Chunyan Li is a social and behavioral researcher in the Department of Health Behavior at the Gillings School of Global Public Health applying socially innovative and community-engaged approaches to promote public health in global settings. For her dissertation, she worked with UNC Project-China to assess barriers to PrEP in the province of Guangdong. She also tested a phone app intervention to improve HIV/sexual health care.
The Guangdong province is a major economic powerhouse for China and a global manufacturing hub, facing the South China Sea to the southeast. As one of the earliest trading ports in Chinese history, Guangdong is the starting point of the “Maritime Silk Road.” Today its capital Guangzhou attracts millions of domestic and international migrants who come to the city to build their lives. By the end of 2021, Guangzhou was home to 18.8 million people, with nearly 50% being young domestic migrant workers. More than 80,000 non-Chinese residents lived in Guangzhou before the COVID-19 pandemic, although this number likely decreased significantly due to China’s strict COVID control policy.
THE HIV EPIDEMIC IN GUANGZHOU
The large flow of migrant workers moving in and out of the Guangzhou city every year brings challenges to the local healthcare system. In 2021, about 4.6 million HIV tests (including rapid and confirmatory tests) were administered in the city of Guangzhou; within the first 10 months, 1,474 individuals were newly diagnosed with HIV, among whom 60% were transmitted through same-sex behaviors. Approximately 7% of the clients receiving volunteer counseling and testing (VCT), who self-identified as men who have sex with men (MSM), tested HIV-positive. According to the Chinese National Center for AIDS/STD Control and Prevention, the percentage of new HIV cases transmitted via same-sex behavior among men has drastically increased from 9.1% in 2009, to 23.3% in 2020. While the increasing HIV prevalence and growing number of infections could be explained by the extended efforts of the Chinese government in scaling up HIV testing, it is certain the HIV epidemic in China will continue expanding in key populations without timely and adequate intervention.
DESIGNING THE STUDY:
CHUNYAN LI BLOGS ABOUT HER RESEARCH EXPERIENCE AND LEARNINGS
With support from her academic advisor Dr. Kate Muessig in the Department of Health Behavior, building on the HIV PrEP research projects of Dr. Joseph Tucker through UNC Project-China and the UNC Institute for Global Health & Infectious Diseases, Chunyan Li focused her dissertation on HIV prevention among Chinese men who have sex with men (MSM) living in the Guangzhou area. She specifically focused on the intention and experience of Chinese MSM using PrEP for HIV prevention and considered how a crowdsourced mobile phone-based application would help to increase actual PrEP initiation by MSM. This research was part of a bigger multi-site PrEP demonstration project in China that aims to recruit 1,200 at-risk individuals to start using PrEP. Li describes her dissertation project in the following blog.
Gay-Friendly Doctor Finder Hackathon Generates Innovative Solutions
“In the spring of 2019, I was recruited by Dr. Joe Tucker to join the organizing committee of the first-ever ‘Gay-friendly Doctor Finder’ hackathon contest in Guangzhou. I was able to sit through the 72 “hacking” hours with over 40 contestants, at a local university’s student center. Within 72 hours, every team was working towards one goal, to develop a mobile phone-based tool that could help MSM access equitable and adequate healthcare in China.” (Figure 2)
“This was my first crowdsourcing contest and certainly my first hackathon experience. I was amazed by the diverse backgrounds of contestants, their enthusiasm for digital health, and their extensive knowledge of local health systems (at this time, I had been living outside of China for two years. The digitalization of Chinese healthcare systems had developed so rapidly that I needed to do some homework to catch up!) Most importantly, contestants from MSM communities were able to lead the design of their desired healthcare systems, as owners, rather than just being studied or only being consulted as subjects. At the end of the 72-hour contest, eight prototypes were produced. One was adapted into a PrEP-focused educational intervention, through an iterative development process. This particular prototype was selected due to its simplified design of functions and user interface, and the fact that it was a mini-app built within the giant Chinese super social app, WeChat. This meant we did not need to create a stand-alone app from scratch. We could release the mini-app directly to the millions of users already registered in WeChat.”
An Iterative Process: Developing and Testing the PrEP Mini-App
“In the summer of 2019, I was able to further my understanding of HIV prevention in China through multi-site field research with support from Dr. Kate Westmoreland, the Carolina Center for Public Service, and the Research Center for Public Health of Tsinghua University. From my interviews with both MSM participants and other key stakeholders working in HIV prevention (e.g. college HIV education course instructors, peer educators, campus health providers, community-based organization staff and volunteers, and officials at local centers for diseases prevention and control), I was surprised by the absence of antiretroviral medicine-based pre-exposure prophylaxis (PrEP) in HIV education campaigns. As a consequence, many people confused PrEP with another more widely known biomedical HIV prevention method, post-exposure prophylaxis, or PEP. It’s noninsured high cost along with traditional Chinese thinking that “是药三分毒” (every medication has side effects) has discouraged people from learning more about biomedical HIV prevention strategies.
