Integrated online-to-offline (O2O) model of care for HIV prevention and treatment among men who have sex with men

摘要 马来西亚的艾滋病毒流行正在迅速扩大，最近的证据表明性传播正在增加， 尤其是在MSM中。男男性行为者中的艾滋病毒流行率目前达到21.6%的历史最高水平，并集中在 在该国首都吉隆坡，2020年MSM的患病率为43%，而仅仅四年的患病率为22 以前对马来西亚不断扩大的艾滋病毒流行病的见解是多因素的：同性恋和物质 在马来西亚，使用毒品是犯罪行为。因此，男男性接触者往往不愿透露自己的性行为或危险行为， 主要是因为害怕耻辱，歧视或刑事定罪。此外，有证据表明， 使用（24%）精神活性物质（例如，安非他明类兴奋剂）， 在马来西亚的男男性接触者中也被称为性化药物使用（chemsex），这导致了高风险的性行为 (e.g.,无避孕套性行为）。卫生保健提供者也对男男性行为者实施羞辱和歧视， 对男男性接触者的敌对环境，使扩大艾滋病毒检测的努力复杂化，并随后与艾滋病毒感染者联系起来。 艾滋病毒预防（接触前预防）和治疗（抗逆转录病毒疗法）服务。艾滋病毒检测 启动艾滋病毒预防和治疗的级联。新的艾滋病毒检测指南建议MSM 每3至6个月进行一次检测，因为早期艾滋病毒检测是遏制艾滋病毒流行的一项具有成本效益的战略。然而， 马来西亚男男性行为者的艾滋病毒检测率仍然很低：曾经检测过（70.3%）和去年检测过（30.9%）。HIV自身 艾滋病毒检测（HIVST）可能对马来西亚的男男性行为者特别有影响。尽管使用HIVST的意愿 在这一群体中，由于缺乏获得艾滋病毒/艾滋病治疗包的机会， 结果，并错过了机会，咨询和联系，以照顾。在这种情况下，电子健康代表了 创新平台，以改变艾滋病毒服务提供的面貌（即，测试和与护理的联系）。利用 马来西亚提供艾滋病毒服务的电子健康平台是理想的，因为几乎所有（>99%）MSM都使用某种形式的 通信技术（例如，智能手机、笔记本电脑），并对基于网络的平台有强烈的偏好 为了艾滋病因此，我们开发了一个名为Jom-Test®的基于网络的HIVST平台，并进行了试点测试，以促进 通过提供免费的匿名艾滋病毒检测服务。结果表明， 平台，但检测后与治疗和预防服务的联系较低。调查结果进一步表明， 需要实时（在线）接触咨询师，以获得检测前和检测后咨询和艾滋病毒关联支持 和与化学性爱有关的减少伤害服务（离线）。为了解决这一证据缺口，我们建议启动 通过调整、扩展和完善现有的Jom-Test®平台，实现更广泛的艾滋病护理连续性。的 增强版，被称为Jom-TestPlus，将包括实时电子咨询（eHIVST）与集成O2O 与艾滋病毒预防和治疗服务的联系，同时共同解决 马来西亚男男性接触者这一模式代表了一种可能影响边缘化人口的战略， 像男男性接触者一样，并允许立即参与测试后的联系过程，以预防或治疗服务。

Abstract Malaysia's HIV epidemic is rapidly expanding, with recent evidence suggesting increasing sexual transmission, especially in MSM. HIV prevalence among MSM is now at an all-time high of 21.6% and is concentrated in the country's capital, Kuala Lumpur, where prevalence among MSM is 43% in 2020, up from 22% just four years before. Insights into Malaysia's expanding HIV epidemic are multi-factorial: Both homosexuality and substance use are criminalized in Malaysia. MSM are, therefore, often hesitant to disclose their sexuality or risk behaviors, primarily due to fear of stigma, discrimination, or criminalization. Further, evidence suggests the widespread use (24%) of psychoactive substances (e.g., amphetamine-type stimulants) before or during a sexual encounter, also known as sexualized drug use (chemsex) among Malaysian MSM, which leads to high-risk sexual practices (e.g., condomless sex). Stigma and discrimination are also enacted on MSM by healthcare providers, which foster a hostile environment toward MSM, complicating efforts to scale-up of HIV testing and subsequent linkage to HIV prevention (pre-exposure prophylaxis) and treatment (antiretroviral therapy) services. HIV testing jumpstarts entry into the HIV prevention and treatment cascades. New HIV testing guidelines recommend MSM test every 3 to 6 months, as early HIV testing is a cost-effective strategy for stemming the HIV epidemic. Yet, HIV testing rates remain low among Malaysian MSM: ever tested (70.3%) and last year tested (30.9%). HIV self- testing (HIVST) may be particularly impactful among MSM in Malaysia. Although willingness to use HIVST is high in this group, its use is still minimal due to lack of access to HIVST kits, concerns related to misinterpreting results, and missed opportunities for counseling and linkage to care. In this context, eHealth represents an innovative platform to transform the face of HIV service delivery (i.e., testing and linkage to care). Leveraging eHealth platforms for HIV services delivery in Malaysia is ideal given that nearly all (>99%) MSM use some form of communication technology (e.g., smartphone, laptop) and has a strong preference for web-based platforms for HIVST. Therefore, we developed and pilot-tested a web-based HIVST platform, called Jom-Test®, to promote HIV testing by providing free anonymous HIVST. The results demonstrated high feasibility and acceptability for the platform but low post-test linkage to treatment and prevention services. The findings further indicated the need for real-time (online) access to counselors for pre- and post-test counseling and support for linkage to HIV and chemsex-related harm reduction services (offline). To address this evidence gap, we propose to jump-start the broader HIV care continuum by adapting, expanding, and refining an existing Jom-Test® platform. The enhanced version, to be called Jom-TestPlus, will include real-time e-counseling (eHIVST) with integrated O2O linkage to HIV prevention and treatment services while simultaneously co-addressing chemsex-related needs for Malaysian MSM. This model represents a potentially impactful strategy for reaching marginalized populations, like MSM, and allows immediate engagement in the post-test linkage process to prevention or treatment services.