Chinese MSM need a multi-layered approach to improve PrEP uptake and adherence

A Chinese qualitative PrEP study shows multiple barriers to PrEP uptake among men who have sex with men (MSM). The men in the study expressed concerns about PrEP efficacy, the authenticity of pills purchased informally and lack of governmental endorsement, as well as concerns about side effects, financial costs and managing PrEP care. They also shared that they were motivated to take PrEP because it would improve their quality of sex and give them greater control of their health.

PrEP was approved in China in 2020. Up until then, the HIV prevention drug was only officially available through clinical trials. This has resulted in PrEP users accessing the drug through unofficial means, for example through informal PrEP buyers (代购, Dài-Gòu) who import it from overseas, or taking PEP instead. Some studies show that only a few thousand Chinese citizens take PrEP.

In a series of cross-sectional online surveys of Chinese MSM, 6% said they had used PrEP in 2019, 14% in 2021 and 27% in 2022. The three surveys had 3,337, 5,313, and 15,758 participants respectively. Despite a high percentage having heard of PrEP, the proportion correctly answering six basic knowledge questions about PrEP was 10%, 18% and 27% in the three surveys, with a correlation between PrEP knowledge and PrEP uptake.

As little is understood about the barriers and motivations to taking the drug in China, the qualitative study published in the International Journal of Behavioral Medicine explored this in more depth. The study team wanted to understand how Chinese male citizens who have sex with men are influenced to take PrEP at an individual and structural level. They held one-to-one virtual interviews.

They spoke to men who had varying experiences of PrEP. In total, 31 men took part in the study. Of them, 24 (78%) were gay, the rest were queer (n=5), bisexual (n=1) or pansexual (n=1). Their median age was 27 years old and most earned a middle to high income.

The majority (n=21) had not used PrEP. The 10 participants with experience of using PrEP had accessed the drug either through an informal PrEP buyer (n=6), clinical PrEP trial (n=3) or using their friend’s supply (n=1). Most of them used PrEP on demand (event-driven).

PrEP information is not enough

There were several informational gaps that negatively affected participants’ ability to access PrEP and their confidence in taking it. Only half of participants knew where to source PrEP.

“[My sources of PrEP information are] mainly two types. One is Twitter, and the other is WeChat… Some people, some strangers, would just follow you (on Twitter) and message you that he is selling some videos [of gay pornography], and then he starts selling you these drugs (imported PrEP and recreational drugs).” – Previous PrEP user (event-driven), 22 years old

Participants shared that formal routes (prescriptions from an HIV clinic) were costly and time consuming, due to the cost of the drugs and transportation, as well as loss of earnings (by going to the clinic instead of work).

“I would definitely prefer to buy it (PrEP) from a friend. Why would I waste my time at the hospital? The hospital can’t do delivery home. It may take me half an hour or a whole hour to travel to the hospital. Not to mention waiting at those [registration and pharmacy] counters.” -  current PrEP user, 25 years old

Few perceived the clinics as friendly to MSM. Informal channels (through social media and social networks) were seen as easier ways to access PrEP. However, some worried about the authenticity of what they were taking.

“I think [you can get PrEP] from Twitter … But I never buy (things from them because) don’t know if they are authentic or fake. But I’m curious about how to get, how to get these drugs through formal and trustworthy channels.” – Never used PrEP, 24 years old

None of those who purchased PrEP from informal buyers received any lab tests, and information about how to use it was scant.

Some were well informed about PrEP and where to access it, however, they perceived PrEP and condoms as mutually exclusive and therefore questioned the effectiveness of PrEP and favoured condoms for overall STI prevention.

“In the beginning, I had half doubt and half trust in this drug (PrEP). I only heard about it from other people. It was around 2016. There was not much evidence or official endorsement to state that “it is really effective”. So, I thought this drug was “神奇” (Shén-Qí, mysterious).” – Intermittent PrEP user, 25 years old

“When I saw this (introduction of PrEP), I had a question. It says PrEP can decrease your chance of getting HIV by over 90%. But the remaining 10% (chance of HIV infection) is still high.” – Never used PrEP, 30 years old

“There are many other diseases, right? Besides HIV, there are also many other diseases. And they can all be transmitted by sex. So, wearing condoms is a better way. Now there’s some people taking PrEP, and you can only prevent HIV, not other STIs.” – PrEP user (event-driven), 27 years old

Some participants also chose to use condoms to minimise financial costs (especially when considering daily PrEP use) and to avoid PrEP side effects.

Motivation for taking PrEP

Beyond HIV prevention, participants highlighted that their motivations for taking PrEP were to improve their overall quality of life. They shared that the drug gave them more control over their sexual health, which was especially true for several participants who feared having sex with individuals who may intentionally attempt to transmit HIV.

“They (partner) might take it (condom) off when you don’t notice or when you don’t pay attention. Physical prevention is not a one-for-all solution. Because, it’s not totally within my control. I can control taking the drug because I am taking it. Though sometimes, I’m also worried about whether I have taken enough (PrEP pills) to be fully protected. So, if using either of the two methods, I would still be worried. But if using them together, I’d feel safer.” – Intermittent PrEP user, 28 years old 

Participants spoke about the role of PrEP in a context of stigmatisation of sexual minorities. While PrEP might reduce HIV among MSM, and thereby reduce stigma, branding PrEP as a medication for MSM may exacerbate stigma. Participants shared that they would be more motivated to take PrEP if it were promoted for the general population.

“After all, I think the biggest burden on people like us, or the point that outsiders don’t like about us the most, is that we can easily get HIV. I think PrEP is a perfect solution to this problem. It can make us free and less concerned.” – Intermittent PrEP user, 28 years old

“Because for them (heterosexual individuals), sometimes, when they see this (PrEP and gay men being shown together), they would have a (negative) reaction. If they are friendly to us (gay men), they may think it’s fine. If they don’t like (gay men), they would resist the drug (PrEP). They may think this drug is not for them.” –  Intermittent PrEP user, 26 years old

Conclusion

Taken together, the qualitative and cross-sectional studies highlight numerous challenges to PrEP access for Chinese MSM which contributes to a low uptake of PrEP in the country. These individual, social and structural barriers require a multi-layered response to increase MSM’s confidence in PrEP, access to it and treatment literacy.

It is important not to overlook the role that informal PrEP channels have played in HIV prevention, especially before PrEP was formally approved in China, however these informal routes create uncertainty about drug quality. Official PrEP providers may consider how informal networks effectively target key populations and use this knowledge to inform the development of community-based provision to increase trust and access. Barriers to HIV clinics need to be removed; government-backed non-discriminatory public health messaging may be key to challenging the perceived and enacted discrimination within these settings.