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A total of 21, 785 App users clicked on the link for the online survey. However, 12, 910 (59.3%) returned to normal App function because they were outside Beijing and a further 112 (0.5%) exited from the survey after declining to provide informed consent. Thus, 8, 763 potential participants (40.2%) were screened. A total of 912 over 8, 763 participants (10.4%) failed to meet inclusion criteria and a further 1, 855 (21.2%) met exclusion criteria. This led to a final study population of 5, 996 (of 8, 763, 68.4%), all of whom completed the online survey and were included in the analysis (Figure 1).
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Characteristics of the participants are presented in Table 1. Most participants were less than 30 years of age (18-24 years: 29.1%; 25-29 years: 32.7%), of Han ethnicity (92.1%), had at least some college-level education (college: 63.3%; ≥ graduate school: 15.9%), were full time employed (79.1%), had monthly incomes above 5, 000 CNY (5, 001-10, 000: 33.9%; > 10, 000: 21.2%), lived in Beijing for at least 2 years (70.9%), were unmarried (85.2%), were cohabitating (67.4%), and self-identified as homosexual (72.0%).
Items All Participants [N = 5, 996] n(%) 'Self-Testers' [N = 2, 383] n(%) 'Non-Self-Testers' [N = 3, 613] n(%) P-value Demographic Characteristics Age (years) 0.001 18-24 1, 746 (29.1) 649 (27.2) 1, 097 (30.4) 25-29 1, 961 (32.7) 841 (35.3) 1, 120 (31.0) ≥ 30 2, 289 (38.2) 893 (37.5) 1, 396 (38.6) Ethnicity 0.12 Han 5, 524 (92.1) 2, 199 (92.3) 3, 325 (92.0) Minority 472 (7.9) 184 (7.7) 288 (8.0) Education level 0.76 ≤ High schoola 1, 247 (20.8) 499 (20.9) 748 (20.7) College 3, 795 (63.3) 1, 515 (63.6) 2, 280 (63.1) ≥ Graduate school 954 (15.9) 369 (15.5) 585 (16.2) Employment status 0.007 Unemployed or part-time 291 (4.9) 114(4.8) 177 (4.9) Student 962 (16.0) 339 (14.2) 623 (17.2) Full-time 4, 743 (79.1) 1, 930 (81.0) 2, 813 (77.9) Monthly Income (CNY) < 0.001 ≤ 1, 500 554 (9.3) 183 (7.7) 371 (10.3) 1, 501-5, 000 2, 139 (35.7) 814 (34.2) 1, 325 (36.7) 5, 001-10, 000 2, 034 (33.9) 810 (34.0) 1, 224 (33.9) > 10, 000 1, 269 (21.2) 576 (24.2) 693 (19.2) Duration of residence in Beijing (years) 0.30 < 2 1, 746 (29.1) 676 (28.4) 1, 070 (29.6) ≥ 2 4, 250 (70.9) 1, 707 (71.6) 2, 543 (70.4) Marital status 0.004 Married 885 (14.8) 313 (13.1) 572 (15.8) Unmarried 5, 111 (85.2) 2, 070 (86.9) 3, 041 (84.2) Cohabitation status < 0.001 Alone 1, 956 (32.6) 851 (35.7) 1, 105 (30.6) Cohabitatingb 4, 040 (67.4) 1, 532 (64.3) 2, 508 (69.4) Sexual orientation < 0.001 Homosexual 4, 318 (72.0) 1, 775 (74.5) 2, 543 (70.4) Bisexual 1, 643 (27.4) 604 (25.3) 1, 039 (28.8) Unknown/unsure 35 (0.6) 4 (0.2) 31 (0.9) Sexual Behavior Characteristics Method for finding sex partners 0.11 Internet or mobile Apps 5, 255 (87.6) 2, 088 (87.6) 3, 167 (87.7) Parties 288 (4.8) 129 (5.4) 159 (4.4) Other 453 (7.6) 166 (7.0) 287 (7.9) Age at sexual debut with male (years) 0.17 < 18 1, 209 (20.2) 498 (20.9) 711 (19.7) 18-29 4, 328 (72.2) 1, 719 (72.1) 2, 609 (72.2) ≥ 30 459 (7.7) 166 (7.0) 293 (8.1) Role in sexual intercourse 0.02 Anal