Willingness to use long-acting injectable PrEP among HIV- negative/unknown men who have sex with men in China: a national multicenter online survey

doi:10.21203/rs.3.rs-2362262/v1

Background: Men who have sex with men (MSM) are at high risk of HIV acquisition. Long-acting injectable- (LAI-) PrEP, requiring less frequent dosing, is being studied as an alternative method to daily oral HIV PrEP. With the addition of this potential new prevention method, it expands the scope for a wider user choice and is expected to increase the acceptability and uptake of HIV prevention measures.

Methods: Participants were recruited from December 2020 to March 2021through banner advertisements on web- and mobile app-based platforms on Blued, a large gay Chinese social media platform. A total of 969 HIV-negative/unknown participants were included in our study. Multivariate logistic regression was used to analyze the factors associated with the willingness to use LAI-PrEP.

Results: In total, 969 participants met the inclusion criteria and finished the survey. 19.5% of participants had never tested for HIV, 66.8% of MSM had multiple male partners, and 51.6% of MSM engaged in the condomless sex with their partner. 66.3% of MSM were aware of PrEP, and only 3.9% of MSM had used PrEP before. The willingness to use daily oral PrEP and LAI-PrEP was 76.6% and 74.0%, respectively. MSM with higher education level were less likely to show willingness to use LAI-PrEP (AOR=0.561, 95%CI: 0.375-0.838). Participants who had the history of HIV test (AOR=1.684, 95%CI: 1.109-2.556), had the willingness to use daily oral PrEP (AOR=10.635,95%CI:7.434-15.214), had multiple male sexual partners (AOR=1.332, 95%CI:0.933-1.903), who used rush popper(AOR=1.494, 95%CI:1.047-2.131), and who were aware of PEP (AOR=1.659, 95%CI: 1.019-2.702) were more likely to show willingness to use LAI-PrEP.

Conclusions: In our study, the study subjects had moderate awareness and low uptake of PrEP. The willingness to use daily oral PrEP and LAI-PrEP among the participants were both high. Education level, history of HIV test, multiple male sexual partnerships, rush popper use, PrEP awareness and willingness to use daily oral PrEP were factors associated with the willingness to use LAI-PrEP. This study provided some evidence for the further scale-up of PrEP among the MSM population.

HIV

LAI-PrEP

Men who have sex with men

PrEP

Men who have sex with men (MSM) are at high risk of HIV acquisition [1]. The Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that there were roughly 1.5 million new HIV infections worldwide in 2021, with MSM accounting for 17% of those infections [2]. In China, 23.3% of new cases of HIV infections were attributed to homosexual transmission in 2020 [3]. The overall prevalence of HIV among MSM in China was 5.7% from 2001 to 2018 and has continued to rise [4]. At present, the main preventive measures against HIV include increasing condom use, increasing HIV testing frequency, and reducing the number of sexual partners [5-7]. However, the new infections globally have not decreased sufficiently [8]. It is necessary to explore a more effective HIV prevention strategy among MSM. At present, pre-exposure prophylaxis (PrEP) has proven effective at preventing HIV infection and has been recommended by the World Health Organization (WHO) to prevent HIV transmission among HIV-negative MSM in 2015 [9,10,11].There is a wide range of acceptability for PrEP among MSM on a global scale, from as little as 28.2% in Australia to as high as 96.2% in Peru [12,13].Previous studies demonstrated that although Chinese MSM had low awareness (11-13%) of PrEP, the willingness to use PrEP was high (64-92%) after learning about the safety and efficacy of PrEP [14,15,16]. The most popular HIV PrEP formula is Truvada, a single tablet containing tenofovir disoproxil fumarate and emtricitabine that protects HIV-negative individuals from acquiring HIV [12]. On August 11, 2020, Truvada (emtricitabine and tenofovir disoproxil fumarate tablets, emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg, FTC/TDF) was approved by China's National Medical Products Administration (NMPA) as PrEP in people at high risk of HIV infection [17]. As of right now, MSM at risk for HIV infection can obtain PrEP online or at infectious disease hospitals in mainland China.

