Socio-demographic characteristics
A total of 19 eligible participants were recruited, including 10 in Shanghai and 9 in Qingdao. The socio-demographic characteristics of the participants were shown in Table 1. Among the participants, 42.1% were aged 30 and below, and 26.3% were aged 50 and above. Fourteen participants were males and 5 were females. Most of them (84.2%) were employed with different monthly income. The majority of participants (63.2%) had never married.
Table 1 Socio-demographic characteristics of in-depth interview participants (N=19)
|
Characteristics
|
Number (%)
|
Age
|
|
30 and below
|
8 (42.1)
|
31-49
|
6 (31.6)
|
50 and above
|
5 (26.3)
|
Gender
|
|
Male
|
14 (73.7)
|
Female
|
5 (26.3)
|
Education
|
|
High school and below
|
9 (47.4)
|
College and above
|
10 (52.6)
|
Occupation
|
|
Employed
|
16 (84.2)
|
Unemployed
|
3 (15.8)
|
Monthly income (RMB)
|
|
Less than 5000
|
11 (57.9)
|
5000 or more
|
8 (42.1)
|
Marital Status
|
|
Married
|
4 (21.1)
|
Divorced
|
3 (15.8)
|
Never married
|
12 (63.2)
|
Awareness and perceptions of nPEP services
Most (17/19) participants reported never hearing of nPEP. Two participants had a rough look on the Internet or heard of it in the pharmacy. However, neither of them had clear knowledge about nPEP or how to get access to nPEP services. None of the participants had any experience of using nPEP.
“I have heard of it (nPEP) in the pharmacy. They said the medication was expensive. I did not try to know more about it.” (27-year-old, QD09)
Demands for nPEP service and associated factors
After being briefly introduced the basic knowledge and effectiveness of nPEP in HIV prevention and intervention, half of the participants reported no demand for the nPEP services. Multiple barriers to using nPEP services were reported. In many cases, participants did not think of obtaining nPEP within the recommended time limit because they would be strung out on drugs for a few days. Besides, the nPEP medication was not always available in the local hospitals. The participants would have to get medication from other institutions in case of exposure, where could be too far to reach.
“I cannot remember such a thing (nPEP) within 72 hours at all. Someone just like me will choose to sleep for a day or one and a half days after taking drugs. Some others with violent temper are impossible to keep calm. The staying power of drugs is too strong for me to keep in mind in taking medications (nPEP). The medications are not available in the hospitals. I have to find institutions even if keeping conscious. I would not like to buy medications in this case.” (24-year-old, QD05)
Second, some participants reported that they couldn’t bear the cost of nPEP services, especially for those participants who relied on basic living allowance. Nevertheless, some participants claimed that they would seek nPEP at any cost if exposed to HIV.
“The biggest barrier (for using nPEP) is the high price which may not be accepted by most people. Only people with high-income may afford it. ”(57-year-old, SH04)
“I can accept the price. I have to weigh the pros and cons. What should I do if I get AIDS? I may lose my job. I just spend money to protect myself.” (27-year-old, QD09)
Third, side effects of nPEP might be another concern. Many participants worried about continued weight loss, headaches and other specific symptoms during treatment. They were reluctant to accept nPEP if the side effects are too severe.
“I worry about (the side effects). I spend a lot of money tidying up my appearance, so it’s better to have no side effects such as falling out hair, skin rash and so on.” (23-year-old, QD06)
“It’s all right to avoid (unprotected sex) and insist on taking medicines for one month. I worry about the side effects of the medicine because I have a history of allergy. I am allergic to something and afraid of being reactive (to nPEP medicines).” (24-year-old, QD01)
The fourth barrier is the difficulty of adherence to the whole course of nPEP. Some participants indicated that a 28-day course of nPEP was too long for them to keep compliance. For one thing, they had difficulties in persistently taking medications every day. For example, it was inconvenient for them to explain to friends and colleagues about why they take medications every day. For another, some participants thought that some peers may have unprotected sex again within the course of taking nPEP medications.