receptive 1, 396 (23.3) 511 (21.4) 885 (24.5) Anal insertive 1, 338 (22.3) 553 (23.2) 785 (21.7) Both 3, 262 (54.4) 1, 319 (55.4) 1, 943 (53.8) Number of male sex partnersc < 0.001 0 1, 856 (31.0) 600 (25.2) 1, 256 (34.8) 1 2, 091 (34.9) 797 (33.4) 1, 294 (35.8) ≥ 2 2, 049 (34.2) 986 (41.4) 1, 063 (29.4) Condom use with latest male sex partner 0.001 Yes 3, 157 (76.3) 1, 406 (78.9) 1, 751 (74.3) No 983 (23.7) 377 (21.1) 606 (25.7) Missing (no male sex partners) 1, 856 - - Condom use with male sex partnersc < 0.001 Never 410 (9.9) 140 (7.9) 270 (11.5) Ever 1, 208 (29.2) 538 (30.2) 670 (28.4) Always 2, 522 (60.9) 1, 105 (62.0) 1, 417 (60.1) Missing (no male sex partners) 1, 856 - - Number of commercial male sex partnersc < 0.001 0 5, 572 (92.9) 2, 182 (91.6) 3, 390 (93.8) 1 271 (4.5) 114 (4.8) 157 (4.3) ≥ 2 153 (2.6) 87 (3.7) 66 (1.8) Condom use with latest commercial male sex partner 0.68 Yes 336 (79.2) 161 (80.1) 175 (78.5) No 88 (20.8) 40 (19.9) 48 (21.5) Missing (no commercial male sex partners) 5, 572 - - Condom use with commercial male sex partnersc 0.22 Never 43 (10.1) 18 (9.0) 25 (11.2) Ever 97 (22.9) 40 (19.9) 57 (25.6) Always 284 (67.0) 143 (71.1) 141 (63.2) Missing (no commercial male sex partners) 5, 572 - - Number of female sex partnersc 0.33 0 5, 265 (87.8) 2, 089 (87.7) 3, 176 (87.9) 1 656 (10.9) 258 (10.8) 398 (11.0) ≥ 2 75 (1.3) 36 (1.5) 39 (1.1) Condom use with latest female partner 0.002 Yes 404 (55.3) 183 (62.2) 221 (50.6) No 327 (44.7) 111 (37.8) 216 (49.4) Missing (no female sex partners) 5, 265 - - Condom use with female partnerc 0.002 Never in lifetime 263 (36.0) 83 (28.2) 180 (41.2) Ever in lifetime 153 (20.9) 69 (23.5) 84 (19.2) Always 315 (43.1) 142 (48.3) 173 (39.6) Missing (no female sex partners) 5, 265 - - Sexual Health Characteristics Sought healthcare for STI symptomsd 0.006 Yes 541 (9.0) 245 (10.3) 296 (8.2) No 5, 455 (91.0) 2, 138 (89.7) 3, 317 (91.8) Results of the latest STI testing 0.48 Gonorrhea 34 (6.3) 16 (6.5) 18 (6.1) Syphilis 164 (30.3) 82 (33.5) 82 (27.7) Chlamydial trachomatis 29 (5.4) 16 (6.5) 13 (4.4) Condyloma acuminate 128 (23.7) 54 (22.0) 74 (25.0) Herpes progenitalis 31 (5.7) 14 (5.7) 17 (5.7) Other 155 (28.7) 63 (25.7) 92 (31.1) Missing (did not seek healthcare) 5, 455 - - Drug Use Behavior Characteristics Drug use ever in lifetime < 0.001 Yes 2, 171 (36.2) 1, 082 (45.4) 1, 089 (30.1) No 3, 825 (63.8) 1, 301 (54.6) 2, 524 (69.9) Anal sex after drug use 0.63 Yes 1, 852 (85.3) 927 (85.7) 925 (84.9) No 319 (14.7) 155 (14.3) 164 (15.1) Missing (no drug use) 3, 825 - - Condom use after drug use 0.03 Never 127 (6.9) 54 (5.8) 73 (7.9) Ever 477 (25.8) 260 (28.0) 217 (23.5) Always 1, 248 (67.4) 613 (66.1) 635 (68.6) Missing (no drug use) 3, 825 - - History of HIV VCT HIV VCT attendance < 0.001 Ever in lifetime 3, 772 (62.9) 1, 914 (80.3) 1, 858 (51.4) Never in lifetime 2, 224 (37.1) 469 (19.7) 1, 755 (48.6) Time since latest HIV VCT (months) < 0.001 ≤ 3 1, 379 (36.6) 786 (41.1) 593 (31.9) 4-6 740 (19.6) 360 (18.8) 380 (20.5) 7-12 539 (14.3) 258 (13.5) 281 (15.1) ≥ 13 1, 114 (29.5) 510 (26.6) 604 (32.5) Missing (never in lifetime) 2, 224 - - Consultation