HIV testing and the PrEP care continuum among Chinese sexual minority men: A comparison by relationship status and sexual agreement

Abstract

Background

Sexual minority men (SMM) in China continue to face a disproportionately high burden of HIV. Yet, little is known about the differences in HIV prevention service utilization including HIV testing and pre-exposure prophylaxis (PrEP) by relationship status and sexual agreements among this population. The study aimed to explore the associations between relationship status and sexual agreements and HIV testing behaviors, PrEP willingness, and PrEP uptake among sexually active SMM in China.

Methods

We surveyed 1,379 sexually active SMM in China on a geosocial networking app and conducted multivariable regression to examine differences in HIV testing and PrEP-related outcomes.

Results

Over one-third of Chinese SMM (36%) were in a relationship (e.g., having a boyfriend or partner) and among these, 44% had a monogamous sexual agreement and 24.6% were having an open relationship agreement. In adjusted models, partnered Chinese SMM were more likely to have received a recent HIV test (AOR = 1.47, 95%CI: 1.14-1.91). Bisexual men were less likely to have tested for HIV (AOR = 0.71, 95% CI: 0.53-0.96) or ever used PrEP compared to gay men (AOR = 0.56, 95% CI: 0.30-0.98). Among partnered SMM, those with an open relationship agreement were less likely to have tested for HIV in the past 6 months (AOR = 0.51, 95% CI: 0.28-0.94) and more willing to use PrEP for HIV prevention (AOR = 1.96, 95% CI: 1.19-3.22), compared to SMM in monogamous relationships.

Conclusions

These findings provided quantitative evidence and insights into the differences in HIV prevention service utilizations among SMM in China and suggest the need for tailored interventions for targeted sub-groups to address the unique sexual health needs of Chinese SMM.

Keywords

relationship sexual agreement HIV testing PrEP China sexual minority men

Introduction

Sexual minority men, including gay, bisexual, and other men who have sex with men continue to be disproportionately impacted by the HIV epidemic in China. Surveillance data show the prevalence of HIV has increased drastically since 2005, reaching 7.8% in 2014 among sexual minority men (SMM).¹ Compared to other key populations at risk for acquiring HIV in China, SMM were the only group that had both a high and rapid increase in HIV prevalence in this period. A meta-analysis estimated the overall national HIV prevalence among SMM at 5.7% (95%CI:5.4-6.1%) between 2001-2018², and these rates were consistently increasing over the past decade.^3,4 In some regions such as the Southwest, HIV prevalence among SMM exceeded 10%.⁵ Despite the high burden of HIV among SMM, utilization of prevention services (e.g., HIV testing) remains suboptimal. A recent study found that nearly one in three SMM who reported engaging in anal sex with other men in China had never tested for HIV.⁶ Key subgroups, including young SMM and those with inconsistent condom use were also less likely to screen for HIV according to China CDC’s recommendations.⁷ Meanwhile, HIV pre-exposure prophylaxis (PrEP) remains underutilized in China, despite its demonstrated potential to reduce HIV incidence. According to China CDC guidelines, individuals at substantial risk for HIV—such as sexually active men who have sex with men (MSM)—should undergo HIV screening every 3 to 6 months and be evaluated for PrEP eligibility.⁸ However, a recent meta-analysis estimated that only 4.9% of SMM in China currently use PrEP and SMM often experience multilevel barriers to PrEP care engagement.^9,10 In contrast, an early modeling study projected that achieving 50% PrEP coverage among MSM could prevent up to 320,000 new HIV infections in China over the next two decades.¹¹ These findings underscore the urgent need for targeted interventions to close critical gaps in HIV prevention among MSM in China.

Historically, HIV prevention research among Chinese SMM has predominantly focused on individual behavioral risk factors, particular assessing those predicting condomless anal sex, and has insufficiently engaged with the context in which sexual behaviors occur. Similarly, there is little research addressing the interpersonal relationships that influence negotiations about sexual behaviors among SMM. Studies in the U.S. suggest that up to two-thirds of new HIV infections among SMM occurred within primary relationships, likely because partnered SMM are more likely to engage in condomless anal sex and have more exposures in terms of the number of sex acts with main partners.^12–14 Central to the risk that occurs within main partnerships are sexual agreements, which are mutual understandings between two partners regarding the boundaries of sexual and relational behaviors. These agreements address factors such as whether and under what prevention conditions partners engage in sex both within and outside of their relationship.^15,16 Sexual agreements include monogamous relationships (in which sex is expected to be exclusively between main partners) and open relationships (in which sex is permitted with partners outside of the relationship).^16,17 In recent years, there is growing evidence that sexual agreements of US SMM are associated with differences in sexual behaviors, HIV prevention service utilization, and substance use outcomes.^12,15–18 Less is known about how relationship status and sexual agreements operate among Chinese SMM.