“We truly care about the side effects of nPEP medications. For example, the side effects of medicines for cold are significant such as marasmus, fatigue or brain symptoms. For instance, you will feel sleepy and fatigued after taking nPEP medications. It is reasonable to explain to friends as catching a cold but illogical to maintain this condition for 28 days, the impact of which is huge. For one thing it is on account of occupation, for another the colleagues will suspect.” (24-year-old, QD05)
“Yes. It is extremely troublesome. Just think normally, I suppose people definitely (have sex) more than once in a month. However, it is very likely for people to have sex again during the course of taking nPEP medications.” (24-year-old, QD01)
Fifth, fear of privacy disclosure was another barrier of seeking nPEP. One participant explicitly pointed out that confidential information was easily leaked in the hospitals owing to case registration system, doctors’ incautions and disordered environment of the hospitals.
“But this sort of thing (AIDS) is disgraceful and confidential. For example, I worry about such a thing (AIDS) after sexual behavior and go to a hospital for checkup. If there are a lot of patients around, I will feel humiliated when the doctors don’t hear me and asked me ‘what’ loudly. If I am tested HIV-positive and the doctors continually repeat, you will feel embarrassed. In this regard, a separated and private institution instead of a hospital is more suitable for this thing (nPEP).” (24-year-old, QD05)
Last, some participants reported that they had a regular sexual life and used condoms consistently during sexual intercourses, which justified their no demand for nPEP
“I think every aspect of my life is stable, especially in sexual life. It seems that I have no demand of it (nPEP) now.” (51-year-old, SH06)
For participants who reported willingness to use nPEP, facilitators included (1) perceiving serious consequences of HIV infection and (2) using nPEP as a remedial measure in emergency.
“Maybe I need it (nPEP). The particular reason is that I am also afraid of getting AIDS. It sounds terrible if someone get AIDS.” (57-year-old, SH04)
“(The nPEP service) is better than nothing. At least there is a way to remedy. It’s not half bad to know that nPEP medicine can reduce the risk of HIV infection when I cannot control myself.” (23-year-old, QD07)
Potential impacts of nPEP service on high-risk sexual behaviors
Most of participants reported the availability of nPEP services would not lead to an increase of their practices of unprotected sexual intercourse because they understood that nPEP medications may not absolutely protect them from getting HIV infection and there are potential side effects of the medications. Meanwhile, four participants thought their high-risk sexual behaviors might slightly increase with the initiation of nPEP services.
“I think I'll be careful. You can't tell immediately if someone has AIDS. It's too late to know a year or two later, so it seems better to be cautious beforehand. So I don't think (the nPEP service) is going to affect my sexual behavior, and it's going to be a protective measure.” (23-year-old, QD07)
“I don't want to be more unscrupulous, but to indulge myself a little. For example, there used to be a lot of things I couldn't do, but now I'm wearing a suit of armor.” (50-year-old, SH02)
Suggestions for nPEP service
Most (15/19) participants thought it was necessary to routinize nPEP services among drug users. Whereas two participants held the opposite attitudes who thought drug users never mind their own health condition.
“I definitely think the routinization of nPEP is necessary. At least the service will help me to prevent HIV infection ahead of time. I did not know the service in detail before.” (27-year-old, QD09)
“There is no need to routinize (nPEP). Drug users care nothing if they have been taking drugs. Because they are clear that taking drugs is by no means a right thing, still they do so. They are indifferent to other things.” (23-year-old, QD06)
For those who supported the routinization of nPEP, social media was cited as the most popular form of advocacy, followed by face-to-face outreach by healthcare professionals or local CBO community groups. Other forms of publicity include posters, bill boards and lectures.
“You can routinize through the WeChat. But don’t organize group chat, just through Wechat applet. You can give a sample introduction on Internet, and let them (drug users) spread forwardly.” (24-year-old, QD05)
With regard to the institutions providing nPEP services, 10 (52.6%) participants preferred pharmacies, which guarantee both convenience and privacy protection. Four (21.1%) participants selected hospitals for their authoritativeness and credibility. Also, there was a suggestion of initiating nPEP services on the Internet if possible.
“It is undoubtedly pharmacies (to get nPEP service) which are more convenient and secure. So is CDC. By comparison, it is not trustful to get medications from friends.” (50-year-old, SH03)
In Shanghai, only two (20%) participants could afford nPEP medications. By contrast, six (66.7%) participants could bear the current cost of nPEP in Qingdao and indicated that they attached more importance to the effect than the price. When asked the perception of cost of nPEP and affordable maximum price, most participants thought current price is a little high and gave their reasonable range, namely 1000 to 2000 RMB. There was a suggestion that the cost of medication should be shared in the form of allowance by the government.
“If so, I think the government should share half or a portion of cost. Then we bear the rest by ourselves.” (30-year-old, QD03)