during latest HIV VCT 0.005 Yes 2, 123 (56.3) 1, 101 (57.5) 1, 022 (55.0) No 1, 037 (27.5) 483 (25.2) 554 (29.8) Can't remember 612 (16.2) 330 (17.2) 282 (15.2) Missing (never in lifetime) 2, 224 - - Site of the latest HIV VCT < 0.001 CDC 1, 343 (35.6) 696 (36.4) 647 (34.8) Hospital 1, 328 (35.2) 559 (29.2) 769 (41.4) Blood donation station 111 (2.9) 70 (3.7) 41 (2.2) NGO 792 (21.0) 423 (22.1) 369 (19.9) Others 198 (5.2) 166 (8.7) 32 (1.7) Missing (never in lifetime) 2, 224 - - HIV Self-testing Knowledge and Attitudes Sources of information on HIV self-testinge Mobile Apps 3, 670 (61.2) 1, 269 (53.3) 2, 401 (66.5) Posters 1, 552 (25.9) 617 (25.9) 935 (25.9) Consultation with medical professionals 1, 090 (18.2) 555 (23.3) 535 (14.8) Friends 1, 556 (26.0) 787 (33.0) 769 (21.3) Websites 2, 668 (44.5) 1, 026 (43.1) 1, 642 (45.4) Other 79 (1.3) 43 (1.8) 36 (1.0) Willingness to use an HIV self-test kit in the future < 0.001 Willing 5, 535 (92.3) 2, 310 (96.9) 3, 225(89.3) Unwilling 461 (7.7) 73 (3.1) 388 (10.7) Best feature of HIV self-testing < 0.001 Easy to purchase 151 (2.5) 79 (3.3) 72 (2.0) Simple operation 967 (16.1) 449 (18.8) 518 (14.3) Protection of privacy 3, 307 (55.2) 1, 203 (50.5) 2, 104 (58.2) Convenient 1, 538 (25.7) 643 (27.0) 895 (24.8) Other 33 (0.6) 9 (0.4) 24 (0.7) Disadvantages of HIV self-testinge Difficult to obtain 2, 143 (35.7) 772 (32.4) 1, 371 (37.9) Lack of consultation 1, 765 (29.4) 584 (24.5) 1, 181 (32.7) Difficult operation 1, 004 (16.7) 365 (15.3) 639 (17.7) Difficult results interpretation 1, 507 (25.1) 491 (20.6) 1, 016 (28.1) High price 1, 385 (23.1) 631 (26.5) 754 (20.9) Quality concerns 3, 438 (57.3) 1, 269 (53.3) 2, 169 (60.0) Other 187 (3.1) 76 (3.2) 111 (3.1) Note.CNY: Chinese Yuan; CDC: Centers for Disease Control; NGO: non-government organization; STI: sexually-transmitted infection; VCT: voluntary counseling and HIV testing. aThe category 'High School' includes also vocational or technical school. bThe category 'Cohabitating' includes those who live with their spouse, roommate, or other. cThese sexual behavior characteristics were limited to the prior 3 months. dSeeking healthcare for STI symptoms was limited to the last year. eFor these two variables, more than one response was allowed in the survey. No statistical comparison was performed for these variables. 'Self-testers' indicates those who had used HIV self-testing and 'non-self-testers' those who had never used HIV self-testing. Table 1. Characteristics of the Participants
Most of the participants reported finding their sex partners via the internet or mobile Apps (87.6%). In the preceding 3 months, 34.9% reported having had one male sex partner and 34.2% reported having two or more male sex partners. The majority of the participants reported using condoms with their latest male sex partner (76.3%) and always using condoms with male sex partners (60.9%). Only 9.0% reported having sought healthcare for symptoms of sexually transmitted infection (STI) during the last year. Lifetime drug use was reported by 36.2% of the participants, the majority of them reporting having had anal sex after drug use (85.3%).
