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Rural MSM is a distinctive and complex population with multiple identities in China. Concurrent multiple sexual partnerships, high mobility and low disclosure rate are the major challenges for HIV prevention and intervention programs in MSM.

Early universal access to antiretroviral treatment (ART) is critical in the control of the HIV epidemic. However, prompt initiation of ART remains problematic in China. This study analyzed the late testing and lag time between HIV diagnosis and initiation of ART from 2004 to 2016 and identified the risk factors for delayed initiation of ART. Data from 16,957 people living with HIV were abstracted from a hospital electronic health record database and a case report database for AIDS prevention and control in Yunnan province. Reasons for delayed initiation of ART were categorized into late testing, defined as CD4 count of < 350 cells/μL at baseline HIV diagnosis, and delayed access, defined as a lag time of > 1 month between the diagnosis and initiation of ART. Binary logistic regression models were used to identify risk factors for late testing and delayed access. The CD4 counts at diagnosis increased from 201 ± 147 cells/μL (mean ± SD) in 2004 to 324 ± 238 cells/μL in 2016 (p = 0.024). The CD4 count was higher for persons < 45 years, unmarried, and men who have sex with men (MSM) (356, 357, and 409 cells/μL, respectively) compared to their peers in 2016 (p < 0.05). The lag time from diagnosis to initiation of ART was significantly reduced from 59.2 months in 2004 to 0.9 months in 2016 (p < 0.05). The shorter lag time over the years was consistent when analysis was stratified by sex, age, marital status, and transmission routes, even though the lag time for people using drugs was longest in 2016 (> 2 months versus 0.82 and 0.72 month of heterosexuals and MSM, respectively). Compared to their peers, married persons (AOR = 0.63, 95%CI: 0.57, 0.69) were less likely to have delayed access to ART, and drugs-using patients (AOR = 3.58, 95%CI: 2.95,4.33) were more likely to have delayed access to ART. Late testing rather than delayed access to ART after a diagnosis remains problematic in China, although improvements have been seen for both parameters from 2004 to 2016. Our data highlight the importance of continued efforts to promote early diagnosis of HIV to prevent transmission, morbidity, and early mortality in HIV infection.

China has made substantial health commitments to Africa in the past several decades. However, while much has been written regarding China-Africa aid overall, relatively little attention has been given to China’s health aid. To better understand these investments, we provide an overview of the current framework and characteristics of China’s health aid to Africa. China’s health assistance has been perceived by some as opportunistic, largely as a demonstration of China’s engagement in “soft power” and an attempt to enhance its access to natural resources and political favors by African countries. Others have attributed altruistic intent, aiming to support the advancement of the health of populations in the African continent with a “no strings attached” approach. Our overview demonstrated that despite the magnitude of China’s health assistance, many questions remain regarding the scope of this aid, its effectiveness and the governance mechanisms that guide the conceptualization and implementation of such efforts. We also identified the need for a systematic and rigorous evaluation of the various elements of China’s health assistance to African countries in order to gain a deeper understanding of how priorities and allocations for health aid are determined, how such aid fits within the specific African country’s health strategies and to assess the effectiveness of such aid. Insights garnered through such an assessment could help determine future priorities for investment as well as inform efforts to optimize the value of China's aid for the populations of the recipient countries.

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Bisexual behaviours are relatively common among men who have sex with men in China. This pilot study aims to reveal the complex processes through which such men manage their sexuality, family responsibilities and sexual behaviours in a rural Chinese setting. A total of 15 men who have sex with men were recruited by purposive sampling. Face-to-face in-depth interviews were conducted to explore participants' views about their sexual experiences and practices. The Chinese traditional moral code, family values and gender roles that form the crucial components of Confucianism were reflected in the participants' efforts to maintain familial and social harmony through a compromised form of sexual partnership. Most study participants demonstrated a mixed experience of social stigma, sexual naiveté and ignorance of HIV and sexually transmitted infections (STIs). Under cultural and family pressure, men who have sex with men entered heterosexual marriages with the intention of maintaining a balance between their collectivist (familial) obligations and their individualistic (same-sex sexual) desires. However, the opaque nature of their concurrent sexual relationships may endanger their personal health and accelerate HIV and STI transmission. Reducing the stigma and social prejudice associated with male same-sex sexual relations is essential for any culturally sensitive HIV-prevention programme to succeed in rural China.

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