In fact, it wasn’t until recently that researchers started to explore the nuances in sexual health outcomes among subgroups of Chinese SMM. For example, recent studies identified differences in PrEP awareness, condom use preferences, and mental health outcomes between gay and bisexual men in China,^6,19,20 and other studies observed differences in HIV testing outcomes among Chinese SMM by their types of sexual partners (main vs causal).^21,22 Given the importance of relationship status and sexual agreements in shaping SMM’s HIV prevention utilization and health outcomes, this study aimed to examine HIV testing and PrEP uptake outcomes for Chinese SMM with diverse relationship agreements.

Methods

Study design and data collection

Data for this analysis were derived from a cross-sectional survey conducted in December 2020, on Blued, a geosocial networking app for SMM in China, as part of an HIV prevention intervention study (R01AI143875) in two cites (Beijing and Chengdu). Briefly, Blued users were invited to participate in a survey that included items regarding HIV prevention service utilization, mental health outcomes, alcohol and substance use, and demographic information. Eligibility criteria include age ≥18, residence in Beijing or Chengdu, male sex assigned at birth and currently self-identify as male, and had anal sex with a male partner in the past 6 months. All study participants provided informed consent and the study procedures were approved by the Emory Institutional Review Board (IRB00116910) and the Institutional Review Board of Danlan Beijing Media Limited (IRB00012406).

Measures

Relationship status and sexual agreement

Partnership and PrEP questions were adapted from the American Men’s Internet Survey, a repeated cross-sectional survey of SMM in the US.²³ All participants were asked if they currently had a boyfriend (Yes = partnered, No = single). Those who were partnered were asked, “How do you and your boyfriend handle sex outside of your relationship?”. Response options include “We only have sex with each other” (monogamous), “We are in an open relationship” (open relationship), and “We haven’t discussed/don’t know” (have not talked, see Table 1).

Table 1.

Sociodemographic and behavioral characteristics and HIV prevention outcomes among Chinese sexual minority men by relationship status, 2020 (n = 1379).

	Total (n = 1379)	Single (n = 883)	Partnered (n = 496)	p-value
Age	29.1 (8.3)	28.6 (8.0)	30.1 (8.8)	0.001
18-24	474 (34.4%)	321 (36.4%)	153 (30.8%)
25-34	593 (43.0%)	387 (43.8%)	206 (41.5%)
35-44	219 (15.9%)	120 (13.6%)	99 (20.0%)
45 and above	93 (6.7%)	55 (6.2%)	38 (7.7%)
Sexual orientation				0.002
Gay	1089 (79.0%)	672 (76.1%)	417 (84.1%)
Bisexual	275 (19.9%)	201 (22.8%)	74 (14.9%)
Heterosexual/another	15 (1.1%)	10 (1.1%)	5 (1.0%)
Sex role				0.116
Top only	436 (31.6%)	274 (31.0%)	162 (32.7%)
Bottom only	459 (33.3%)	311 (35.2%)	148 (29.8%)
Versatile	484 (35.1%)	298 (33.7%)	186 (37.5%)
Education level				0.005
High school and below	157 (11.4%)	119 (13.5%)	38 (7.7%)
Some college	266 (19.3%)	169 (19.1%)	97 (19.6%)
College and above	956 (69.3%)	595 (67.4%)	361 (72.8%)
Employment status				0.257
Employed	1017 (73.7%)	640 (72.5%)	377 (76.0%)
Student	289 (21.0%)	197 (22.3%)	92 (18.5%)
Unemployed and other	73 (5.3%)	46 (5.2%)	27 (5.4%)
Income level (monthly in CNY)				0.170
<3000	322 (23.4%)	220 (24.9%)	102 (20.6%)
3000-6999	380 (27.6%)	245 (27.7%)	135 (27.2%)
7000-10000	287 (20.8%)	183 (20.7%)	104 (21.0%)
>10000	390 (28.3%)	235 (26.6%)	155 (31.2%)
Number of sexual partners^a	4.563 (9.390)	4.895 (10.588)	3.974 (6.722)	0.081
Did not use condom last time having anal sex	211 (15.3%)	114 (12.9%)	97 (19.6%)	0.001
Sexual agreement
Monogamous	-	-	218 (44.0%) b
Open relationship	-	-	122 (24.6%) ^b
Have not discussed/don’t know	-	-	156 (31.5%) ^b
HIV Testing in last 6 months	962 (69.8%)	591 (66.9%)	371 (74.8%)	0.002
STI testing in last 6 months	549 (39.8%)	348 (39.4%)	201 (40.5%)	0.685
STI diagnosis in last 6 months	92 (6.7%)	59 (6.7%)	33 (6.7%)	0.984
PrEP awareness	983 (71.3%)	610 (69.1%)	373 (75.2%)	0.016
PrEP willingness	490 (35.5%)	311 (35.2%)	179 (36.1%)	0.747
PrEP use ever	106 (7.7%)	66 (7.5%)	40 (8.1%)	0.693

