Treatment-seeking behaviour and barriers to service access for sexually transmitted diseases among men who have sex with men in China: a multicentre cross-sectional survey

To the best of our knowledge, this is the first multisite study that explores factors related to STD treatment-seeking behaviour among MSM in China. Our study expands upon existing knowledge of the reasons for the severe HIV/AIDS epidemic among Chinese MSM. Improving patterns of STD treatment-seeking behaviour and reducing HIV transmission among MSM requires understanding this information. Our results can also be used as a reference for researchers who wish to carry out in-depth studies on STD treatment and measures among MSM populations, both within China and internationally.

The prevalence of suspected STD infections (24.4%) found in our study was much higher than reported among MSM in Guangzhou (23.2% in 2012 and 17.0% in 2013) [25] and central Brazil (4.3%) [26], but lower than among MSM in the Jiangsu province of China (34.1%) [27] and El Salvador (49.8%) [28] and among female sex workers (FSWs) in Shanxi province (53.6%) [29] of China (the comparisons of prevalence of suspected STD infection were all made under the same definition). The HIV prevalence among suspected STD-infected MSM was 16.7%, which was also higher than Chinese MSM in general (6.5%) [30] and Chinese FSWs (0.2%) [31], as reported in two recently published meta-analyses. This indicates that STD clinics and medical institutions at all levels ought to recommend HIV screening for suspected STD-infected MSM through provider-initiated HIV testing and counselling (PITC). This could aid in early discovery of HIV infections, thus laying the foundation for timely HIV treatment and behavioural interventions.

Alarmingly, slightly more than one-third (35.7%) of suspected STD-infected MSM in our survey sought STD treatment in clinics; although this was slightly higher than reported data about MSM in Hong Kong [10], it is lower than South Africa [8] and Indonesia [9], and almost 2 to 3 times lower than Liuzhou (87.0%) [12] and Chengdu (81.1%) [11]. The discrepancy in participants’ STD treatment-seeking behaviour may be partly attributable to the differences in survey subject recruitment standards. Our study also included participants who did not know their STD testing statuses, while previous studies did not; it is believed that a small proportion of men in this subgroup exhibit STD treatment-seeking behaviour. Concurrently with the ongoing goal of “Ending the HIV epidemic by 2030” proposed by the Joint United Nations Programme on HIV and AIDS (UNAIDS), the World Health Organization (WHO) also proposes the target of ending STD epidemics as public health concerns. This relates directly to the continuum of available STD service, including accessibility of STD testing and access to short-term care, treatment and chronic care [32]. However, the low levels of STD treatment in our study indicate that current STD prevention and control efforts in China are far from sufficient. Additionally, this study found that MSM who failed to seek STD treatment in clinics had a significantly higher prevalence of syphilis/HSV-2 than those who sought STD treatment in clinics. This poses a non-trivial threat to the control of HIV transmission and, to a certain extent, explains high HIV incidence [33] and the rising HIV prevalence among China’s MSM population [6]. This may be attributable to the distinct objectives of HIV and STD prevention and control efforts in China. The National Center for AIDS Prevention and Control (NCAIDS) of China Centers for Disease Control (CDC) system focuses more heavily on HIV-related work, while the National Center for Sexually Transmitted Disease (NCSTD) of China CDC focuses on STDs. Integrated HIV and sexual reproductive health (SRH) services could reduce high-risk sexual behaviours and improve the utilization of SRH services [34]. Expanding physician training on STD treatment and management may be a similarly efficient strategy in preventing HIV/STD transmission [35]. Therefore, as a response to WHO’s goal, Chinese policymakers and healthcare workers in CDCs ought to adopt the aforementioned measures and work to establish long-term cooperation between public health institutions and local medical services through policies like efficient transfer protocols for STD-infected MSM to formal hospitals. By adopting such an approach, with the objective of promoting their STD treatment-seeking behaviour and curing STDs as soon as possible after diagnosis of infection, health professionals can further decrease the risk of MSM transmitting and acquiring HIV.

