Lack of Sexual Identity Disclosure in China May Distort Efforts to Combat STI Epidemics

5 Background. To evaluate whether Chinese men who have sex with men (MSM) select 6 an STI test (rectal vs urethral) appropriate for their sexual behavior (insertive and/or 7 receptive role in anal sex). 8 9 Methods. We studied uptake of gonorrhea and chlamydia testing among Chinese 10 MSM (N=431) in a multi-site RCT (December 2018 to January 2019). We collected 11 socio-demographics, relevant medical and sexual history, and disclosure of sexual iden-12 tity (outness). We estimated the decision to test and test choice, and the extent to 13 which disclosure plays a role in decision-making. 14 15 Results. Among 431 MSM, mean age was 28 years (SD=7.10) and 65% were out to 16 someone. MSM who indicated the versatile role and were out to someone had a 26.8% 17 (95%CI=6.1, 47.5) increased likelihood for selecting the rectal test vs the urethral test, 18 compared to those versatile and not out. Versatile MSM out to their health provider 19 outside of the study context had a 29.4% (95%CI=6.3, 52.6) greater likelihood for se-20 lecting the rectal STI test vs the urethral test, compared to versatile MSM not out to 21 their health provider. 22 23 Conclusions. Anal sex role and identity disclosure may affect gonorrhea and chlamydia 24 testing provision. Apart from clinicians, community-based efforts may reduce stigma-25 based barriers to testing.


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Conclusions. Anal sex role and identity disclosure may affect gonorrhea and chlamydia 24 testing provision. Apart from clinicians, community-based efforts may reduce stigma-25 based barriers to testing. Men who have sex with men (MSM) globally have a high burden of curable sexually 30 transmitted infections (STIs) [1]. The World Health Organization (WHO) estimates 131 variables of interest. We overcame this problem by using random assignment as an 132 instrument. We applied a probit model with sample selection (an extension of the 133 Heckman selection model for outcomes that are binary rather than continuous) [20]. 134 We model the decision to take the test and the subsequent test choice. All models 135 included demographics, socioeconomic measures and sexual history as controls. Further 136 information about statistical methods is in the supplement.

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INSERT TABLE 1 HERE 139 We approached 431 men intending to test for HIV. After exclusion criteria and de-140 cision to participate, 301 men were enrolled and STI test uptake was 40%. Seven men 141 chose to get both tests and were dropped from the analysis. As we are exploring whether 142 anal sex role is related to the choice of rectal over urethral testing, those who took both 143 tests were not a focus of our analysis. Forty-four % (50/114) chose the rectal gonorrhea 144 and chlamydia test and 56 % (64/114) picked the urethral gonorrhea and chlamydia test. 145 Among the RCT participants, 35 % (187/288) had disclosed their identity to someone 146 (non-specific disclosure) and 21 % (59/288) of men had disclosed their identity to their 147 health provider. Five MSM were diagnosed with gonorrhea (urethral -two, rectal -three) 148 and 19 with chlamydia (urethral -six, rectal -13). We present descriptive statistics in 149  Using three separate models, we explore if MSM make a test choice in line with 154 their indicated sex role. Table 2 indicates that a receptive role is associated with 45.2% 155 (95%CI=33.8, 56.5) increased likelihood for selecting a rectal test. Selecting an insertive 156 role is related to 51.1% (95%CI=-58.7, -43.5) decreased likelihood for selecting the rectal 157 test. Finally, indicating a versatile role is not significantly associated with selecting 158 a rectal test, possibly indicating that versatile MSM have no preference for a rectal 159 gonorrhea and chlamydia test. 160 We then explore disclosure and likelihood to select the rectal gonorrhea and chlamy-161 dia test. Table 3 indicates that there is no significant relationship between non-specific 162 disclosure or disclosure to one's health provider, and selecting a rectal gonorrhea and 163 chlamydia test. Table 4 indicates that, for versatile MSM, non-specific disclosure was 164 associated with a 26.8% (95%CI=6.1, 47.5) increased likelihood of selecting the rectal 165 gonorrhea and chlamydia test, compared to the urethral test. We also find that for versa-166 tile MSM, disclosure to one's health provider was associated with a 29.4% (95%CI=6.3, 167 52.6) greater likelihood for selecting the rectal gonorrhea and chlamydia test, compared 168 to the urethral test. These results are visualized in Figure 1, focusing on the interaction 169 effects between disclosure and the versatile anal sex role. While being versatile alone 170 is not significantly associated with rectal test uptake, once non-specific disclosure or 171 disclosure to health providers comes into the picture, the model suggests a large and 172 significant increase in rectal test uptake. Note that this is a marginal effect, controlling 173 for sociodemographics, sexual history and medical history relevant to STI testing.