^ain the past 6 months.

^bpercentage among partnered SMM.

Bold values are statistically significant p values of less than or equal to 0.05, as noted in footnotes.

PrEP willingness, uptake, and HIV testing

Participants were asked, “Have you ever heard of PrEP?” (Yes/No). Those who had heard of PrEP were asked, “have you taken or are you currently taking PrEP?”. Response options were (1) I’m currently taking PrEP; (2) I have taken PrEP, but not now, (3) Haven’t taken PrEP at all. For this current analysis, we created a dichotomized variable suggesting the history of PrEP use by combining the first two options (ever used) versus never used. Next, we presented a brief introduction of daily oral PrEP to every study participant, “Pre-exposure prophylaxis (PrEP) is taking an antiretroviral pill, also called Truvada, every day for months or years to reduce a person’s chance of getting HIV. Research has shown PrEP is up to 99% effective in preventing HIV when taken daily” and asked if PrEP were available at no cost, would they be interested in taking PrEP.²⁴ Response options include (1) I don’t think I would be a good candidate for PrEP, (2) I would not be willing to take PrEP, (3) I might be willing to take PrEP, (4) I would plan to see a provider soon about taking PrEP. To simplify interpretation, we categorized persons as either willing to use PrEP (3 or 4) or unwilling to use PrEP (1 or 2). Items assessing HIV outcomes were adapted from the American Men’s Internet Survey (AMIS).²³ We asked the participants when the last time was that they were tested for HIV (less than 3 months; 4-6 months; 7-12 months ago; more than 12 months ago; never tested), and those who received an HIV test within the past 6 months were considered as recently tested.

Demographic and behavioral characteristics

The survey also collected information on participants’ age, sexual orientation, highest education level, employment, and income level, items adapted from the China census (Table 1). Items regarding sexual behavior were adapted from the American Men’s Internet Survey, with participants asked about their sex roles (Top only; bottom only; versatile), whether they used condom the last time they had anal intercourse (Yes/No), and the number of sexual partners in the past 6 months. In addition, participants were asked if they had received an STI test in the past 6 months and if yes, whether they received an STI diagnosis (Yes/No).

Statistical analysis

We used descriptive statistics to present participant’s sociodemographic and behavioral characteristics. Chi-square tests were used to explore the differences in these characteristics by relationship status (single vs partnered). We then conducted multivariable logistic regression models to assess differences in HIV prevention outcomes by relationship status among all eligible participants, adjusting for sociodemographic characteristics and sexual behaviors including numbers of sexual partners in the past 6 month and condom use during last anal sex. Last, we restricted analyses to partnered SMM only and examined differences by sexual agreements. A p-value <0.05 was considered statistically significant and all analyses were conducted using RStudio.

