Willingness to Accept HIV Pre-Exposure Prophylaxis among Chinese Men Who Have Sex with Men

Abstract

We investigated the awareness and acceptability of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) and potential predicting factors.
This study was conducted among MSM in Beijing, China. Study participants, randomly selected from an MSM cohort, completed a structured questionnaire, and provided their blood samples to test for HIV infection and syphilis. Univariate logistic regression analyses were performed to evaluate the factors associated with willingness to accept (WTA) PrEP. Factors independently associated with willingness to accept were identified by entering variables into stepwise logistic regression analysis.
A total of 152 MSM completed the survey; 11.2% had ever heard of PrEP and 67.8% were willing to accept it. Univariate analysis showed that age, years of education, consistent condom use in the past 6 months, heterosexual behavior in the past 6 months, having ever heard of PrEP and the side effects of antiretroviral drugs, and worry about antiretroviral drugs cost were significantly associated with willingness to accept PrEP. In the multivariate logistic regression model, only consistent condom use in the past 6 months (odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.13-0.70) and having ever heard of the side effects of antiretroviral drugs (OR: 0.30; 95% CI: 0.14-0.67) were independently associated with willingness to accept PrEP.
The awareness of PrEP in the MSM population was low. Sexual behavioral characteristics and knowledge about ART drugs may have effects on willingness to accept PrEP. Comprehensive prevention strategies should be recommended in the MSM community.

Full text

Willingness to Accept HIV Pre-Exposure Prophylaxis
among Chinese Men Who Have Sex with Men
Feng Zhou
1.
, Lei Gao
1.
, Shuming Li
2
, Dongliang Li
2
, Lifen Zhang
3
, Wensheng Fan
4
, Xueying Yang
2
,
Mingrun Yu
5
, Dong Xiao
6
, Li Yan
7
, Zheng Zhang
2
, Wei Shi
8
, Fengji Luo
2
*, Yuhua Ruan
5
*, Qi Jin
1
1Institute of Pathogen Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China, 2Beijing Chaoyang Center for Disease Control and
Prevention, Beijing, China, 3Department of Epidemiology and Statistics, Institute of Basic Medical Sciences, Chinese Academic of Medical Sciences and School of Basic
Medicine, Peking Union Medical College, Beijing, China, 4Department of Public Health, College of Health and Human Service, Western Kentucky University, Bowling
Green, Kentucky, United States of America, 5State Key Laboratory for Infectious Disease Prevention and Control, and National Center for AIDS/STD Control and Prevention
(NCAIDS), Chinese Center for Disease Control and Prevention, Beijing, China, 6Chaoyang Chinese AIDS Volunteer Group, Beijing, China, 7Beijing Jingcheng Skin Diseases
Hospital, Beijing, China, 8Beijing Chaoyang Health Bureau, Beijing, China
Abstract
Objective:
We investigated the awareness and acceptability of pre-exposure prophylaxis (PrEP) among men who have sex
with men (MSM) and potential predicting factors.
Methods:
This study was conducted among MSM in Beijing, China. Study participants, randomly selected from an MSM
cohort, completed a structured questionnaire, and provided their blood samples to test for HIV infection and syphilis.
Univariate logistic regression analyses were performed to evaluate the factors associated with willingness to accept (WTA)
PrEP. Factors independently associated with willingness to accept were identified by entering variables into stepwise
logistic regression analysis.
Results:
A total of 152 MSM completed the survey; 11.2% had ever heard of PrEP and 67.8% were willing to accept it.
Univariate analysis showed that age, years of education, consistent condom use in the past 6 months, heterosexual behavior
in the past 6 months, having ever heard of PrEP and the side effects of antiretroviral drugs, and worry about antiretroviral
drugs cost were significantly associated with willingness to accept PrEP. In the multivariate logistic regression model, only
consistent condom use in the past 6 months (odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.13–0.70) and having ever
heard of the side effects of antiretroviral drugs (OR: 0.30; 95% CI: 0.14–0.67) were independently associated with willingness
to accept PrEP.
Conclusions:
The awareness of PrEP in the MSM population was low. Sexual behavioral characteristics and knowledge
about ART drugs may have effects on willingness to accept PrEP. Comprehensive prevention strategies should be
recommended in the MSM community.
Citation: Zhou F, Gao L, Li S, Li D, Zhang L, et al. (2012) Willingness to Accept HIV Pre-Exposure Prophylaxis among Chinese Men Who Have Sex with Men. PLoS
ONE 7(3): e32329. doi:10.1371/journal.pone.0032329
Editor: Chen Liang, Lady Davis Institute for Medical Research, Canada
Received October 26, 2011; Accepted January 25, 2012; Published March 30, 2012
Copyright: ß2012 Zhou et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by the grants from the Ministry of Science and Technology of China. The funders had no role in study design, data collection
and analysis, desicion to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: luofengji@yahoo.com.cn (FL); ruanyuhua92@gmail.com (YR)
.These authors contributed equally to this work.
