Awareness of and Willingness to Use On-Demand HIV Pre-Exposure Prophylaxis Among Gay,Bisexual,and Other Men Who Have Sex with Men Using a Gay Social Networking App in China

Abstract

To the Editor:

Pre-exposure prophylaxis (PrEP) is a promising biomedical intervention for HIV prevention that could reduce the risk of getting HIV through sex by up to 99% when taken as prescribed.¹ To maximize benefit and provide alternative prevention options matching an individual's HIV risk profile, researchers investigated on-demand dosing PrEP (on-demand PrEP) for gay, bisexual, and other men who have sex with men (GBMSM) who have intermittent exposures, also known as intermittent or event-drive PrEP. On-demand PrEP uses a “2-1-1” schedule, which means individuals take two pills up to 24 h before sex, one pill 24 h after the first two pills, and another pill 24 h after the second dose.

Recently, the US Centers for Disease Control (CDC) updated the clinical PrEP guidelines and recommended on-demand PrEP to GBMSM who had infrequent sexual exposures.² Indeed, on-demand PrEP offers flexibility to match individuals' unique needs and is considered cost-effective when scaled up at the population level.³

In China, GBMSM are disproportionately affected by the HIV epidemic.⁴ However, it was not until late 2020 that the National Medical Products Administration approved oral PrEP (Truvada) as an HIV prevention tool for people at risk for acquiring HIV,⁵ and there is no official guidance for clinical practice in China yet. Previous research on PrEP among Chinese GBMSM has mainly focused on daily oral PrEP, and currently very limited information on awareness of and willingness to use on-demand PrEP is available. Two existing studies conducted in southwest China suggested that the awareness of on-demand PrEP in this area was only about 30%.^6,7 Neither of these studies explored factors associated with willingness to use on-demand PrEP and both studies recruited their participants from existing clients at a community-based organization.

Therefore, the generalizability of these results to the larger Chinese GBMSM population is unclear. Since the COVID-19 pandemic, there is an increasing trend of using on-demand PrEP.⁸ Considering the potential benefit of on-demand PrEP for Chinese GBMSM, we aim to assess the overall awareness of and willingness to use on-demand PrEP and the associated factors among a sample of GBMSM recruited on a gay social networking (GSN) app. The findings could fill this gap in the literature and provide evidence for policymaking and program design for future PrEP implementation among GBMSM in China.

We conducted an analysis using data collected from a popular GSN in China in July 2020, as described elsewhere.^9,10 Eligibility for the survey included being: (1) aged 18 years and older; (2) assigned male sex at birth; (3) active Blued user; and (4) able to provide informed content to participate in the study. Eligible participants were presented with a consent form and asked to click “I agree” if they were willing to participate in the study. All study procedures were approved by the Institutional Review Board of the Beijing CDC. For this analysis, we only included GBMSM who reported being HIV-negative or of unknown HIV status who had anal sex with a male partner in the past 6 months.

The survey collected participant's sociodemographic and behavioral characteristics including age, residential city, sexual orientation, gender identity, types of sexual partners, income and education level, and employment and relationship status. Participants were asked to report their sexual behaviors, condom use consistency in the past 6 months, and awareness of and willingness to use on-demand PrEP, as well as their perceived PrEP efficacy. To assess the factors associated with awareness of and willingness to use on-demand PrEP, we used bivariate logistic regression to examine the association between sociodemographic and behavioral factors with awareness of and willingness to use on-demand PrEP. All variables that were statistically significant at p < 0.05 in bivariate analyses were included in a multi-variate logistic regression model to identify independent correlates of each study outcome, which were reported using adjusted odds ratios (AORs) with corresponding 95% confidence intervals (CIs).

A total of 1308 participants completed the survey, 68 (4.9%) self-reported being HIV positive, and 284 (21.7%) had not had anal sex with a male partner in the past 6 months and were excluded from the final sample (n = 956). The mean age of participants was 31.0 (standard deviation = 8.13; range, 18–64) and most were self-identified as gay (79.4%) and of Han ethnicity (93.5%). More than half (57.8%) indicated consistent condom use during anal sex and 10.3% reported having engaged in group sex in the past 6 months. About one-third (34.3%) reported using substances in the past 6 months and 70.1% reported having received an HIV test in the past 6 months. See Table 1 for descriptions of participants' sociodemographic and behavioral characteristics.

