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Journal of Peking University (Health Sciences) ›› 2023, Vol. 55 ›› Issue (3): 511-520. doi: 10.19723/j.issn.1671-167X.2023.03.018

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Discrepancy between behavioral-indicated and perceived candidacy for HIV pre-exposure prophylaxis among men who have sex with men in Chengdu, China

Hao LIN1,Jing-hua LI2,Xiao YANG2,Xiao-ting CHEN2,Yu-hui SHI1,Chun CHANG1,Yuan-tao HAO1,2,Wang-nan CAO1,*()   

  1. 1. Department of Social Medicine and Health Education, Peking University School of Public Health, Beijing 100191, China
    2. Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, China
  • Received:2023-02-28 Online:2023-06-18 Published:2023-06-12
  • Contact: Wang-nan CAO E-mail:wangnancao@bjmu.edu.cn
  • Supported by:
    National Natural Sciences Foundation of China(81803334);National Science and Technology Major Project(2018ZX10715004);Guangdong Basic and Applied Basic Research Foundation(2023A1515030093);Peking University Faculty Startup Research Grant(BMU2022RCZX032)

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Abstract:

Objective: To explore the discrepancy between behavioral-indicated candidacy and perceived candidacy (behavioral-perceived gap) and its associated factors of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM), so as to identify the focus population of PrEP interventions and to design and implement targeted interventions. Methods: We recruited a sample of 622 HIV-negative MSM who were regular clients of a community-based organization located in Chengdu, China, from November to December 2021. A cross-sectional questionnaire was used to collect the participants' information on social demographics, PrEP-related knowledge and cognitions, and risk behaviors. In this study, behaviorally eligible for PrEP was defined as performing at least one type of high-risk behavior in the past six months, including inconsistent condom use, sex with an HIV-positive partner, confirmed sexual transmitted infections (STI) diagnosis, substance use, and post-exposure prophylaxis (PEP) experience. Logistic regression models were fitted, and multivariate analyses were adjusted for social demographics. Results: Among the 622 eligible participants, 52.6% (327/622) were classified as behaviorally eligible for PrEP. Only 37.9% (124/327) of the participants perceived themselves as appropriate candidates for PrEP and 62.1% (203/207) had discrepancy between behavioral-indicated and perceived candidacy. 85.9% (281/327) had heard of PrEP, and 14.2% (40/281) accessed PrEP information through health care providers. Of the 327 participants eligible for behavior-indicated PrEP use, about half (47.1%) knew how to obtain PrEP medication and 33.0% had a professional PrEP counseling experience. The majority (93.3%) had no or few friends using PrEP. 54.1% scored eight or above in PrEP knowledge level. 66.7% reported having two or more sexual partners in the past six months. After adjusting for age and recruitment channel, we found six factors that were associated with perceived candidacy for PrEP, including PEP use [adjusted odds ratio (ORA)=2.20; 95% confidence interval (CI): 1.33-3.63], PrEP availability (ORA=1.69; 95%CI: 1.06-2.68), a greater number of PrEP-using friends (ORA=4.92; 95%CI: 1.77-13.65), PrEP know-ledge (ORA=2.21; 95%CI: 1.38-3.56), multiple sexual partnership (ORA=1.77; 95%CI: 1.07-2.94), and perceiving a higher risk of HIV infection (ORA=4.02; 95%CI: 1.73-9.32). Substance use during sex and PrEP information channel were not statistically associated with this beha-vioral-perceived gap. Conclusion: We observed a high discrepancy between behavioral-indicated and perceived candidacy for PrEP among Chengdu MSM in China. Future PrEP implementation efforts should be made in skills training in assessing HIV infection risk, increasing PrEP knowledge, providing professional PrEP counselling, and fostering PrEP support environment.

Key words: Homosexuality, male, Sexual behavior, Pre-exposure prophylaxis, HIV infections, Cognitive dissonance, Risk perception

CLC Number: 

  • R167

Table 1

Socio-demographic characteristics among behavioral-indicated PrEP eligible participants"

