ORIGINAL STUDY

Effects of Case Management on Risky Sexual Behaviors

and Syphilis Among HIV-Infected Men Who Have Sex
With Men in China: A Randomized Controlled Study
Nianhua Xie, MPH,* Xuejiao Hu, MPH,* Han Yan, MPH,* Lianguo Ruan, PhD,† Cong Liu, MPH,*
Rong Hu, MPH,* Hongfei Ma, MPH,* Yanhe Luo, BD,† Li Liu, BD,† and Xia Wang, MPH*

Conclusions: A case management intervention reduced the incidence of

Background: The prevalence of syphilis is very high in human immuno- syphilis in HIV-positive MSM. We should further increase the content of case
deficiency virus (HIV)–positive men who have sex with men (MSM), and management on the basis of providing routine HIV-related care to those people.
effective interventions are needed to educate HIV-positive individuals about
behavioral and biological risk factors. Therefore, we developed a standard case
management process and conducted a randomized controlled study to investi-
gate the impact on risky sexual behaviors and syphilis in HIV-positive MSM. I n the last few years, the prevalence of human immunodeficiency
virus (HIV)/acquired immunodeficiency syndrome (AIDS) among
men who have sex with men (MSM) in China has rapidly increased.1
Methods: Men who have sex with men (n = 220) were enrolled and ran-
domized to the case management intervention group and the control group The reported prevalence of HIV in MSM ranges from an estimated
between May 2016 and January 2017. The control group received routine 3.5% (northwest China) to 10.7% (southwest China).2 Concurrent
HIV-related care. In addition to routine HIV-related care, those in the inter- with the increasing prevalence of HIV/AIDS, the incidence of syphi-
vention group regularly received extended services from a well-trained case lis has also risen in MSM populations.3 The positive association be-
manager. Epidemiological information was collected during the baseline tween syphilis and HIV infection among MSM can be explained on
face-to-face interviews by a trained investigator. Serological tests for syph- the same basis of biological mechanisms and risky behaviors.4 Syph-
ilis and assessments of risky sexual behaviors were performed at baseline ilis may increase the immune activation of host cells and the secretion
and 6 and 12 months after the initiation of treatment. of cytokines, thus enhancing HIV replication and decreasing CD4 cell
Results: The syphilis incidence rates in the intervention and control groups counts.5 Although antiretroviral therapy (ART) can restore immune
were 11.3 per 100 person-years and 20.6 per 100 person-years, respectively. function and reduce the HIV transmission rate, it cannot reduce the
The multivariable-adjusted hazard ratio (95% confidence inter) for syphilis in unsafe sexual behaviors or incidence and recurrence of syphilis in
case management group was 0.34 (0.14–0.87). The percentages of partici- HIV-positive patients.6 Therefore, interventions targeting psychology
pants who resumed risky sexual behaviors in both groups were significantly and behavior are needed to educate HIV-positive individuals about
reduced (P < 0.05) but did not significantly differ between the 2 groups. behavioral and biological risks factors for sexually transmitted dis-
eases (STDs) and strategies for modifying those risk factors.7
HIV case management is a collaborative process of assessment,
From the *Department of HIV/AIDS Prevention and Control, Wuhan Cen-
ter for Disease Control and Prevention; and †Department of Infectious planning, facilitation, and advocacy for options and services to meet the
Diseases, Wuhan Jin Yin-tan Hospital, Wuhan, Hubei, China social needs of patients of HIV/AIDS.8 Previous studies showed that
Acknowledgments: The authors appreciate the staff in district Centers for the percentage of HIV-positive patients reporting behaviors that put
Disease Prevention and Control of Wuhan and the case manager in a them at risk of transmitting the HIV declined from 41.3% to 29.4% af-
designated hospital that provided case management services in this study. ter they received prevention case management services.9 However,
Conflict of Interest and Sources of Funding: The authors declare that they existing studies have mostly been conducted in countries other than
have no competing interests. This work was supported by the Medical China10,11 and have focused on ARTadherence,12 clinical parameters,13
Research Project of Health and Family Planning Commission of and health-related quality of life.14 Few studies have reported the impact
Wuhan Municipality (WG18A06). of case management on the behavioral and biological risks factors for
Ethics: This study was approved by the ethics committee of Wuhan Center
for Disease Control and Prevention. contacting syphilis among MSM in China.15,16 Moreover, the interven-
N.X. and X.H. contributed equally to this work. tional efficiency and effects of case management models differed ac-
Correspondence: Xia Wang, MPH, Department of HIV/AIDS Prevention and cording to a previous study.17 Therefore, the influence of case
Control, Wuhan Center for Disease Control and Prevention, management on high-risk sexual behaviors and the incidence of
No. 288 Machang Rd, Jianghan District, Wuhan 430024, China. syphilis in patients with HIV/AIDS needs further investigation.
E‐mail: [email protected]. Wuhan introduced the case management model developed
Received for publication March 2, 2021, and accepted June 7, 2021. by Taiwan Chengkung University and was equipped with a trained
Supplemental digital content is available for this article. Direct URL full-time case manager to offer support to HIV-positive patients in
citations appear in the printed text, and links to the digital files are 2014.12 Therefore, we explored the impact of case management
provided in the HTML text of this article on the journal’s Web site
(http://www.stdjournal.com).
on unsafe sexual behaviors and the incidence of syphilis in
DOI: 10.1097/OLQ.0000000000001502 HIV-positive individuals in Wuhan.
Copyright © 2021 The Author(s). Published by Wolters Kluwer Health,
Inc. on behalf of the American Sexually Transmitted Diseases Associ- MATERIALS AND METHODS
ation. This is an open-access article distributed under the terms of the
Creative Commons Attribution-Non Commercial-No Derivatives License
4.0 (CCBY-NC-ND), where it is permissible to download and share Study Setting and Population
the work provided it is properly cited. The work cannot be changed in Recruitment of this study was conducted between May 2016
any way or used commercially without permission from the journal. and January 2017 in Wuhan. The participant inclusion criteria were

