Multilingual abstracts

Please see Additional file 1 for translations of the abstract into the five official working languages of the United Nations.

Background

Sexual orientation among men who have sex with men (MSM) is not only culturally and psychologically considered abnormal in China, but also highly discriminated against, as it is considered a high risk for HIV infection. The HIV epidemic and incidence among MSM continues to rise at an alarming rate [1], however the percentage of HIV occurrence in MSM in China used to be relatively low compared to other Asian countries such as Cambodia (7.8 %), Indonesia (9.0 %), and Thailand (24.6 %) [2]. According to the reported statistics in 2002, Chinese MSM represents about 2 to 5 % of the sexually active male population [3]. In recent years, the male-to-male homosexual transmission has become one of the major modes of HIV transmission [4, 5], and the proportion of newly diagnosed HIV cases due to male homosexual contact has increased from 12.2 % in 2007, 21.4 % in 2013, to 23.4 % in 2014, respectively in China [6, 7]. The HIV incidence had increased in Liaoning Province from 5.1 to 10.2 % during 2007–2009 [8], and the HIV infection rate among MSM increased from 4.48 % in 2009 to 12.00 % in Dalian in 2012 [9].

The city of Dalian is in Liaoning province as a peninsula in the Huanghai and the Bohai Sea with an elaborate coastline. It’s beautiful beaches and close proximity to Korea and Japan make it both a domestic and international tourist destination in summer. This flow of people carves and modifies the disposition of local Dalian cultural morays along with the associated sex business with increasing connections via the internet. Although the Chinese society is relatively conservative on sexual issues, the increased number of visitors may impact the culture of the society at large.

The development of highly active antiretroviral therapy (HAART) for HIV/AIDS has helped the patients tremendously in coping with the chronic, complex and unpredictable course of the disease [10–12]. The multiple and complex factors of personality traits [13, 14], age [15] sociocultural stigmatization [16], psychological elements, discrimination and disclosure of HIV/AIDS status pose a substantial challenge to the concept of HRQoL issues among HIV/AIDS infected individuals/patients [17]. Consequently, the aforementioned factors can provoke psychopathological problems and may eventually lead to subnormal quality of health (QoL).

Attitudes towards sex and sexual behaviors have changed throughout eons of cultural revolution in China, however, sexual attitudes towards homosexual engagement are not yet well acceptable and official institutionalization among the gay population is lacking. This is primarily due to the reason that the Chinese society associates a negative connotation to homosexuality and considers it as an aberrant and unacceptable behaviour [18, 19]. Though physical and psychological distress is common amongst the people living with HIV/AIDS [20], the negative implication of the cultural influence and HIV infection might lead to psychosocial instability, which eventually affects the HRQoL of HIVMSM. Also, the emergence of psychopathology and HRQoL is a common observation among the people living with HIV/AIDS [21].

Although a lot of work has been carried out on the risk of HIV/AIDS in the MSM population prior to their infection, far less work has been done to assess the factors that influence the mental health of the HIVMSM post-infection. Until a few years ago, the focus of most researches was on the investigation of HRQoL among the general HIV population and knowledge, attitude and practice towards HIV infection, prevention and test for HIV infection among MSM rather than the mental health wellbeing and HRQoL post-HIV infection. These studies have indicated that socio-demographic characteristics i.e. age, gender, ethnicity, education level, marital status, employment, and transmission route seem to be the primary influential factors affecting the quality of life of the people living with HIV/AIDS [22–24]. Also, the findings from the study related to the quality of life for people living with HIV/AIDS revealed that the factors such as younger age, single, not farmers, and higher education level, high level of CD4 count and good ART adherence tend to have positive effects on QoL [25].

Despite the increased recognition of MSM wellbeing and mental health issues in many parts of China, there is paucity of data on their HRQoL, particularly in Dalian. Also, it is important to consider the alternative foci of research that addresses the post infection mental wellbeing and HRQoL of affected MSM. The present study was designed to assess the self-reported psychopathology and HRQoL for HIVMSM and to explore the associated factors. Since the WHOQOL-HIV- Bref [26] and SCL 90 [27] have proven to be reliable for the assessment of the quality of life and self-reported psychopathology of Chinese people with HIV/AIDS, they were selected to indicate the QoL and self-reported psychopathology in this study. The present study included perceived discrimination, living conditions, and medical follow-up attendance which were not assessed in the earlier studies.