The majority of the participants reported having attended VCT (62.9%). Among those who had attended VCT, 36.6% reported attending at least once in the past three months while 29.5% reported that it had been at least 13 months since they last attended. The most frequently selected source of information on HIV self-testing was mobile Apps (61.2%). A large majority reported willingness to use HIV self-testing kits (92.3%) and most participants selected either privacy (55.2%) or convenience (25.7%) as the best features of these products.
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Among all 5, 996 participants, 2, 383 (39.7%) reported having used an HIV self-test kit before ('self-testers'), while 3, 613 (60.3%) reported never having self-tested ('non-self-testers'). As shown in Table 1, a larger proportion of 'self-testers' were aged between 25 to 29 years (35.3% vs. 31.0% for 'non-self-testers', P = 0.001), employed full-time (81.0% vs. 77.9%, P = 0.007), had monthly incomes > 10, 000 CNY (24.2% vs. 19.2%, P < 0.001), were unmarried (86.9% vs. 84.2%, P = 0.004), lived alone (35.7% vs. 30.6%, P < 0.001), and self-identified as homosexual (74.5% vs. 70.4%, P < 0.001).
A larger proportion of 'self-testers' had two or more male sex partners in the prior 3 months (41.4% vs. 29.4%, P < 0.001). Among those who had had at least one male sex partner in the prior 3 months, a larger proportion of 'self-testers' used condoms with their latest male sex partner than 'non-self-testers' (78.9% vs. 74.3%, P = 0.001) and always used condoms with male sex partners (62.0% vs. 60.1%, P < 0.001). Among those who had had at least one female sex partner, a greater proportion of 'self-testers' also used condoms with their latest female sex partner (62.2% vs. 50.6%, P = 0.002) and always used condoms with female sex partners (48.3% vs. 39.6%, P = 0.002) than 'non-self-testers'.
A greater proportion of 'self-testers' had sought healthcare for symptoms of STIs (10.3% vs. 8.2%, P = 0.006) and had used drugs in their lifetimes (45.4% vs. 30.1%, P < 0.001). A larger proportion of 'self-testers' had attended VCT in their lifetimes (80.3% vs. 51.4%, P < 0.001). Among those that had attended VCT, a greater proportion of 'self-testers' reported that their most recent visit to VCT had been within the prior 3 months (41.1% vs. 31.9%, P < 0.001), had included a consultation (57.5% vs. 55.0%, P = 0.005), and that the VCT site they attended was located at sites other than hospitals [CDC: 36.4% vs. 34.8%, blood donation station: 3.7% vs. 2.2%, non-governmental organization (NGO): 22.1% vs. 19.9%, or other: 8.7% vs. 1.7%, P < 0.001].
A larger proportion of 'self-testers' reported obtaining knowledge about HIV self-testing from medical professionals (23.3% vs. 14.8%) and friends (33.0% vs. 21.3%) and reported being willing to use HIV self-test kits in the future (96.9% vs. 89.3%, P < 0.001). A greater proportion of 'self-testers' selected simple operation (18.8% vs. 14.3%) and convenience (27.0% vs. 24.8%, P < 0.001) as the best features of HIV self-testing. The only disadvantage that 'self-testers' selected more frequently that 'non-self-testers' was high price (26.5% vs. 20.9%).
