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The Mediating Role of Condom Use and Rectal Bleeding in a National Onli Epidemiology Sex Transm Infect: first published as 10.1136/sextrans-2019-054415 on 5 May 2020. Downloaded from Original research Association between rectal douching and HIV acquisition: the mediating role of condom use and rectal bleeding in a national online sample of Chinese men who have sex with men Tianyi Lu,1 Xiang Mao,1 Erlei Peng,1 Yangyang Gao,1 Zhenxing Chu,1 Willa Dong,2 Wenran Zhang,1 Yong- Jun Jiang,1 Junjie Xu 1 1NHC Key Laboratory of AIDS ABSTRact challenge imposed by the HIV epidemic among Immunology (China Medical Objectives Previous studies have demonstrated that certain populations, particularly MSM. National University), National Clinical Research Center for Laboratory rectal douching (RD) is associated with HIV acquisition surveillance data have indicated that the preva- Medicine, The First Affiliated among men who have sex with men (MSM). However, lence of HIV among MSM increased from 0.9% in Hospital of China Medical the precise mechanism underlying the association 2003 to 8% in 2015.3 4 Given the disproportion- University, Shenyang, China 2 between RD and HIV remains unclear. ately high burden of HIV infection among MSM, Department of Health Behavior, Methods We recruited participants over WeChat from it is essential to understand the sexual behaviours Gillings School of Global Public Health, The University of North October 2017 to October 2018. Respondents received and preferences of this key population in order to Carolina at Chapel Hill, Chapel mailed HIV self-testing kits, uploaded images of HIV develop a novel and effective strategy to prevent Hill, North Carolina, USA self-test results and completed an online electronic HIV infection. questionnaire simultaneously. The questionnaire assessed Rectal douching (RD) is the act of using tools Correspondence to sociodemographic characteristics, RD practices and to insert liquid into the rectum for the purpose Dr Junjie Xu, NHC Key sexual risk behaviours. HIV status was measured as of cleansing. Recent research has raised concerns Laboratory of AIDS Immunology (China Medical University), the result of the HIV self-testing. The Baron and Kenny over the association between RD and HIV infec- National Clinical Research statistical method was used to assess the association tion. A large- scale cross- sectional study, involving Center for Laboratory Medicine, between RD and HIV, controlling for condomless anal 112 countries and 1725 respondents, demon- The First Affiliated Hospital intercourse (CAI) and rectal bleeding. strated that 66% of participants reported experi- of China Medical University, 5 Shenyang, 110001, China, Results Of 1365 participants, 39.93% (545/1365) encing RD during their lifetime. Several previous Shenyang, China; xjjcmu@ 163. reported RD in the past 6 months, 60.07% had multiple studies have reported that RD is associated with an com male sexual partners and 43.08% had CAI in the past increased prevalence of HIV in MSM.6–9 There are 6 months. The prevalence of HIV, based on self-testing, various explanations for the association between http://sti.bmj.com/ Received 22 December 2019 was 3.37% (46/1365). Multivariable logistic analysis Revised 30 March 2020 RD behaviour and HIV infection. Traditionally, it Accepted 14 April 2020 showed RD was significantly associated with bottom was assumed that RD might result in damage being Published Online First sexual role (adjusted OR (aOR) 14.0; 95% CI 9.8 to incurred by the effect of friction on the single-cell 5 May 2020 20.2), having multiple male sexual partners (aOR 1.8; epithelium of the rectum, thereby facilitating the 95% CI 1.4 to 2.2), CAI (aOR 1.3; 95% CI 1.0 to 1.6), entry of pathogens and increasing the acquisition 10 11 rectal bleeding (aOR 2.0; 95% CI 1.6 to 2.6) and HIV of HIV and other STIs. Some academics assume on September 25, 2021 by guest. Protected copyright. infection (aOR 1.9; 95% CI 1.0 to 3.4). Baron and Kenny that RD is correlated with STIs, including chla- analysis found both CAI (aOR 2.2; 95% CI 1.2 to 4.1) mydia and gonorrhoea,12 hepatitis B virus (HBV) and rectal bleeding (aOR 1.9; 95% CI 1.0 to 3.4) play a and hepatitis C virus (HCV),13 14 and therefore mediating role in the association between RD and HIV. increases the risk of HIV infection by an indirect Conclusions Our study results confirmed the manner. Previous studies have also investigated the relationship between RD and HIV, and found CAI and association between RD and certain high- risk sexual rectal bleeding mediated HIV infection in Chinese MSM behaviours. For example, Noor’s study demon- who douched. Strategies should be encouraged to strated that MSM who douched were more likely strengthen health education and reduce high-risk sexual to engage in unprotected anal intercourse (AI), and behaviour in order to