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175 Discussion 176 We first demonstrated that MSM selected tests in line with their indicated sex role. 177 We then indicated that versatile MSM out to a non-specific individual or one's health 204 likely to select rectal STI testing compared to urethral testing. Past China research 205 indicated that larger disclosure networks were associated with greater propensity of HIV 206 testing [19,31]. Increased probability of never testing for HIV or syphilis was associated 207 with non-disclosure to anyone or health professionals [32,33] [42] where patient factors drive health outcomes. As participants would have to pay an 234 additional amount to take both tests, it could be that some selected a single test due 235 to lack of funds. We utilized income as a control to account for this concern. Due to 236 resource limitations, we were unable to offer rectal and urethral testing to all participants 237 and then determine the number of mismatches between a positive test at a particular 238 site and anal sex role (e.g. MSM reporting an insertive role but with a positive rectal 239 test). Future research will incorporate such a study design. We did not consider the 240 complex issues around the MSM identity. MSM can be a problematic term as it may 241 obscure social aspects of sexuality, undermine self-labels of LGBT communities, among 242 other issues [14]. Future work can detail how variants of LGBT identities are related to 243 testing preference.

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Greater efforts are needed to ensure that patient factors do not adversely affect 246 MSM testing outcomes. Anal sex role and identity disclosure may affect gonorrhea and 247 chlamydia testing provision. Apart from clinicians, community-based efforts may reduce 248 stigma-based barriers to testing. The datasets generated and/or analyzed for this study are not publicly available due 263 to privacy issues but are available from the corresponding author on reasonable request.   (2)         Participants were randomly assigned into clusters within the study arms. A cluster 444 is a group of ten eligible men who arrived one after another at the study sites and 445 decided to participate. Cluster randomization was utilized to minimize intervention 446 contamination to account for MSM who turned up in pairs and to simplify processes 447 undertaken by site staff. MSM in the same cluster were collectively assigned to the same 448 study arm. Similarly, those who arrived with partners were placed in the same study 449 arm. RCT randomization sequence was designed through STATA 15. For the PIF arm, 450 participants were told the experiment was for promoting gonorrhea and chlamydia test 451 uptake and that the standard price of a gonorrhea and chlamydia test was 150RMB 452 (US$22). They were offered a free test and told it was paid for by another MSM. In the 453 PW introduction, MSM were told the standard gonorrhea and chlamydia test price was 454 150RMB (US$22). MSM were told that they could first receive a free gonorrhea and 479 where Y 1* represents the decision to test and Y2* represents the decision to select

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Given the relatively small number of participants both versatile and out, we were 492 limited in the number of controls to include. We thus did not include controls co-493 linear with reported variables (e.g. marital status, education). Regarding the STI 494 symptoms variables, participants were not asked where on the body symptoms were 495 observed, just whether they had symptoms. Thus, the symptoms variable may affect 496 test uptake but not rectal gonorrhea and chlamydia test choice, perhaps indicative of a 497 strong instrument. The Arm variable varies the attractiveness of testing, but does not 498 affect rectal gonorrhea and chlamydia test choice, perhaps indicating its strength as an   . Confidence interval (CI) estimated using jackknife with clustering by sites and within-site groups. Non-specific disclosure: Compared to those not out to anyone, those out to someone are more likely to select the rectal gonorrhea and chlamydia test, compared to the urethral test; Disclosure to health provider: Compared to those not out to their health provider, those out to their health provider are more likely to select the rectal gonorrhea and chlamydia test, compared to the urethral test. . Confidence interval (CI) estimated using jackknife with clustering by sites and within-site groups. Non-specific disclosure: Compared to versatile MSM not out to someone, versatile MSM who are out to someone (disclosed sexual identity) are more likely to select the rectal gonorrhea and chlamydia test, compared to the urethral test; Disclosure to health provider: Compared to versatile MSM not out to their health provider, versatile MSM out to their health provider are more likely to select the rectal gonorrhea and chlamydia test, compared to the urethral test. Coefficients of probit with sample selection. Confidence interval (CI) estimated using jackknife with clustering by sites and within-site groups. Receptive: Compared to MSM not indicating the receptive role, MSM indicating the receptive role are more likely to select the rectal gonorrhea and chlamydia test, compared to the urethral test; Insertive: Compared to MSM not indicating the insertive role, MSM indicating the insertive role are less likely to select the rectal gonorrhea and chlamydia test, compared to the urethral test; Versatile: Compared to MSM not indicating the versatile role, MSM indicating the versatile role have no gonorrhea and chlamydia test preference; Non-specific disclosure: Compared to those not out to anyone, those out to someone are more likely to select the rectal gonorrhea and chlamydia test, compared to the urethral test; Disclosure to health provider: Compared to those not out to their health provider, those out to their health provider are more likely to select the rectal gonorrhea and chlamydia test, compared to the urethral test; Versatile MSM-Non-specific disclosure: Compared to versatile MSM not out to someone, versatile MSM who are out to someone (disclosed sexual identity) are more likely to select the rectal gonorrhea and chlamydia test, compared to the urethral test; Versatile MSM-Disclosure to health provider: Compared to versatile MSM not out to their health provider, versatile MSM out to their health provider are more likely to select the rectal gonorrhea and chlamydia test, compared to the urethral test.