https://orcid.org/0000-0002-6835-664X
ABSTRACT
This study aimed to examine correlates of lifetime and past-year HIV testing among men who have sex with men (MSM) in Japan. A unique, anonymous online self-report survey was conducted in 2015. A total of 776 participants completed the survey and answered questions on sociodemographic information, HIV-testing experience, history of syphilis, experience talking about HIV, recognition of AIDS-related community-based organization (CBO) materials, and sex behaviors. HIV-testing experience and related factors were assessed for two groups: regional cities and Tokyo and Osaka. A Poisson regression analysis revealed that higher lifetime HIV testing was associated with older age, previous syphilis diagnosis, and experience talking about HIV. Moreover, higher HIV testing in the past year was associated with experience talking about HIV with friends and recognition of HIV-related CBO materials. Increased dissemination of HIV-related information provided by CBOs may, therefore, be an effective prevention policy intervention targeted at Japanese MSM to promote regular testing and maintain their interest in HIV issues.
KEYWORDS:
Introduction
The primary infection route of HIV in Japan is male-to-male sexual contact, accounting for 78% of HIV cases in 2018 (AIDS Surveillance Committee. The Japanese Ministry of Health, Citation2019; Ichikawa, Citation2017a). Therefore, men who have sex with men (MSM) are the predominant target group for HIV-testing promotion efforts in Japan. In 2017, over 30% of newly-diagnosed HIV cases were reported as AIDS (National Institute of Infectious Diseases, Citation2018), which was much higher than in developed Western countries (Kirwan et al., Citation2016). Furthermore, AIDS’ prevalence is particularly high in regional cities, unlike Tokyo and Osaka (AIDS Surveillance Committee. The Japanese Ministry of Health, Citation2019). Therefore, there is an urgent need to promote HIV-testing behaviors among MSM in regional cities.
The 90-90-90 strategy launched by the Joint United Nations Program on HIV/AIDS (UNAIDS) set goals with the ultimate aim of ending the AIDS epidemic by the end of 2030 (UNAIDS, Citation2014). To meet the first target, 90% of HIV-positive individuals must become aware of their status. However, recent findings indicate that this goal has not yet been attained in Japan (Iwamoto et al., Citation2017), suggesting that increased promotion of testing behavior is essential.
Previous studies among Japanese MSM have demonstrated that knowledge and conversations about HIV, a history of sexually transmitted infections (STIs), and accessible testing are positively associated with testing behaviors (Koerner et al., Citation2012; Shiono et al., Citation2013). However, most of these studies were conducted with gay commercial-facility users in Tokyo and Osaka, and did not investigate whether these factors also apply to regional cities.
In Japan, the Ministry of Health, Labour, and Welfare (MHLW) contracted community centers in Sendai, Shinjuku (Tokyo), Nagoya, Osaka, Fukuoka, and Naha to provide advice and support to users of gay commercial facilities and promote HIV testing and prevention (Japanese foundation for AIDS Prevention, Citation2019). These centers are run by AIDS-related community-based organizations (CBOs). However, to continually conduct these activities effectively, the relationship between the participation in gay community center activities and testing behaviors needs to be further clarified.
In regional cities (defined in this study as cities other than Tokyo and Osaka), there are no permanent HIV-testing facilities; thus, there are possible barriers to testing accessibility. Further, users of facilities in regional cities tend to have more anxiety regarding personal information being leaked and are more reluctant to be tested in their home cities (Ichikawa, Citation2017a). They are also less likely to be tested for HIV at the same time as diagnosis or treatment for syphilis and other non-HIV STIs (Ichikawa, Citation2017b). Few studies in Japan have investigated how these factors are associated with increased testing behaviors through community-based surveys. For effective testing promotion that meets the needs of MSM in regional cities, it is first necessary to examine their testing behaviors. Therefore, the purpose of this study was to examine correlates of HIV testing among MSM in regional cities.