Introduction
In pre-exposure prophylaxis (PrEP), antiretroviral (ARV) drugs
are given to HIV-negative people to decrease their chance of
becoming infected. Severalstudies conducted among men who have
sex with men (MSM) have shown that PrEP awareness was very
low, and few participants reported having the experience of PrEP
use, even in some countries where it is available [1–3]. Although
strategies including abstinence, being faithful, and condom use
(ABC) have been proved to be effective for prevention of HIV
transmission, the virus still prevails among MSM. It was estimated
that 2.6 million individuals were newly infected in 2009 worldwide,
which 19% fewer than the 3.1 million in 1999 [4]. China had about
740,000 people living with HIV and 105,000 with AIDS by the end
of 2009 [5]. Homosexual intercourse has become a major mode of
HIV transmission since 2009, and the prevalence of HIV in MSM
has increased significantly from 2.5% in 2006 to 8.6% in 2009 [5]. A
sociological study has estimated that there are 1.8–2.4 million
homosexual or bisexual men in mainland China [6]. In China,
high-risk behavior, such as multiple partners and unprotected sex,
have been reported to be common in this group [7–14]. Also, recent
studies have reported rapid transmission of HIV in this specific
population from various geographic areas in China, despite the
efforts made by the national and local governments and non-
governmental organizations in the past few years [15–18]. New
effective approaches are urgently needed for this population.
In recent decades, researchers have made great efforts to
explore alternative biomedical interventions, such as male
PLoS ONE | www.plosone.org 1 March 2012 | Volume 7 | Issue 3 | e32329

circumcision (MC), HIV PrEP and post-exposure prophylaxis
(PEP), HIV vaccines, and microbicides. Among these potential
strategies, PrEP is considered to be one of the most promising
strategies in MSM. Several animal and human studies have
suggested that ARV drugs might reduce the risk of HIV infection
either by PrEP or by non-occupational PEP [10,15,19,20]. A 12-
month PrEP clinical trial of daily oral tenofovir disoproxil
fumarate (TDF) for HIV prevention was performed among 400
HIV-negative Ghanaian women, and achieved good acceptability
and .82% adherence [21]. In November 2010, the US National
Institutes of Health (NIH) announced the results of the iPrEx trial
of PrEP conducted among 2499 HIV-seronegative MSM in six
countries, which showed that daily oral Truvada, a combination of
emtricitabine (FTC) and TDF, reduced risk of HIV incidence by
44%, with a median 1.2 years follow-up, compared with the
placebo group, and .75% adherence was reached [22]. These
findings represent a major advance in HIV prevention research,
providing the first evidence that PrEP, when combined with other
prevention strategies, can reduce HIV risk among MSM. A further
study is ongoing in HIV Prevention Trials Network (HPTN) 067
to evaluate the feasibility of intermittent dosing of PrEP. Recent
results from Partners PrEP and CDC TDF2 have shown that PrEP
with daily oral TDF/FTC or TDF was effective at reducing HIV
risk in heterosexual men and women [23,24]. However, the Fem-
Prep program on Truvada, a closed clinical trial implemented by
Family Health International (FHI) in partnership with research
centers in Africa, does not support the theory of PrEP having an
effect on HIV prevention [25]. Therefore, some factors that might
influence the efficacy of PrEP, including adherence, sexual
behavior, or other factors still need to be determined.
The awareness and acceptability of new strategies are very
important when they are recommended for use. Therefore, the
objective of our study was to investigate the awareness and
acceptability of PrEP among MSM and potential impact factors,
which will provide suggestions and guidelines for future clinical
trials in China.
Results
Demographic characteristics
A total of 159 participants were enrolled in the study. Seven
were deleted because of not having sex with men in the past 6
months, by self-reports. Finally, 152 were used for the analyses.
Age of the participants ranged from 18 to 61 years, with a mean
age of 29.768.6 years. One hundred and three (67.8%) subjects
expressed willingness to definitely or probably take PrEP if it were
available in China in the future. In the univariate logistic
regression model, age and years of education were found to be
associated with WTA (Table 1).
Behavioral characteristics and laboratory test results
Homosexual men accounted for 84.9%, and bisexual men for
15.1% of the selected population, and 53.3% of them were using
condoms consistently. The median number of their homosexual
partners was three before baseline. In the past 6 months, insertive
or predominantly insertive anal sexual intercourse was reported by
101 participants (66.4%) and receptive or predominantly receptive
anal sexual intercourse was reported by 51 participants (33.6%);
eight participants (5.3%) had received money for sex from male
partners, and five (3.3%) had provided money for sex to male
partners; 49.3% reported having bought condom lubricant. All of
the participants were tested for HIV infection or syphilis and none
of them were found to be infected. In the univariate regression
model, inconsistent condom use in homosexual behavior in the
past 6 months and heterosexual behavior in the past 6 months
were shown to be associated significantly with WTA (Table 2).
