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Between May and Decembera cross-sectional survey was conducted among MSM recruited through snowball sampling in physical locations frequented by MSM and through social media applications. Exploratory factor analysis was used to group reasons for being willing or not willing to use PrEP. Chi-square tests were used to explore bivariate associations between groupings of reasons for being willing or unwilling to use PrEP, and key sociodemographic and sexual-behavioral characteristics of MSM.

Overall, The main reasons for being unwilling to use PrEP were being worried about side effects Individual characteristics that influenced the type of reasons given for being willing or unwilling to use PrEP included being married to a woman, having a regular sex partner, rates of condom use with regular and casual sex partners, and the of casual sex partners. The introduction of PrEP in China could benefit from promotion campaigns that emphasize its role in preventing HIV infection, in taking responsibility for own sexual health, and in protecting family members from potential harm.

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To reduce uptake barriers, it will be essential to provide accurate information to potential PrEP users about the mild and short-term nature of side effects, and the possibility of taking PrEP only during particular periods of life when the risk of HIV exposure might be highest. This is an open access article distributed under the terms of the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data files are available from the Dryad database accession is doi: The funder had no role in study de, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Human Immunodeficiency virus HIV is a ificant cause of global mortality and morbidity [ 1 ]. In China, unprotected sex has been the dominant route of HIV transmission since the beginning of the epidemic.

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The proportion of new cases of HIV infection attributable to sexual transmission has increased in recent years, from The most recent estimates suggest that there are between 5—10 million MSM in China [ 6 ]. HIV incidence among this population has been reported to be as high as 6. Despite the availability of various HIV prevention methods, such as condoms and lubricants, testing and treatment for sexually transmitted infections STIand linkage to treatment and care for people diagnosed with HIV in China [ 3 ], a ificant HIV prevention need remains.

Despite high levels of awareness about HIV and its prevention among Chinese MSM, condom use during anal intercourse has remained sub-optimal [ 1013 ]. While PrEP has proved to be effective in preventing HIV transmission, it is important to better understand how it can be implemented within combination HIV prevention programs based on local contexts. Similar findings have been reported in a recent review [ 22 ] that found a need to provide widespread and accurate information about PrEP to MSM globally.

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Beyond understanding awareness levels, formative research is required to identify sub-populations of MSM willing to use PrEP as part of comprehensive prevention efforts, and in what ways they can be supported to access it. In addition, it is essential to identify ways in which MSM can be empowered to make informed decisions on if, how, and when to use it as part of a package of interventions to protect themselves from acquiring HIV. To do so, knowledge, attitudes, and beliefs towards PrEP should be understood, including motivators and barriers to potential utilization.

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In order to respond to this imperative, we conducted this study among MSM in Wuhan and Shanghai, with an aim of determining their willingness to use oral PrEP, and the underlying reasons influencing such willingness. In addition, the study sought to identify demographic factors and sexual behavior characteristics associated with willingness to use PrEP among this population. The study comprised a cross-sectional survey conducted between May and December in the cities of Wuhan and Shanghai, which were selected based on their geographical location Central and Eastern China respectivelythe economic status of their residents, and their large MSM populations.

Recruitment occurred via two methods: 1 three rounds of face-to-face snowball sampling at physical spaces frequented by MSM, such as parks, bathhouses, and bars; and 2 via messages sent over social media applications WeChat, QQ. Eligibility criteria included: 1 being a man who had sex with men in the 12 months; 2 living in Wuhan or Shanghai; 3 being aged 18 years or older; 4 having never received a positive HIV diagnosis; and 5 being willing to a consent form. Respondents were given the choice of completing either a paper-and-pencil survey onsite, or an electronic survey online.

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Both versions of the survey included the same set of questions and information. Stipend amounts differed due to higher general costs of living in Shanghai. After the initial contact and screening of potential participants, eligible respondents were provided with a choice to either fill out the survey onsite at the time of initial contact or to do so at a future date. Those who chose to fill out the survey at a future date were scheduled for a face to face appointment based on their availability.

Before completing the survey, all respondents were provided with a detailed overview of the study, and asked to provide written informed consent. To reduce the chance of potential confidentiality breaches, respondents were permitted to use nicknames when ing the informed consent forms. Filling out the survey form took an average of 30—40 minutes. Respondents who preferred to respond to the online version of the survey were identified in MSM physical or social spaces or through social media applications and provided with a link to the web address hosting the survey, a unique access code, and a password.