Daily oral PrEP, the main form of PrEP currently available, could reduce incident HIV infection by 44% among MSM [10]. A meta-analysis of five clinical trials of oral PrEP in women estimated an efficacy of 36% across all study participants and 61% for participants with high adherence [18]. Therefore, the effectiveness of PrEP is highly dependent on PrEP adherence [19,20]. Poor adherence to daily PrEP would impair the efficacy of daily oral PrEP and remains a concern among MSM [21,22]. At present, a novel modality of PrEP, long-acting injectable- (LAI-) PrEP that requires less frequent dosing is being studied as an alternative method to daily oral PrEP [23,24,25]. Animal studies of LAI-PrEP demonstrated HIV prevention efficacies ranging from 75% to 100% [26,27]. If LAI-PrEP is still effective in human beings, it may be able to circumvent some of the adherence issues associated with daily oral PrEP, such as remembering to take medicine daily, pill fatigue over time, or unintended disclosure of PrEP use to partners [28,29,30,31]. At the same time, as a different form from daily oral PrEP, LAI-PrEP could help improve the coverage of PrEP among MSM due to its convenience and longer protection duration [24]. Gorden et al. found a high willingness (74%) among daily oral PrEP users to use LAI-PrEP due to the inconvenience of daily oral PrEP [32]. In a study by Meyers et al., 80% of young MSM in New York City expressed interest in using LAI-PrEP, and Parsons et al. found 46% of gay and bisexual men preferred LAI-PrEP compared to oral PrEP [33]. Compared with high-income countries, less is known about willingness to use LAI-PrEP in China and other low- and middle-income countries [34].

As a potential new HIV prevention method, LAI-PrEP expands the scope for a wider user choice and is expected to increase the acceptability and uptake of PrEP [35]. To ensure that HIV prevention resources are used as effectively as possible, it is critical to identify who among potential users might be interested in using various types of PrEP. The main objective of this study was to investigate the willingness to use LAI-PrEP and related factors among MSM in mainland China. To the best of our knowledge, this is the largest sample size study exploring the willingness to use LAI-PrEP among MSM in China up to now. This research might offer insight into the level of interest in LAI-PrEP among MSM and can inform strategies for scaling up LAI-PrEP to target populations if it is found to be safe and efficacious and provide direct evidence for policy-making service planning in terms of PrEP implementation among MSM in China.

Participants and Procedures

Participants were recruited from December 2020 to March 2021 through banner advertisements on web- and mobile app-based platforms on Blued, a large gay Chinese social media platform. The inclusion criteria were as follows: (1) born biologically male; (2) aged 18 and above; (3) self-reported anal intercourse with at least one man in the last six months; and (4) self-reported HIV-negative/unknown. Exclusion criteria: people who are unable to complete the questionnaire. Informed consent was obtained from all participants. Eligible participants completed an online survey. To ensure confidentiality, participants entered their data directly into a computer-based questionnaire. The aim of our study is to explore the willingness to use LAI-PrEP and associated influential factors. Ethics approval was obtained from the ethics committee of Danlan Beijing Media Limited on May 20, 2020 (Number: DLIRB202005-01).

Measurements

Sociodemographic information was collected including age, ethnicity, marital status, work or study status, education level, personal monthly income, and sexual orientation. Items assessing sexual risk behaviors included multiple male sexual partners in the past 6 months (individuals who had more than one male partner were classified as having multiple male sexual partners), HIV positive status among sexual partners in the past 6 months, type of sexual partners (regular/casual sexual partners), sex with sex workers in the past 6 months (yes/no), sex with females in the past 6 months (yes/no), usage of rush popper in the past 6 months (yes/no), and consistent condom use in the last 6 months (yes/no). We also asked participants whether they had tested for HIV in the past. The situation of awareness and usage of post-exposure prophylaxis (PEP, one of the biomedical interventions for HIV infection) was asked in similar ways.

