The Impact of Homophobia and HIV Stigma on HIV Testing Uptake Among Chinese Men Who Have Sex With Men: a Mediation Analysis.
BACKGROUND
Gay and HIV-related stigma and discrimination are major barriers to accessing HIV prevention services among Men Who Have Sex with Men (MSM) worldwide. We aimed to identify modifiable factors that mediate the relationships between gay and HIV-related stigma and discrimination and HIV testing uptake among Chinese MSM.


METHODS
We conducted a cross-sectional survey study of 523 HIV-uninfected or unknown HIV status MSM in Jiangsu Province, China between November 2013 and January 2014. Multivariable analyses were conducted to examine the associations among experienced homophobia, HIV stigma, and recent HIV testing. Causal mediation parametric analyses were conducted to assess whether depression and social norms mediated hypothesized associations.


RESULTS
Stronger subjective norms toward testing was associated with higher odds of recent HIV testing (adjusted odds ratio [AOR]: 1.10, 95% confidence interval [CI]: 1.01 to 1.21), whereas increasing levels of depression and HIV stigma were both associated with lower odds of recent testing (AOR: 0.96, 95% CI: 0.92 to 0.99; and AOR: 0.91, 95% CI: 0.84 to 0.99, respectively). There was an indirect relationship (natural indirect effect [NIE]) of experienced homophobia on recent testing (ORNIE: 0.96, 95% CI: 0.93 to 0.98) mediated (35.0%) through depression. Furthermore, there was an indirect relationship of HIV stigma on recent testing (ORNIE: 0.98, 95% CI: 0.95 to 0.99) mediated (19.2%) through subjective norms.


CONCLUSIONS
Depression and social norms are important mediators of HIV testing uptake among stigmatized Chinese MSM. Therefore, in addition to advocacy efforts and policies that address social-level stigma and discrimination, HIV prevention programs should also address mental health issues and incorporate community-based approaches to changing social norms toward HIV testing.
*Department of Epidemiology and Biostatistics and Global Health Sciences, University of California-San Francisco, San Francisco, CA;†Harvard School of Public Health, Boston, MA;‡Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China; and§San Francisco Department of Public Health, Center for Public Health Research, San Francisco, CA.
Chongyi
C
Wei
Doug H
DH
Cheung
Hongjing
H
Yan
Jianjun
J
Li
Ling-en
LE
Shi
Henry F
HF
Raymond
D000328:Adult; D044466:Asian People; D002681:China; D003430:Cross-Sectional Studies; D003863:Depression / Q000523:psychology; D015658:HIV Infections / Q000517:prevention & control / Q000523:psychology*; D007722:Health Knowledge, Attitudes, Practice; D063509:Homophobia / Q000523:psychology*; D018451:Homosexuality, Male / Q000523:psychology*; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010342:Patient Acceptance of Health Care / Q000523:psychology* / Q000706:statistics & numerical data; D057545:Social Stigma