Results

Participant characteristics

The average age of all study participants (n = 1,379) was 29.1 years old (SD = 8.3); over three quarters (77%) were between 18 and 34 years old. Nearly all participants identified as gay or bisexual; for sex role, approximately one-third each identified as top, bottom, and versatile (Table 1). Nearly 70% had a college degree or higher and about half (49%) had a monthly income of 7,000 CNY or higher (about 1,000 USD). In terms of relationship status, 36% were currently partnered and among those, 44.0% were in monogamous relationships, 25% were in open relationships and 31% said they did not talk about this with their partner. Nearly 70 percent (69.8%) of all participants received a recent HIV test in the past 6 months and 39.8% had tested for STI in the past 6 months. In terms of PrEP awareness, 71.3% had heard of PrEP before taking the survey and 7.7% had ever taken PrEP. Over one-third (36%) were willing to use PrEP for HIV prevention if it were widely available at no cost. Partnered SMM were older, had higher education levels, and were more likely to report no condom use at last anal sex (p < 0.01 for all).

HIV testing, willingness to use and uptake PrEP by relationship status and sexual agreement

In bivariate analyses, partnered SMM were more likely to have received an HIV test in the past 6 months (OR = 1.47, 95%CI: 1.15–1.88). SMM with a college degree or higher were also more likely to have been tested compared to those with a high school education or less (OR = 1.56, 95%CI: 1.10–2.20), as were those with a monthly income greater than 10,000 Chinese yuan (OR = 1.66, 95%CI: 1.19–2.29). A greater number of sexual partners was associated with higher odds of recent HIV testing (OR = 1.04, 95%CI: 1.01–1.06). However, participants who did not use a condom during their last anal sex encounter were less likely to have been tested (OR = 0.73, 95%CI: 0.54–0.99). Regarding PrEP willingness, versatile participants reported greater willingness to use PrEP compared to those who identified as top-only (OR = 1.57, 95%CI: 1.20–2.06). SMM with a monthly income above 10,000 CNY were more willing to use PrEP than those earning less than 3,000 CNY (OR = 1.55, 95%CI: 1.14–2.21). Participants with a college degree or higher were also more likely to report PrEP willingness than those with a high school education or less (OR = 2.39, 95%CI: 1.10–6.15). A higher number of sexual partners was similarly associated with greater PrEP willingness, although the effect approached but did not reach strong statistical significance (OR = 1.02, 95%CI: 1.00–1.03).

In multivariable models adjusting for sociodemographic and behavioral characteristics, partnered SMM were more likely to have had a recent HIV test (AOR = 1.47, 95%CI: 1.14-1.91), compared to single SMM. Compared to gay men, bisexual men were less likely to have tested for HIV recently (AOR = 0.71, 95%CI: 0.53-0.96), and were also less likely to have used PrEP (AOR = 0.56, 95%CI: 0.30-0.98). Those who self-identified as versatile were more willing to use PrEP compared to those who identified as tops (AOR = 1.67, 95%CI: 1.26-2.23). A great number of sexual partner was associated with higher odds of receiving an HIV test and having used PrEP (AOR = 1.04, 95%CI: 1.01-1.07, AOR = 1.02, 95%CI: 1.00-1.04). SMM who reported not using condoms at last anal sex were less likely to receive a recent HIV test (AOR = 0.70, 95%CI: 0.51-0.99) (Table 2). In addition, HIV testing and PrEP outcomes also differed by sexual agreement among partnered SMM in adjusted analyses (Table 3). Compared to SMM with a monogamous relationship agreement, those with an open relationship agreement were less likely to be tested for HIV in the past 6 month (AOR = 0.51, 95%CI: 0.28-0.94) and conversely were more willing to use PrEP for HIV prevention (AOR = 1.96, 95%CI: 1.19-3.22). Similarly, partnered men without a relationship agreement were more willing to use PrEP compared to monogamous men (AOR = 1.72, 95%CI: 1.09-2.71).

Table 2.

HIV testing, PrEP utilization and associated factors among Chinese sexual minority men, 2020 (n = 1379).