Materials and methods
Survey method
This was an online-based cross-sectional study. An anonymous self-report survey was conducted between June and August 2015. This self-reported online survey was conducted by the MHLW research group for the prevention of HIV among MSM, and was limited to regions they designated as intervention targets. Six volunteer gay community non-government organizations (NGOs) in Sendai city, Tokyo, Aichi prefecture, Chugoku and Shikoku regions, and Naha recruited participants from among attendees at nine nightclub events that were open only to gay and bisexual men, in collaboration with the event organizers. The survey was open to gay and bisexual men aged 20 years (the legal age to attend clubs and drink alcohol). Participants reporting no sexual experience with men, including oral sex, were allowed to participate in the survey and removed later during data cleaning. Survey participants were recruited exclusively through online promotions on the nightclub event websites, gay community NGO websites, and the Facebook and Twitter accounts of the nightclub event hosts (a gay or bisexual MSM hosted each nightclub event). As compensation, participants were offered a 33% discount on a nightclub entrance fee upon completing the survey. Participants received a unique, anonymous identification number only after completing the survey and received the discount on presenting this identification number to the staff prior to entering the club events. The survey staff checked the identification number shown by the respondents, recorded it, and allowed them to enter. The identification numbers could only be used once. In total, 8,267 participants accessed the survey landing page, 1,101 started it, and 869 completed it. During data cleaning, IP addresses were checked and duplicate and incomplete responses removed; non-Japanese and/or HIV-positive participants were also removed. Finally, data from 776 gay or bisexual men who responded to all the questions were used for this study.
Ethical considerations
Questionnaire items and methods were designed in consultation with the CBO staff. The study’s purpose, confidentiality, data management policies, and the voluntary nature of participation were explicitly displayed on the first page of the survey. There was a specific consent question. Participants could only begin the survey after clicking the “I consent, proceed with survey” button. This study protocol was approved by the Institutional Review Board of the Graduate School of Nursing Nagoya City University (Approval number: 14025-2).
Survey items
The questionnaire comprised 43 items pertaining to basic demographic characteristics, HIV-testing behaviors, use of gay commercial facilities (i.e., Bars and saunas), sexual behavior, history of syphilis, experience talking about HIV with friends and acquaintances, and whether participants were aware of community papers issued by CBOs in six regions. HIV-testing behaviors were determined by whether respondents had ever been tested, and whether it had happened in lifetime/the past year. Gay commercial-facility use was measured by asking whether respondents had visited a gay bar or sauna in the past six months. Respondents were asked how often they used condoms during anal intercourse in the past six months on a five-point scale: “always,” “often,” “about half the time,” “often not used,” and “never.” Following previous international literature (Ramanathan et al., Citation2013), the respondents were dichotomized into two groups—those who had always used a condom during anal sex with men in the past six months (consistent users) and all others (inconsistent users)—and variables representing these two categories were used in the analyses. Respondents were also asked, “have you had anal intercourse with five or more male partners in the past six months?” Response options were “less than five” and “five or more.” Binary response options “yes” and “no” were provided for the following variables: Lifetime HIV testing, HIV test in the past year, previous syphilis diagnosis, experience/s discussing HIV, and recognition of HIV-prevention materials issued by CBOs.
Data analysis
The data analysis was limited to participants who responded to this survey for the first time. Respondents who had no sexual experience with men, including oral sex, were excluded. The purpose of this study was to examine factors associated with lifetime HIV-testing experience; thus, individuals with a history of HIV infection were excluded from the analysis.
All analyses were conducted for two discrete groups: regional city residents and Tokyo and Osaka residents. In Tokyo and Osaka there are large HIV testing facilities that make testing much more accessible. While in Tokyo and Osaka, there are HIV-testing facilities that are open on Saturdays and evenings, this is not widely available anywhere else in Japan. The numbers of people being initially diagnosed with AIDS, as opposed to HIV, are vastly different outside of Tokyo and Osaka: the AIDS percentage among all newly-reported HIV and AIDS cases is 17% in Tokyo and 26% in Osaka, but is over 35% in other regional cities (AIDS Surveillance Committee. The Japanese Ministry of Health, Citation2019). HIV-testing promotion strategies have been developed separately for Tokyo and Osaka from other areas, where there are limited gay community centers. This paper therefore separates Tokyo and Osaka from other Japanese suburban cities.
Lifetime HIV-testing experience and testing experience in the past year were cross-tabulated with basic demographic characteristics, use of commercial facilities, knowledge of CBOs’ interventions, and sexual behaviors using Chi-squared and Fisher’s Exact tests. A Poisson regression analysis with robust variance estimators was conducted to examine the associations between potential correlates and the lifetime testing experience and testing experience in the past year.
Items with significant difference levels < 10% in univariate analysis were used as explanatory variables for multivariable analysis. All statistical analyses were performed using IBM SPSS version 22.0. Significance levels < 5% were considered statistically significant.
Results
Sociodemographic characteristics and lifetime HIV testing
Participant characteristics and lifetime HIV testing by areas are shown in .
Table 1. Sociodemographic characteristics and lifetime HIV testing by regional cities and Tokyo and Osaka in 2015 (N=776).