22 Sexually Transmitted Diseases • Volume 49, Number 1, January 2022

 Case Management on Risky Sexual Behavior and Syphilis

as follows: (1) male, (2) diagnosed with HIV, (3) ART-naive and by the case manager consisted of 3 parts: (1) medical education to
planning to initiate ART, and (4) self-reported of having been in- promote adherence to ART and address access to health services;
fected with HIV by having had sex with a man. The excluded (2) risky behavior interventions aimed at avoiding sexual-related
criteria were as follows: (1) severe neuropsychological impairment and drug-related risky behaviors that increased the risk of HIV
or psychosis, (2) current involvement in another behavioral inter- transmission or the acquisition of additional STDs, strategies for
vention study related to HIV, and (3) refusal to participate in the disclosing their HIV status to potential partners, and provision of
investigation and follow-up. We calculated the appropriate and a convenient way to offer testing to partners; and (3) mental health
minimum sample size according to sample size calculation pro- services, including social support and psychological counseling
cedures in randomized trials. Considering 10% of lost to follow- aimed at achieving a positive affect and cultivating supportive social
up, the final sample size was 110 in each group (Supplement relationships. The case manager evaluated the physical and psycho-
1, http://links.lww.com/OLQ/A710). logical status of the patients during each interview and provided the
This study was approved by the ethics committee of Wuhan appropriate services according to their needs. The different services
Center for Disease Control and Prevention. Adult participants gave for patients in the intervention and control groups are shown in
written informed consent before the survey, and minors younger Table 1.18
than 18 years provided consent forms signed by their parents or
guardians. The study flowchart is shown in Figure 1.
Data Collection
Randomization and HIV Case
Management Intervention Epidemiological data including sociodemographic factors
To account for the differences in regional economic condi- (age, education, marital status, and employment status) and health
tions, all participants were stratified into urban and suburban status were collected during face-to-face interviews by a trained in-
groups based on their addresses. Then, the participants were ran- vestigator at the baseline examination. Education was classified
domized within their subgroups to participate in the intervention into junior high school or lower, senior high school, or college
or control group. The control group received routine HIV-related or higher. Marital status was classified as single, married, or
care from a designated hospital, including ART guidance and lab- divorced/widowed. The self-reported STDs, which were diagnosed
oratory follow-up tests. Those in the intervention group regularly in the last 1 year before enrollment, were categorized into yes, no,
received additional services from a well-trained case manager via and unknown. The data extracted from the medical records included
face-to-face interviews. The medical worker who was selected to HIV-related symptoms, the HIV viral load, and the CD4 cell counts.
be the case manager attended 2- to 5-day trainings 3 or 4 times ev- Baseline and 6- and 12-month follow-up examinations were con-
ery year from April 2014 to November 2016 and practiced in the ducted at a designated hospital providing combined antiretroviral ther-
designated hospital before participating in our study. The training apy (cART) for most people living with HIV (PLWH) in Wuhan.
was conducted by the National Center for AIDS/STD Control and Nontreponemal antibodies against Treponema pallidum were
Prevention and included a comprehensive explanation of case measured by the rapid plasma reagin (RPR) test (Rongsheng-
management model, such as HIV-positive status notification, social biotech, Shanghai, China), and anti–treponemal-specific antibodies
support, and psychological and behavioral interventions. The case were measured by a chemiluminescent microparticle immunoassay
manager obtained second-level psychologist qualifications and (AR-CHITECT Syphilis TP; Abbott Laboratories, Chicago, IL).
was engaged in our study full-time. Positive RPR test (at any titer) and AR-CHITECT syphilis TP test
The case management process was individually tailored to results confirmed the diagnosis of syphilis (new infection). Patients
participants' specific life context, stressors, and goals. If a partici- who had a 4-fold increase in RPR test titers after the treatment of the
pant met the inclusion criteria and was randomized into the inter- prior infection were diagnosed as having a reinfection.
vention group, the case manager met with the participant in a To further explore the reasons for the difference in the inci-
private environment and informed the participant of his status dence of syphilis between the intervention group and the control
and offered support, giving them personalized advice with regard group among HIV-positive MSM, we recorded the risky sexual be-
to ART and their lifestyle. The case manager performed face-to-face haviors, which included multiple anal sex partners or unprotected
interviews with the patients every 2 weeks for the first month of the sexual intercourse engaged in by the members of both groups. The
intervention and then every month for the next 2 months, followed risky sexual behaviors of MSM were collected with the National
by every 3 months for the next 9 months. The intervention provided Sentinel Monitoring Questionnaire.

