Pay-it-forward strategy to enhance uptake of dual gonorrhea and chlamydia testing among men who have sex with men in China: a pragmatic, quasi-experimental study

Lancet Infect Dis. 2019 Jan;19(1):76-82. doi: 10.1016/S1473-3099(18)30556-5.


Background: Chinese men who have sex with men (MSM) rarely receive gonorrhoea and chlamydia testing. The purpose of this pilot study was to evaluate a pay-it-forward strategy to increase uptake of gonorrhoea and chlamydia testing among MSM.

Methods: We performed a quasi-experimental pragmatic study to compare a pay-it-forward model with standard of care at two HIV testing sites for MSM in Guangzhou, China: an STD clinic for MSM and a local MSM community-based organisation. All men who arrived at the STD clinic or the community-based organisation were invited to participate. In the pay-it-forward programme, men were offered free gonorrhoea and chlamydia testing and given the option of donating money toward testing for future participants. In the standard-of-care group, men were offered gonorrhoea and chlamydia testing at the standard patient price of ¥150 (about US$21·50). The pay-it-forward programme was implemented for 3 months, after which both sites switched to standard of care offering dual testing for 3 months. The primary outcome for this study was uptake of dual gonorrhoea and chlamydia testing, which we compared using χ2 test and logistic regression, reported as crude odds ratios (cOR) and adjusted odds ratios (aOR), by adjusting for nationality, marital status, income, and site of testing.

Findings: The pay-it-forward programme took place from Dec 2, 2017, to Feb 3, 2018, and the standard-of-care control took place from March 11, 2018, to May 1, 2018. 408 men were included in this study. 203 men were offered pay-it-forward, and 205 were offered standard of care. Overall, 109 (54%) of 203 men in the pay-it-forward group and 12 (6%) of 205 men in the standard-of-care group received gonorrhoea and chlamydia testing (cOR 18·65, 9·78-35·54; p<0·0001; aOR 19·73, 95% CI 10·02-38·85; p<0·0001). Of all 121 men who tested, this was the first gonorrhoea test for 97 (80%) men and the first chlamydia test for 104 (86%) men. Five (4%) of these 121 men were diagnosed with gonorrhoea and 15 (12%) were diagnosed with chlamydia. 97 (89%) of 109 men who received testing in the pay-it-forward group donated some money toward testing for future participants.

Interpretation: Pay-it-forward might be a sustainable model for expanding integrated HIV testing services among MSM in China.

Funding: National Institutes of Health, Southern Medical University Dermatology Hospital, Doris Duke Charitable Foundation.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • China
  • Chlamydia / genetics
  • Chlamydia Infections / diagnosis*
  • Chlamydia Infections / microbiology
  • Gonorrhea / diagnosis*
  • Gonorrhea / microbiology
  • HIV / immunology
  • HIV Infections / diagnosis
  • HIV Infections / virology
  • Homosexuality, Male*
  • Humans
  • Logistic Models
  • Male
  • Mass Screening / economics*
  • Mass Screening / methods*
  • Neisseria gonorrhoeae / genetics
  • Non-Randomized Controlled Trials as Topic
  • Odds Ratio
  • Pilot Projects
  • Pragmatic Clinical Trials as Topic
  • Sexual and Gender Minorities*