Methods

A cross-sectional survey of patients aged > 18 years who attended the Center for Disease Control (CDC) in Dalian was conducted. This was a pilot study that targeted the newly diagnosed MSM with HIV/AIDS. All HIVMSM who visited the CDC between December 2012 and December 2013, who were returning to the CDC for antiretroviral treatment follow-up were invited to participate. The patients who were older than 18 years, had sex with men, HIV-infected and exclusively diagnosed in the year of 2012 were eligible for this survey. Patients who had no sexual history with men and were diagnosed earlier or later than 2012, or were transferred from the other parts of China were excluded.

Participants were interviewed using a structured questionnaire to obtain demographic and clinical information, quality of life, and the presence and severity of psychological symptoms. Public health professionals who were trained specifically to collect the data for this study were involved in administering the questionnaires. Newly diagnosed MSM with HIV/AIDS was defined as HIVMSM who had their seropositivity for the first time in year 2012. Income was measured at the household level and classified into 3 groups: low (< 2 000 Yuan), middle (2 000–4 000 Yuan) and high income (> 4 000 Yuan). Fear of discrimination was assessed subjectively by asking the participants about their agreement and disagreement (1 = yes, 2 = no) with a question that assesses if they perceive discrimination from the community or health professionals because of being MSM with HIV/AIDS. Living conditions were determined from the participants’ response (yes or no) to a question whether they are living alone or with family/partner/friend/relative. Medical follow-up attendance was assessed by if the patients regularly attended their follow-up services. Their response recorded 1 = regular or 2 = not regular.

Psychopathology was measured by a Chinese version of SCL-90; a reliable, valid and accepted tool for psychological evaluation [27]. This regimen has been used in several studies in China [28, 29] to explore the presence and severity of psychological symptoms. There are nine subscales of SCL-90 namely; (somatization, obsessive–compulsive, interpersonal sensitivity, depression, anxiety, anger/hostility, phobic anxiety, paranoid ideation and psychoticism). SCL-90 is scored using a five-point scale (0 to 4) to measure the symptoms experienced in the last 7 days. Higher scores indicate more severe psychopathologic symptoms on the SCL- 90.

Participants were appraised for quality of life by WHOQOL-HIV-Bref, a cross-cultural instrument that contains 31-items and six domains. The six domains included in this study were physical, psychological, independence, social relationships, environment, and spirituality, as used in other studies. This self-administered questionnaire explores the issues pertaining to capacity, frequency and intensity or satisfaction. Each item was rated on a five-point Likert scale (1 to 5), with higher scores indicating better functioning. The multidimensional evaluations of the respondents’ health and social life-related conditions were based on how they rate themselves on their daily living activities in all aspects of their lives. The Chinese version of WHOQOL-BREF has been widely used and validated in China [25, 30].

A total of 303 HIV-positive men were reported in Dalian in 2012. In the first stage, all HIV-positive men were included in the study. In the second stage, the HIV-positive men were classified into two groups (HIVMSM and heterosexuals) based on their response to their sexual preferences. A total of 117 HIVMSM were identified and included in this study while 186 heterosexuals were excluded from the study. In the third stage, the 117 HIVMSM were classified into homosexuals (n = 106) and bisexuals (n = 11). All 117 HIVMSM were approached and only 112 (97.5 %) HIVMSM (homosexuals (n = 103) and bisexuals (n = 9)) participated in this study. Figure 1 demonstrates the flow chart of the recruited and participated HIVMSM.

Fig. 1
figure 1

Flow chart of the recruited and participated HIVMSM

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The data were entered in Epidata 3.1 software to get optimized documentation and error detection, which was further analyzed using IBM SPSS (Statistical Package for Social Sciences), version 21. The differences in psychopathology and HRQoL among the nominal variables of demographic characteristics were tested using independent t-tests or one-way analysis of variance (ANOVA). Pearson’s product–moment correlation coefficients were obtained to examine the associations between the continuous variables of demographic characteristics (age and CD4 + T cell count) and, total SCL 90 scores and total HRQoL. The relationship between the self-reported psychopathology (as measured by SCL90) and HRQoL (as measured by the WHO HRQOL-BREF) was also investigated using Pearson’s product moment of correlation. Spearman rank order correlation was used with ranked demographic variables (Marital status, education, family income, employment, living condition, perceived discrimination, sexual behavior and medical follow-up). Multiple regression analyses were conducted to explore the factors that associate with self-reported psychopathology and HRQoL in MSM with HIV/AIDS. The assumptions of normality, independence, linearity and homoscedasticity were checked with a residual analysis. Multicollinearity was assessed for all variables by means of correlation coefficients, tolerances, and the variance inflation factors. Neither assumptions were violated nor was multicollinearity detected. A P value of < 0.05 was considered significant.