Items Total (n=327) No behavioral-perceived gap (n=124) Behavioral-perceived gap (n=203)
Recruitment channel
  MSM activity venues 52 (15.9) 13 (10.5) 39 (19.2)
  MSM peer network 169 (51.7) 70 (56.5) 99 (48.8)
  MSM community organization 106 (32.4) 41 (33.1) 65 (32.0)
Age
  18-24 years 92 (28.1) 34 (27.4) 58 (28.6)
  25-35 years 165 (50.5) 69 (55.6) 96 (47.3)
  >35 years 70 (21.4) 21 (16.9) 49 (24.1)
Current relationship status
  Single 48 (14.7) 21 (16.9) 27 (13.3)
  Relationship with a man 246 (75.2) 88 (71.0) 158 (77.8)
  Married 33 (10.1) 15 (12.1) 18 (8.9)
Education level
  College degree and below 176 (53.8) 62 (50.0) 114 (56.2)
  Undergraduate and above 151 (46.2) 62 (50.0) 89 (43.8)
Employment status
  Unemployed/part-time/retired/student 107 (32.7) 38 (30.6) 69 (34.0)
  Full-time 220 (67.3) 86 (69.4) 134 (66.0)
Personal monthly income
  ≤4 000 yuan 111 (33.9) 42 (33.9) 69 (34.0)
  4 001-6 000 yuan 107 (32.7) 45 (36.3) 62 (30.5)
  6 001-8 000 yuan 109 (33.3) 37 (29.8) 72 (35.5)
Sexual orientation
  Homosexual 274 (83.8) 106 (85.5) 168 (82.8)
  Bisexual/heterosexual/other 53 (16.2) 18 (14.5) 35 (17.2)

Table 2

Characteristics related to PrEP and sexual behavior among behavioral-indicated PrEP eligible participants"

Items Total (n=327) No behavioral-perceived gap (n=124) Behavioral-perceived gap (n=203)
Any condomless anal intercourse
  No 151 (46.2) 61 (49.2) 90 (44.3)
  Yes 176 (53.8) 63 (50.8) 113 (55.7)
Have HIV-positive partner(s)
  No 298 (91.1) 115 (92.7) 183 (90.1)
  Yes 29 (8.9) 9 (7.3) 20 (9.9)
Ever STI diagnosis
  No 303 (92.7) 118 (95.2) 185 (91.1)
  Yes 24 (7.3) 6 (4.8) 18 (8.9)
Substance use
  No 206 (63.0) 70 (56.5) 136 (67.0)
  Yes 121 (37.0) 54 (43.5) 67 (33.0)
PEP user
  No 231 (70.6) 76 (61.3) 155 (76.4)
  Yes 96 (29.4) 48 (38.7) 48 (23.6)
PrEP awareness
  No 46 (14.1) 15 (12.1) 31 (15.3)
  Yes 281 (85.9) 109 (87.9) 172 (84.7)
Sources of PrEP information
  Others 241 (85.8) 104 (83.9) 183 (90.1)
  HCP 40 (14.2) 20 (16.1) 20 (9.9)
PrEP availability
  No 173 (52.9) 58 (46.8) 115 (56.7)
  Yes 154 (47.1) 66 (53.2) 88 (43.3)
PrEP counseling experience with HCP
  No 219 (67.0) 79 (63.7) 140 (69.0)
  Yes 108 (33.0) 45 (36.3) 63 (31.0)
Peers who are on PrEP
  Many 22 (6.7) 15 (12.1) 7 (3.4)
  Few 166 (50.8) 59 (47.6) 107 (52.7)
  None 139 (42.5) 50 (40.3) 89 (43.8)
PrEP knowledge scorea
  ≤7 155 (45.9) 41 (33.1) 109 (53.7)
  >7 177 (54.1) 83 (66.9) 94 (46.3)
Sexual roleb
  Insertive 104 (31.8) 33 (26.6) 71 (35.0)
  Receptive 100 (30.6) 42 (33.9) 58 (28.6)
  Both 107 (32.7) 44 (35.5) 63 (31.0)
  No anal sex 16 (4.9) 5 (4.0) 11 (5.4)
Multiple homosexual partnershipb
  No 109 (33.3) 33 (26.6) 76 (37.4)
  Yes 218 (66.7) 91 (73.4) 127 (62.6)
Engagement in group sexb
  No 189 (57.8) 82 (90.1) 107 (84.3)
  Yes 29 (8.9) 9 (9.9) 20 (15.7)
Engagement in transactional sexb
  No 288(88.1) 112 (90.3) 176 (86.7)
  Yes 39 (11.9) 12 (9.7) 27 (13.3)
HIV test historyb
  No 82 (25.1) 33 (26.6) 49 (24.1)
  Yes 245 (74.9) 91 (73.4) 154 (75.9)
Perceived risk of HIV infectionc
  High-risk 29 (8.9) 18 (14.5) 11 (5.4)
  Medium-risk 85 (26.0) 34 (27.4) 51 (25.1)
  Low-risk 213 (65.1) 72 (58.1) 141 (69.5)

