MSM who were 16–24 years old non-students, having more male sexual partners, more group sex, more CAI, more rush and illicit drug use than other MSM, were at higher risk of HIV infection. HIV testing frequency of the MSM were also higher than other MSM, demonstrating that the MSM had HIV risk awareness. However, their PrEP or PEP awareness and uptake were almost similar to other MSM. Only PrEP uptake of the MSM was slightly higher than that of other MSM. Due to the pretty high HIV risk behaviours and low PrEP or PEP uptake, the MSM who were 16–24 years old non-students could be the highlighted population for promoting PrEP or PEP uptake. This has not been reported in previous studies.
Awareness of PrEP or PEP among MSM in our study was generally high of around 70%, yet uptake was very limited for either PrEP (6.0%) or PEP (11.4%). Awareness was obviously higher than that reported in previous relative studies, while uptake was similar (8–13). This demonstrates that expanded PrEP or PEP knowledge dissemination in recent years was effective in increasing relative awareness, yet efforts of promoting the uptake saw little improvement among MSM in China. Previous studies showed that awareness of PrEP was associated with potential PrEP uptake (10, 14). Increasing accurate knowledge for PrEP could promote PrEP initiation among MSM in China (12). Our study showed that ever consulted PrEP or PEP was associated with PrEP or PEP uptake. This supports the point that relative knowledge dissemination could be helpful in facilitating PrEP or PEP uptake. Accurate knowledge dissemination should be strengthened and conducted consistently. Also, PrEP and PEP uptake was highly associated with each other. This indicates that disseminating PrEP and PEP knowledge to those who is taking PrEP or PEP might be helpful for them to switch between PrEP and PEP according to their risk behaviours for HIV infection.
Table 3 shows that MSM having less previous HIV tests also had less PEP uptake than other MSM, which indicates that HIV tests might help to facilitate PEP uptake. Probably MSM being tested for HIV frequently may have higher HIV risk awareness and be more acceptable to other interventions than MSM testing for HIV less frequently. As 16–24 years old non-student MSM were at higher HIV risk and had tested for HIV more frequently than other MSM, and PrEP and PEP uptake were highly associated with each other in our study, integrated intervention combining HIV testing, PrEP and PEP may effectively promote PrEP and PEP uptake among MSM who are at comparatively high risk of HIV infection.
High cost of PrEP/PEP medicine might be a barrier for the MSM who intended to take PrEP or PEP but chose not to take (7). One study showed that only 6.8% of MSM would like to pay for PrEP at current price (15). Willingness of PrEP uptake reported in previous studies varied from 7.7% if it should be paid through 84.9% if free among MSM in China (9, 16, 17). In a pilot program of promoting PrEP and PEP uptake among MSM in seven sites in China, almost all the MSM who took PrEP participated in a program that provided free PrEP medicine (7). Therefore, reducing cost of PrEP and PEP medicines may effectively promote PrEP/PEP uptake.
Previous studies demonstrated that high education level and HIV risk male-male sexual behaviour were associated with awareness of PrEP or PEP (8, 13). Tables 2 and 3 in our study showed that most of MSM being involved in pretty high HIV risk behaviours like group sex and illicit drug use might realize the necessity of taking PrEP/PEP. However, the MSM only accounted for a very small part of MSM at risk of HIV infection. The MSM having CAI with male sex partners and multiple male sex partners accounting for the larger part of MSM at risk of HIV infection may lack the awareness. This indicates that PrEP/PEP knowledge dissemination and promotion had not be conducted precisely. The latter part of MSM should be targeted and highlighted in future PrEP/PEP promotion programs. The association between lower education level and PrEP uptake might be due to that more MSM of lower education level had engaged in HIV risk behaviours than other MSM.
Limitation
As a cross-sectional study, we cannot determine the causal relationship between associated factors and PrEP or PEP uptake. The study population was not a random sample and might not be representative. However, the MSM in our study were diverse, as various recruiting methods were used by local researchers of each study cities. This reduced bias caused by single recruiting method.