Figure 1. Study design and process. A, Flowchart of syphilis analysis. B, Flowchart of risky sexual behavior analysis.

Sexually Transmitted Diseases • Volume 49, Number 1, January 2022 23

Xie et al.

TABLE 1. Case Management Intervention Group Versus Routine Care Control Group
Intervention Control
Materials used
1. Easy-to-remember graph explaining how to take the medicine 1. Patient information leaflet
2. Pill box with electronic alarm clock to remind patients 2. Questionnaire to evaluate risky sexual behaviors
3. Questionnaire to evaluate risky sexual behaviors. The risky sexual
behaviors included sexual activities, the number of regular and casual
sexual partners and the use of condoms
4. Real-world examples about risky sexual behaviors (e.g., crime for
spreading HIV deliberately)
5. Information leaflet for safe sexual behaviors
6. Condom
7. HIV oral fluid self-test kits
Procedures (interventions and how they relate to the materials described)
1. Patients are explained the risks (e.g., viral resistance) of nonadherence and When the physician and patient agreed that treatment should
benefits (e.g., healthy immune system) of adherence. Case manager use be initiated, typically the following activities were done:
material 1 and material 2 to improve adherence 1. Patients are explained the risks (e.g., viral resistance)
2. Patients are given a personal phone number to call in case of difficulties and of nonadherence and benefits (e.g., healthy immune
reported medication spontaneously at any time system) of adherence (material 1)
3. Collect risky sexual behaviors in the past 6 mo by questionnaire and 2. Patients are given a working phone number to call in
why and how to reduce risky sexual behaviors by leaflets and cases case of difficulties (e.g., side effects)
(materials 3, 4 and 5) 3. Collect risky sexual behaviors in the past 6 mo by
4. Patients are provided condoms if they needed (material 6) questionnaire and explained why and how to reduce risky
5. Promote partner testing by oral education and provided HIV oral fluid sexual behaviors (material 2)
self-test kits (material 7) During follow-up visits:
6. Inform about the kinds and harm of new drugs, and consult patients with 4. Physician ask about any adverse effects and deal with
how to identify and avoid using them them (if severe, change of regimen is considered)
7. If patients had anxiety, depression, or sleep disorders, the case manager 5. Collect risky sexual behaviors by questionnaire every
carries out psychological consultation and referral to a psychiatrist when 6 mo
they need it
8. Inform patients of relevant social support, and provide consultation for
patients' family and friends if they need to create a better supportive
environment
During follow-up:
9. Physician and case manager ask about any adverse effects and deal with
them (if severe, change of regimen is considered)
10. Case manager evaluates whether risky sexual behaviors were reduced, if
there were any new barriers, and how the patient dealt with them
11. Replicate step 4–8