Participants were asked whether they had ever heard of PrEP and used PrEP before the survey. The participants were told that LAI-PrEP was a long-acting injection for HIV prevention that was administered every two months [36]. The willingness to use LAI-PrEP was asked on a 5-point Likert scale (1= strongly willing to use LAI-PrEP, 2=willing to use LAI-PrEP, 3= uncertain, 4=unwilling to use LAI-PrEP, 5= definitely unwilling to use LAI-PrEP). Participants were classified into the “willing to use LAI-PrEP” group when they endorsed responses 1 or 2 and into the “unwilling to use LAI-PrEP” group when they endorsed responses 3, 4 or 5.

Data analysis

The sample for this analysis included 969 self-reported HIV-negative/unknown MSM. Descriptive analyses were used to summarize socio-demographic characteristics and sexual behaviors of the sample. Logistic regression models were used to identify correlates of the willingness to use LAI-PrEP. Univariate logistic regression was used to identify associations between the willingness to use LAI-PrEP and the variables. All factors with p<0.1 in univariate logistic regression or considered relevant in previous studies were then included in the multivariable logistic regression models, adjusting for potential confounders. Odds ratios (OR) and adjusted odds ratios (AOR) were reported with 95% confidence intervals (95%CI) in logistic regression models. All analyses were conducted in IMB SPSS Statistics (version 21, SPSS Inc., Chicago, IL, USA), and two-tailed p<0.05 was considered statistically significant.

Sociodemographic characteristics and sexual behaviors

The median age was 31.1 (±9.669) years. Of 969 MSM who self-reported HIV-negative or unknown status, 72.5% were below 36 years old. Most participants were of Han ethnicity (88.4%), were unmarried (76.0%), had a full/part-time job (69.9%), and had obtained a bachelor’s degree or above (73.2%). Over half earned CNY 3000-9999 per month (53.4%). Nearly three-quarters (74.9%) of the participants identified themselves as gay. Most MSM had previously tested for HIV (80.5%) in their lifetime. In the past 6 months, about two-thirds had more than one sexual partner (66.8%), and 34.8% only had sex with regular partner. 11.4% of participants reported ever having sex with at least one partner who was HIV positive. Most of participants were not sex with sex worker and female (94.5% and 88.3% respectively). Approximately half (51.6%) of the participants reported consistent condom use in the past 6 months. Rush poppers were used by 43% of MSM (43.2%) in the previous 6 months. (Table 1)

Table 1. Sociodemographic characteristics and sexual behaviors of HIV-negative/unknown MSM in China (N=969)

Variables	Frequency	Percentage
Age (years)
18-25	332	34.3%
26-35	370	38.2%
≥36	267	27.6%
Ethnicity
Han	857	88.4%
Others	112	11.6%
Marital status
Unmarried	736	76.0%
Married	136	14.0%
Divorced/Widowed	97	10.0%
Work or study status
Full/part-time job	677	69.9%
Student	219	22.6%
Unemployed/Retired	73	7.5%
Education
High school or below	260	26.8%
University or above	709	73.2%
Monthly income (CNY)
<3000	295	30.4%
3000-9999	517	53.4%
≥10000	157	16.2%
Sexual orientation
Gay	726	74.9%
Other	243	25.1%
Ever had HIV tested
No	189	19.5%
Yes	780	80.5%
Had multiple male sexual partners
No	322	33.2%
Yes	647	66.8%
Had HIV-positive sexual partners
No	859	88.6%
Yes	110	11.4%
Type of sexual partners
regular sexual partners	337	34.8%
casual sexual partners*	632	65.2%
Had sex with sex workers
No	916	94.5%
Yes	53	5.5%
Had sex with female
No	856	88.3%
Yes	113	11.7%
Consistent condom use
No	469	48.4%
Yes	500	51.6%
Ever used rush popper
No	550	56.8%
Yes	419	43.2%

* Casual sexual partners are defined as those who have had one or more non-regular sexual partners during the past six months in our study.

