Low willingness to pay for pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in China

Men who have sex with men (MSM) experience a disproportionate burden of HIV/AIDS disease in China [1]. The HIV prevalence among MSM ranged between 7 to 32% globally in a recent systematic review (2016) [2], but among Chinese MSM HIV prevalence has increased from 1% in 2005 to 7% in 2012 [1]. HIV prevalence is strikingly high in some Chinese cities, such as Chengdu (18% in 2013 [3]) and Kunming (17% in 2015 [4]).

Pre-exposure prophylaxis (PrEP) is regarded as a promising HIV prevention strategy, with a common treatment regimen consisting of a single pill composed of a compound of antiretroviral (ARV) drugs. There are three types of PrEP available, including daily oral PrEP, on-demand PrEP (refers to taking ARV before and after sex) and long-acting injectable PrEP (LAI-PrEP, refers to injecting long-acting drugs every 4 to 12 weeks). Given the demonstrated safety and efficacy of PrEP [5], the World Health Organization [6] recommends oral PrEP as an additional prevention strategy for key populations, and UNAIDS [7] has established a 2016–2021 strategy with an ambitious target of ensuring access to PrEP for three million people at substantial risk by 2020. In China, there is an ongoing multi-center trial among MSM (2018–2020, ChiCTR-IIN-17013762).

Along with these PrEP promotion programs, awareness of PrEP (11–58% [5, 8‐12]) and willingness to PrEP uptake (64–92%) [13, 14] have increasing among MSM globally. The 2017 Chinese National Internet Survey among 4581 MSM showed that 22.4% of them had heard of PrEP and the majority (76%) would like to try PrEP [12]. In a recent study about half (46%) of 708 Chinese MSM were considered eligible for PrEP based on objective criteria (e.g., in a non-monogamous relationship, had condomless anal sex with a casual male partner in the past 3 months) [15], and 42% of 323 Chinese MSM self-perceived as appropriate PrEP candidates [16]. Literature reported that facilitators of PrEP uptake included risky sexual behaviors, high self-perceived HIVrisk, and possessing a high level of HIV literacy [17, 18], while barriers to PrEP uptake included worries about side effects, low positive expectations of its efficacy, and no experience of HIV testing [12].

Most of these acceptability studies and randomized controlled trials (RCTs) provided PrEP to the MSM participants for free, and participants’ willingness to pay for PrEP are rarely investigated. However, in the real world, PrEP is expensive and costs around $670 per month in overseas countries [19] and $212–990 per month in different regions of China [20, 21]. Costs associated with PrEP uptake include the prescription of ARV, and provision of PrEP counseling and adherence monitoring. The costs of tests (HIV, STIs, eGFR) would not be an issue as the current health care system in China provides free HIV/STIs testing for MSM, and the price for eGFR is cheap ($7–$14 each time). However, PrEP drugs are not covered so far by any of the existing health care and insurance systems in China, and the variation in cost of PrEP is affected by various factors, such as the local living expense (e.g., urban area is usually higher than rural area), source of the drug (e.g., hospitals usually charge higher than LGBT friendly non-governmental organizations). Poverty and economic constraints are identified barriers access to HIV prevention and treatment services, and the cost of TDF/FTC is a major barrier to PrEP implementation even in Western Europe’s high-income countries [22]. In settings where PrEP is considered unaffordable from a public policy perspective, studies of willingness to pay are important to understand the degree of private purchasing of PrEP.

Six quantitative papers and two qualitative papers have reported on the willingness to pay for PrEP among MSM [19, 23‐27]. The majority of the MSM participants in these studies (65–77% in 2012–2015 [23‐25]) were unwilling to pay or only willing to pay a small proportion of the full cost (e.g., 12% in 2014–2015 [19]). For example, an online survey among 1151 MSM reported that 77% of the participants were unwilling to pay the market rate of $340 for PrEP in 2014 [23] in Taiwan, China. PrEP-30, a fee-based program among 195 Thai MSM, showed that they were willing to pay for PrEP only when it was delivered at an affordable price (<$1 per day) [28]. Two qualitative studies (one among 19 young African-American urban MSM in 2009 and the other among 30 young MSM in Mississippi, US) reported that few of the participants were willing to pay for PrEP, and most participants felt that the cost would make PrEP inaccessible to them [26, 27]. Only one of these studies investigated factors associated with willingness to pay among MSM, and identified factors included the previous receipt of nonoccupational postexposure prophylaxis and positive attitudes toward PrEP [23]. To the best of our knowledge, no similar studies have been conducted among MSM living in Mainland China and factors associated with the willingness to pay for PrEP are poorly understood in the existing literature.

Therefore, the aim of the present study was to investigate the willingness to pay for PrEP and its factors among MSM living in Mainland, China. Two PrEP pay indicators were introduced as the outcome: pay or not (> 0 vs. 0), pay the market rate or not (≥ $283 vs. < $283 per month). In addition, we did a supplementary analysis (See Supplementary) using the generic drug market rate of ≥85 per month as the willingness to pay threshold [29]. Based on relevant published studies and the PrEP cascade, we hypothesized that trust in health professionals, risk perception of HIV infection, and PrEP-related cognition (awareness, acceptability, perceived PrEP adherence, and perceived PrEP benefit in reducing condom use) would be associated with the willingness to pay for PrEP among MSM.

Socio-demographic information collected included age, ethnicity, education level, marital status, personal income, job, and local residence. We also asked the participants about sexual orientation and the age of first homosexual intercourse.