Outcomes STDs were entered into the GEE models as fixed variables,
Risky sex behaviors included sexual activities, the number whereas time was entered as time-varying variables.
of regular and casual sexual partners, and the use of condoms. We evaluated the relations between the case management
Condom use was described as always or sometimes. intervention and syphilis in HIV-positive MSM using Cox propor-
Syphilis episodes included new infections and reinfections, tional hazard models. We calculated the unadjusted hazard ratio.
which were both diagnosed by professional infectious disease spe- The adjusted hazard ratio (aHR) was calculated after controlling
cialists. A subject was defined as having a new episode of syphilis for age group, education, marital status, employment status,
if he was syphilis negative at baseline and diagnosed with syphilis HIV-related symptoms, HIV viral load, CD4 cell counts, and
at 6 or 12 months of follow-up. Patients with syphilis reinfections self-reported STDs.
were defined in a previous study as those who were diagnosed as Analyses were conducted with SAS (version 9.3; SAS Insti-
having syphilis at baseline, diagnosed as having syphilis recovery tute Inc.). A 2-sided P < 0.05 was considered statistically significant.
at 6 months, and rediagnosed as having syphilis at 12 months.6
RESULTS
Statistical Analysis
Baseline characteristics are presented as percentages for Characteristics of Study Population
discrete variables, and the χ2 test or Fishers exact test was used The baseline characteristics of the study participants are
to evaluate the distribution of categorical data. Generalized esti- presented in Table 2. There were no statistically significant differ-
mating equation (GEE) modeling, which included those partici- ences between the participants in the intervention and control
pants who attended at least 1 follow-up visit (n = 219) across the groups with regard to sociodemographic factors, HIV-related
3 time points (baseline, 6 months, 12 months), was used to calcu- symptoms, HIV viral load, CD4 cell counts, or self-reported STDs
late odds ratios and 95% confidence intervals (CIs) for HIV trans- at baseline. A description of the 166 participants involved in the
mission behaviors and the case management intervention.19 Age syphilis analysis is shown in Supplement 2, http://links.lww.com/
group, education, marital status, employment status, and self-reported OLQ/A710.

24 Sexually Transmitted Diseases • Volume 49, Number 1, January 2022

 Case Management on Risky Sexual Behavior and Syphilis

TABLE 2. Characteristics of Participants at Baseline

All Cases, Intervention, Control,
Characteristics n (%) n (%) n (%) χ2/t P
Age, mean ± SD, y 31.3 ± 11.2 31.8 ± 12.0 30.7 ± 10.4 0.76 0.449
Age group, y 2.00 0.369
≤24 71 (32.3) 34 (30.9) 37 (33.6)
25–49 129 (58.6) 63 (57.3) 66 (60.0)
≥50 20 (9.1) 13 (11.8) 7 (6.4)
Marital status 1.95 0.377
Single 170 (77.3) 82 (74.5) 88 (80.0)
Married 21 (9.5) 10 (9.1) 11 (10.0)
Divorced/widowed 29 (13.2) 18 (16.4) 11 (10.0)
Education 3.19 0.203
College or higher 141 (64.1) 72 (65.5) 69 (62.7)
Senior high school 55 (25.0) 30 (27.3) 25 (22.7)
Junior high school or lower 24 (10.9) 8 (7.3) 16 (14.5)
Employment status 0.16 0.686
Permanent job 105 (47.7) 51 (46.4) 54 (49.1)
Unemployed/temporary 115 (52.3) 59 (53.6) 56 (50.9)
HIV-related symptoms*† 1.22 0.269
Yes 88 (40.4) 48 (44.0) 40 (36.7)
No 130 (59.6) 61 (56.0) 69 (63.3)
CD4 cell counts, cells/μL* 1.61 0.448
<200 51 (23.4) 28 (25.7) 23 (21.1)
200–350 78 (35.8) 41 (37.6) 37 (33.9)
≥350 89 (40.8) 40 (36.7) 49 (45.0)
HIV viral load (Log10), copies/mL* 0.40 0.525
<5 166 (76.1) 81 (74.3) 85 (78.0)
≥5 52 (23.9) 28 (25.7) 24 (22.0)
Self-reported STDs 5.19 0.075
Yes 16 (7.3) 10 (9.1) 6 (5.5)
No 173 (78.6) 90 (81.8) 83 (75.5)
Unknown 31 (14.1) 10 (9.1) 21 (19.1)
Syphilis at baseline 6.09 0.014
Positive 47 (21.4) 16 (14.5) 31 (28.2)
Negative 173 (78.6) 94 (85.5) 79 (71.8)

