Pay-it-forward gonorrhea and chlamydia testing among men who have sex with men in China: a study protocol for a three-arm cluster randomized controlled trial

Tiange P Zhang, Fan Yang, Weiming Tang, Marcus Alexander, Laura Forastiere, Navin Kumar, Katherine Li, Fei Zou, Ligang Yang, Guodong Mi, Yehua Wang, Wenting Huang, Amy Lee, Weizan Zhu, Peter Vickerman, Dan Wu, Bin Yang, Nicholas A Christakis, Joseph D Tucker, Tiange P Zhang, Fan Yang, Weiming Tang, Marcus Alexander, Laura Forastiere, Navin Kumar, Katherine Li, Fei Zou, Ligang Yang, Guodong Mi, Yehua Wang, Wenting Huang, Amy Lee, Weizan Zhu, Peter Vickerman, Dan Wu, Bin Yang, Nicholas A Christakis, Joseph D Tucker

Abstract

Background: Gonorrhea and chlamydia testing rates are poor among Chinese men who have sex with men (MSM). A quasi-experimental study suggested that a pay-it-forward strategy increased dual gonorrhea/chlamydia testing among MSM. Pay-it-forward offers an individual a gift (e.g., a free test) and then asks the same person if they would like to give a gift to another person. This article reports the protocol of a randomized controlled trial to evaluate dual gonorrhea/chlamydia test uptake and other outcomes among MSM in three arms - a pay-it-forward arm, a pay-what-you-want arm, and a standard of care arm.

Methods: Three hundred MSM will be recruited at three HIV testing sites in Guangzhou and Beijing. Testing sites include two hospital-based MSM sexually transmitted diseases clinics and one MSM community-based organization. Eligible participants will be born biologically male, aged 16 years or older, reporting previous anal sex with another man, having never participated in the pay-it-forward program, without previous gonorrhea and chlamydia testing in the past 12 months, and residing in China. Following a cluster randomized design, every cluster of ten participants will be randomly allocated into one of three arms: (1) a pay-it-forward arm in which men are offered free gonorrhea and chlamydia testing and then asked whether they would like to donate ("pay it forward") toward testing for future testers; (2) a pay-what-you-want arm in which men are offered free testing and told to decide how much to pay after receiving the test; (3) a standard of care arm in which men can pay the full price for dual gonorrhoea and chlamydia testing. The primary outcome is dual gonorrhoea/chlamydia testing as verified by administrative records. Secondary outcomes include incremental cost per test, incremental cost per diagnosis, community connectedness, and social cohesion. Primary outcome will be calculated for each arm using intention-to-treat and compared using one-sided 95% confidence intervals with a margin of 20% increase defined as superiority.

Discussion: This study will examine the pay-it-forward strategy in comparison to the standard of care in improving test uptake for gonorrhea and chlamydia. We will leverage the cluster randomized controlled trial to provide scientific evidence on the potential effect of pay-it-forward. Findings from this study will shed light on novel intervention methods for increasing preventive health service utilization and innovate ways to finance it among communities.

Trial registration: ClinicalTrials.gov, NCT03741725 . Registered on 12 November 2018.

Keywords: China; Gonorrhoea and chlamydia testing; Integrated HIV testing; Men who have sex with men; Pay-it-forward; Randomized controlled trial.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Schematic of three trial arms. The block diagrams describe the implementation steps for each arm
Fig. 2
Fig. 2
Schematic of cluster randomization procedure and sample allocation. This schematic diagram illustrates the cluster randomization procedure, average volume of testers who visit the study site for HIV tests during a typical week, and allocation. There are 30 clusters and 300 total participants, which satisfy the sample size. The sequence shown is for illustration and is not the actual allocation sequence