reduce the risk of HIV in MSM more likely to be associated with HIV, compared who use enemas. Rectal microbicides may represent with those who did not.7 Furthermore, MSM who an efficient means of providing HIV prophylaxis among practised RD also reported a history of group sex © Author(s) (or their MSM. and multiple sexual partners15 16; collectively, these employer(s)) 2021. Re-use permitted under CC BY-NC . No behaviours increase the possibility of HIV infection. commercial re-use . See rights However, very little is known with regard to the and permissions. Published potential role of high-risk sexual behaviour in the by BMJ. BACKGROUND pathway associating RD with the acquisition of HIV. To cite: Lu T, Mao X, Peng E, The epidemic of HIV infection remains dispropor- The complex nature of this relationship et al. Sex Transm Infect tionately high globally among men who have sex suggested that a more accurate and complex model 2021;97:69–74. with men (MSM).1 2 China also faces a significant was needed in order to examine the associations Lu T, et al. Sex Transm Infect 2021;97:69–74. doi:10.1136/sextrans-2019-054415 69 Epidemiology Sex Transm Infect: first published as 10.1136/sextrans-2019-054415 on 5 May 2020. Downloaded from between RD, high- risk sexual behaviour and HIV infection. As zone. Finally, Alera Retermine Chase solution was added onto expected, a mediation model was previously used to assess the the reaction zone.18 Respondents were then instructed to read mediating role of high- risk sexual behaviours in the association the HIV testing results in approximately 15 min.18 To ensure the between recreational drug use (RDU) and HIV/STIs.17 Further- accuracy of HIV self- testing results, the instructions of HIVST more, previous studies of RD by MSM were mainly conducted kits detail each step of self- testing process in the form of pictures in western countries, adopted small sample sizes and were only and text. Besides, a two- dimensional code is provided in the carried out at a small number of sites, thus limiting the generalis- instruction, which allows participants to watch the operation ability of the results. Therefore, we conducted a national, behav- video of HIVST by scanning the two-dimensional code. More- ioural and epidemiological online survey of Chinese MSM in an over, we also provide a personal WeChat account and phone attempt to propose a conceptual model to assess the mediating number dedicated to this project, and participants can contact role of high- risk sexual behaviours and the association of RD us if they encountered any difficulties during the testing process. and HIV. We also aimed to acquire a significant body of data For individuals with a reactive HIV test result, we would provide relating to the prevalence of RD and its association with HIV advice for further HIV testing in order to confirm the diagnosis. infection and high- risk sexual behaviour. If a positive diagnosis was confirmed, then we also referred the patient for treatment and care. METHODS Study design Statistical analysis Between October 2017 and October 2018, we invited five oper- Chi- square statistics were used to compare the differences in ators of WeChat public platforms (software product of Tencent, demographics, HIV risk behaviours, and HIV test variables Shenzhen, China), which were actively followed and used by between MSM who reported RD and those who did not. their MSM fans, to help the project release HIVST recruit- Multiple logistic regressions were also used to estimate the asso- ment advertisements. Individuals were able to click the link of ciations between RD and condomless anal intercourse (CAI), a recruitment advertisement to attend the HIVST project inclu- RDU, multiple male sexual partners, rectal bleeding, HIV infec- sion criteria screening. MSM participants were eligible and are tion and other variables. included in the project if they met all the following criteria: (1) We also used the mediation model, using the methods 19 born biologically male; (2) aged ≥18 years; (3) having no HIV- described by Baron and Kenny. We performed a series of regres- positive test history previously; (4) self-reporting had oral or anal sion models to estimate the mediating role of CAI and rectal sex with other males at least once in their lifetime; (5) agreed to bleeding on the association between RD and HIV. In the media- the study contents of this project and provided online informed tion model, CAI (M1) and rectal bleeding (M2) served as media- consent. Then the eligible MSM participants were required to tors, RD served as an independent variable (X) and HIV served provide their address, phone number and nickname for getting as a dependent variable (Y). First, we regressed CAI on RD, HIV self-testing kits through express mail. After receiving the and then regressed HIV on RD and CAI, respectively.
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