*Two participants were missing the information.

†
HIV-related symptoms refer to continuous or intermittent fever (>38°C), skin damage, thrush, persistent diarrhea, and others.

Risky Sexual Behaviors of Participants During the (0.24–1.14), and multivariable-adjusted HR (95% CI) was
12-Month Follow-Up 0.34 (0.13–0.90). The significant predictors of a new case of
As shown in Table 3, the proportion of participants who al- syphilis during follow-up among HIV-positive MSM were be-
ways used condoms with regular sexual partners (25.6%–87.5%, ing divorced or widowed (aHR = 5.86, 95% CI = 1.46–23.62),
P < 0.001) or casual sexual partners (31.8%–94.4%, P < 0.001) being unemployed (aHR = 2.99, 95% CI = 1.05–8.47), and having
significantly increased over the 12 months in the intervention self-reported STDs at baseline (aHR = 6.14, 95% CI = 1.80–20.93;
group. The same trend was observed in the percentage of partici- Table 4).
pants who did not have casual sexual partners (23.9%–50.0%,
P < 0.001). A total of 56.6% and 40.6% of the control group and DISCUSSION
intervention groups, respectively, had sexual activities in the past
6 months, although the proportions significantly decreased in both In this study, we found that supporting patients by case
groups at follow-up. However, GEE model analyses showed that management reduced the risk of syphilis in HIV-positive MSM
there were no significant differences in sexual behaviors over time China. We also observed a significant reduction in multiple anal
between the intervention and control groups. sex partners or unprotected sexual intercourse in both the interven-
tion and control groups over the 1-year follow-up but did not differ
by group.
Associations Between Case Management The risk of syphilis in the intervention group in our study
and Syphilis Among PLWH was significantly reduced, which indicated the effectiveness of this
After an average of 12.3 months (total person-years, 166) of strategy. Studies on behavioral interventions aimed at preventing
follow-up, we documented 26 incident infection syphilis cases (22 concurrent syphilis have rarely been conducted among HIV-positive
new infections and 4 reinfections). The incidence rates in the inter- MSM. Previous studies have shown that interventions educating indi-
vention and control groups were 11.3 per 100 person-years and viduals could enhance their understanding of risky sexual behaviors
20.6 per 100 person-years, respectively, and Kaplan-Meier sur- and increase self-reported condom use, thereby preventing them from
vival analysis showed no significant difference between the 2 contacting syphilis.20 In addition, case management services could
groups (P = 0.098, Supplement 4, http://links.lww.com/OLQ/ address the need for emotional counseling and other supportive ser-
A710). The number needed to treat in our study was 11. The vices and improve adherence to highly active antiretroviral therapy.21
unadjusted HR (95% CI) for the intervention group was 0.52 Treatment of HIV infections with highly active antiretroviral therapy