References

    1. Chen XS, Peeling RW, Yin YP, Mabey DC. The epidemic of sexually transmitted infections in China: implications for control and future perspectives. BMC Med. 2011;9(1):111. doi: 10.1186/1741-7015-9-111.
    1. Yang LG, Zhang XH, Zhao PZ, Chen ZY, Ke WJ, Ren XQ, et al. Gonorrhea and chlamydia prevalence in different anatomical sites among men who have sex with men: a cross-sectional study in Guangzhou, China. BMC Infect Dis. 2018;18(1):675. doi: 10.1186/s12879-018-3579-6.
    1. Wong FY, Huang ZJ, Wang W, He N, Marzzurco J, Frangos S, et al. STIs and HIV among men having sex with men in China: a ticking time bomb? AIDS Educ Prev. 2009;21(5):430–446. doi: 10.1521/aeap.2009.21.5.430.
    1. Bernstein KT, Marcus JL, Nieri G, Philip SS, Klausner JD. Rectal gonorrhea and chlamydia reinfection is associated with increased risk of HIV seroconversion. J Acquir Immune Defic Syndr. 2010;53(4):537–543. doi: 10.1097/QAI.0b013e3181c3ef29.
    1. Cohen MS, Hoffman IF, Royce RA, Kazembe P, Dyer JR, Daly CC, et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1. AIDSCAP Malawi Research Group. Lancet. 1997;349(9069):1868–1873. doi: 10.1016/S0140-6736(97)02190-9.
    1. Kent CK, Chaw JK, Wong W, Liska S, Gibson S, Hubbard G, et al. Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003. Clin Infect Dis. 2005;41(1):67–74. doi: 10.1086/430704.
    1. Detels R, Green AM, Klausner JD, Katzenstein D, Gaydos C, Handsfield HH, et al. The incidence and correlates of symptomatic and asymptomatic chlamydia trachomatis and neisseria gonorrhoeae infections in selected populations in five countries. Sex Transm Dis. 2011;38(6):503–509.
    1. Cecil JA, Howell MR, Tawes JJ, Gaydos JC, McKee JKT, Quinn TC, et al. Features of chlamydia trachomatis and neisseria gonorrhoeae infection in male army recruits. J Infect Dis. 2001;184(9):1216–1219. doi: 10.1086/323662.
    1. WHO . Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people. 2011.
    1. CDC . Sexually transmitted diseases treatment guidelines 2015. 2015.
    1. Wu D, Li KT, Tang W, Ong JJ, Huang W, Fu H, Lee A, Wei C, Tucker JD. Low chlamydia and gonorrhea testing rates among men who have sex with men in Guangdong and Shandong provinces, China. Sex Transm Dis. 2019;46(4):260–265. doi: 10.1097/OLQ.0000000000000963.
    1. Lin L, Nehl EJ, Tran A, He N, Zheng T, Wong FY. Sexually transmitted infection testing practices among ‘money boys’ and general men who have sex with men in Shanghai, China: objective versus self-reported status. Sex Health. 2014;11(1):94–96. doi: 10.1071/SH13199.
    1. Davis A, Best J, Luo J, Van Der Pol B, Dodge B, Meyerson B, et al. Risk behaviours, HIV/STI testing and HIV/STI prevalence between men who have sex with men and men who have sex with both men and women in China. Int J STD AIDS. 2016;27(10):840–849. doi: 10.1177/0956462415596302.
    1. Zheng N, Guo Y, Padmadas S, Wang B, Wu Z. The increase of sexually transmitted infections calls for simultaneous preventive intervention for more effectively containing HIV epidemics in China. BJOG. 2014;121(s5):35–44. doi: 10.1111/1471-0528.12999.
    1. Tucker JD, Yang L-G, Yang B, Zheng H-P, Chang H, Wang C, et al. A twin response to twin epidemics: integrated HIV/syphilis testing at sti clinics in South China. J Acquir Immune Defic Syndr. 2011;57(5):e106–ee11. doi: 10.1097/QAI.0b013e31821d3694.
    1. Ong JJ, Fu H, Pan S, Smith K, Wu D, Wei C, et al. Missed opportunities for HIV and syphilis testing among men who have sex with men in China: a cross-sectional study. Sex Transm Dis. 2018;45(6):382–386. doi: 10.1097/OLQ.0000000000000773.