Awareness of PrEP and willingness to use LAI-PrEP

Nearly two-thirds (66.3%) of MSM reported ever heard about PrEP, however only less than 4 percent (3.9%) had ever used PrEP. The willingness to use daily oral PrEP was almost equal to the willingness to use LAI-PrEP, 76.6% and 74.0% respectively. More than sixty percent (64.1%) of the participants heard about PEP, and less than 10% (8.4%) of MSM ever used PEP. (Table 2)

Table 2. Awareness and willingness for PrEP among HIV-negative/unknown MSM in China (N=969)

Variables	Frequency	Percentage
Heard of PrEP
No	327	33.7%
Yes	642	66.3%
Ever used PrEP
No	931	96.1%
Yes	38	3.9%
Willingness to use daily oral PrEP
No	227	23.4%
Yes	742	76.6%
Willingness to use LAI-PrEP
No	252	26.0%
Yes	717	74.0%
Heard of PEP
No	348	35.9%
Yes	621	64.1%
Ever used PEP
No	888	91.6%
Yes	81	8.4%

Univariate factors associated with willingness to use LAI-PrEP

In the univariate logistic analysis, marital status was associated with the willingness to use LAI-PrEP. Participants who were divorced or widowed were more willing to use LAI-PrEP compared with participants who were unmarried (OR=1.756, 95%CI:1.015-3.038). Participants with higher education level had lower willingness to use LAI-PrEP (OR=0.740, 95%CI:0.528-0.937). MSM who had ever taken HIV test (OR=1.820, 95%CI:1.296-2.557) were more likely to show willingness to use LAI-PrEP. Those who reported two or more sexual partners in the past 6 months had higher odds to show the willingness to use LAI-PrEP (OR=1.572, 95%CI:1.168-2.116). The history of using rush poppers in the past 6 months was significantly and positively associated with the willingness to use LAI-PrEP (OR=1.839, 95%CI:1.360-2.486). Participants who had ever heard of PrEP (OR=1.667, 95%CI:1.240-2.241) were more likely to choose LAI-PrEP. Men who showed willingness to use daily oral PrEP had a higher likelihood of choosing LAI-PrEP relative to those unwilling to use daily oral PrEP (OR=9.598, 95%CI:6.856-13.438). Participants who had ever heard of PEP (OR=1.705, 95%CI:1.272-2.286) were more likely to use LAI-PrEP. Participants who had ever used PEP (OR=21.752, 95%CI:0.967-3.176) were more likely to use LAI-PrEP, with marginal significance. (Table 3)

Table 3. Univariate factors associated with willingness to use LAI-PrEP (N=969)