Potential benefits/risks from PrEP
Seventeen participants (11.2%) had ever heard of PrEP before
our study; 69.1% reported having ever heard that ARV drugs can
help control AIDS development; and 32.9% reported having ever
heard of side effects of ARV drugs. With regard to the potential
risks of PrEP, 63.8% expressed being worried about not working
due to the side effects from PrEP; 44.1% expressed worry that
PrEP has no prevention efficacy; 44.7% expressed worry about
diet and sleep being disrupted by PrEP; 21.7% expressed worry
about drug resistance from PrEP; 20.1% expressed worry about
being treated as an AIDS patient by people; 14.5% expressed
worry about being refused sex by male partners after using ARV
drugs; and 26.3% expressed worry about not being able to afford
ARV drugs. Univariate logistic regression found that having ever
heard of PrEP and the side effects of ARV drugs, and being
worried about not being able to afford ARV drugs were
significantly associated with WTA (Table 3).
Results from multivariate analyses
All of the variables associated with WTA in univariate analyses
were included in a multivariate logistic regression model and were
applied for variable selection stepwise to determine a final model.
In the multivariate logistic regression model, those who did not
have consistent condom use in homosexual behavior in the past 6
months (OR: 0.31; 95% CI: 0.13–0.70), and had never heard of
Table 1. Associations between demographical characteristics
and willingness to accept PrEP.
Factors
WTA
Event/Total (%) OR (95% CI) p value
Age
,30 years 66/96 (68.8) 1.00
$30 years 47/56 (83.9) 2.37 (1.03, 5.46) 0.04
Marital status
Single/divorced/widowed 76/104 (73.1) 1.00
Married/cohabitated 37/48 (77.1) 1.24 (0.56, 2.76) 0.60
Registered Beijing residence
No 94/122 (77.1) 1.00
Yes 19/30 (63.3) 0.52 (0.22, 1.21) 0.13
Han Ethnic
No 8/10 (80.0) 1.00
Yes 105/142 (73.9) 0.71 (0.14, 3.49) 0.67
Years of education
,12 64/80 (80.0) 1.00
$12 49/72 (68.1) 0.53 (0.26, 1.12) 0.09
Monthly income (RMB)
#2000 54/70 (77.1) 1.00
.2000 59/82 (72.0) 0.76 (0.36, 1.59) 0.47
Good HIV/AIDS knowledge
No 55/71 (77.5) 1.00
Yes 58/81 (71.6) 0.73 (0.35, 1.53) 0.41
Abbreviation: CI, confidential interval; OR, odds ratio; PrEP, pre-exposure
prophylaxis; WTA, willingness to accept.
doi:10.1371/journal.pone.0032329.t001
Willingness to Accept PrEP among Chinese MSM
PLoS ONE | www.plosone.org 2 March 2012 | Volume 7 | Issue 3 | e32329

the side effects of ARV drugs (OR: 0.30; 95% CI: 0.14–0.67) were
willing to accept PrEP (Table 4).
Discussion
To our knowledge, this is the first study to assess the awareness
and acceptability of PrEP among MSM in China, and potential
factors associated with the willingness to accept PrEP were also
evaluated. Awareness of PrEP in MSM was rather low, only
accounting for 11.2%. However, 67.8% reported that they were
definitely or probably willing to accept PrEP if available in China.
Those who did not practice consistent condom use and had never
heard of the side effects of ARV drugs were more willing to accept
PrEP.
Antiretroviral prophylaxis has been shown to be effective in
preventing HIV transmission among MSM, pregnant women, and
HIV-discordant couples in recent clinical trials [22,28–30].
However, some issues still need further research, such as long-
Table 2. Associations between sexual behaviors and willingness to accept PrEP.