	HIV testing¹		PrEP willingness		PrEP use ever
Relationship status	OR (95% CI)	AOR (95% CI)	OR (95% CI)	AOR (95% CI)	OR (95% CI)	AOR (95% CI)
Single	Ref	Ref		Ref	Ref	Ref
Partnered	1.47 (1.15, 1.88)	1.47 (1.14, 1.91)	1.04 (0.83, 1.31)	1.00 (0.78, 1.27)	1.08 (0.72, 1.63)	0.97 (0.63, 1.47)
Age
18-24	Ref	Ref		Ref	Ref	Ref
25-34	1.35 (1.04, 1.76)	1.08 (0.78, 1.50)	1.34 (1.04, 1.73)	1.27 (0.71, 2.06)	2.25 (1.39, 3.76)	1.82 (1.00, 3.40)
35-44	1.01 (0.72, 1.43)	0.80 (0.54, 1.22)	1.28 (0.90, 1.77)	1.24 (0.83, 1.85)	1.55 (0.79, 2.97)	1.40 (0.64, 3.06)
45 and above	1.09 (0.68, 1.78)	1.03 (0.60, 1.78)	1.13 (0.70, 1.80)	1.22 (0.71, 2.06)	1.35 (0.49, 3.22)	1.28 (0.43, 3.45)
Sexual orientation
Gay	Ref	Ref	Ref	Ref	Ref	Ref
Bisexual	0.73 (0.55, 0.96)	0.71 (0.53, 0.96)	0.84 (0.63,1.11)	0.85 (0.63, 1.14)	0.63 (0.37, 1.08)	0.56 (0.30, 0.98)
Heterosexual/another	2.66 (0.73, 17.06)	3.25 (0.87, 21.14)	1.17 (0.39, 3.27)	1.29 (0.42, 3.69)	-	-
Sex role
Top only	Ref	Ref	Ref	Ref	Ref	Ref
Bottom only	0.77 (0.58, 1.02)	0.85 (0.63, 1.16)	1.10 (0.83, 1.46)	1.18 (0.87, 1.60)	0.32 (0.36, 1.09)	0.62 (0.34, 1.11)
Versatile	(1.12 (0.84, 1.49)	1.15 (0.84, 1.57)	1.57 (1.20, 2.06)	1.67 (1.26, 2.23)	1.33 (0.85, 2.12)	1.33 (0.82, 2.19)
Education level
High school and below	Ref	Ref	Ref	Ref	Ref	Ref
Some college	1.32 (0.87, 1.99)	1.23 (0.79, 1.92)	0.93 (0.61, 1.42)	0.87 (0.56, 1.36)	1.83 (0.75, 5.13)	1.69 (0.65, 5.04)
College and above	1.56 (1.10, 2.20)	1.37 (0.91, 2.06)	1.19 (0.83, 1.71)	0.94 (0.63, 1.43)	2.36 (1.10, 6.15)	1.79 (0.75, 5.08)
Employment status
Employed	Ref	Ref	Ref	Ref	Ref	Ref
Student	0.75 (0.57, 0.99)	0.86 (0.52, 1.42)	0.89 (0.67, 1.16)	1.21 (0.74, 1.97)	0.65 (0.36, 1.10)	1.54 (0.60, 3.74)
Unemployed and other	0.64 (0.39, 1.05)	0.73 (0.41, 1.29)	0.61 (0.35, 1.02)	0.74 (0.40, 1.34)	0.66 (0.38, 2.19)	1.73 (0.58, 4.43)
Income level (monthly in CNY)
<3000	Ref	Ref	Ref	Ref	Ref	Ref
3000-6999	1.19 (0.87, 1.63)	1.03 (0.67, 1.62)	0.91 (0.66, 1.25)	0.93 (0.59, 1.44)	1.50 (0.79, 2.96)	1.66 (0.69, 3.97)
7000-10000	1.37 (0.97, 1.93)	1.11 (0.66, 1.86)	1.14 (0.81, 1.59)	1.16 (0.70, 1.94)	1.78 (0.92, 3.56)	1.93 (0.72, 5.22)
>10000	1.66 (1.19, 2.29)	1.29 (0.76, 2.18)	1.55 (1.14, 2.11)	1.56 (0.94, 2.61)	2.47 (1.37, 4.68)	2.52 (0.95, 6.76)
Number of sexual partners^a	1.04 (1.01, 1.06)	1.04 (1.01, 1.07)	1.00 (0.99, 1.02)	1.00 (0.99, 1.02)	1.02 (1.00, 1.03)	1.02 (1.00, 1.04)
Did not use condom last time having anal sex	0.73 (0.54, 0.99)	0.70 (0.51, 0.99)	1.23 (0.75, 1.39)	0.94 (0.68, 1.30)	1.06 (0.60, 1.78)	1.15 (0.63, 2.04)

OR: odds ratio; AOR: Adjust odds ratio; CI: confidence interval.