Eligible respondents were then required to provide consent electronically, after which they gained access to the full survey. The survey examined knowledge, attitudes and beliefs pertaining to PrEP, and to identify potential reasons for being willing to use it, or not. It consisted of 6 sections, covering demographic characteristics, HIV status, sexual risks and practices, awareness of and willingness to use PrEP, common concerns regarding potential PrEP use, and preferred ways of accessing PrEP.

The survey was initially developed in Chinese then translated in English to enable non-Chinese literate team members to provide inputs and comments, and finally back- translated in Chinese by a different translator to avoid bias. To ensure that the survey items were clear, concise, and acceptable to respondents, the survey was piloted with 12 MSM and revised based on feedback. While PrEP is not yet available in Chinait is thought that PrEP will probably be of most benefit to people who perceive themselves to be at a higher risk of contracting HIV at certain points in their lives.

Howeverit may also be useful for people who have experienced difficulty in using condoms consistently. PrEP works best if you take it every day and while there can be some side-effects at first such as nausea and headachesthese generally reduce after a few weeks of use. People who take PrEP should have regular sexual health check-upsincluding HIV testing to ensure the medication is working.

To determine willingness to use PrEP, respondents were asked to indicate their level of agreement on a Likert scale strongly disagree, disagree, neither agree nor disagree, agree, strongly agree with seven statements, adapted from a willingness to use PrEP scale used in a study [ 24 ]. To understand what are the main reasons for being willing to use PrEP, respondents were provided with a multiple choice question that included the following potential answers multiple response options were allowed : 1 to prevent me from contracting HIV, 2 I have problems using condoms, 3 to take responsibility for my own sexual health, 4 I have difficulties persuading my sexual partners to use condoms, 5 to feel more in control of my sexual health, 6 to protect my family from potential harm, 7 other reasons with an option to specify other reasons not listed above, or to state no special reasons.

Survey questions and response options were generated from existing literature regarding potential factors influencing willing to use PrEP in other settings, as reported in studies [ 2125 — 27 ] and reviews [ 28 ].

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A total of men completed the survey, however nine respondents were removed from the final database due to duplicate, suspicious or ineligible entries. The final sample comprised eligible respondents. Descriptive analysis was undertaken to summarize the sexual behavior and demographic characteristics of the sample.

The seven possible reasons for being willing to use PrEP and the eight possible reasons for being unwilling to use PrEP were grouped using exploratory factor analysis with oblique rotation given that the reasons were correlated [ 29 ]. Only items with factor loadings of 0.

After factor analysis, chi-square tests were conducted to determine the association between reasons for being willing to use PrEP or not and demographic and sexual behavior characteristics. All analyses were conducted using SPSS version Participation in this PrEP study could have potentially exposed MSM in their communities and exacerbated perceived stigma related to sexual orientation.

For this reason, robust strategies were employed to protect the confidentiality and privacy of all study respondents. Only voluntarily consenting respondents were interviewed. Respondents were assured of confidentiality, anonymity, and their right to withdraw. All were provided with details of the organizations carrying out the survey and a list of websites providing information about HIV, Women seeking sex Bourne, and broader sexual health topics.

Of the respondents included in the analysis, Almost a quarter of the sample, More than four-fifths of respondents In the 12 months preceding the survey, nearly one-third of all the respondents Nearly three-quarters of the men with a regular partner Just over half of respondents with a regular partner Nearly two-thirds Nearly 1 in 5 respondents The majority of respondents who had heard of PrEP prior to the survey understood that PrEP was a kind of antiretroviral medicine used to prevent HIV infection before engaging in high risk behaviours.

Among the See Table 1 for a full of selected willingness to use PrEP responses.

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Among the respondents who stated that they were not willing to use PrEP, the most commonly selected reason by Following factor analysis of the seven possible reasons why men were willing to use PrEP see Table 3the first two factors extracted ed for No other factor had a loading of 0.

The first factor loaded at almost 0. In factor analysis of the eight possible reasons why men were unwilling to use PrEP, the first three components extracted ed for Factor loadings for the eight items are shown in Table 4. The second factor loaded at almost 0.

The third factor loaded at almost 0. Tables 5 and 6 display the relationship between willingness to use PrEP and key demographic and sexual behavior characteristics. Compared with respondents whose marital status was single, divorced or widowed, men who were married to a woman were more likely to explain their willingness to use PrEP in terms of taking responsibility or control of sexual health In addition, men who reported never using condoms with their regular sexual partners were more likely to explain their willingness to use PrEP in terms of problems using condoms compared to men who said they always used condoms The same pattern was observed with respect of condom use with casual male partners As shown in the following Tables 7 and 8men who had regular sexual partners were likely to select responses that related to a perception of insufficient need compared to those who did not have a regular sexual partner The same pattern was observed between those who had no casual sexual partners within the last year compared to those who had Those who said they always used condoms with casual partners were more likely to indicate responses that comprised the perception of insufficient need factor compared to those who said they never did so Respondents without a regular sexual partner were more likely to select responses that comprise the practical concerns of everyday use factor, compared to those that did This study reports a high level of willingness to use PrEP This estimate is within the range of several studies among MSM in China, that have reported levels of willingness to use PrEP ranging from However, the strength of this study is its in-depth exploration of reasons influencing willingness to use PrEP, and the use of multiple recruitment strategies, including social media applications, to reduce potential recruitment bias.