Factors
WTA
Event/Total (%) OR (95% CI) p value
Sexual orientation
Bisexual or uncertain 42/57 (73.7) 1.00
Homosexual 71/95 (74.7) 1.06 (0.50, 2.24) 0.89
Total number of MSM friends
,10 48/68 (70.6) 1.00
$10 65/84 (77.4) 1.43 (0.69, 2.96) 0.34
Age at the first insertive sexual intercourse
,20 years 36/50 (72.0) 1.00
$20 years 77/102 (75.5) 1.20 (0.56, 2.57) 0.64
Gender of the first sexual partner
Male 69/97 (71.1) 1.00
Female 44/55 (80.0) 1.62 (0.73, 3.59) 0.23
Styles of homosexual behavior in the past 6 months
Receptive or predominantly receptive 38/51 (74.5) 1.00
Insertive or predominantly insertive 75/101 (74.3) 0.99 (0.46, 2.14) 0.97
Seeking sexual partners via internet
No 49/64 (76.6) 1.00
Yes 64/88 (72.7) 0.82 (0.39, 1.72) 0.59
Only one male sexual partner in the past 6 months
No 94/122 (77.1) 1.00
Yes 19/30 (63.3) 0.52 (0.22, 1.21) 0.13
Diagnosed as STDs in the past 6 months
No 97/134 (72.4) 1.00
Yes 16/18 (88.9) 3.06 (0.67, 13.92) 0.15
Consistent condom use in homosexual behaviors in the past 6 months
No 60/71 (84.5) 1.00
Yes 53/81 (65.4) 0.35 (0.16, 0.76) 0.01
Having bought condom lubricant in the past 6 months
No 58/77 (75.3) 1.00
Yes 55/75 (73.3) 0.90 (0.44, 1.87) 0.78
Heterosexual behaviors in the past 6 months
No 92/129 (71.3) 1.00
Yes 21/23 (91.3) 4.22 (0.94, 18.92) 0.06
Having received money for sex from male partners
No 109/147 (74.2) 1.00
Yes 4/5 (80.0) 1.39 (0.15, 12.86) 0.77
Having given money for sex to male partners
No 105/144 (72.9) 1.00
Yes 8/8 (100.0) – –
Abbreviation: CI, confidential interval; OR, odds ratio; PrEP, pre-exposure prophylaxis; STD, sexually transmitted diseases; WTA, willingness to accept.
doi:10.1371/journal.pone.0032329.t002
Willingness to Accept PrEP among Chinese MSM
PLoS ONE | www.plosone.org 3 March 2012 | Volume 7 | Issue 3 | e32329

term effects of using PrEP with regard to drug resistance, the side
effects of PrEP drugs, and adherence. These issues may affect the
willingness to take PrEP. In the past several years, several studies
have been conducted among MSM to investigate their attitudes
towards HIV biomedical prevention technologies in developed
countries [1–3]. However, such studies have not been conducted
in China. The awareness of PrEP in our study was lower (11.2%)
compared to previous studies from the United States (16–23.2%)
[2,31,32]. The most plausible explanation might be knowledge
limitation and source limitation of ARV drugs in China. Although
PrEP was unfamiliar in China, the potential for PrEP generaliza-
tion still seemed highly feasible, and a 67.8% WTA rate could be
considered as a moderate level.
Education levels and knowledge about PrEP and ARV drugs
may also have affected the WTA of this strategy. Studies have
shown that MSM who have less education and knowledge about
PrEP and ARV drugs are likely to start using PrEP for HIV
prevention [2,31], which is consistent with our study. A qualitative
study that has investigated initial commitment to PrEP and MC
among Indian truck drivers has suggested that cultural beliefs
towards medication and physicians, and cost of HIV preventive
interventions may affect WTA [33]. Although there was no
significant effect of cultural factors on WTA in our study, the
feasibility of PrEP in different cultural, ethical, legal and political
contexts is still one of the key action points in planning for PrEP.
Preventing HIV is complex and involves many social issues [34].
Therefore further studies should be conducted in the process of
preparing for PrEP.
PrEP should never be seen as the first line of defense against
HIV, because it has only been shown to be effective in clinical
trials when provided in combination with regular HIV testing,
condoms, and other proven prevention methods. One study that
showed that more than 35% of those who expressed willingness to
accept PrEP use for HIV prevention reported that they would be
likely to decrease condom use during PrEP use [32]. Our results
indicate that participants who do not insist on using condoms in
homosexual behavior showed higher willingness to accept PrEP.
These results showed the competitive selection between PrEP and
condom use that might occur because people are more prone to
use a simple and effective way to solve a problem. Therefore,
combination of consistent condom use and PrEP, even including
other confirmed efficient strategies, should not be ignored when
PrEP is introduced.
Several limitations of this study should be kept in mind. First,
potential bias about sensitive questions could not be excluded
definitely because our questionnaires were interviewer-adminis-
tered. Second, non-probability sampling methods might have
induced potential selection bias and therefore limited the
generalization of the study findings to the whole MSM population
in China. Third, the willingness to change was also an important
issue, which could not be ignored. If other new biomedical
prevention interventions were also available in China, study
participants would balance the benefits and risks from each
intervention.
Methods
Study design and participants
The study aimed to explore the acceptability of new biomedical
prevention strategies, including MC, HIV PrEP, HIV vaccines,
and microbicides among the MSM population in Beijing.
