Depressive symptoms, perceived social support, and anticipated HIV stigma among HIV‐negative/unknown men who have sex with men in China during the COVID‐19 pandemic: A multicenter online cross‐sectional study

Abstract Objective To investigate the prevalence of depressive symptoms among human immunodeficiency virus (HIV)‐negative/unknown men who have sex with men (MSM) in China and explore the relationship between perceived social support, anticipated HIV stigma, and depressive symptoms. Methods Participants in this study were recruited from a gay social networking app (Blued) in China by convenience sampling from December 16, 2020 to March 1, 2021. Perceived Social Support Questionnaire, Anticipated HIV Stigma Questionnaire, and Center for Epidemiologic Studies Depression Scale were used to measure the social support, anticipated HIV stigma, and depressive symptoms of participants. Confirmatory factor analysis was performed to assess the reliability and validity of the measurement model. Structural equation modeling was employed to evaluate the association of perceived social support, anticipated HIV stigma, and depressive symptoms, as well as the mediation effects. Results Overall, 47.70% (665/1394) of the participants had depressive symptoms. Perceived social support could have both direct and indirect effects on depressive symptoms with the mediating role of anticipated HIV stigma among HIV‐negative/unknown MSM. Conclusion Tailored interventions regarding perceived social support and anticipated HIV stigma, such as group therapy, mutual support groups and mindfulness training, with the involvement of non‐governmental or governmental organizations, should be taken into account to reduce depressive symptoms and stigma among HIV‐negative/unknown MSM in China.


INTRODUCTION
Men who have sex with men (MSM) refer to men who have anal or oral sex with men, regardless of their sexual orientation (Shadaker et al., 2017). High-risk sexual behaviors among MSM could increase their risk of human immunodeficiency virus (HIV) infections and other sexually transmitted diseases (Ochonye et al., 2019). It was estimated that MSM are 26 times more likely to be infected with HIV than the general population (UNAIDS, 2020). Previous results of meta-analyses indicated that the prevalence of HIV infection among MSM was 12.37% in the United States, 17.81% in sub-Saharan Africa, and 5.7% in China, which were higher than that of men in the general population and had a tendency of continuous increase as time progressed (Crepaz et al., 2019;Dong et al., 2019;Hessou et al., 2019). In China, sexual transmission is the main route of HIV infection, and about 28% of HIV infections in China were attributed to high-risk sexual behaviors among MSM (CDC, 2016).
Due to the stigma associated with homosexual activity, low social acceptance toward them was prevalent in many countries (Jiang et al., 2019). It was estimated that 78.53% of the Chinese people did not fully accept MSM behavior because of the high rate of HIV infection among MSM and the conservative cultural context (Xie & Peng, 2018). In this case, MSM often suffer much incomprehension, prejudice, discrimination, and stigmatization against them, which may lead to negative psychological outcomes, especially depressive symptoms (Ross et al., 2020;Su et al., 2018;Wei et al., 2020). Previous systematic reviews suggested that the prevalence of depressive symptoms among Chinese MSM was 30.0%-40.0%, which was higher than that of the general population in China Lu et al., 2021;Wei et al., 2020).
Additionally, evidence suggested that the outbreak of the coronavirus disease 2019  has also had a great impact on the mental health of MSM in the United States and France as the lockdown may separate them from sexual partners and reduce the acquisition of pre-exposure prophylaxis (PrEP) (Di Ciaccio et al., 2022;Roux et al., 2022;Wang et al., 2022). Long-term depressive symptoms could not only deteriorate MSM's psychological health but also increase the occurrence of unhealthy lifestyles, including high-risk sexual behaviors, low adherence to PrEP, self-harm, and even suicide intentions (Velloza et al., 2020;Vijayakumar et al., 2022). Hence, reducing the risk of depressive symptoms among MSM, especially during the COVID-19 pandemic, may be helpful in reducing the risk of contracting HIV, which will in turn improve their quality of life and well-being.
In addition to the previous SES and behavioral indicators, psychosocial factors also played important roles on psychological well-being of MSM, especially perceived social support and anticipated HIV stigma, which have been proved to be related to depressive symptoms by various studies (Stahlman et al., 2015;Storm et al., 2021;Wagner et al., 2019;Yan et al., 2019). Perceived social support refers to one's abil-ity to perceive the material, psychological, and comprehensive support from their surroundings when in need (Ioannou et al., 2018). Studies have shown the association between a low level of social support and depressive symptoms in young adults, trans women, adolescents, and HIV-positive MSM (Ioannou et al., 2018;Ren et al., 2018;Tantirattanakulchai & Hounnaklang, 2022). Additionally, the previous research also showed the influence of HIV-related stigma on psychological functioning among MSM, including depressive symptoms (Starks et al., 2013;Tao et al., 2017). For HIV-negative/unknown MSM, the HIV-related stigma is often regarded as "anticipated HIV stigma," which is defined as the expectation of the prejudice, rejection, and bias one may experience if they were infected with HIV .
Anticipated HIV stigma is common among HIV-negative/unknown MSM and could hurt their psychological functioning (Golub & Gamarel, 2013). Literatures have also suggested that low perceived social support is a predictor of disease-related stigma among tuberculosis patients and MSM Galvan et al., 2008).
Hence, the effect of anticipated HIV stigma and social support on depressive symptoms has garnered considerable empirical support, and the mediation effect of anticipated HIV stigma between perceived social support and depressive symptoms may exist among HIV-negative/unknown MSM (Choi et al., 2016;Hylton et al., 2017;Yan et al., 2019   and has been used among Chinese MSM population . It contains two items, and each item is 11-point Likert scaled from 0 to 10 (0 = Strongly Disagree; 10 = Strongly Agree). Higher total scores indicated a higher level of perceived support. Cronbach's α of the questionnaire in this study was 0.716.

