Chinese men who have sex with men living with HIV (MSMLWH) experience substantial psychological distress driven by both HIV-related challenges and sexual minority-related stressors. The literature indicates a scarcity of culturally tailored digital mental health interventions in China that explicitly address HIV-specific maladaptive cognitive schemas and culturally specific psychosocial stressors. The authors sought to address this gap by adapting an evidence-based, LGBTQ-affirmative cognitive behavioral therapy (CBT) intervention for delivery on a widely used Chinese digital platform.
The primary objective was to systematically adapt the CBT intervention Effective Skills to Empower Effective Men (ESTEEM) into a WeChat Mini-Program-based intervention (iESTEEM) tailored for Chinese MSMLWH and to evaluate preliminary feasibility and usability. The adaptation process prioritized cultural relevance, privacy, and acceptability for a highly stigmatized population.
A three-phase user-centered design approach was used, guided by the ADAPT-ITT framework (Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, and Testing). The study comprised: (1) a qualitative needs assessment with MSMLWH, (2) systematic adaptation and platform development including theater testing, and (3) a short pilot study to evaluate feasibility, usability, and acceptability using both qualitative feedback and objective platform analytics.
The research team conducted semistructured interviews with 20 MSMLWH (mean age 23.25 years, SD 3.08). Analysis identified three major thematic areas of psychological distress:
Participants also expressed specific preferences for intervention features: strong emphasis on anonymity, brief or bite-sized learning modules compatible with mobile use, and content that directly addresses HIV-specific scenarios.
Guided by Phase 1 findings and the ADAPT-ITT framework, the team adapted ESTEEM into iESTEEM, a counselor-assisted, privacy-preserving WeChat Mini-Program. Key adaptations included:
The development process included theater testing with five participants to refine content and user interface elements prior to pilot deployment.
A 2-week pilot involved 10 MSMLWH and five counselors. Evaluation methods included focus groups with participants and counselors, as well as collection of objective platform usage analytics to assess engagement. Outcomes of interest were feasibility, usability, acceptability, and preliminary clinical signals.
Platform analytics and self-reported use during the 2-week pilot indicated substantial engagement:
Regarding brief clinical outcomes measured during the pilot, mean anxiety scores decreased from 8.9 (SD 2.3) at baseline to 7.2 (SD 3.0) post-pilot. Depression scores were reported as stable across the pilot period. All pilot participants indicated willingness to continue using the program and to recommend it to peers.
Qualitative feedback from participants and counselors supported the intervention’s contextual relevance, perceived privacy protections, and clinical utility. Participants emphasized the value of anonymity and the bite-sized structure of the modules. Counselors endorsed the program’s usefulness as a clinically relevant, digitally delivered adjunct to counseling, noting its potential to reach individuals who might not access in-person services due to stigma or resource constraints.
The study demonstrates a theory- and evidence-informed approach to culturally adapting an LGBTQ-affirmative CBT intervention for Chinese MSMLWH using a user-centered design and the ADAPT-ITT framework. The resulting WeChat Mini-Program, iESTEEM, combined LGBTQ-affirmative CBT principles, HIV-specific content, counselor assistance, and privacy-preserving features. Preliminary feasibility, high engagement, and positive acceptability findings suggest potential for digitally delivered, culturally tailored mental health interventions to expand access for highly stigmatized populations in resource-constrained settings.
This report describes the adaptation process and a short 2-week pilot; it does not provide long-term outcome data or definitive evidence of efficacy. The authors note that ongoing randomized controlled trials will further evaluate iESTEEM’s efficacy, implementation outcomes, and mechanisms of action. Details or results from those trials were not reported in this source.