Sexually Transmitted Diseases • Volume 49, Number 1, January 2022 25

26
Xie et al.

TABLE 3. Sexual Behaviors Changes Among Participants in Different Groups During the 12-Month Follow-Up
Intervention Control
Baseline, 6 mo, 12 mo, Baseline, 6 mo, 12 mo, OR aOR
Behaviors in the Past 6 mo n (%) n (%) n (%) χ2 P n (%) n (%) n (%) χ2 P (95% CI)* (95% CI)†
Sexual activities‡ 38.73 <0.001 19.79 <0.001 0.26 (−0.16 to 0.68) 0.21 (−0.28 to 0.69)
No 22 (20.0) 57 (53.3) 57 (59.4) 24 (22.0) 49 (51.0) 36 (43.4)
Yes 88 (80.0) 50 (46.7) 39 (40.6) 85 (78.0) 47 (49.0) 47 (56.6)
Regular sexual partners 4.83 0.089 3.22 0.200 0.97 (0.58 to 1.63) 0.97 (0.39 to 2.43)
No 45 (51.1) 17 (34.0) 14 (35.9) 41 (48.2) 17 (36.2) 16 (34.0)
Yes§ 43 (48.9) 33 (66.0) 25 (64.1) 44 (51.8) 30 (63.8) 31 (66.0)
Condom use with regular sexual partner¶ 29.56 <0.001 30.41 <0.001 1.21 (0.64 to 2.26) 1.05 (0.21 to 5.24)
Always 11 (25.6) 24 (72.7) 21 (87.5) 9 (20.5) 21 (72.4) 24 (77.4)
Sometimes 32 (74.4) 9 (27.3) 3 (12.5) 35 (79.5) 8 (27.6) 7 (22.6)
No. casual sexual partner 17.96 <0.001 2.56 <0.281 0.76 (0.46 to 1.23) 0.47 (0.18 to 1.21)
0 21 (23.9) 29 (58.0) 19 (50.0) 33 (38.8) 23 (48.9) 24 (52.2)
≥1 67 (76.1) 21 (42.0) 19 (50.0) 52 (61.2) 24 (51.1) 22 (47.8)
Condom use with casual sexual partner|| 32.51 <0.001 9.01 0.011 1.20 (0.66 to 2.17) 0.23 (0.03 to 1.67)
Always 21 (31.8) 17 (85.0) 17 (94.4) 17 (32.7) 15 (62.5) 14 (63.6)
Sometimes 45 (68.2) 3 (15.0) 1 (5.6) 35 (67.3) 9 (37.5) 8 (36.4)

*Odds ratios (ORs) and 95% confidence intervals (CIs) for HIV transmission behaviors and case management intervention with bivariable GEE model.
†
Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) HIV transmission behaviors and case management intervention adjusted by age, marital status, education, employment status, self-reported

Sexually Transmitted Diseases

STDs, time, and group  time.

•
‡
Sexual activities was defined as participants having sex with men during the last 6 months.
§
Participants who had at least one regular sexual partner.
¶
There are one participant in the intervention group who refused to answer this question at 12 months and one participant in the control group who refused to answer this question at 6 months.
||
There is one participant in the intervention group who refused to answer this question at 12 and 6 months, respectively.

Volume 49, Number 1, January 2022

 Case Management on Risky Sexual Behavior and Syphilis

TABLE 4. Hazard Ratio (95% CIs) for Case Management Intervention and Syphilis Among PLWH
Unadjusted Hazard Adjusted Hazards
Characteristics Ratio (95% CI) P Ratio (95% CI)† P
Group
Control Ref Ref
Intervention 0.52 (0.24–1.14) 0.104 0.34 (0.14–0.87) 0.023*
Age group, y
≤24 Ref Ref
25–49 1.29 (0.52–3.21) 0.578 0.55 (0.17–1.74) 0.306
≥50 2.80 (0.89–8.82) 0.079 0.75 (0.14–3.93) 0.736
Marital status
Single Ref Ref
Married 1.38 (0.40–4.71) 0.609 2.46 (0.55–10.95) 0.237
Divorced/Widowed 3.11 (1.22–7.92) 0.017* 5.86 (1.46–23.62) 0.013*
Education
Junior high school or lower Ref Ref
Senior high school 1.15 (0.47–2.79) 0.763 0.33 (0.09–1.20) 0.092
College or higher 01.26 (0.37–4.31) 0.717 0.32 (0.08–1.31) 0.113
Employment status
Permanent job Ref Ref
Unemployed/Temporary 2.79 (1.19–6.29) 0.018* 2.99 (1.05–8.47) 0.040*
HIV-related symptoms‡
No Ref Ref
Yes 0.84 (0.38–1.86) 0.668 1.08 (0.46–2.58) 0.855
CD4 cell counts, cells/μL
<200 Ref Ref
200–350 1.17 (0.39–3.51) 0.774 1.41 (0.45–4.48) 0.558
≥350 1.27 (0.45–3.60) 0.658 1.68 (0.54–5.30) 0.373
HIV viral load (Log10), copies/mL
<5 Ref Ref
≥5 1.19 (0.52–2.74) 0.682 1.63 (0.65–4.10) 0.298
Self-reported STDs
No Ref Ref
Yes 4.69 (1.82–12.06) 0.001* 6.14 (1.80–20.93) 0.004*
Unknown 1.25 (0.42–3.74) 0.695 1.04 (0.32–3.46) 0.944

