Digitally Adapting LGBTQ-Affirmative Cognitive Behavioral Therapy for Chinese Men Who Have Sex With Men Living With...

Chinese men who have sex with men living with HIV (MSMLWH) experience substantial psychological distress driven by minority stress and HIV-related challenges. However, culturally tailored digital mental health interventions that address HIV-specific maladaptive cognitive schemas and culturally specific psychosocial stressors remain scarce in China.

This study aimed to systematically adapt an evidence-based cognitive behavioral therapy (CBT) intervention Effective Skills to Empower Effective Men (ESTEEM) into a WeChat (Tencent) Mini-Program-based intervention (iESTEEM) specifically for Chinese MSMLWH and to evaluate its preliminary feasibility and usability.

We used a three-phase user-centered design approach guided by the Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, and Testing (ADAPT-ITT) framework. The study proceeded in three phases: (1) a qualitative needs assessment using semistructured interviews with 20 MSMLWH (mean age 23.25, SD 3.08 years); (2) systematic intervention adaptation and platform development, including theater testing (n=5); and (3) a 2-week pilot study involving 10 MSMLWH and five counselors to evaluate feasibility, usability, and acceptability through focus groups and objective platform analytics.

Phase 1 identified 3 major themes of psychological distress: persistent health anxiety fueled by catastrophizing, intersectional stigma internalization, the disclosure dilemma, and intimacy barriers rooted in defectiveness and shame schemas. Participants also prioritized anonymity and bite-sized learning. Guided by these findings, iESTEEM was developed as a counselor-assisted, privacy-preserving WeChat Mini-Program incorporating HIV-specific scenarios, multimodal learning modules, and a back-end risk-alert system. During the 2-week pilot, participants logged into the platform 14.1 (SD 6.7) times per person and completed 134.3 (SD 103.1) minutes of learning activities; all participants accessed module 1, and 90% (9/10) accessed modules 2-5. Anxiety scores decreased from 8.9 (SD 2.3) to 7.2 (SD 3.0), whereas depression scores remained stable. All participants expressed a willingness to continue using the program and to recommend it to peers. Participants and counselors endorsed its contextual relevance, privacy protections, and clinical utility.

This study provides a theory- and evidence-informed model for culturally adapting digital mental health interventions for highly stigmatized populations. By integrating lesbian, gay, bisexual, transgender, and queer (LGBTQ)-affirmative CBT principles, HIV-specific adaptations, and a privacy-preserving, counselor-assisted WeChat Mini-Program, iESTEEM demonstrated promising preliminary feasibility, acceptability, and engagement among Chinese MSMLWH. These findings support the potential of culturally tailored digital interventions to expand access to psychological support for this stigmatized population in resource-constrained settings. Ongoing randomized controlled trials will further evaluate its efficacy, implementation outcomes, and mechanism of action.