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Results of univariate and multivariate regression assessing determinants of HIV self-testing are presented in Table 2. After controlling for confounding factors, elements associated with HIV self-testing uptake included age ≥ 30 years (adjusted OR = 0.69, CI = 0.57-0.83, P < 0.001), monthly income > 10, 000 CNY (adjusted OR = 1.49, CI = 1.10-2.02, P = 0.010), self-identifying as bisexual (adjusted OR = 0.85, CI = 0.73-0.99, P = 0.034), having ≥ 2 male sex partners in the prior 3 months (adjusted OR = 1.24, CI = 1.09-1.43, P = 0.002), having ≥ 2 commercial male sex partners in the prior 3 months (adjusted OR = 1.94, CI = 1.34-2.82, P = 0.001), having history of VCT (adjusted OR = 3.62, CI = 3.11-4.22, P < 0.001), and being unwilling to use an HIV self-test kit in the future (adjusted OR = 0.20, CI = 0.15-0.28, P < 0.001).
Items Unadjusted OR(CI) P-value Adjusted OR(CI) P-value Age (years) 18-24 1.00 1.00 25-29 1.27 (1.11-1.45) < 0.001 0.94 (0.78-1.13) 0.495 ≥ 30 1.08 (0.95-1.23) 0.233 0.69 (0.57-0.83) < 0.001 Employment status Unemployed or part-time 1.00 - Student 0.84 (0.64-1.11) 0.221 - - Full-time 1.07 (0.84-1.36) 0.609 - - Monthly income (CNY) ≤ 1, 500 1.00 1.00 1, 501-5, 000 1.25 (1.02-1.5) 0.029 1.18 (0.89-1.55) 0.245 5, 001-10, 000 1.34 (1.10-1.64) 0.004 1.13 (0.85-1.50) 0.403 > 10, 000 1.69 (1.37-2.08 < 0.001 1.49 (1.10-2.02) 0.010 Marital status Married 1.00 - Unmarried 1.24 (1.07-1.44) 0.004 - - Cohabitation status Alone 1.00 - Cohabitating 0.79 (0.71-0.89) < 0.001 - - Sexual orientation Homosexual 1.00 1.00 Bisexual 0.83 (0.74-0.94) 0.002 0.85 (0.73-0.99) 0.034 Unknown/unsure 0.18 (0.07-0.52) 0.002 0.36 (0.11-1.21) 0.098 Role in sexual intercourse Anal receptive 1.00 1.00 Anal insertive 1.22 (1.05-1.42) 0.011 1.37 (1.12-1.68) 0.002 Both 1.18 (1.03-1.34) 0.014 1.34 (1.13-1.59) 0.001 Number of male sex partners 0 1.00 - 1 1.29 (1.13-1.47) < 0.001 1.00 ≥ 2 1.94 (1.70-2.21) < 0.001 1.24 (1.09-1.43) 0.002 Condom use with latest male sex partner Yes 1.00 - No 0.77 (0.67-0.90) 0.001 - - Condom use with male sex partner Always 1.00 - Ever 1.03 (0.90-1.18) 0.678 - - Never 0.66 (0.53-0.83) < 0.001 - - Number of commercial male sex partner 0 1.00 1.00 1 1.13 (0.88-1.44) 0.339 1.18 (0.88-1.59) 0.258 ≥ 2 2.05 (1.48-2.83) < 0.001 1.94 (1.34-2.82) 0.001 Sought healthcare for STI symptoms No 1.00 - Yes 1.28 (1.07-1.53) 0.006 - - Drug use ever in lifetime No 1.00 1.00 Yes 1.93 (1.73-2.15) < 0.001 1.42 (1.23-1.62) < 0.001 HIV VCT attendance Ever in lifetime 3.85 (3.42-4.35) < 0.001 3.62 (3.11-4.22) < 0.001 Never in lifetime 1.00 1.00 Willingness to use an HIV self-test kit in the future Willing 1.00 1.00 Unwilling 0.26 (0.20-0.34) < 0.001 0.20 (0.15-0.28) < 0.001 Table 2. Determinants of HIV self-testing as assessed by univariate and multivariate regression