*P < 0.05
†
Adjusted age, marital status, education, employment status, BMI, HIV-related symptoms, CD4 cell counts, HIV viral load, and self-reported STDs.
‡
HIV-related symptoms refer to continuous or intermittent fever (>38°C), skin damage, thrush, persistent diarrhea, and others.

improves syphilis serological responses in coinfected patients,22 incidence of asymptomatic syphilis supports the need for rou-
which could promote recovery from syphilis and reduce reinfections. tine annual syphilis testing for HIV-positive persons.28 We also
However, participants who received the case management found that being divorced or widowed may be a risk factor for
intervention did not differ significantly from those receiving rou- syphilis, as were being unemployed and self-reported STDs at
tine care with regard to the reduction in multiple anal sex partners baseline. Participation in syphilis screening is important for these
or unprotected sexual intercourse. This finding was similar to the high-risk groups.
effects on risky sexual behaviors observed in other studies on in- To our knowledge, this is the first study to demonstrate that
terventions among HIV-infected MSM.23 Previous studies have supporting PLWH beyond supplying the ART regimen with stan-
shown that HIV-positive patients decrease the frequency of engag- dard case management could reduce the incidence of syphilis in
ing in risky sexual behaviors by 30% to 55% under regular medi- MSM in China. Nevertheless, our study has several limitations.
cal care, especially in the initial years, followed by a 61% increase First, 19% of the participants did not complete the 3 follow-up
in unprotected anal sex 4 years after seroconversion.24 Subjects re- visits, which could have affected the analysis of risky behaviors.
cruited for our study were newly diagnosed HIV-positive patients We calculated the proportion of patients with missing data (Supple-
and were followed up for 1 year, which was too short a duration to re- ment 3, http://links.lww.com/OLQ/A710), and the GEE model is
veal the long-term effect. It is necessary to extend the follow-up pe- capable of addressing random missing repeated-measures data.29
riod to determine the long-term impact of case management. In Meanwhile, the unbalanced loss to follow-up in syphilis analysis be-
addition, studies have shown that syphilis is a more objective bio- tween the 2 groups could underestimate the treatment effect. In ad-
logical outcome than self-reported sexual behaviors.25 dition, relying on self-reports of sexual behavior could have led to
Our study revealed that the observed incidence of syphilis reporting bias, which may have led to the underestimation of risky
was approximately 11.8%, with 11.3 incident cases per 100 sexual behaviors.30 Hence, we used syphilis as the main outcome
person-years of follow-up, in the case management group and to evaluate the effect of case management.
20.5%, with 20.6 incident cases per 100 person-years of follow- In conclusion, there is a substantial risk to contacting syph-
up, in the control group. This prevalence was higher than that pre- ilis for HIV-positive MSM who receive regular ART in Wuhan.
viously reported among heterosexual males in Jiangsu, China,26 Case management is an effective and feasible strategy to reduce
males in Singapore,27 and MSM in Taiwan, China.16 The high the risk of syphilis.

Sexually Transmitted Diseases • Volume 49, Number 1, January 2022 27

Xie et al.

REFERENCES 16. Ko NY, Liu HY, Lee HC, et al. One-year follow-up of relapse to risky
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28 Sexually Transmitted Diseases • Volume 49, Number 1, January 2022