Bold values are statistically significant p values of less than or equal to 0.05.

Multivariable logistic model controlled for all sociodemographic and behavioral variables.

^ain the past 6 months.

Table 3.

HIV testing and PrEP utilization outcomes by sexual agreement among partnered Chinese sexual minority men (n = 496).

	HIV testing^a		PrEP willingness		PrEP use ever
Sexual agreement	OR (95%CI)	AOR (95%CI)	OR (95%CI)	AOR (95%CI)	OR (95%CI)	AOR (95%CI)
Monogamous	Ref	Ref	Ref	Ref	Ref	Ref
Open relationship	0.95 (0.56, 1.58)	0.51 (0.28, 0.94)	1.99 (1.26, 3.18)	1.96 (1.19, 3.22)	2.63 (1.18, 6.08)	1.99 (0.83, 4.89)
Have not discussed/don’t know	0.77 (0.48, 1.24)	0.62 (0.37, 1.03)	1.70 (1.10, 2.64)	1.72 (1.09, 2.71)	1.86 (0.82, 4.30)	1.77 (0.75, 4.34)

^aIn the past 6 months.

OR: odds ratio; AOR: Adjust odds ratio; CI: confidence interval.

Bold values are statistically significant p values of less than or equal to 0.05.

Multivariable logistic model controlled for all sociodemographic and behavioral variables.

Discussion

Among an online sample of SMM recruited on a geosocial networking app in China, we described the prevalence of and the differences in HIV testing and PrEP care continuum engagement outcomes by their relationship status and sexual agreement. While the high rates of recent HIV testing and PrEP awareness are encouraging, PrEP uptake remained low. The low levels of actual PrEP use are similar with previous findings on HIV service utilization outcomes among Chinese SMM.¹⁰ Our present analysis adds to the evidence base by demonstrating differences in HIV prevention outcomes within the large Chinese SMM community, providing separate estimates by relationship status, and identifying critical gaps in service utilization among SMM with unique socio-behavioral and relationship characteristics. Therefore, there is an urgent need to investigate the barriers and facilitators to PrEP uptake among Chinese MSM to increase the utilization of this promsing biomedical HIV prevention intervention and future research is needed to recognize diverse relationship and sexual agreements among Chinese SMM and design, test, implement, and evaluate tailored HIV prevention among targeted population based on these differences.

In our study, partnered Chinese SMM were more likely to report receiving a recent HIV test, which was different than two studies conducted in the U.S., where SMM with a main partner reported less recent HIV testing behaviors.^12,25 Although the reasons for these differences are unknown, it is possible that partnered Chinese men might be more concerned about their partners’ health and well-being or more concerned about partner’s infidelity, and they may consider regular HIV testing as a mechanism to maintain the relationship. In addition, drawing from the Minority Stress Theory,²⁶ partnered SMM may have greater social support from their partners and experience lowers levels of internalized homophobia and other minority stressors, or have greater connectedness to the LGBT community, which may encourage them to engage in HIV prevention activities. We also found that Chinese SMM with a higher number of sexual partners were more likely to have been tested for HIV and to report a history of PrEP use. Although having multiple sexual partners is typically considered a risk factor for HIV acquisition,²⁷ participants with more partners may have been more aware of their heightened risk and therefore more motivated to access HIV prevention services. It is also possible that SMM with larger sexual networks are more connected to community resources, peers, or online platforms where HIV testing and PrEP information is frequently disseminated. However, among our study participants, those who did not use a condom at last anal sex were less likely to receive an HIV test, regardless of relationship status. This is particularly concerning given the rapid increase in HIV transmission through condomless anal sex in China.²⁸ Therefore, renewed efforts are needed to enhance HIV testing among both partnered and single SMM; there is also a need to offer HIV tests in alternative ways, such as HIV-self testing, to fill the HIV testing gap in China.^21,29