Recruitment was based on a seroepidemiological cohort study
on HIV incidence among HIV-negative MSM in Beijing. Nine
hundred and twenty-six potential participants were enrolled and
Table 3. Associations between perceived PrEP benefits/risks
and willingness to accept PrEP.
Factors
WTA
Event/Total (%) OR (95% CI) p value
Having ever heard of PrEP*
No 97/135 (71.9) 1.00
Yes 16/17 (94.1) 6.27 (0.80, 48.92) 0.08
Having ever heard that ARV drugs can help control AIDS development
No 33/47 (70.2) 1.00
Yes 80/105 (76.2) 1.36 (0.63, 2.93) 0.44
Having ever heard of side effects on ARV drugs*
No 83/102 (81.4) 1.00
Yes 30/50 (60.0) 0.34 (0.16, 0.73) 0.01
Having worry not to work due to the side effects from PrEP
No 38/55 (69.1) 1.00
Yes 75/97 (77.3) 1.53 (0.73, 3.21) 0.27
Having worry that PrEP have no prevention efficacy
No 63/85 (74.1) 1.00
Yes 50/67 (74.6) 1.03 (0.49, 2.14) 0.94
Having worry diet and sleep to be interrupted for PrEP
No 61/84 (72.6) 1.00
Yes 52/68 (76.5) 1.23 (0.59, 2.56) 0.59
Having worry drug resistance from PrEP
No 87/119 (73.1) 1.00
Yes 26/33 (78.8) 1.37 (0.54, 3.46) 0.51
Having worry to be treated as a AIDS patient by people
No 90/122 (73.8) 1.00
Yes 23/30 (76.7) 1.17 (0.46, 2.98) 0.75
Having worry to be refused having sex by male sexual partners after using ARV
drugs*
No 96/130 (73.9) 1.00
Yes 17/22 (77.3) 1.20 (0.41, 3.51) 0.73
Having worry not to afford the ARV drugs
No 79/112 (70.5) 1.00
Yes 34/40 (85.0) 2.37 (0.91, 6.17) 0.08
Abbreviation: ARV, antiretroviral; AIDS, Acquired Immune Deficiency Syndrome;
CI, confidential interval; OR, odds ratio; PrEP, pre-exposure prophylaxis; WTA,
willingness to accept.
doi:10.1371/journal.pone.0032329.t003
Table 4. The associations of willingness to accept PrEP with
potential factors in multivariate logistic regression model.
Factors Multivariate OR (95% CI) p value
Consistent condom use in homosexual behaviors in the past six months
Yes vs. No 0.31 (0.13, 0.70) ,0.01
Having ever heard of side effect of ARV
Yes vs. No 0.30 (0.14, 0.67) ,0.01
Abbreviation: ARV, antiretroviral; CI, confidential interval; OR, odds ratio; PrEP,
pre-exposure prophylaxis.
doi:10.1371/journal.pone.0032329.t004
Willingness to Accept PrEP among Chinese MSM
PLoS ONE | www.plosone.org 4 March 2012 | Volume 7 | Issue 3 | e32329

808 were eligible and agreed to participate, between August 2009
and January 2010. Inclusion criteria of the cohort study were age
$18 years, male sex, having had sex with other men in the past 6
months, HIV-negative or unknown status by self-reports, being
willing to participate and provide written informed consent.
Eligible subjects returned to the clinic every 3 months. Structured
interviewer-administered questionnaires and blood samples were
collected at baseline and at each follow-up. The cohort study
participants were recruited using convenience sampling through
three approaches. First, study participants were recruited through
website advertisements in the charge of a non-governmental AIDS
volunteer group (www.hivolunt.net). Second, peer educators were
hired and trained, who were responsible for distributing cards
including information about our study at MSM-frequented venues,
such as MSM clubs, bars, parks and bathhouses. Third, subjects
were encouraged to introduce MSM around them to participate in
the study [26]. Participants were randomly selected from this cohort
at the first follow-up visit between November 2009 and April 2010.
Participants were separated into four units according to the
ascending order of study identification numbers. Each unit had
25 participants. Units were subsequently distributed into four
groups, which were asked to complete questionnaires about the
willingness to accept MC, microbicides, HIV vaccine, or PrEP.
Only the willingness to accept PrEP is focused upon in this paper.
An introductory statement about our program was written in
Chinese on the website or printed materials. To keep participant
information confidential, actual names were not required, so
nicknames were permitted when signing the informed consent
forms. After obtaining written informed consent, trained health
workers provided a brief introduction about PrEP for one MSM or
a group. PrEP explanation was translated into English as follows.