Variables	Willingness to use LAI-PrEP
Variables	Yes(n(%))	OR	p
Age (years)
18-25	234(70.5%)	1
26-35	280(75.7%)	1.303(0.932-1.821)	0.121
≥36	203(76.0%)	1.328(0.920-1.917)	0.129
Ethnicity
Han	633(73.9%)	1
Others	84(75.0%)	1.062(0.674-1.672)	0.796
Marital status
Unmarried	536(72.8%)	1
Married	101(74.3%)	1.077(0.709-1.634)	0.728
Divorced/Widowed	80(82.5%)	1.756(1.015-3.038)	0.044
Work or study status
Full/part-time job	505(74.5%)	1
Student	157(71.7%)	0.862(0.613-1.213)	0.395
Unemployed/Retired	55(75.3%)	1.041(0.595-1.821)	0.889
Education
High school or below	203(78.1%)	1
University or above	514(72.5%)	0.740(0.528-0.937)	0.008
Monthly income (CNY)
<3000	216(73.2%)	1
3000-9999	386(74.7%)	1.078(0.779-1.492)	0.652
≥10000	115(73.2%)	1.001(0.647-1.551)	0.995
Sexual orientation
Gay	540(74.4%)	1
Other	177(72.8%)	0.924(0.665-1.282)	0.636
Ever had HIV tested
No	121(64.0%)	1
Yes	596(76.4%)	1.820(1.296-2.557)	0.001
HIV knowledge	13.84±3.082	1.030(0.986-1.076)	0.185
Multiple male sexual partners
No	219(68.0%)	1
Yes	498(77.0%)	1.572(1.168-2.116)	0.003
Had HIV-positive sexual partners
No	629(73.2%)	1
Yes	88(80.0%)	1.463(0.895-2.390)	0.129
Type of sexual partners
regular sexual partners	247(73.3%)	1
casual sexual partners	470(74.4%)	1.057(0.783-1.427)	0.717
Had sex with sex workers
No	680(74.2%)	1
Yes	27(69.8%)	0.803(0.438-1.469)	0.476
Had sex with female
No	638(74.5%)	1
Yes	79(69.9%)	0.794(0.516-1.221)	0.293
Consistent condom use
No	341(72.7%)	1
Yes	376(75.2%)	1.138(0.854-1.517)	0.377
Ever used rush popper
No	380(69.1%)	1
Yes	337(80.4%)	1.839(1.360-2.486)	<0.001
Heard of PrEP
No	220(67.3%)	1
Yes	497(77.4%)	1.667(1.240-2.241)	0.001
Willingness to use daily oral PrEP
No	85(37.4%)	1
Yes	632(85.2%)	9.598(6.856-13.438)	<0.001
Heard of PEP
No	234(67.2%)	1
Yes	483(77.8%)	1.705(1.272-2.286)	<0.001
Ever used PEP
No	650(73.2%)	1
Yes	67(82.7%)	1.752(0.967-3.176)	0.065

Multivariate factors associated with willingness to use LAI-PrEP

In the multivariable model, MSM with higher education level (AOR=0.561, 95%CI: 0.375-0.838) were less likely to show willingness to use LAI-PrEP. And participants with the history of HIV test in their lifetime (AOR=1.684, 95%CI: 1.109-2.556), had multiple male sexual partners (AOR=1.332, 95%CI:0.933-1.903), ever used rush popper (AOR=1.494, 95%CI:1.047-2.131) and ever heard of PEP (AOR=1.659, 95%CI: 1.019-2.702) were more likely to show willingness to use LAI-PrEP. Of note, MSM who were willing to use daily oral PrEP were more likely to use LAI-PrEP (AOR=10.635,95%CI:7.434-15.214). (Table 4)

Table 4. Multivariate factors associated with willingness to use LAI-PrEP

Reasons for unwillingness to use LAI-PrEP

Among participants who were unwilling to use LAI-PrEP, most participants thought the daily oral PrEP was more convenient compared with LAI-PrEP (129/252). “Do not want to go to the hospital” (103/252) and “LAI-PrEP was difficult to hide from partners” (89/252) were also main concerns for participants who were unwilling to use LAI-PrEP. Only 39 participants thought LAI-PrEP was not as safe as daily oral PrEP. (Figure 1)

This study investigated the willingness to use LAI-PrEP among MSM who were HIV-negative or serostatus-unknown in mainland China. The prevalence of consistent condom use (51.6%) among MSM in our study was higher than previous studies conducted in Shanghai (44.9%) and Chengdu (44.0%), but far lower than UNAIDS’ target (95%) [37, 38, 39]. In addition, we found that about two-fifths of MSM in our study used rush popper, one of the psychoactive substances, which could cause high-risk sexual behaviors and further increase the risk of HIV infection [40]. While lowering the HIV disease burden caused by MSM is crucial to ending the HIV epidemic, to decrease the high-risk sexual behaviors among MSM remains a challenge in this key population [41]. Therefore, apart from the preventive measures on reducing high-risk behaviors, it is of importance to seek additional efficacious alternatives to prevent HIV infection. PrEP, as an effective HIV prevention intervention, has been recommended by the WHO to prevent HIV infection [42]. It is necessary to explore some methods to increase the coverage of PrPE among MSM.

