Study On Influencing Factors And Countermeasures For Hiv Pre-Exposure Prophylaxis Among Men Who Have Sex With Men In Nanjing

Background Sexual transmission is the main route of HIV transmission in China,and men who have sex with men(MSM)are the majority of the population infected with HIV.Among the new HIV infections reported annually in Jiangsu province,the proportion of HIV transmission through MSM increased from 0.91% in 2007 to 55.07%in 2021,and more than half of the new HIV cases reported in Nanjing in 2019 were also transmitted through MSM.Although condom use and regular HIV testing can effectively reduce HIV transmission,national MSM sentinel monitoring showed that the rate of condom use among MSM was only about 50%,and the rate of HIV testing in the last year was lower than that of high-risk groups such as commercial sex workers.Behavioral interventions such as condom use promotion,early HIV testing and early HIV detection for MSM population have failed to achieve the expectation of control the HIV epidemic.Therefore,new prevention methods are urgently needed to introduce to control the Acquired Immune Deficiency Syndrome(AIDS)epidemic.Pre-exposure prophylaxis(PrEP),recommended by the World Health Organization as a promising biological intervention for HIV.Foreign real-world studies have proved that PrEP can effectively reduce the risk of HIV infection in MSM,transgender women and families with single-positive HIV by more than 90%,thus significantly reducing the national burden of AIDS public health disease.MSM is the critical population of AIDS prevention and control in Jiangsu Province and even the whole country,and also is a potential key population for the PrEP promotion.Their willingness to use PrEP and final utilization determines the feasibility of the promotion and implementation of PrEP strategy in China and the effectiveness of AIDS epidemic control.In this study,a cross-sectional questionnaire survey was conducted to understand the willingness to use and the intention to adhere to PrEP among MSM in Nanjing and its associated factors.Then,the interconnectedness of interpersonal communication and the characteristics of social network space of MSM population were explored through social network analysis.Meanwhile,highly sex active and “key”MSM in the center of the network were selected as candidates for in-depth personal interview.Finally,through qualitative research,in-depth personal interviews were conducted with “key” MSM and PrEP stakeholders,including doctors,CDC staff,the cadre of MSM social organization,and the boss of entertainment venues.We will understand their cognition and suggestions on the widespread implementation of PrEP in China from the perspective of both MSM and PrEP stakeholders.Moreover,explore the potential impacts that facilitate and impede the use of PrEP among MSM,as well as suggestions and countermeasures,which provides scientific basis for the formulation of PrEP prevention strategies for MSM in China.Objective1.Investigate the sociodemographic characteristics,sexual behavior characteristics,psychologies,willingness to use,and intention to adhere PrEP among MSM in Nanjing and its influencing factors.2.Investigate the interconnectedness of interpersonal communication and the characteristics of social network space of MSM population,as well as the characteristics of highly sex active and "key" MSM at the center of the network to provide a basis for precise intervention and resource allocation of PrEP.3.Investigate the facilitators and barriers to using PrEP from the perspective of both MSM and PrEP stakeholders and explore effective strategies to promote PrEP implementation to provide constructive suggestions for the formulation of PrEP strategies for MSM in China.Methods1.Cross-sectional surveys is conducted.MSM in Nanjing are recruited through time and place sampling and online to conduct questionnaire survey,rapid HIV and syphilis antibodies testing.Questionnaire investigated the sociodemographic characteristics,sexual behavior characteristics,psychologies,willingness to use and intention to adhere PrEP among MSMas well as its influencing factors.2.Social network analysis is performed.UCINET 6.0 software and Net Draw 2.0 software are used to conduct the social network centrality analysis and visual analysis with the spatial data of MSM seeking sexual partners of surveyed individuals.Furthermore,to understand the distribution characteristics of MSM social-spatial network,the risk of different spaces,and "key" MSM characteristics at the center of the network.3.Qualitative study is conducted.In-depth personal interviews are conducted on MSM and stakeholders.The content of the interview is focused on PrEP cognition,facilitators and barriers to the widespread implementation,and recommendations for PrEP services.Nvivo 11 qualitative research and analysis software is used to import Word text of interview content and encode it line by line or paragraph by paragraph.Finally,a summary is given and specific results are expressed with examples.Results1.311 MSM participated in the questionnaire survey,and 309 are effective questionnaires;the effective response rate is 99.4%.The median age of all subjects is 27 years old(interquartile range: 23-34);the youngest is 18 years,and the maximum is 65 years;48.9%(151/309)MSM are bachelor or above;the monthly income is mainly less than 5,000 