‘‘PrEP means pre-exposure prophylaxis, which means to take
some medicine for preventing a disease before risk exposure. ARV
drugs have been suggested effective and safe to treat AIDS and
regularly applied in treatment of HIV/AIDS patients in the past
several years. Currently, foreign and domestic scientific research-
ers are making efforts to generalize some ARV drugs into HIV-
negative risk population before HIV exposure. In this survey, you
are invited to answer some questions about your awareness and
willingness to accept future PrEP intervention.’’
After the explanation, a structured questionnaire was adminis-
tered by a trained interviewer for each participant in a private
room. ARV drugs used in PrEP were described after assessing the
awareness of PrEP, but before asking the questions about the
willingness to accept PrEP, because most participants might have
never heard of PrEP, TDF and FTC in China. The details of PrEP
were translated into English as follows.
‘‘Several clinical trials using TDF and/or FTC for PrEP are
ongoing or have been completed in some countries. There are two
suggested regimens and doses so far, which were recommended for
clinical trails of PrEP. One is one-drug PrEP (TDF), whose
suggested dose is tenofovir disoproxil fumarate (TDF) 300 mg
once a day; the other is two-drug PrEP (TDF/FTC), and
suggested dose is TDF/FTC 300 mg/200 mg once a day. Both
drugs have possible side effects, such as nausea, vomiting,
headache etc, similar to other ARV drugs, but it would be
improved after a few weeks of PrEP use. Unlike ARV drug
treatment for AIDS patients, however, treatment withdrawal and
resistance prevention should be considered simultaneously. No
definite strategies are available so far for PrEP clinical research.
Although there are still some challenges in PrEP research, it is still
one promising strategy in HIV prevention. In this study, we want
to know whether you want to accept it and have worries about it, if
PrEP is proved to be safe and effective.’’
Participants were asked their willingness to accept PrEP. Some
potential predictors were also investigated, which might influence
PrEP acceptability and desirable information acquisition ap-
proaches. Blood samples were collected for HIV and syphilis
testing after each questionnaire interview. Confidential HIV pre-
test counseling was conducted and post-test counseling was also
provided when participants returned to clinics to hear the results of
their HIV test. The study protocol and informed consent were
approved by the institutional review board of Beijing Chaoyang
District Center for Disease Control and Prevention.
Data collection
Each participant was assigned an exclusive identification
number that was used to link the questionnaire and specimens.
Face-to-face interviews were conducted in a private room. The
content of the structured questionnaire included sociodemo-
graphic information (i.e. age, marital status, registered Beijing
residence, ethnics, years of education, monthly income), HIV/
AIDS knowledge (i.e. five indicators of UN General Assembly
Special Session on HIV/AIDS, UNGASS, including HIV can be
avoided by having sex with only one faithful, uninfected partner;
HIV can be avoided by using condoms; a healthy looking person
can have HIV; a person cannot acquire HIV from mosquito bites;
a person cannot acquire HIV by sharing a meal with someone
who is infected [27]), sexual behavior (i.e. sexual orientation, total
number of MSM friends, age at first insertive sexual intercourse,
sex of the first partner, styles of homosexual behavior in the past 6
months, seeking sexual partners via the internet, only one male
sexual partner in the past 6 months, diagnosed with sexually
transmitted disease in the past 6 months, consistent condom use in
homosexual behavior in the past 6 months, having bought condom
lubricant in the past 6 months, heterosexual behavior in the past 6
months, having received money for sex from male partners, having
given money for sex to male partners). Participants were also asked
about awareness and use of ARV drugs for PrEP, the likelihood of
using PrEP in the future, and their worries about PrEP.
Willingness to accept PrEP was assessed on four scales, which
were translated into English as follows.
N‘‘I am definitely willing to take PrEP.’’ [Definitely yes];
N‘‘I am probably willing to take PrEP.’’ [Probably yes];
N‘‘I am probably not willing to take PrEP.’’ [Probably no];
N‘‘I am definitely not willing to take PrEP.’’ [Definitely no]
Laboratory tests
HIV infection status was determined by an enzyme immuno-
assay (EIA) (Shanghai Kehua Bio-Engineering Co. Ltd., China)
and an HIV-1/2 Western Blot confirmation (HIV Blot 2.2
WBTM, Genelabs Diagnostics, Singapore). Syphilis infection was
determined using an EIA (Beijing Kinghawk Pharmaceutical Co.
Ltd., China) and confirmed with a Passive Particle Agglutination
Test for Detection of Antibodies to Treponema pallidum (TPPATM,
FUJIREBIO, Japan).