Results

Sociodemographic and clinical characteristics, and self-reported psychopathology and HRQoL

Table 1 shows socio-demographic characteristics of MSM with HIV/AIDS. Out of the total 112 MSM with HIV/AIDS, 9 (8 %) were homosexuals and 103 (92 %) were bisexuals. The mean age of the participants was 34.31 and the mean of their CD4+ T cells was 498.5 (SD = 191.6).

Table 1 Sociodemographic and clinical characteristics of MSM with HIV/AIDS (n = 112)
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The participants who perceived discrimination reported significantly higher levels of severity of self-reported psychopathology and poorer HRQoL than those who did not perceive discrimination (P < 0.01). Moreover, the participants who reported low family income and lack of regular attendance with their medical follow-ups reported poorer HRQoL than those who had high-income levels and regular medical follow-ups (P = 0.001 and P = 0.014 respectively). Table 2 shows the differences between sociodemographic and clinical characteristics of MSM with HIV/AIDS in their self-reported psychopathology and HRQoL.

Table 2 Differences between sociodemographic and clinical characteristics of MSM with HIV/AIDS, and their self-reported psychopathology and HRQoL
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Determinants of HRQoL

  1. a.

    Psychopathology

Table 3 illustrates the correlation between sociodemographic characteristics and psychopathologic symptoms among MSM with HIV/AIDS. For MSM with HIV/AIDS, SCL 90 scores were significantly correlated with fear of discrimination (P < 0.01).

Table 3 Self-reported psychopathology among MSM with HIV/AIDS
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  1. b.

    HRQoL

Table 4 shows the correlation of HRQoL among MSM with HIV/AIDS. Family income (P < 0.01), fear of discrimination (P < 0.01) and medical follow-up attendance (P < 0.05) were significantly correlated with WHO-HIV-Bref-QOL domains among MSM with HIV/AIDS. In addition, subscales of SCL 90 (somatization, obsession, depression and phobia) and total scores of SCL 90 were found to be correlated with total scores of HRQoL.

Table 4 Health-related quality of life among MSM with HIV/AIDS
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  1. c.

    Predictors of self-reported psychopathology

Total SCL 90 score explained 8.4 % of variance (R2 = 0.084). All measures of psychopathology were predicted by the perception of discrimination. Interpersonal sensitivity was also predicted by marital status (β = −0.251; P = 0.041). Table 5 describes the predictors of self-reported psychopathology among MSM with HIV/AIDS.

Table 5 Predictors of self-reported psychopathology among MSM with HIV/AIDS
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  1. d.

    Predictors of health-related quality of life among MSM with HIV/AIDS

All domains of HRQoL, except social domain, were predicted by family income. Social and spirituality domains, and total HRQoL were predicted by fear of discrimination (β = 0.404; P < 0.001, β = 0.218; P = 0.049 and β = 0.433; P < 0.001 respectively). Medical follow-up attendance seems to be a significant predictor of physical, psychological and social domains, and total HRQoL. Table 6 illustrates the predictors of health-related quality of life among MSM with HIV/AIDS.

Table 6 Predictors of health-related quality of life among MSM with HIV/AIDS
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Discussion

This study presents prevalent bisexual preferences among HIVMSM in Dalian. The findings from this study demonstrate that 92 % of the HIVMSM were bisexuals while only 8 % were homosexuals. Culturally, homosexuality is an unacceptable behaviour in China [19], which could be a reason for the high bisexual preference to cover up and decrease the pressure from the society.

In this study, MSM who reported the perception of discrimination had a higher level of severity of psychopathology (P = 0.001) and poor HRQoL (P < 0.001). This could be attributed to internalization of negative attitudes and assumptions of guilt, inferiority and lack of self-worth [31], which may lead to self-blame and self-isolation due to perceived discrimination, probably exacerbating hostility to social environments. Evidence from a published report revealed that a hostile social environment has an impact on mental health and QOL as homosexuals reported higher levels of sexual minority-specific victimization, depressive symptoms, and suicidality compared to the heterosexuals [32].