Table 3

Background characteristics associated with perceived PrEP candidacy"

Items Row% ORu (95%CI)
Recruitment channel
  MSM activity venues 25.0 1.00
  MSM peer network 41.4 2.12 (1.06-4.27)*
  MSM community organization 38.7 1.89 (0.90-3.96)?
Age
  18-24 years 37.0 1.37 (0.70-2.66)
  25-35 years 41.8 1.68(0.92-3.05)?
  >35 years 30.0 1.00
Current relationship status
  Single 43.8 1.00
  Relationship with a man 35.8 0.72 (0.38-1.34)
  Married 45.5 1.07 (0.44-2.61)
Education level
  College degree and below 35.2 1.00
  Undergraduate and above 41.1 1.28 (0.82-2.01)
Employment status
  Unemployed/part-time/retired/student 35.5 1.00
  Full-time 39.1 1.17 (0.72-1.88)
Personal monthly income
  ≤4 000 yuan 37.8 1.00
  4 001-6 000 yuan 42.1 1.19 (0.69-2.05)
  6 001-8 000 yuan 33.9 0.84 (0.49-1.47)
Sexual orientation
  Homosexual 38.7 1.00
  Bisexual/heterosexual/other 34.0 0.82 (0.44-1.51)

Table 4

Univariate analysis on factors associated with perceived PrEP candidacy"

Items Row% ORu (95%CI) ORA (95%CI)a
Any condomless anal intercourse
  No 40.4 1 1
  Yes 35.8 0.82 (0.53-1.29) 0.87 (0.55-1.37)
Have HIV-positive partner(s)
  No 38.6 1 1
  Yes 31 0.72 (0.32-1.63) 0.79 (0.33-1.87)
Ever STI diagnosis
  No 38.9 1 1
  Yes 25 0.52 (0.20-1.35) 0.71 (0.26-1.93)
Substance use
  No 34 1 1
  Yes 44.6 1.57 (0.99-2.48) 1.42 (0.88-2.29)
PEP user
  No 32.9 1 1
  Yes 50 2.04 (1.26-3.31)** 2.20 (1.33-3.63)**
PrEP awareness
  No 32.6 1 1
  Yes 38.8 1.31 (0.68-2.54) 1.29 (9.66-2.51)
Sources of PrEP information
  Others 36.2 1 1
  HCP 50 1.76 (0.91-3.42) 1.60 (0.82-3.15)
PrEP availability
  No 33.5 1 1
  Yes 42.9 1.49 (0.95-2.33) 1.69 (1.06-2.68)*
PrEP counseling experience with HCP
  No 36.1 1 1
  Yes 41.7 1.27 (0.79-2.03) 1.43 (0.88-2.32)
Peers who are on PrEP
  None 36 1 1
  Few 35.5 0.98 (0.61-1.57) 1.05 (0.65-1.70)
  Many 68.2 3.81 (1.46-9.98)** 4.92 (1.77-13.65)**
PrEP knowledge score (total 9)
  ≤7 27.3 1 1
  >7 46.9 2.35 (1.48-3.74)*** 2.21 (1.38-3.56)**
Sexual roleb
  Insertive 31.7 1 1
  Receptive 42 1.56 (0.88-2.76) 1.58 (0.88-2.83)
  Both 41.1 1.50 (0.85-2.64) 1.45 (0.82-2.56)
  No anal sex 31.3 0.98 (0.31-3.04) 0.92 (0.29-2.92)
Multiple homosexual partnershipb
  No 30.3 1 1
  Yes 41.7 1.65 (1.01-2.69)* 1.77 (1.07-2.94)*
Engagement in group sexb
  No 43.4 1 1
  Yes 31 0.59 (0.25-1.36) 0.64 (0.27-1.51)
Engagement in transactional sexb
  No 38.9 1 1
  Yes 30.8 0.70 (0.34-1.44) 0.71 (0.34-1.51)
HIV test historyb
  No 40.2 1 1
  Yes 37.1 0.88 (0.53-1.46) 0.89 (0.53-1.49)
Perceived risk of HIV infectionc
  Low-risk 33.8 1.00 1.00
  Medium-risk 40.0 1.31 (0.78-2.19) 1.35 (0.79-2.29)
  High-risk 62.1 3.21 (1.44-7.15)** 4.02 (1.73-9.32)**
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