behavior among MSM in China. However, according to other research assessing the effect of social marketing on HIV testing behavior globally, there is evidence—albeit limited—that social marketing can significantly increase uptake of HIV testing in low-, middle-, and high-income countries.22,23 Other research on Chinese MSM has shown the potentially deleterious effects of homophobia and its association with unprotected anal intercourse.8 Our study did not find an association between homophobia and HIV testing behavior. However, having access to the Internet may provide a venue for MSM to disclose sexual orientation without stigma, build community, and/ or develop a sense of belonging, which in turn may offset the negative effects of homophobia.24 Thus, because this sample was recruited online, the impact of homophobia on men in this sample may have been different from what would have been found if they had been recruited by other means. Consistent with and related to our finding that internalized homophobia is correlated with never having been tested for HIV, a previous cross-sectional study showed that “fear of people learning about [one’s] homosexuality” is a barrier to HIV testing uptake among MSM.8 This same study also revealed a positive association between “being out” and having ever tested for HIV. These past study findings underscore that indicators of and/or proxies for internalized homophobia are associated with HIV testing behavior. To our knowledge, our study is the first to utilize an inventory to measure internalized homophobia among Chinese MSM and its subsequent relationship with HIV testing behavior. Furthermore, we note that this measure for internalized homophobia exhibited high internal validity.
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There are several limitations to our study that are important to highlight. Our use of convenience sampling via the MSMGF’s online network may have created a selection bias for MSM who are connected to gay and HIV-related organizations and communities as well as for those who have access to the Internet. There may also be selection bias for MSM who are particularly motivated to participate. However, this bias is likely to overestimate access and underestimate sexual stigma. In addition, our study did not collect information on other structural barriers that may affect HIV testing such as HIV stigma, cost of testing, and difficulties arranging time off to get tested. Furthermore, we did not assess other dimensions of health that may also play a role in getting tested for HIV, including views on health and illness, potential impact of illness, and concerns over privacy of one’s sexual orientation.7,8 Nonetheless, this study is one of the first to examine correlates of HIV testing behavior among Chinese MSM using a series of social and behavioral scales, including homophobia and internalized homophobia. Many of our findings validate and corroborate findings from other research examining the relationship between social or structural factors and HIV prevention behaviors among MSM.25,26 The results of this study have several important implications for future programs to prevent HIV among MSM in China. First, HIV prevention efforts targeting Chinese MSM should be comprehensive and include social marketing and other behavioral change communication components in conjunction with HIV testing and treatment. Social marketing efforts to promote HIV testing among MSM in low- and middle-income countries are rare or relatively nascent; more funding support should be directed toward these efforts, and additional research will be needed to determine its efficacy.23 Second, future efforts to address homophobia should include a focus on internalized homophobia in both programmatic design and public health policy initiatives. Although China decriminalized homosexuality in 1997, interventions are urgently needed that promote education countering stigmatization and discrimination of gay men and other sexual minorities in daily life. Social discrimination and stigma associated with sexual orientation, identity, and behavior may make it difficult for MSM to engage in health promoting behaviors.27 From both a policy and programmatic standpoint, prevention efforts targeting MSM in China should focus on community engagement, outreach, reduction of homophobia and internalized homophobia, and the provision of culturally sensitive services, including HIV testing and counseling, to improve the safety and accessibility of services for MSM clients. Reducing internalized homophobia and stigma related to homosexuality and HIV is essential for optimizing access to HIV prevention services for MSM. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research was funded by a grant from the Bill and Melinda Gates Foundation.
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