Crowdsourcing to expand HIV testing among men who have sex with men in China: A closed cohort stepped wedge cluster randomized controlled trial

Abstract

Background: HIV testing rates are suboptimal among at-risk men. Crowdsourcing may be a useful tool for designing innovative, community-based HIV testing strategies to increase HIV testing. The purpose of this study was to use a stepped wedge cluster randomized controlled trial (RCT) to evaluate the effect of a crowdsourced HIV intervention on HIV testing uptake among men who have sex with men (MSM) in eight Chinese cities.

Methods and findings: An HIV testing intervention was developed through a national image contest, a regional strategy designathon, and local message contests. The final intervention included a multimedia HIV testing campaign, an online HIV testing service, and local testing promotion campaigns tailored for MSM. This intervention was evaluated using a closed cohort stepped wedge cluster RCT in eight Chinese cities (Guangzhou, Shenzhen, Zhuhai, and Jiangmen in Guangdong province; Jinan, Qingdao, Yantai, and Jining in Shandong province) from August 2016 to August 2017. MSM were recruited through Blued, a social networking mobile application for MSM, from July 29 to August 21 of 2016. The primary outcome was self-reported HIV testing in the past 3 months. Secondary outcomes included HIV self-testing, facility-based HIV testing, condom use, and syphilis testing. Generalized linear mixed models (GLMMs) were used to analyze primary and secondary outcomes. We enrolled a total of 1,381 MSM. Most were ≤30 years old (82%), unmarried (86%), and had a college degree or higher (65%). The proportion of individuals receiving an HIV test during the intervention periods within a city was 8.9% (95% confidence interval [CI] 2.2-15.5) greater than during the control periods. In addition, the intention-to-treat analysis showed a higher probability of receiving an HIV test during the intervention periods as compared to the control periods (estimated risk ratio [RR] = 1.43, 95% CI 1.19-1.73). The intervention also increased HIV self-testing (RR = 1.89, 95% CI 1.50-2.38). There was no effect on facility-based HIV testing (RR = 1.00, 95% CI 0.79-1.26), condom use (RR = 1.00, 95% CI 0.86-1.17), or syphilis testing (RR = 0.92, 95% CI 0.70-1.21). A total of 48.6% (593/1,219) of participants reported that they received HIV self-testing. Among men who received two HIV tests, 32 individuals seroconverted during the 1-year study period. Study limitations include the use of self-reported HIV testing data among a subset of men and non-completion of the final survey by 23% of participants. Our study population was a young online group in urban China and the relevance of our findings to other populations will require further investigation.

Conclusions: In this setting, crowdsourcing was effective for developing and strengthening community-based HIV testing services for MSM. Crowdsourced interventions may be an important tool for the scale-up of HIV testing services among MSM in low- and middle-income countries (LMIC).

Trial registration: ClinicalTrials.gov NCT02796963.

Conflict of interest statement

WT and JDT are advisors to SESH Global. All remaining authors declare that they have no competing interests relevant to this work.

Figures

Fig 1. Steps in intervention development.

Details are provided in S2 Text. *Exceptional defined by ranking after scores from three independent judges. CBO, community-based organization; MSM, men who have sex with men.

Fig 2. Two of the six crowdsourced HIV promotion images used in the intervention package.

The six images were delivered biweekly during the 3-month intervention period via WeChat. Left text: “Let’s test for HIV together. Stop HIV from spreading in our community.” Right text: “Son, what’s your rank? HIV test: one line means negative; two or three lines means suspected positive. Please go and get HIV tested”.

Fig 3. Conditions during the control, intervention, and post-intervention phases.

*Self-testing platform for Group 1 was delayed until the post-intervention period. #Length of these periods varied by randomization group. CBO, community-based organization; CDC, Center for Disease Control.

Fig 4. Trial profile.

The intervention was implemented in a closed cohort stepped wedge design. Shaded cells represent intervention and post-intervention periods and white cells represent the control period. Each group consists of two cities: one each from Guangdong and Shandong provinces. Group 1—Guangzhou and Yantai; Group 2—Jiangmen and Jinan; Group 3—Zhuhai and Qingdao; Group 4—Shenzhen and Jining. Surveys were distributed at each follow-up.