HIV-testing experience was 65.7% in regional cities and 75.8% in Tokyo and Osaka. Age, frequency of visiting gay bars, history of syphilis, talking about HIV issues, recognition of HIV-prevention materials, having had anal sex with more than six partners, and condom-less anal sex were associated with lifetime HIV testing in regional cities. However, age, history of syphilis, talking about HIV issues, and recognition of HIV-prevention materials were associated with lifetime HIV testing in Osaka and Tokyo.
Sociodemographic characteristics and HIV testing in the past year
Participant characteristics and HIV testing in the past year by areas are shown in .
Table 2. Sociodemographic characteristics and HIV testing in the past year by regional cities and Tokyo and Osaka in 2015 (N=776).
HIV-testing experience was 36.9% in regional cities and 48.3% in Tokyo and Osaka. Area, age, frequency of visiting gay bars, talking about HIV issues, recognition of HIV-prevention awareness materials, having had anal sex with more than five partners, and condom-less anal sex were associated with HIV testing in the past year in regional cities. However, history of syphilis, talking about HIV issues, and recognition of HIV-prevention materials were associated with HIV testing in the past year in Osaka and Tokyo.
Correlates of lifetime HIV testing
The univariate and multivariate models examining the correlates of lifetime HIV testing are presented in .
Table 3. Correlates of lifetime HIV testing by regional cities and Tokyo and Osaka in 2015 (N=776).
In the regional cities group, the final multivariate model showed that the PR of lifetime HIV testing was higher among MSM who were 25–35 years old and over 35 years old compared to <25 years old (APR, 1.28; 95%CI, 1.05–1.56; APR, 1.32; 95%CI, 1.10–1.61, respectively), had a history of syphilis (APR, 1.26; 95%CI, 1.10–1.45), had talked about HIV in the past six months (APR, 1.29; 95%CI, 1.13–1.47), had HIV-prevention materials issued by CBOs (APR, 1.22; 95%CI, 1.09–-1.38), and had sex with more than five partners in the past six months (APR, 1.42; 95%CI, 1.28–1.58). In the Tokyo and Osaka group, the PR of having ever been tested for HIV was higher among MSM who were older (APR, 1.52; 95%CI, 1.11–2.07; APR, 1.51; 95%CI, 1.11–2.07), had a history of syphilis (APR, 1.28; 95%CI, 1.11–1.47), had talked about HIV in the past six months (APR, 1.25; 95%CI, 1.07–1.46), and had HIV-prevention materials issued by CBOs (APR, 1.20; 95%CI, 1.06–1.36).
Correlates of HIV testing in the past year
The univariate and multivariate models examining the correlates of HIV testing in the past year are presented in .
Table 4. Correlates of HIV testing in the past year in Japan in 2015 (N=776).
In the regional cities group, the final multivariate model showed that the prevalence ratio of HIV testing in the past year was lower among MSM who were older (APR, 0.70; 95%CI, 0.53–0.94), and higher among those who had talked about HIV (APR, 1.41; 95%CI, 1.09–1.81), were aware of HIV-prevention materials issued by CBOs (APR, 1.28; 95%CI, 1.07–2.33), and had anal sex with more than five partners in the past six months (APR, 3.26; 95%CI, 1.91–5.57). In the Tokyo and Osaka group, PRs of HIV testing in the past year were higher among MSM with a history of syphilis (APR, 1.47; 95%CI, 1.06–2.04), who had spoken with a friend about HIV (APR, 1.49; 95%CI, 1.11–1.99), and were aware of HIV-prevention materials issued by CBOs (APR, 1.38; 95%CI, 1.07–1.78).
Discussion
Overall, 65.7% in regional cities and 75.8% in Tokyo and Osaka had been tested for HIV in their lifetime, while 36.9% in regional cities and 48.3% in Tokyo and Osaka had been tested for HIV in the last year. Our results are similar to previous studies, including a nationwide survey that found that lifetime testing experience was 62.7%, and 36.2% in the past year (Shiono et al., Citation2013). A 2016 online MSM survey in Tokyo found that lifetime testing experience was 72.8% (Hill et al., Citation2019). This suggests that HIV testing may be on the rise; however, a cohort study is needed to clarify this trend.