Table 1.

Characteristics of Gay, Bisexual, and Other Men Who Have Sex with Men Who Reported Having Had Anal Sex in China (N = 956)

Characteristics	n (%)
Age (mean = 30.99, SD = 8.13, ranged 18–64)
18–24	209 (21.9)
25–34	477 (49.9)
35–44	199 (20.8)
45 and older	71 (7.4)
Sexual orientation
Gay	759 (79.4)
Bisexual	190 (19.9)
Other	7 (0.7)
Gender identity
Cisgender	928 (97.1)
Transgender/others	28 (2.9)
Ethnicity
Han	894 (93.5)
Ethnic minorities	62 (6.5)
Education
College and higher	665 (69.6)
Below college	291 (30.4)
Employment status
Employed	783 (81.9)
Student	111 (11.6)
Unemployed	35 (3.7)
Other	27 (2.8)
Income level
<3000 CNY	150 (15.7)
3000–6999 CNY	279 (29.2)
7000–10,000 CNY	212 (22.2)
>10,000 CNY	315 (32.9)
Anal sexual partners in the last 6 months
Main partner(s) only	249 (26.0)
Casual partner(s) only	423 (44.2)
Both	284 (29.7)
Relationship status and length
Single	645 (67.5)
In a relationship	311 (32.5)
Consistent condom use	553 (57.8)
Engaged in group sex in the past 6 months	98 (10.3)
Substance use in the past 6 months	328 (34.3)
Tested for HIV in the past 6 months	670 (70.1)
PrEP for HIV prevention
PrEP awareness (either daily dosing or on-demand)	736 (77.0)
On-demand PrEP awareness	531 (55.5)
Willingness to use on-demand PrEP	395 (41.3)
Perceived PrEP efficacy (>90% in preventing HIV)	579 (60.6)

PrEP, pre-exposure prophylaxis; SD, standard deviation.

Overall, 77.0% of all participants reported having heard of PrEP for HIV prevention, 55.5% said they had heard of on-demand PrEP, and 41.3% indicated that they would be willing to start using on-demand PrEP as soon as possible if it were available in China. Approximately 60% (60.6%) of respondents perceived PrEP as more than 90% effective in HIV prevention. In bivariable analyses, greater on-demand PrEP awareness was associated with higher education level, having had anal sex with casual partners only and with both main and casual partners, used substances, and higher perceived daily oral PrEP efficacy in prevention HIV (OR = 7.05, 95% CI: 5.29–9.47; Table 2).

Table 2.

Factors Associated with On-Demand Pre-Exposure Prophylaxis Awareness and Willingness (N = 956)

Characteristics	Awareness		Willingness
Characteristics	OR (95% CI)	AOR (95% CI)	OR (95% CI)	AOR (95% CI)
Age
18–24	—		—
25–34	1.10 (0.79–1.52)		0.97 (0.70–1.35)
35–44	1.19 (0.80–1.76)		0.80 (0.54–1.19)
45 and older	0.74 (0.43–1.26)		0.66 (0.37–1.15)
Sexual orientation
Gay	—		—	—
Bisexual	0.81 (0.59–1.12)		0.64 (0.46–0.90)	0.83 (0.57–0.91)
Other	0.76 (0.09–6.37)		0.65 (0.03–6.81)	1.35 (0.05–8.86)
Gender identity
Cisgender	—		—
Transgender	0.62 (0.27–1.37)		1.11 (0.49–2.47)
Ethnicity
Han	—		—
Ethnic minorities	0.97 (0.58–1.64)		1.03 (0.60–1.72)
Education
College and higher	—	—	—	—
Below college	0.58 (0.44–0.76)	0.84 (0.61–1.15)	0.66 (0.49–0.87)	0.93 (0.68–1.28)
Employment status
Employed	—
Student	1.09 (0.73–1.64)		1.02 (0.83–1.84)
Unemployed	0.85 (0.43–1.68)		0.97 (0.48–1.92)
Other	0.86 (0.40–1.88)		1.00 (0.45–2.16)
Income level
<3000 CNY	—		—
3000–6999 CNY	0.82 (0.55–1.22)		0.95 (0.64–1.43)
7000–10,000 CNY	1.09 (0.72–1.66)		0.88 (0.57–1.35)
>10,000 CNY	1.37 (0.92–2.02)		1.14 (0.77–1.69)
Anal sexual partner type in the last 6 months
Main partner(s) only	—	—	—	—
Casual partner(s) only	1.42 (1.03–1.94)	1.42 (0.99–2.02)	1.39 (1.01–1.93)	1.39 (0.96–2.02)
Both	2.14 (1.52–3.04)	1.56 (1.06–2.31)	1.81 (1.27–2.57)	1.27 (0.86–1.89)
Relationship status and length
Single	—		—	—
In a relationship	0.96 (0.73–1.26)		0.77 (0.58–1.01)
Consistent condom use	1.05 (0.81–1.36)		0.85 (0.65–1.10)
Engaged in group sex^a	1.30 (0.85–2.00)		2.24 (1.47–3.45)	1.89 (1.21–2.99)
Substance use^a	2.08 (1.57–2.75)	1.69 (1.24–2.30)	1.45 (1.11–1.90)	1.16 (0.87–1.55)
Tested for HIV^a	2.76 (2.08–3.68)	1.68 (1.29–2.47)	2.18 (1.63–2.95)	1.56 (1.13–2.18)
Perceived PrEP efficacy (>90% in preventing HIV)	7.05 (5.29–9.47)	6.26 (4.65–8.46)	3.19 (2.31–4.24)	2.23 (1.53–3.29)
PrEP awareness (either daily dosing or on-demand)	—		3.41 (2.41–4.91)	1.42 (0.84–2.42)
On-demand PrEP awareness	—		2.06 (1.58–2.69)	1.18 (0.85–1.66)

