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Human immunodeficiency virus (HIV) testing is a crucial strategy for HIV prevention. HIV testing rates remain low among men who have sex with men (MSM) in China. Digital network-based secondary distribution is considered as an effective model to enhance HIV self-testing (HIVST) among key populations. Digital platforms provide opportunities for testers to apply for HIVST kits by themselves, and secondary distribution allows them to apply for multiple kits to deliver to their sexual partners or members within their social network. We describe a three-arm randomized controlled trial to examine the effect of monetary incentives and peer referral in promoting digital network-based secondary distribution of HIVST among MSM in China.
HIV testing rates remain suboptimal among MSM in China. Innovative interventions are needed to further expand the uptake of HIV testing among key populations. The findings of the trial can provide scientific evidence and experience on promoting secondary distribution of HIVST to reach key populations who have not yet been covered by existing testing services.
Digital network-based secondary distribution of HIVST could be an effective strategy for promoting HIVST. This is a strategy that individuals (defined as indexes) to apply for multiple HIVST kits and distribute them to their sexual partners or other members (defined as alters) within their social network [14, 15]. A cohort study conducted in Kenya has proven the feasibility and acceptability of secondary distribution of HIVST among female sex workers [14]. One observational study in China also indicated that secondary distribution of HIVST successfully reached people who were not covered by traditional testing services and promoted case identification [16].
In this study, we intend to examine two modified secondary distribution approaches for HIVST through a three-arm randomized controlled trial in Zhuhai, China. The main purpose of this study is to compare the effectiveness of two modified secondary distribution approaches (monetary incentives, and monetary incentives plus peer referral) with the traditional secondary distribution approach, in order to determine whether these two approaches can increase the uptake of HIVST among MSM, especially the first-time testers among alters.
Index MSM in this arm will first receive the same intervention as the participants received in the monetary incentives arm. In addition, apart from applying for up to five self-testing kits, each index MSM in this arm will obtain a unique referral link, which can be shared with up to 5 individuals within their social network to apply for kits, and each alter can apply for only one kit through the link. Similarly, indexes will be given 20 RMB for each matched alter who returns the result (whether through peer referral or direct distribution). All testers will receive a monetary incentive of 20 RMB once they complete uploading their results.
The primary outcomes of this trial consist of three parts: 1) Mean number of motivated alters who have photo-verified self-testing per index in each arm; 2) Proportion of first-time HIV testing among alters in each arm; 3) Proportion of alters with a positive HIV testing result in each arm.
The secondary outcomes of this study consist of three parts 1) Risky sexual behavior among indexes and alters in each arm; 2) Adverse events reported during secondary distribution among indexes and alters in each arm; 3) Attitude towards and past experiences of HIVST and sexual behavior among alters in each arm.
In the baseline survey, we will collect the socio-demographic characteristics, sexual orientation, sexual behavior, HIV testing history, and social network. When alters return the results, they will also complete a questionnaire online. In this survey, except for basic information on socio-demographic characteristics, sexual orientation, sexual behavior, HIV testing history, and social network will be collected. We will also investigate the attitudes and experiences towards self-test. The follow-up survey for indexes will take place 3 months after the application completed, which focuses on experiences and attitudes on using and distributing self-test kits. The survey mainly inquires about the occurrence of intimate partner violence (IPV) or other adverse events, the relationship between the indexes and the alters, whether indexes have tested together with the alters, and whether indexes have guided the alters on how to perform HIVST.
However, it is necessary to consider several limitations of this trial. First, due to the digital network strategy, access to this HIVST service is limited so that the recruitment might overlook individuals who cannot access online social tools. However, the mobilization and promotion from the local CBO Xutong, as well as the face-to-face distribution initiated by index MSM can somehow resolve the problem. Second, in the online surveys, behaviors of participants are self-reported, which may increase the possibility of social desirability bias. It can lead to the Hawthorne effect that participants may have deviations in behavior reporting because of the awareness of the trial. However, the form of the online questionnaire and limiting collection of identifiers can reduce bias. Third, from the perspective of implementation and promotion, each participant can only apply once due to the design of the trial, while there may be participants who have the habit of regular testing and request to apply for HIVST kits multiple times. While in this project we cannot satisfy such demand, the future implementation model can expand access to multiple applications.
The study timeline was designed from 01, September 2019 to 31, May 2020. At the time of writing this draft protocol, study enrollment and data collection are ongoing. Due to COVID-19 pandemic, study recruitment expects to be delayed till 31, September 2020, and the follow-up will be finished by 31 December 2020. Thus, we have further updated the trial registration status, and updated the study period as 01, September 2019 to 31, December 2020. Ethics approval will be renewed annually. Statistical analysis has not begun. The trial protocol conforms to the Standard Protocol Items: Recommendation for Interventional Trials (SPIRIT) 2013 statement.
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At Passover this April 5 (Murray calculates the date for Passover according to his own interpretation of the Jewish calendar), the 81-year-old Arkansas pastor is all smiles as the packed audience in the Grand Palace country music hall rises to give him a long standing ovation before he's even said a word. His son Dennis introduces him as a man who is "taking names and kicking dragons." One woman can't contain herself. "We love you, Pastor Murray," she yells out. Murray jokes that he should get her number before pushing back his sleeves and opening his King James Bible. "Let's get to work," he commands. And they do. The audience is so rapt that throughout the 45-minute sermon the only sound they make is the onionskin rustle of thousands of Bible pages turning. But there are some things they're not being taught.
While Murray doesn't outright endorse these hardliner views, by promoting the "Serpent Seed" doctrine on 225 broadcast stations he's gone further than any Christian Identity preacher in pushing what seem clearly to be anti-Semitic Identity teachings into the mainstream.
During a live taping of Shepherd's Chapel in 1998, an audience member yelled, "Blasphemer!" Murray turned around at his desk and pulled out a gun. The broadcast cut to Shepherd's Chapel's satellite logo but the audio continued. "Here. Take this 9mm to that boy," Murray said. The clip aired on "The Daily Show" and remains widely available on the Internet, as is another Shepherd's Chapel clip in which Murray reaches into his desk and pulls out what he claims is the fossil of an angel footprint, from a pre-Adamic time when angels walked the earth.
Few chapel students will ever attend services at the actual Shepherd's Chapel in Gravette, a tiny and remote town of 1,800 in far northwest Arkansas. Located just a couple of blocks from the town's main street, the headquarters chapel is a former roller rink, flanked by four satellites, one the size of a carousel. A stone plaque that reads, "I Am That I Am," sits in front of the church. The chapel holds videotaped services on the first and third Sunday of every month. As with his live appearances at the Passover in Branson this April, Murray seldom lingers on stage to chat with or greet his followers after his sermon concludes. 2ff7e9595c
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