Data analysis
Data were double-entered and made consistent using EpiData
version 3.1 (EpiData Association, Odense, Denmark). Those who
were definitely or probably willing to accept PrEP were combined
as willingness to accept (WTA), and those who were probably not
or definitely not willing to accept PrEP were combined as non-
willingness to accept (non-WTA). Those who gave all five correct
answers to UNGASS questions were considered to be aware of the
Willingness to Accept PrEP among Chinese MSM
PLoS ONE | www.plosone.org 5 March 2012 | Volume 7 | Issue 3 | e32329

HIV/AIDS-related knowledge. Univariate logistic analysis was
performed to evaluate the associations of WTA with the
characteristics of demographics, sexual risk behavior, and
perceived PrEP benefit/risk. Factors associated with WTA were
identified by entering variables with P values,0.1 into stepwise
logistic regression analysis. The statistics software SAS version 9.2
(SAS Institute Inc., Cary, NC, USA), was used for the analyses.
Acknowledgments
The authors are grateful to the following individuals for their support: Lu
Yin for providing editorial comments and suggestion on data analysis; Ray
Chen for language editing; and Yu Yang and Xiangwei Li for their work
on project management and technical support.
Author Contributions
Conceived and designed the experiments: FZ DL YR. Performed the
experiments: FZ DL DX LY XY MY. Analyzed the data: LZ FZ.
Contributed reagents/materials/analysis tools: SL DL ZZ FL WS. Wrote
the paper: FZ. Oversaw the data analysis and revised the manuscript: LG
WF YR. Played a key role in revision process, especially in the data
interpretation: QJ.
References
1. Nodin N, Carballo-Dieguez A, Ventuneac AM, Balan IC, Remien R (2008)
Knowledge and acc eptability of alterna tive HIV prevention bio-medical
products among MSM who bareback. AIDS Care 20: 106–115.
2. Mimiaga MJ, Case P, Johnson CV, Safren SA, Mayer KH (2009) Preexposure
antiretroviral prophylaxis attitudes in high-risk Boston area men who report
having sex with men: limited knowledge and experience but potential for
increased utilization after education. J Acquir Immune Defic Syndr 50: 77–83.
3. Poynten IM, Jin F, Prestage GP, Kaldor JM, Imrie J, et al. (2010) Attitudes
towards new HIV biomedical prevention technologies among a cohort of HIV-
negative gay men in Sydney, Australia. HIV Med 11: 282–288.
4. UNAIDS website. Available: http://www.unaids.org/globalreport/documents/
20101123_GlobalReport_full_en.pdf. Accessed 2011 Nov 30.
5. Ministry of Health, China, WHO (2010) 2009 Estimates for the HIV/AIDS
epidemic in China. Beijing.
6. Zhang B, Li X, Shi T, Yang P, Zhang J (2002) Preliminary estimate of the size of
population and HIV prevalance in men who have sex with men in China.
Chin J STD/AIDS Prev Cont 8: 197–199. [Chinese].
7. Choi KH, Liu H, Guo Y, Han L, Mandel JS, et al. (2003) Emerging HIV-1
epidemic in China in men who have sex with men. Lancet 361: 2125–2126.
8. Choi KH, Ning Z, Gregorich SE, Pan QC (2007) The influence of social and
sexual networks in the spread of HIV and syphilis among men who have sex
with men in Shanghai, China. J Acquir Immune Defic Syndr 45: 77–84.
9. He Q, Wang Y, Lin P, Liu Y, Yang F, et al. (2006) Potential bridges for HIV
infection to men who have sex with men in Guangzhou, China. AIDS Behav 10:
S17–23.
10. Smith DK, Grohskopf LA, Black RJ, Auerbach JD, Veronese F, et al. (2005)
Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other
nonoccupational exposure to HIV in the United States: recommendations from
the U.S. Department of Health and Human Services. MMWR Recomm Rep
54: 1–20.
11. Lu F, Wang N, Wu Z, Sun X, Rehnstrom J, et al. (2006) Estimating the number
of people at risk for and living with HIV in China in 2005: methods and results.
Sex Transm Infect 82 Suppl 3: iii87–91.
12. Ma X, Zhang Q, He X, Sun W, Yue H, et al. (2007) Trends in prevalence of
HIV, syphilis, hepatitis C, hepatitis B, and sexual risk behavior among men who
have sex with men. Results of 3 consecutive respondent-driven sampling surveys
in Beijing, 2004 through 2006. J Acquir Immune Defic Syndr 45: 581–587.
13. Zhang B, Li X, Hu T, Shi T, Cao N (2001) Survey on the high risk behaviors
related to acquired immunologic deficiency syndrome and sexually transmitted
diseases among men who have sex with men in mainland China.
Chin J Epidemiol 22: 337–340. [Chinese].
14. Zhang D, Bi P, Lv F, Zhang J, Hiller JE (2007) Changes in HIV prevalence and
sexual behavior among men who have sex with men in a northern Chinese city:
2002–2006. J Infect 55: 456–463.