Our findings highlight the complex associations between sexual agreements, HIV testing, and PrEP utilization among Chinese SMM. Among our SMM in sexual partnerships, those in an open relationships were less likely to get tested for HIV compared to those in monogamous relationships; this relationship is the inverse of findings regarding partnered US SMM.¹² Being in an open relationship may indicate a whole range of agreements and scenarios that might shape one’s sexual behavior and HIV risk. For example, partners in an open relationship may see another sexual partner together or separately; couples may also have different conditions and negotiations on condom use within and outside of the relationship; other agreements may involve permissions and prohibition on different types of sex (e.g., oral vs anal sex). As such, future research should include more detailed descriptions of sexual agreements and specify and evaluate HIV risks under all relationship scenarios. One possible explanation for lower HIV testing among SMM in open relationships is the influence of internalized or anticipated stigma. Individuals who anticipate judgment for being non-monogamous may avoid disclosing their sexual agreements—not only to providers but also within surveys—and may be less likely to seek out healthcare services altogether, including HIV testing.^30,31 This can be especially true given that same-sex sexual behaviors are still highly stigmatized in China.³² Notably, partnered SMM in open relationships or who never discussed sexual agreements were more willing to use PrEP. It is unclear why some Chinese SMM did not report discussing or establishing agreements with their partners. In the US, counseling and testing services tailored to men in partnerships, and interventions to guide the development of sexual safety agreements among partnerships, have been evaluated and made available in parts of the US for a decade.^33,34 Taken together, these findings provide critical insights for tailoring HIV prevention interventions that account for relationship dynamics, sexual agreement, and the interplay between behavioral and biomedical strategies among Chinese SMM. Moreover, the relatively high PrEP willingness among partnered SMM in non‐monogamous arrangements represents an opportunity: by facilitating PrEP initiation in this subgroup, programs can not only improve uptake of this effective prevention tool but also leverage the required quarterly follow‐up visits to reinforce routine HIV testing. Such integrated approaches could simultaneously narrow gaps in both PrEP coverage and HIV screening among partnered SMM in China.

To the best of our knowledge, this study is among the first to examine differences in HIV prevention utilization outcomes by relationship status and sexual agreement among SMM in China. There are a number of limitations of the current analysis. First, we recruited an online sample of SMM who used a geosocial networking app that attracts those who are young, employed, and have high levels of education. Therefore, the generalizability to Chinese SMM who did not use this app and older, less educated men is unknown. The survey was cross-sectional, and associations cannot be interpreted as causal. Future research using longitudinal data is needed to explore the causal nature of these associations. The questions on the PrEP awareness, willingness, and uptake referred only to daily oral PrEP, which was the only PrEP regimen that was available to Chinese SMM at the time of the study; future studies should also evaluate other PrEP modalities such as event-driven PrEP.³⁵ In fact, previous studies have suggested that Chinese SMM indicate preferences for different PrEP modalities such as on-demand PrEP and long-acting injectable PrEP based on their risk perception.^36–38 Further research that explores differences in PrEP-related outcomes including PrEP dosing option preferences among SMM with diverse relationship and sexual agreements is needed. In addition, questions regarding PrEP willingness was conditioned on it being available at no cost. This hypothetical may overestimate the actual willingness to use PrEP, given that previous research has suggested that cost was a main barrier to PrEP uptake among Chinese SMM.

Conclusion

Our study provides novel, quantitative evidence and insights into the differences in HIV testing, willingness to use PrEP for HIV prevention outcomes by relationship status and sexual agreement status among Chinese sexual minority men. We emphasize that there are important gaps in service utilization; our findings support the need for tailored and culturally specific HIV prevention interventions to address the needs of SMM in China.

Footnotes

ORCID iDs

Chenglin Hong

Aaron J. Siegler

Ethics approval

All study procedures were reviewed and approved by the Emory Institutional Review Board (IRB00116910) and the Institutional Review Board of Danlan Beijing Media Limited (IRB00012406).

Consent to participate

All study participants provided informed consent.

Authors’ contributions

CH conceptualized the study, analyzed the data, and drafted the manuscript with WH. IWH, PSS, AJS provided critical feedback data analysis, interpretation of results, and manuscript revisions. All authors provided intellectual content to the paper and reviewed and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute of Allergy and Infectious Diseases (R01AI143875). The work was facilitated by the Emory Center for AIDS Research (P30AI050409).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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