Overall, the results demonstrated that MSM had moderate awareness of PrEP (66.3%) and low uptake of PrEP (3.9%). The awareness of PrEP in this study is much higher than in other studies in mainland China, which ranged from 11.20–43.1% [1, 14, 43, 44, 45]. This could be because of the fact that participants in our study were recruited via a gay-friendly app that routinely disseminates HIV knowledge to users. Spreading health information through app that MSM use frequently may be an effective way to promote awareness of PrEP [46]. However, in most cases, the perceived willingness is not translated into actual action completely. The actual uptake of PrEP was only 3.9% in our study, which was slightly higher than previous research in Shanghai (2.5%), but far below the rate of uptake in the U.S. (60.5%) [34, 47]. The gap between intention and behavior is common [48]. The high cost of PrEP is one of the reasons for its low uptake. In mainland China, for example, the cost of daily oral PrEP is around CNY 780–2000 (USD 111–285) per month. Another reason for poor uptake is concern about adverse effects of PrEP such as nausea, vomiting, and abdominal pain [49]. Furthermore, due to traditional cultural beliefs about medicine, it is widely acknowledged in China that all drugs have some toxicity and that individuals are unwilling to take medicine until they have symptoms, which also acts as a roadblock to PrEP uptake among MSM at high risk of HIV infection [50]. It is urgent to explore a more effective strategy to narrow the gap between actual uptake of PrEP and perceived willingness to use PrEP. The transmission of HIV-related information, particularly through internet media, financial support, and destigmatizing PrEP and PrEP users are some strategies that have been suggested to bridge the gap between willingness and PrEP uptake behavior [51, 52].

The willingness to use LAI-PrEP in this study was lower than that of young MSM in New York City (80%) in a previous study [33]. One of the probable reasons may be the higher availability of PrEP and higher awareness of LAI-PrEP in the U.S [14, 15]. Compared to the studies conducted in Chengdu in 2018 (62.8%) and other three southern cities (Guangzhou, Shenzhen, and Wuxi) in 2019 (38.5%), LAI-PrEP is more attractive for MSM in our study [1, 42]. A possible explanation is that the above research was conducted earlier than the current study. Therefore, the coverage of HIV-related knowledge has been gradually expanding in recent years, which may lead to an increase in awareness of LAI-PrEP and willingness to use LAI-PrEP. Furthermore, unlike the previous recruiting method, our participants were recruited through a popular and widely used gay dating app. Previous studies proved gay-dating app users had more sexual partners than non-app users [53]. This difference in sexual partners might be another reason why participants were more positive about PrEP usage in our study, as the medication would be more useful to these MSM than to those who have less frequent sex [54]. In accordance with Chen's study, compared with participants recruited from sexual health clinics and gay-friendly health consulting service centers, MSM recruited from a gay dating app were more likely to be willing to use PrEP [1]. Thus, Lauren et al. pointed out that using gay-dating apps to deliver services or HIV prevention information is both cost-effective and potentially successful [53].

