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Introduction
The proportion of men who have sex with men (MSM) in the HIV epidemic of China appears to be growing. 1 Epidemiological studies of MSM suggest a national prevalence of HIV at 4.9%, continuing high incidence and high levels of risk behaviour. 2-7
However, many MSM in China have never tested for HIV, with coverage estimated between 25% and 49%. 8-11 As a consequence, few HIV-positive MSM are aware of their infection. For example, a study in Beijing found only 5 of 36 HIV-positive MSM (13.9%) detected in the survey were aware of their infection. 11 Barriers included not knowing where to get tested and fear of discrimination if positive. Low HIV status awareness may drive transmission among MSM for behavioural and biological reasons. Persons with HIV who are aware of their status are more likely to take precautions to prevent transmission. 12-16 One randomised controlled trial among heterosexual couples demonstrated reduction of HIV transmission to partners from persons on antiretroviral therapy (ART). 17 Meanwhile, evidence indicates earlier treatment of HIV is beneficial to the individual. 18
In order to maximise the benefits of ART, high levels of engagement in services are required at multiple steps. 19 Figure 1 illustrates the 'treatment cascade' with adaptations for the Chinese context. In many provinces of China, initial HIV-positive ELISA tests require western blot confirmation by the Centres for Disease Control and Prevention (CDC) for diagnosis. Following a wait of 2-7 days for confirmatory results, patients require CDC follow-up for case management to HIV care. Linkage to care is made in the jurisdiction of diagnosis if the patient is an official/permanent resident; otherwise linkage is made through referral to their place of residence. Prescription of ART depends on the stage of HIV infection, in practice based on CD4 count. In 2012, the CD4 criterion for ART initiation in China was <=350 cell/mm 3 . 20 Viral load suppression (the final stage of the cascade) depends on adherence and drug resistance.
In brief, there are formidable barriers to achieving a high level of treatment among MSM with HIV in China. While all steps need to be maximised, clarifying which steps produce the greatest losses will help efficiently target interventions. For Chinese MSM, data indicate great loss from...