This study also investigated barriers to STD treatment-seeking in clinics among MSM in order to offer evidence about ways in which STD treatment-seeking behaviour might be improved and HIV transmission risk reduced. Suspected STD-infected MSM with higher incomes were more likely to attend STD clinics, consistent with results from studies in Nigeria [36] and several Chinese cities [13, 14, 37]. Lower incomes was associated with poorer choices of treatment for STDs, for several reasons, including its correlation with lower educational level as well as unaffordable STD services and a general lack of appropriate healthcare resources in certain communities [24]. Additionally, easy access to antibiotics in pharmacies acts functions as a good alternative to time-consuming, potentially costly clinic visits. As such, the government ought to launch economic assistance or compensation initiatives for essential STD treatments in serious HIV epidemic areas. This observation similarly underscores the need for greater regulation of the sale and purchase of antibiotics in pharmacies.

Suspected STD-infected subjects with higher education levels were also more likely to seek STD treatment in clinics, which corroborated previous studies [13, 14, 36, 37]. It indicates subjects with better education could be more knowledgeable about STDs and had more access to necessary STD education, resulting to their higher rates of clinic-based treatment seeking behaviour. In contrast, regarding those with lower education level who tended to underestimate their STD symptoms due to insufficient STD-related knowledge, simple and direct measures like videos or posters could be utilized to popularize information about STD prevention and treatment among them.

This study also found that MSM infected with syphilis and HSV-2 were less likely to seek STD treatment in clinics, which is an interesting but alarming phenomenon. One possible explanation is that symptoms of these two STDs are easily neglected in their early infection stage. Additionally, social stigma deters individuals from seeking STD treatment in clinics, as STDs are still considered shameful and are viewed as “losing face” China. In order to address this issue, it is imperative that public health sectors scale up STD testing and education targeted at the MSM population.

MSM who experienced obvious STD-related symptoms were more likely to seek STD treatment in clinics, according to this study. However, this may only be the case for certain noticeable symptoms, as we also observed that MSM who experienced mild STD symptoms tended to buy antibiotics in pharmacies or sought no treatment at all. For this reason, public health institutions should not only perform tests for STDs that have noticeable symptoms like syphilis or HSV-2, but should also strengthen and expand the screening for asymptomatic STDs among MSM that can have serious consequences in their later stages, like Chlamydia and gonorrhoea. More thorough testing would help this high-risk population to understand STD infection statuses more completely, allowing them to make fully informed, correct choices about treatment.

Among MSM subgroup who sought STD treatment in clinics, HIV prevalence was significantly higher than those who did not, which is a surprisingly, seemingly contradictory phenomenon that is, nevertheless, consistent with a similar study conducted in Germany [15]. A possible explanation is public hospitals or clinics are usually equipped with professional HIV diagnosis facilities [38], so suspected STD-infected MSM who sought STD treatment in clinics may have high chance of being screened for HIV, therefore had higher prevalence.

Although the HIV prevalence and incidence in the subgroup of MSM who did not seek STD treatment in clinics are relatively lower, it still reached up to 14.5% and 12.2/100PYs, respectively. The epidemic synergistic effect of STDs on HIV acquisition risk means that these figures may continue to increase within this subpopulation. Public health authorities should pay more attention to interventions aimed to address treatment-seeking behaviours among MSM and ought to consider them a crucial part of any HIV epidemic prevention measures in China.

This study’s strengths include its large sample size and the different levels of HIV epidemic zones in China represented by the seven investigated cities. All study sites utilized a uniform study protocol, and carefully prescribed training was conducted for all investigators and healthcare workers to ensure the quality and consistency of the study. Inevitably, however, there remain some limitations. Typical STD symptoms and standard laboratory tests for syphilis and HSV-2 were used as standards to determine whether subjects were recently infected with STDs. These standards do not include all STD symptoms and STD items that could be tested in a laboratory; to some extent, this approach may underestimate the prevalence of STD infections. As such, caution should be used when explaining or extrapolating the study’s results. Moreover, owing to the nature of cross-sectional studies, causal inferences could not be made, and social desirability could exist. As such, we interpreted results with caution. Although we adjusted for possible confounding variables in multivariate models, it is possible that some confounders were omitted.