yuan,accounting for 58.9%(151/309);79.0%(244/309)MSM are in the single state and 68.9%(213/309)self-identity are homosexual.The median age of the first anal sex is20 years old(interquartile range: 19-24);the youngest is 10 years,and the maximum is 52 years.In the past6 months,31.7%(98/309)and 26.2%(81/309)MSM have had unprotected anal intercourse when had insertive and receptive anal sex,respectively.9(2.9%)are the new HIV positive cases and 32(10.4%)are syphilis antibody positive.The median of self-homophobia and community homophobia are 20 points(IQR:16 ～ 24)and 27 points(IQR:22 ～ 30),respectively.85.8%(265/309)and 87.4%(270/309)of MSM have high self-homophobia and community homophobia.The median of anticipated HIV stigma is 20(IQR:17 ～ 23),and 92.6%(286/309)of MSM have high anticipated HIV stigma.There are 59.2%(183/309)of MSM had heard of PrEP,75.7%(234/309)of MSM are willing to use PrEP,and 55.3%(171/309)have a high intention to adhere to PrEP.Heard of PrEP(OR = 2.366,95% CI: 1.232-4.545)and anticipated HIV stigma(OR= 4.173,95% CI: 1.367-12.74)are significantly associated with willingness to use PrEP.Bachelor degree or above(OR=1.854,95%CI: 1.126-3.051),high community homophobia(OR=0.444,95%CI: 0.202-0.978),and anticipated HIV stigma(OR=3.804,95%CI: 1.282-11.289)were significantly associated with high intention to adhere to PrEP.2.With 309 valid questionnaires,300(97%)MSM mention at least one space for seeking sexual partners.MSM chose Blued(81.0%),We Chat(34.3%),and Xingda bar(34.0%)as the top three places for seeking sexual partners.The top three of the HIV infectious risk spaces are Taige Bar(8.3%),Bibochi Bathroom(8.0%),and Tan Tan(7.4%).The top three places of risk for syphilis infection are Shencemen Park(29.2%),Half-past nine Bar(19.4%),and Juhuatai Park(15.4%).The highest proportion of non-condom sex is Shenzhimen Park(58.3%).Aloha(77.1%)is the most aware of PrEP and the most willing to use PrEP(85.7%),while Taige Bar(63.9%)has the highest percentage of high intention to adhere to PrEP.The proportion of highly sexually active MSM in the center of the network who had their first anal intercourse under the age of 18 is significantly higher than that of non-highly active MSM(P=0.001).In the past six months,the proportion of highly sexually active MSM who had insertive anal sex with more than one partner(P=0.003),receptive anal sex with more than one partner(P=0.006),alcohol consumption before or during sex(P=0.011)and use of substance such as Rush(P<0.001)are also significantly higher than that of nonhighly active MSM.3.21 people are interviewed,including 15 MSMs and 6 stakeholders.13 MSM(including 2 PrEP user)have heard of PrEP,but most(66.7%,10/15)are just to heard of PrEP,very little known about specific knowledge.Internet(66.7%%,8/12),social organizations(33.3%,4/12),and friends(8.3%,1/12)are main way for MSM who heard about PrEP.Most MSM think that MSM would increase high-risk behavior after using PrEP,but the risk compensation problem may be mitigated if the condom use is informed correctly.12 MSM say they would actively recommend PrEP to friends.In terms of issuing drug prescriptions and drug acquisitions,most of the MSM mention CDC(86.7%,13/15),some MSM refer to hospital(40.0%,6/15),pharmacies(33.3%,5/15),social organization(online and offline)(33.3%,5/15)and the Community Health Service Center(26.7,4/15).All interviewees(n = 21)believe that the main barriers to widely implemented in China are priced(76.2%,16/21)traditional cognition(66.7%,14/21),discrimination,and privacy(47.6%,10/21).The recommendations widely implemented in China mainly are propaganda(100.0%,21/21)and drug price reduction(71.4,15/21).Conclusion1.MSM with HIV negative or unknown infection status in Nanjing show a high willingness to use PrEP but a low intention to adhere to PrEP,especially for MSM with low education levels.Meanwhile,attention should be paid to the psychosocial problems of MSM during the whole process of PrEP initiation and medication taking to reduce its negative impact on PrEP use and medication compliance,so as to achieve the maximum benefits of PrEP intervention strategies.2.The MSM in Nanjing consist of an extensive social network through various spaces,and they mainly seek sex partners by virtual space.The MSM in virtual places are more aware of and willing to use PrEP,while MSM in real space have a high risk of HIV and syphilis infection,but a relatively low awareness and willingness to use PrEP.MSM who are at the center of the network and highly active have a high risk of direct or indirectly transmitting HIV.3.Most of the MSMs who heard of PrEP are not clear about PrEP,and most of the PrEP information is commercially available,so the authority should release the correct PrEP information to eliminate the negative impression and misunderstanding on PrEP among MSM.Barriers to widespread PrEP implementation include high drug prices,traditional perceptions,privacy and discrimination.The facilitators and recommendations for widespread implementation of PrEP in our province and even in China include correct publicity,drug price control,government leadership,improvement of PrEP related policies and guidelines,improvement of pre-medication physical examination and post-medication follow-up management,integration of psychological services into the PrEP service system,and development of specific PrEP implementation measures.