“Though my previous research work had helped me establish some understanding of the reception of PrEP in Chinese populations, the quickly evolving PrEP-related policies in China warranted the need for a deeper and updated investigation into Chinese MSM’s thoughts around PrEP. As an iterative intervention development process, my dissertation was designed to start with a formative assessment of barriers and facilitators to PrEP initiation among Chinese MSM and a usability test of the crowdsourced PrEP mini-app with a small group of MSM users, and then continue to a randomized clinical trial (RCT) to generate preliminary evidence for efficacy and acceptability. Like everyone else planning to travel around the end of 2019, I did not foresee a global pandemic near the corner. Then, everything had to move online, including the interviews and follow-up RCT.
“Luckily, the PrEP mini-app–the intervention being tested–could be fully delivered online (Figure 3). Before my dissertation project, I had built plenty of experience in interviewing Chinese MSM both in person and through the video call function built in WeChat, even before the COVID era. Since online interviews no longer pose a limitation on the participant’s geographic location, with help from UNC Project-China and local LGBTQ community-based organizations, I was able to recruit PrEP users across China and understand their experience in accessing PrEP medicines in different parts of the country. This greatly helped me achieve the sample size (10 participants with PrEP using experience) more quickly and easily for Aim 1 of my dissertation, by removing the restriction to Guangzhou-based participants. At that time, there were an estimated fewer than 6,000 PrEP users across the country.
“During the summer of 2020, I completed 31 online interviews with China-based participants from my apartment in Carrboro, North Carolina, which means I was 12 hours behind my participants. To make the scheduling process easier, I created an Excel spreadsheet of my available times marked in China time and asked participants to choose time slots for interviews. Unsurprisingly, many of the participants chose to receive the interview in the evening, as they need to work during the daytime and did not feel comfortable talking about HIV and their sexuality in the workplace. As a result, several of the interviews were interrupted by unexpected family members coming in, or the participant had to take a walk outside to continue our conversation. Many young people, especially college students or fresh graduates who could not afford single housing, are still living with family members or in rental apartments shared with roommates (especially in expensive cities like Guangzhou). This made at-home interviews particularly challenging for gender and sexual minority young people, who often have to hide their identities at home in fear of unintended disclosure. When realizing that my participants might be in such a situation, I always asked them at the beginning of each interview if they’d like to use alternative words to describe sensitive topics related to sex or HIV, or if they wanted to reschedule.
“However, the challenge of recruiting participants came back during the RCT, where participants needed to pay at least two in-person visits to the PrEP clinic, located within an infectious diseases hospital, for an initial physical examination and prescription for PrEP initiation. Although many of the study-related procedures (for example, eligibility screening, enrollment, appointment, and consultation) could be done online, for safety concerns and administrative purposes, initial lab tests, and medication pick-up had to be done in person. In addition to the uncertainty or concerns about PrEP’s efficacy in HIV prevention, the required clinical procedures also discouraged some MSM interested in PrEP from joining our study. Furthermore, our study hospital was one of the biggest infectious disease hospitals in the Guangdong province, and some participants mentioned they did not feel confident navigating through the hospital complex to find the PrEP clinic. Although the mini-app provided comprehensive information on how to access PrEP through the study, and an online chat function, many participants highlighted the key role of our research assistant from UNC Project-China who helped walk them through the initial clinical visit. This again reminded us of the importance of a decentralized healthcare system for the scale-up of preventive services like PrEP, and showed how essential the in-person clinical navigation is no matter how we digitalized certain aspects of the service delivery process. In fact, in a later PrEP demonstration trial at the same study hospital (currently enrolling), we’ve applied learnings from the pilot, setting up a workspace within the hospital to help facilitate enrollment and the initial PrEP consultation process.”
Study Results Reveal Substantial Interest in Using PrEP
“The results from my dissertation have revealed substantial interest in using PrEP among Chinese MSM; however, the procedural barriers are often too significant to change potential PrEP candidates into actual PrEP users. This has grown worse during the zero-COVID era in mainland China, where many people were locked down at home for weeks. Hospitals have also imposed stricter COVID testing rules for visitors, with reduced capacity for PrEP care provision due to a redistribution of resources. All of these changes have substantially increased the risks of PrEP discontinuation. It may also be a set back for China’s efforts to end the HIV epidemic, for years to come. Without an adaptive healthcare system or a supportive social environment, sexual and gender minority individuals, and many other socially disadvantaged groups, are more likely to suffer from adverse health impacts during such social changes.”
After almost a 3-year lockdown, China eased its COVID-19 restriction policy in early December 2022. As of January 2023, people no longer need COVID-19 tests to enter most hospitals or health centers, although some hospitals still require patients with certain diseases to be COVID-negative before admission for inpatient care.
After graduating from UNC-Chapel Hill in August 2022, Chunyan Li has started post-doctoral research at Tokyo College, the University of Tokyo, where she continues her research on HIV prevention and sexual health promotion among sexual and gender minority communities through social and behavioral innovations, particularly among Chinese and other international migrants living in Japan.
Read Li’s Published Articles
A Men Who Have Sex With Men-Friendly Doctor Finder Hackathon in Guangzhou, China: Development of a Mobile Health Intervention to Enhance Health Care Utilization
(JMIR mHealth uHealth, 2020)
Community-engaged mHealth intervention to increase uptake of HIV pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men in China: study protocol for a pilot randomised controlled trial
(British Medical Journal Open, 2022)