Anticipated HIV stigma
Participants' anticipated HIV stigma was measured by Anticipated HIV Stigma Questionnaire developed by Golub and Gamarel (2013). The questionnaire contains seven items and each item is rated on a 4-point Likert scale (1 = Strongly Disagree; 4 = Strongly Agree). This questionnaire has been validated and used among MSM with HIV-negative or unknown status to investigate their anticipated stigma Lian et al., 2022). Higher total values indicated greater anticipated stigma. Cronbach's α of the questionnaire in this study was 0.837.

Depressive symptoms
Center for Epidemiologic Studies Depression Scale (CES-D 10 ) was used to measure the depressive symptoms of participants in the current study. The scale was developed by Radloff (1977) and was introduced and adapted to the Chinese cultural context by Yu et al. (2013). It contains 10 items and each item was 4-point Likert scaled (0 = Never or seldom; 4 = Most or all of the time). Higher total scores indicated a higher level of depressive symptoms, a total score equal to or higher than 10 could indicate having depressive symptoms. Cronbach's α of the scale in this study was 0.863.

Statistical analysis
Descriptive and univariate analyses were performed to identify the participants' demographic characteristics and their association with depressive symptoms. Before the structural equation model analysis, a three-factor confirmatory factor analysis with oblique rotation was performed to evaluate the reliability and validity of the measurement model (Jackson et al., 2009). The maximum likelihood sandwich estimator with robust standard errors method was employed to modify model fit and parameter estimates to accommodate the lack of multivariate normality (Yuan & Bentler, 2000). The model fit of the  (Segars, 1997). The discriminant validity of the measurement model was evaluated using the AVE method (Fornell & Larcker, 1981).
Structural equation modeling analysis was employed to evaluate the association of perceived social support, anticipated HIV stigma, and depressive symptoms. Mediation analysis was used to test the mediating effect of anticipated HIV stigma between perceived social support and depressive symptoms by a maximum likelihood method with 5000 bootstrap sampling (Mackinnon, 2008). All the statistical analyses were performed using SAS 9.4 and Mplus 8.3.

Demographic characteristics
In this study, 47.70% (665/1394) of the participants had depressive symptoms. Age, marriage, work status, income, having sex with a male in the last 6 months, and having sex with a female in the last 6 months were negatively associated with depressive symptoms. The descriptions of demographic characteristics and depressive symptoms, perceived social support, and anticipated HIV stigma are presented in Table 1.

Structural equation model analysis
In  Table 5.