Better educational background was found to be negatively associated with the willingness to use LAI-PrEP in our study. This result contradicts with the previous studies that MSM with higher education level had higher willingness to use PrEP [45, 55, 56]. When our survey was conducted, LAI-PrEP was still under clinic trial and had not been approved both in China and other countries. Participants were unfamiliar with this new product since they were unaware of its efficacy, side effects, and safety. Similar to the preventive vaccines that were not developed at the beginning of the COVID-19 pandemic, Metin et al. found that vaccine rejection increased significantly as education level increased [57]. Opel et al.’s research has also demonstrated that parents with higher education levels are approximately four times more likely to worry about vaccine safety than those with lower education levels [58]. Hence, MSM with higher education level may be more cautious about the usage of LAI-PrEP because they do not know about all the benefits and drawbacks of this new PrEP and would show more hesitancy about LAI-PrEP that is still being tested. Participants who had multiple male sexual partners in the preceding 6 months had a higher likelihood of choosing LAI-PrEP, which was similar to a prior study finding that young MSM with a greater number of recent sexual partners were more likely to be willing to use LAI-PrEP [59]. One study conducted in Chengdu revealed that multiple male sexual partnerships increased the risk of contracting HIV [38]. Therefore, MSM were more likely to select LAI-PrEP for self-protection purposes when they perceived a high risk for HIV acquisition [60]. When compared to individuals who were unwilling to use daily oral PrEP, those who were willing to use it were 10 times more likely to choose LAI-PrEP. This is in line with a previous study in a cohort that found that 95.4% of participants were interested in using LAI-PrEP among those who were willing to use daily oral PrEP [16]. It is possible that the individuals who were willing to use daily oral PrEP learned more about the significance of PrEP in HIV prevention and were more conscious of the challenges associated with daily medication. Thus, when participants learned that LAI-PrEP required less frequency and had the same effect as daily oral PrEP, they showed greater interest in LAI-PrEP [61].

About a third of participants in this study showed a refusion attitude towards LAI-PrEP, as an alternative formulation of daily oral PrEP. Individuals who are ready to use LAI-PrEP need to accept the injection at regular intervals. In addition to going to the hospital to accept injection, MSM who accept the LAI-PrEP need to take frequent blood tests to monitor the hepatotoxicity of injection [61]. In addition to the inconvenience of receiving injections, MSM were also afraid of being found out about their HIV-related biomedical interventions. In other words, receiving an HIV-related injection in the hospital will potentially lead to MSM being labeled as being HIV-positive [61].

Our study also has some limitations. Firstly, sexual risk behaviors were self-reported. Participants might underreport such behaviors owing to social stigma. Therefore, the situation like multiple male sexual partners may be underestimate. Secondly, participants were recruited from a gay social networking app, whose users are mostly gay. Therefore, the results from our study should be generalized to other MSM populations with caution. However, this study still has implications for expanding PrEP use and exploring willingness to use LAI-PrEP among MSM in mainland China.

MSM at high risk of HIV infection have a moderate awareness of PrEP and low uptake of PrEP. The willingness to use daily oral PrEP and LAI-PrEP both high. LAI-PrEP could expand the coverage of PrEP among MSM. Among those who were willing to use daily oral PrEP, had lower education level, had ever taken HIV test, had ever heard of PrEP were more likely to choose LAI-PrEP. This research provides some evidence for the widespread use of PrEP.

Men who have sex with men	MSM
Pre-exposure prophylaxis	PrEP
Long-acting injectable PrEP	LAI-PrEP
Post-exposure prophylaxis	PEP
World Health Organization	WHO
The Joint United Nations Programme on HIV/AIDS	UNAIDS

Ethics approval and consent to participate: Ethics approval was obtained from the ethics committee of Danlan Beijing Media Limited on May 20, 2020 (Number: DLIRB202005-01).

Consent for publication: Not applicable

Availability of data and materials: The datasets used and analyses during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: This research was funded by Asian Regional Special Cooperation Fund of National Health Commission of the People’s Republic of China (BLXM01) and the Innovative Engineering Program sponsored by Chinese Academy of Medical Sciences (2020-I2M-2-015).

Authors’ contributions: Conceptualization, JF and XS; methodology, JF; software, JF; validation, MS, YW and ZD; formal analysis, JF, H.W. and X.C; investigation, HW, WX, YH, FY. and G.M.; resources, XS; data curation, JF; writing—original draft preparation, JF; writing—review and editing, XS; visualization, JF; supervision, XS; project administration, XS; funding acquisition, XS. All authors read and approved the final manuscript.

Acknowledgements: Not applicable.

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No competing interests reported.

Willingness to use long-acting injectable PrEP among HIV- negative/unknown men who have sex with men in China: a national multicenter online survey

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