In the past 6 months; bold text indicates statistically significant results.

AOR, adjusted odds ratio; OR, odds ratio.

In multi-variate analysis, awareness of on-demand PrEP was associated with having anal sex with both a main partner and casual partners (AOR = 1.51, 95% CI: 1.02–2.23), substance use (AOR = 1.69, 95% CI: 1.24–2.30), and recent HIV testing and higher perceived PrEP efficacy (AOR = 1.68, 95% CI: 1.29–2.47; AOR = 6.26, 95% CI: 4.65–8.46). Similarly, greater willingness to use on-demand PrEP was associated with being gay (compared with bisexual), higher education level, having engaged in group sex, used substances, and receiving an HIV test in the past 6 months. In the multi-variable model, greater willingness to use on-demand PrEP was associated with being gay (compared with bisexual), engaged in group sex (AOR = 1.89, 95% CI: 1.21–2.99), and recent HIV testing and greater perceived daily oral PrEP efficacy (AOR = 1.56, 95% CI: 1.13–2.18; AOR = 2.23, 95% CI: 1.53–3.29).

High awareness of on-demand PrEP observed in our GSN-using GBMSM suggests the continuous need to utilize online platforms for sexual health information dissemination and service delivery. While it is unclear why the willingness to use on-demand was lower compared with previous studies when questions about on-demand PrEP willingness were asked hypothetically and with the condition that PrEP would be free of charge,⁷ it is possible that cost is a barrier to using on-demand PrEP. Future research should use qualitative approaches to understand the barriers and facilitators to on-demand PrEP. Besides, studies of on-demand PrEP must consider the dynamics of sexual behaviors such as engaging in group sex and substance use and how these impact sexual health service utilizations. This is particularly important for GBMSM who may switch their PrEP dosing based on changes in their perceived risk of HIV infection.^11,12

The association between perceived PrEP efficacy and willingness to use on-demand PrEP also indicates the need to develop tailored PrEP educational materials with meaningful messages and languages that are culturally appropriate and acceptable to Chinese GBMSM. As the HIV epidemic continues to disproportionately impact Chinese GBMSM, our findings have substantial policy, research, and practice implications, and the program should consider promoting this alternative PrEP dosing option to maximize its public health benefit. Given the wide disruption to PrEP use and persistence due to the lockdown measures and medical facility disclosure during the COVID-19 pandemic,⁸ on-demand PrEP may provide an alternative option for people with less HIV risk exposure, and telemedicine could be a potential solution to promote consistent and persistent PrEP prescription.¹³

Footnotes

Authors' Contributions

C.H. conceptualized research questions, analyzed the data, and wrote the article. I.W.H., S.M.G., and J.M.S. provided feedback on data analysis and interpretation. F.Y., H.X., D.Z., and G.M. designed the research project and collected the data. All authors provided intellectual content to the article and agreed to submission.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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