15. Feng L, Ding X, Lu R, Liu J, Sy A, et al. (2009) High HIV prevalence detected
in 2006 and 2007 among men who have sex with men in China’s largest
municipality: an alarming epidemic in Chongqing, China. J Acquir Immune
Defic Syndr 52: 79–85.
16. Guo H, Wei JF, Yang H, Huan X, Tsui SK, et al. (2009) Rapidly increasing
prevalence of HIV and syphilis and HIV-1 subtype characterization among men
who have sex with men in Jiangsu, China. Sex Transm Dis 36: 120–125.
17. Ruan S, Yang H, Zhu Y, Wang M, Ma Y, et al. (2009) Rising HIV prevalenc e
among married and unmarried among men who have sex with men: Jinan,
China. AIDS Behav 13: 671–676.
18. Ruan Y, Luo F, Jia Y, Li X, Li Q, et al. (2009) Risk factors for syphilis and
prevalence of HIV, hepatitis B and C among men who have sex with men in
Beijing, China: implications for HIV prevention. AIDS Behav 13: 663–670.
19. Michael NL (2010) Oral preexposure prophylaxis for HIV–another arrow in the
quiver? N Engl J Med 363: 2663–2665.
20. Schechter M, do Lago RF, Mendelsohn AB, Moreira RI, Moulton LH, et al.
(2004) Behavioral impact, acceptability, and HIV incidence among homosexual
men with access to postexposure chemoprophylaxis for HIV. J Acquir Immune
Defic Syndr 35: 519–525.
21. Guest G, Shattuck D, Johnson L, Akumatey B, Clarke EE, et al. (2010)
Acceptability of PrEP for HIV prevention among women at high risk for HIV.
J Womens Health (Larchmt) 19: 791–798.
22. Grant RM, Lama JR, Anderson PL, McMah an V, Liu AY, et al. (2010)
Preexposure chemoprophylaxis for HIV prevention in men who have sex with
men. N Engl J Med 363: 2587–2599.
23. UW website. Available : http://depts.washington.edu/uwicrc/research/
studies/files/PrEP_PressRelease-UW_13Jul2011.pdf. Accessed 2011 Dec 13.
24. CDC website. Available : http://cdc.gov/nchhstp/newsroom/
PrEPHeterosexuals.html. Accessed 2011 July 13.
25. FHI website. Available at: http://wwwfhiorg/en/R esearch/Projects/FEM-
PrEPhtm. Accessed 2011 April 27.
26. Li Q, Luo F, Zhou Z, Li S, Liu Y, et al. (2010) Willingness to participate in HIV
vaccine clinical trials among Chinese men who have sex with men. Vaccine 28:
4638–4643.
27. UNAIDS (2005) Monitoring the Declaration of Commitment on HIV/
AIDS:guidelines on construction of core indicators.
28. Paintsil E, Andiman WA (2009) Update on successes and challenges regarding
mother-to-child transmission of HIV. Curr Opin Pediatr 21: 94–101.
29. Nyandiko WM, Otieno-Nyunya B, Musick B, Bucher-Yiannoutsos S, Akhaabi P,
et al. (2010) Outcomes of HIV-exposed children in western Kenya: efficacy of
prevention of mother to child transmission in a resource-constrained setting.
J Acquir Immune Defic Syndr 54: 42–50.
30. Anglemyer A, Rutherford GW, Egger M, Siegfried N (2011) Antiretroviral
therapy for prevention of HI V transmission in HIV-discor dant couples.
Cochrane Database Syst Rev 5: CD009153.
31. Liu AY, Kittredge PV, Vittinghoff E, Raymond HF, Ahrens K, et al. (2008)
Limited knowledge and use of HIV post- and pre-exposure prophylaxis among
gay and bisexual men. J Acquir Immune Defic Syndr 47: 241–247.
32. Golub SA, Kowalczyk W, Weinberger CL, Parsons JT (2010) Preexposure
prophylaxis and predicted condom use among high-risk men who have sex with
men. J Acquir Immune Defic Syndr 54: 548–555.
33. Schneider JA, Dandona R, Pasupneti S, Lakshmi V, Liao C, et al. (2010) Initial
commitment to pre-exposure prophylaxis and circumcision for HIV prevention
amongst Indian truck drivers. PLoS One 5: e11922.
34. Kim SC, Becker S, Dieffenbach C, Hanewall BS, Hankins C, et al. (2010)
Planning for pre-exposure prophylaxis to prevent HIV transmission: challenges
and opportunities. J Int AIDS Soc 13: 24.
Willingness to Accept PrEP among Chinese MSM
PLoS ONE | www.plosone.org 6 March 2012 | Volume 7 | Issue 3 | e32329