A survey from Jinan, Qingdao, and Yantai of Shandong province in China concluded that the bisexual behaviour is independently associated with higher levels of HIV/AIDS-related discrimination [33]. Social (P < 0.001) and spirituality (P = 0.049) domains, and total HRQoL (P < 0.001) were predicted by perceived discrimination. On the other hand, self-reported symptoms; somatization (P < 0.05), obsession (P < 0.01), depression (P < 0.05), phobia (P < 0.01) and overall SCL 90 scores (P < 0.05) were significantly correlated with total quality of life (TQOL). A similar study among the individuals living with HIV/AIDS reported significant associations between poor HRQoL and a high degree of depression, anxiety, anger and low self-confidence [13]. Homosexuality is taboo in China, and therefore, MSM often feel guilt, low self-esteem, and fear of discrimination, which may eventually lead to depression and decreased HRQoL [34, 35]. The negative impact of depression in QOL among people living with HIV/AIDS and its role in disease progression has been described before [36, 37]. The present study shows that all subscales of SCL 90 including total SCL 90 score were predicted by perceived discrimination. The self-reported psychopathology due to the experience of perceived discrimination may affect the HRQoL of the HIVMSM through: (i) impairing their self-esteem and self-confidence, (ii) worsening their stress, (iii) increasing unemployment that can affect their income level, (iv) increasing social withdrawal that can result in loneliness and poor medical follow-up attendance, and (v) decreasing their motivation that may result in self-care deficit and poor self-image. The poor HRQoL observed among HIVMSM in this study could benefit from psychological and social support.

Lack of proper medical follow-up emerged as a significant predictor of physical (P = 0.045), psychological (P = 0.001), social domains (P = 0.042) and total HRQoL (P = 0.015) in this study. Medical check-ups provide a better opportunity to the people living with HIV/AIDS to communicate with the health professional on their medications and any concerns regarding their physical and mental health. One qualitative study in Zambia identified lack of follow-up and counselling as a barrier to patient’s adherence to ART [38]. Hence, follow-up and counselling should be strengthened to provide the information about ART and better comprehensive medical check-ups.

The persistent influence of family income in HRQoL between HIVMSM observed in this study and ordinary HIV/AIDS cases from the previous studies might show the exposure of the same influential or risk factors that are associated with socioeconomic status. High family income [39] and unemployment [15] have positive and negative associations respectively with QOL among people living with HIV/AIDS. Furthermore, economic satisfaction and family support were reported among the conditions that can positively influence HRQoL among the adults with HIV/AIDS [40].

The findings from our study provide primary predictors (perceived discrimination, low-income, and irregular medical follow-up) that are associated with psychopathology and poor HRQoL, and the corresponding proportions of the sexual behaviours among the MSM with HIV/AIDS. The understanding of the correlations and predictors that may impact the mental wellbeing and quality of life among the HIVMSM is essential for improving the continuum of healthcare plan for MSM in Dalian. This will foster the accessibility of HIVMSM to HIV patient care and consequently contribute to the healthcare policy development regarding the prevention and intervention. HIV transmission among MSM is surging in China and our current study revealed significantly high psychopathological symptoms and poor HRQoL among HIVMSM who have reported perceived discrimination.

This study has several limitations. First, this study is subjected to self-reported data. Second, there was no confirmatory assessment that can prove the presence or severity of psychopathology, and the magnitude of the perception of discrimination in addition to the participants’ report. The strength of this study lies in its broad representative samples for the recorded HIVMSM and the use of a standardized instrument.

Conclusion

According to this study total quality of life was predicted by family income, perceived discrimination and medical follow-up attendance whereas self-reported psychopathology was predicted by perceived discrimination. To reduce the psychopathologic symptoms among HIVMSM, social and psychological support is of crucial importance to improve HRQoL in this targeted population. More needs to be emphasized on the newly diagnosed HIVMSM in Dalian in order to develop a more targeted intervention to prevent perceived discrimination and lack of proper medical follow-up services. The strategies targeting MSM and focusing on linking and engaging HIV-positive patients in a healthcare are the keys to bridging the steps to improving HIV healthcare. This can be accomplished by establishing free HIV care, advocacy for MSM with HIV-positive by health professionals, and extending community health education to avoid stigma and discrimination from the society in order to improve the mental well-being and health-related quality of life.