    1. Neilands TB, Steward WT, Choi KH. Assessment of stigma towards homosexuality in China: a study of men who have sex with men. Arch Sex Behav. 2008;37(5):838–844. doi: 10.1007/s10508-007-9305-x.
    1. 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):S98–103. doi: 10.1097/QAI.0b013e3181c7df71.
    1. Li H, Kuo NT, Liu H, Korhonen C, Pond E, Guo H, et al. From spectators to implementers: civil society organizations involved in AIDS programmes in China. Int J Epidemiol. 2010;39(Suppl 2):ii65–ii71.
    1. Cheng W, Cai Y, Tang W, Zhong F, Meng G, Gu J, et al. Providing HIV-related services in China for men who have sex with men. Bull World Health Organ. 2016;94(3):222–227. doi: 10.2471/BLT.15.156406.
    1. Li KT, Tang W, Wu D, Huang W, Wu F, Lee A, et al. Pay-it-forward strategy to enhance uptake of dual gonorrhea and chlamydia testing among men who have sex with men in China: a pragmatic, quasi-experimental study. Lancet Infect Dis. 2018;19:76–82. doi: 10.1016/S1473-3099(18)30556-5.
    1. Chiang YS, Takahashi N. Network homophily and the evolution of the pay-it-forward reciprocity. PLoS One. 2011;6(12):e29188. doi: 10.1371/journal.pone.0029188.
    1. Hyde CR. Pay it forward. New York: Simon & Schuster; 1999.
    1. Jung MH, Nelson LD, Gneezy A, Gneezy U. Paying more when paying for others. J Pers Soc Psychol. 2014;107(3):414–431. doi: 10.1037/a0037345.
    1. Gray K, Ward AF, Norton MI. Paying it forward: generalized reciprocity and the limits of generosity. J Exp Psychol Gen. 2014;143(1):247–254. doi: 10.1037/a0031047.
    1. Tucker JD, Fenton KA. Innovation challenge contests to enhance HIV responses. Lancet HIV. 2018;5(3):e113–e1e5. doi: 10.1016/S2352-3018(18)30027-4.
    1. Yared N, Horvath K, Fashanu O, Zhao R, Baker J, Kulasingam S. Optimizing screening for sexually transmitted infections in en using self-collected swabs - a systematic review. Sex Transm Dis. 2017;45:294-300.
    1. StataCorp . Stata statistical software: release 15. College Station: StataCorp LLC; 2017.
    1. Xiridou M, Vriend HJ, Lugner AK, Wallinga J, Fennema JS, Prins JM, et al. Modelling the impact of chlamydia screening on the transmission of HIV among men who have sex with men. BMC Infect Dis. 2013;13:436. doi: 10.1186/1471-2334-13-436.
    1. Zhang TP, Liu C, Han L, Tang W, Mao J, Wong T, et al. Community engagement in sexual health and uptake of HIV testing and syphilis testing among MSM in China: a cross-sectional online survey. J Int AIDS Soc. 2017;20(1):21372. doi: 10.7448/IAS.20.01/21372.
    1. Frost DM, Meyer IH. Measuring community connectedness among diverse sexual minority populations. J Sex Res. 2012;49(1):36–49. doi: 10.1080/00224499.2011.565427.
    1. Swann WB, Jr, Gomez A, Seyle DC, Morales JF, Huici C. Identity fusion: the interplay of personal and social identities in extreme group behavior. J Pers Soc Psychol. 2009;96(5):995–1011. doi: 10.1037/a0013668.
    1. Grover E, Grosso A, Ketende S, Kennedy C, Fonner V, Adams D, et al. Social cohesion, social participation and HIV testing among men who have sex with men in Swaziland. AIDS Care. 2016;28(6):795–804. doi: 10.1080/09540121.2015.1131971.
    1. Lippman SA, Donini A, Diaz J, Chinaglia M, Reingold A, Kerrigan D. Social-environmental factors and protective sexual behavior among sex workers: the Encontros intervention in Brazil. Am J Public Health. 2010;100(Suppl 1):S216–S223. doi: 10.2105/AJPH.2008.147462.

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