The present study found that the majority of the 689 Chinese MSM were unwilling to pay for PrEP: 14.1% would not pay any money and 93.2% would not pay the market rate. We found that PrEP awareness, acceptability, perceived PrEP adherence, and perceived PrEP benefit in reducing condom use were all associated with participants’ willingness to pay for PrEP. Other facilitators of this pay willingness included full disclosure of sexual orientation to health professionals, high HIV literacy, and a high degree of HIV disclosure with sex partners while barriers to this pay willingness included older age and marital status.

The low willingness to pay for PrEP among this sample of MSM in Mainland China was consistent with similar studies conducted in the other regions, including Taiwan, the United States, Cannada, and Thailand [23, 26, 27]. Participants reported a high initial willingness to use PrEP (when it was free) but a low pay willingness, and this discrepancy might be a consequence of PrEP cost and affordability. Consequently, our finding that only 6.8% of participants were willing to pay $283 monthly for PrEP in this study may reflect a more realistic level of PrEP acceptability among Chinese MSM. Policy advocacy and program promotion should take this low pay willingness into consideration. Researchers are suggested to include the willingness to pay in future scales of PrEP acceptability. It is worth noting that, despite the high risk of HIV infection among MSM in general, some MSM may be less risky than others for HIV infection due to various reasons (e.g., consistent condom use) and thus are not in great need of PrEP. Those who are not at high risk of HIV (as an individual) are potentially less likely to want to pay for PrEP, perhaps because the cost outweighs the individual benefit for them.

This study suggests that a strong incentive for the private use of PrEP among MSM is to enable condomless intercourse that is safe from the risk of HIV transmission. Safe sex messages for MSM using PrEP, however, should highlight potential risks of acquiring other STIs when condomless intercourse is practiced.

The present study is subject to several limitations. First, all participants were recruited from a local NGO in Chengdu, and this single recruitment site was likely to have led to a highly selected sample. Findings based on this sample might not be generalizable to all MSM living in Chengdu, MSM living in other parts of China and worldwide. Further studies in other regions of China and worldwide are needed. The cultural perspectives of paying for PrEP should be taken into consideration as well. Second, self-report bias might exist as we asked the participants to recall their STI history and the age of first homosexual intercourse. Social desirability bias might also exist regarding questions on intention to test HIV and sexual behaviors. To reduce such bias, we emphasized to the participants that participation was totally voluntary, and participants were guaranteed that their personal data was highly confidential and inaccessible to third parties. In addition, the questionnaire was self-administrated using an iPad, which would introduce less bias than interviewer-administrated questionnaire using paper-and-pencil. Third, we measured some key variables with a single item, including risk perception of HIV infection and perceived PrEP benefit in reducing condom use. Some self-developed measures (e.g., PrEP awareness scale) present low Cronbach’s alpha coefficients. Further improvements in these measures are suggested, including revising items based on the result of Explanatory Factor Analysis (EFA) and further testing among other samples of MSM living in other places. Fourth, LAI-PrEP is not yet proven efficacious and it is not available anywhere except in efficacy trials currently in the field. It might be problematic by grouping LAI-PrEP with oral daily and oral on-demand PrEP together. Fifth, we did not make detailed differentiation between regular sex partners and casual sex partners when reporting condom use behavior. This might lead to an inaccurate estimation on the association between condom use and pay willingness for PrEP. Last, the present study investigated participants’ willingness (intention) to pay for PrEP, but there might be an intention-behavior gap between this willingness and the actual pay for PrEP (behavior) later, therefore, interpretation of findings should be cautious.

Despite the above limitations, this is one of the first studies to investigate the willingness to pay for PrEP among Chinese MSM. Also, we assessed a comprehensive profile of PrEP-related cognitions with reliable scales, including awareness, acceptability, and perceived adherence to PrEP scale. Some of the investigated factors were novel, including trust with health professionals, HIV communication patterns with sex partners, and an updated scale of HIV literacy. Findings on the low willingness to pay for PrEP indicate that policy support is needed to PrEP implementation and scale-up, such as decrease the cost of PrEP by supporting the development of generic PrEP drugs or cover some cost of PrEP by health insurance plans. Service providers should be trained in identifying high risk subgroups who are more likely to be benefited from PrEP, providing high-quality counseling service to clients who are interested in PrEP, and offering follow-up services to PrEP users. Findings on its associated factors could suggest priority subgroups and inform design of programs tailored in terms of PrEP implementation among MSM in China in the near future. By developing programs that are realistic about attitudes to PrEP, policy makers can ensure that PrEP is properly incorporated into HIV prevention strategies, and ensure that it contributes to realizing the goal of zero new infections in China.

This study investigated the willingness to pay for PrEP among a less investigated sample of Chinese MSM. We found the overall willingness to pay for PrEP was low, which indicated a great barrier to PrEP implementation and scale-up under the current health care system in China. High PrEP awareness, acceptability, and perceived PrEP adherence were identified facilitators of the pay willingness while none disclosure of sexual orientation to health professionals and low HIV literacy were identified barriers. Programs aiming to promote PrEP pay willingness should pay attention to the important roles of providing enhanced counseling to improve PrEP-related cognitions, delivering accurate HIV/PrEP information to increase health literacy, and decreasing stigma towards sexual minority to develop trust with health professionals. In addition to promote PrEP pay willingness among MSM, efforts should also be made to provide financial assistance to those MSM in need but in low economic affordability to ensure equity. In summary, to promote PrEP uptake in the near future in China, particular efforts should be made to develop supportive policies regarding PrEP drug approval and reimbursement, train staff in providing high-quality PrEP counseling and services, and engage MSM community for PrEP key message delivery.