In comparison with MSM HIV-testing experience in the ASEAN region, in a 2016 Korean MSM online survey, the lifetime testing experience was 52.8% (Yang et al., Citation2018), which was lower than this study. In an MSM online survey in the ASEAN region, test experience was 70.1% (Guadamuz et al., Citation2015), which was higher than this study. However, these testing levels are markedly lower than in Western countries; for instance, American studies reported that 76.4–84.8% of MSM (Fredriksen-Goldsen et al., Citation2013; Pathela et al., Citation2011) Had lifetime testing experience, and 53.6% had been tested in the last year. In the UK (Knussen et al., Citation2014; Witzel et al., Citation2016), the MSM lifetime testing experience was 73.9–80.0%, with 53.7% tested in the previous year. The lower testing levels in Japan and ASEAN countries may reflect the lower knowledge of HIV among MSM and lower structural investment by governments than in Western developed countries (Philbin et al., Citation2018).
As for lifetime HIV testing, older respondents in regional cities and in Tokyo and Osaka had more testing experience. However, older respondents in the regional cities were less likely to have been tested in the past year. This finding warrants promoting frequent HIV testing targeted toward middle-aged MSM in regional cities.
Our findings also showed that respondents with a history of syphilis had a higher rate of lifetime HIV-testing experience, as per the Japanese Guidelines for Diagnosis and Treatment of HIV (The Japanese Society for AIDS Research, Citation2018). STI clinic doctors should encourage regular HIV testing when treating syphilis patients. However, no relationship existed between history of syphilis and testing in the past year.
Lifetime HIV testing and testing in the last year were associated with talking about HIV. Previous studies (Kaneko et al., Citation2017; Shiono et al., Citation2013) showed a relationship between talking about HIV and the intention to be tested; however, this study ascertained a relationship between talking about HIV and actually being tested. HIV as a familiar subject may enable individuals to feel more comfortable with information about HIV and testing behaviors, highlighting the importance of addressing the topic in everyday life. However, previous studies have demonstrated that obtaining information about HIV and AIDS is becoming remarkably less common in Japanese society overall (Kaneko et al., Citation2017). Therefore, it is important to continue HIV-testing promotion efforts to ensure that interest in HIV and AIDS is retained within the MSM community.
Respondents who were aware of materials from AIDS CBOs had higher rates of lifetime testing in Tokyo and Osaka and of testing in the past year in both areas. This was consistent with a previous study’s results (Kaneko et al., Citation2011). In Japan, community centers run by AIDS CBOs provide testing information to users of commercial facilities targeting gay men, and conduct programs to promote HIV testing; it is possible that community centers or commercial facilities give the target clientele access to testing information, thereby fostering testing behaviors.
This study had some limitations. First, the design was a cross-sectional survey that merely captured a phenomenon pertaining to the target population at a given time; thus, it does imply causal relationships between testing behaviors and associated factors. Future studies using a cohort design are required to more clearly identify changes in testing behaviors and causal relationships with associated factors. Second, this study used a self-report questionnaire. HIV testing and sexual behaviors are intimate topics, and respondents tend to give socially-desirable answers when asked related questions; thus, the actual rates of behaviors associated with high risk of infection may be higher. Third, there may have been a memory bias among respondents. The names of actual community centers and papers in the various regions were used for items on knowledge of them; however, it is unknown whether respondents necessarily remembered their names. Thus, there may have been a gap between the results and respondents’ actual knowledge. Future studies could use a combination of images and interview surveys to ease respondents’ recognition of these items. Furthermore, it is important to acknowledge that knowledge of community papers is not necessarily an indicator of HIV or testing knowledge. Fourth, the population’s representation is of concern. This survey contained items on sexual behaviors and other private subjects; thus, there may be a bias in the group that was relatively cooperative. Furthermore, respondents were recruited in regional cities where community centers are established and in regions where CBOs are active; thus, it is noteworthy that our results do not reflect situations in regional cities where there are no such centers. Future studies should modify the questionnaire to make it easier for respondents, and increase the sample size.
Conclusion
This study observed that lifetime HIV-testing behaviors were positively associated with older age, a history of syphilis, experience talking about HIV, and recognition of AIDS-related CBO materials. In both regional cities and Tokyo and Osaka, experience talking about HIV with friends and recognition of AIDS-related CBO materials were correlated with testing experience in the past year. In future, community-based outreach should be expanded to MSM who are currently not targeted for HIV testing, such as those not attending gay community centers or events. Furthermore, initiatives should be taken within the community to prevent decreasing interest in HIV, as our results indicated that talking about HIV and knowledge of community centers are positively related to testing behaviors.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The data that support the findings of this study are available from the corresponding author, NK, upon reasonable request.
Additional information
Funding
References
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