DISCUSSION
In this cross-sectional study, a structural equation The accompanying social isolation is likely to be detrimental to mental health, particularly for MSM (Evans & Fisher, 2022). A previous study also reported that levels of depressive symptoms increased with high levels of loneliness among youth during the pandemic . Abbreviations: CI, confidence interval; LL, lower limit; UL, upper limit.
also indicated that living with a partner can be a protective factor against loneliness for MSM (Groarke et al., 2020). The COVID-19 pandemic and resulting preventive measures made it difficult for MSM to seek sexual partners and live with them together (Hyndman et al., 2021). Hence, a high level of loneliness caused by the lockdown might reduce their perceived social support (Liu et al., 2016). Though relatively low compared to the previous study, perceived social support was still a protective factor against depressive symptoms among HIVnegative/unknown MSM in the current study, which was consistent with the previous research (Yan et al., 2019). MSM with a higher level of perceived social support were easier to perceive the care and respect from their surroundings; in this case, their negative emotions could be buffered, thus preventing the occurrence of depressive disorders when encountering negative events (Yoneda et al., 2021). In this case, developing more online or offline supportive interaction systems for MSM during the COVID-19 pandemic is warranted to enhance their peer support and material support, thus improving their level of perceived social support (Wu et al., 2019;Zhao et al., 2021). Additionally, given the discrimination and prejudice toward MSM from some other people, the government and relative social media should consider appealing general population to understand and support MSM, to help them perceive the support from their surroundings more easily, then their depressive disorders could be reduced accordingly (Wu et al., 2019).
In the current study, having had intercourse with either a male or a female partner was negatively associated with depressive symptoms.
According to a case-control study, a lack of sexual activity during lock-down is connected with a considerably increased chance of developing depression (Mollaioli et al., 2021). A possible explanation is that sexual activity decreased due to lockdown, and consequent loneliness and the absence of the sexual partner could be a risk factor for depressive symptoms (Mollaioli et al., 2021). At the same time, the previous studies also showed that depressive symptoms could cause decreased libido (Lourenco et al., 2011;Phillips & Slaughter, 2000). It has been demonstrated that MSM with depressive symptoms have lower testosterone level, which is associated with lower sexual desire, than those without depressive symptoms (Baischer et al., 1995;Burris et al., 1992;Osran et al., 1993). Moreover, depressive symptoms have been proved to be one of the most common comorbid problems among various populations (Perelman, 2011). Therefore, for MSM who seek assistance via counseling services on sexual dysfunction, it is of importance for the medical care workers to screen depressive symptoms among them, pay attention to the comorbidity of depression and sexual dysfunction, and further provide appropriate treatment on both illness and address the relationship between them.
The score of Anticipated HIV Stigma Questionnaire was similar to the result of a cross-sectional study in 2016 in China, indicating a continuous high prevalence of anticipated HIV stigma among MSM in China whether there is COVID-19 or not . In addition, the score of anticipated HIV stigma in this study is higher than that reported in the United States among MSM in 2013, which might result from the varied attitude toward the MSM population under different cultural and social contexts (Golub & Gamarel, 2013;. Studies have shown some potential causes of high anticipated HIV stigma among MSM in China. First, HIV infection is still regarded to be associated with a lack of morality and profligacy by certain amount of people in China, which could increase anticipated stigma of MSM due to the relatively high prevalence of HIV infection among this population . Second, the government and society have been dedicated to the promotion of HIV prevention measures like PrEP among MSM, which might inadvertently cause anticipated stigma through images that they have to take daily pills to avoid HIV infection (Dubov et al., 2018). Third, the lack of sex education and inaccurate beliefs about HIV may lead to unnecessary and exaggerated fears of HIV, which is particularly prominent among MSM as they are usually described as the ones at high risk of HIV infection; therefore, they are usually more intended to develop anticipated HIV stigma than general population .
The model of this study revealed that anticipated stigma is positively associated with depressive symptoms among HIV-negative/unknown MSM, which was similar to the result of the previous research (Lo Hog Tian et al., 2021). HIV-negative/unknown MSM with anticipated HIV stigma may have low self-identity, hence, often take negative coping styles when facing negative events, which may further lead to depressive symptoms (Choi et al., 2016). helping people achieve a state of alert, focused relaxation by deliberately paying attention to thoughts and sensations without judgment at present, and mindfulness intervention has proved effective to improve mental health among various population (Slomski, 2020;Wells et al., 2021). Researchers have proposed a protocol aimed at implementing an online mindfulness intervention named "Mindfulness Living With Challenge" (MLWC) in COVID-19 patients in China . A randomized controlled trial has demonstrated its effect on improving the psychological well-being of Chinese nursing students

CONCLUSIONS
In sum, our study suggested that both perceived social support and anticipated HIV stigma were associated with depressive symptoms among HIV-negative/unknown MSM in China, and that anticipated HIV stigma could serve as a mediator between perceived social support and depressive symptoms. Tailored interventions regarding perceived social support and anticipated HIV stigma such as group therapy, mutual support groups, and mindfulness training, with the involvement of nongovernmental or governmental organizations, should be taken into account to reduce depressive symptoms among HIVnegative/unknown MSM in China. All authors have read and agreed to the published version of the manuscript.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

INFORMED CONSENT STATEMENT
Informed consent was obtained from all subjects involved in the study.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author, upon reasonable request.