JMIR Publications

ABSTRACT

Background:

Chinese men who have sex with men living with HIV (MSMLWH) face significant mental health challenges exacerbated by cultural stressors and intersectional stigma. However, evidence-based digital mental health resources tailored for this population remain scarce in China.

Objective:

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

Methods:

Guided by the ADAPT-ITT framework, the study proceeded in three phases : (1) a qualitative needs assessment via semi-structured interviews with 20 MSMLWH (mean age 23.25 years) to identify psychological distress and maladaptive schemas; (2) systematic content adaptation and platform development, including theater testing (n=5); and (3) a 2-week pilot study with 10 MSMLWH and five counselors to evaluate implementation feasibility and usability using a multidimensional qualitative framework.

Results:

Phase 1 identified that psychological distress was driven by maladaptive cognitive schemas across three domains: (1) persistent health anxiety fueled by catastrophizing; (2) intersectional stigma internalization and the disclosure dilemma; and (3) intimacy barriers sustained by a defectiveness/shame schema. Functionally, participants prioritized absolute anonymity and "bite-sized" learning. In Phase 2, the iESTEEM manual was adapted and refined to target these schemas. By keeping the key components of counseling, generic scenarios were transformed into HIV-specific scenarios, such as adapting "coming out" to “dual disclosure;” illustrative videos were created; and a secure, user-friendly WeChat Mini-Program integrated with a safety monitoring back-end was developed. The Phase 3 pilot study period confirmed high feasibility of implementation. Participants validated the relevance of the adaptations and reported high perceived utility of core cognitive and behavioral skills. The platform was praised for its "invisibility" (privacy) and accessibility, leading to high acceptability and strong peer recommendation. Counselors highlighted the clinical utility of the risk-alert system and engagement tracking features.

Conclusions:

This study underscores the need for a systematic approach to adapt an evidence-based online CBT intervention for MSMLWH. It confirms that leveraging the accessible WeChat Mini-Program ecosystem is a feasible and acceptable strategy to deliver tailored support to this stigmatized population in China. Preliminary user feedback from both users and counselors suggests promise, and a large-scale trial is ongoing to establish its clinical efficacy. Clinical Trial: Chinese Clinical Trial Registry ChiCTR2400080263; https://www.chictr.org.cn/showproj.html?proj=216926