Studies from China [ 36 ] and elsewhere [ 37 ], have shown that internet and app-based partner selection is frequently associated with riskier sexual behaviors. Hence recruitment through these channels can be appropriate for reaching potential PrEP users at substantial risk of HIV.

The from this study indicate that the predominant motivations for using PrEP among MSM are: 1 to prevent HIV infection, 2 to be more responsible for their own health, and, 3 to protect their family from potential harm.

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These reasons were reported by For MSM who are unwilling to use PrEP, the main reasons given related to concerns regarding potential side effects, the need to take PrEP medication for a long time, and the fact they were using condoms consistently reported by This finding is consistent with other studies which have reported wanting to stay HIV negative as a ificant motivator for being willing to use PrEP [ 2738 ].

An additional finding in our study was that the subgroup of MSM who were currently married to women were more likely to be willing to use PrEP for reasons related to taking responsibility of own health, control of sexual health, or to protect their families from potential harm[ 27 ]. This subgroup of MSM were also more likely to cite difficulties in using condoms as a reason for being willing to take PrEP. Taken together, these findings suggest that the potential for PrEP to protect the well-being of ificant others could be a capitalized on in social marketing interventions targeting MSM, although this could be limited by the extent to which they are openly living as MSM.

Problems using condoms and difficulties in persuading sexual partners to use condoms were common reasons for being willing to use PrEP. In addition, the subgroup of men who reported never using condoms with their regular and casual sexual partners were more willing to use PrEP given problems related to condom use, which is consistent with other studies [ 26 ]. Acknowledging and identifying sub-populations of MSM who are facing difficulties in using condoms could provide an opportunity to distinguish those who are at substantial risk, and to provide them with PrEP, while emphasizing that as opposed to condoms, PrEP does not prevent other STIs.

For such sub-populations, PrEP provision could form an entry point for STI prevention and treatment and other health services. Our suggest that concerns about daily use of medications, including potential side effects, the need to take medication for a long time, and potential problems or worries about adherence are the dominant reasons for not being willing to use PrEP.

These barriers have been noted in other studies [ 2138 ], and their predominance suggests that communicating about the generally mild and short-term nature of side effects and about the possibility of taking PrEP only during particular periods of life, when the risk of HIV exposure is highest will be essential to future PrEP uptake [ 20 ]. In addition, exploring convenient dosing forms e.

Another distinct factor influencing willingness to use PrEP related to perception of insufficient need and practical concerns of everyday use. This finding suggests that PrEP programs in the study setting may not be overwhelmed with unnecessary requests if PrEP were made available. Our findings are consistent with other studies in relation to the negative influence of cost [ 40 ] and suggest that eliminating, subsidizing or discriminating user costs based on purchasing ability will be needed as noted in, Myanmar, Kenya and Taiwan respectively [ 274041 ].

As such, social marketing and health promotion campaigns should be broad based in-order to reach public, community and private sector channels. While not grouped within a specific factor, To successfully overcome stigma directed at PrEP users, it will Women seeking sex Bourne important to emphasize that all current and potential PrEP users, including MSM, sex workers, injecting drug users, clients of sex workers, negative partners in sero-discordant relationships, young people or other sub-populations at substantial risk are not being irresponsible, but that on the contrary they are taking responsible steps to remain HIV-negative and prevent HIV transmission.

It will also require educating communities in-order to address other intersecting issues such as HIV-related stigma and homophobia, among others [ 42 ]. Our study has several limitations. First, due to its cross-sectional de, this study assessed associations rather than causal relationships. Second, we utilized a quantitative de with close ended questions to explore reasons affecting willingness to use, and while useful and based on literature, the fielding of pre-specified reasons may could have limited reasons provided by respondents as influencing their willingness to use it. Given the hypothetical basis of this study, it is uncertain if, and what proportions of MSM would actually use it when it is made available.

Evidence from several studies suggests that reported willingness does not always predict actual use of PrEP [ 3143 ] and could be contingent on the infrastructure, communication and user-support available to potential users [ 22 ].

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