Examining potential effects of non-occupational post-exposure prophylaxis (nPEP) on sexual behaviors of Chinese men who have sex with men: a cross-sectional study

Non-occupational post-exposure prophylaxis (nPEP) is effective in reducing human immunodeficiency virus (HIV) transmission and involves the administration of antiretroviral drugs within 72 h of an exposure where there is a substantial likelihood for HIV transmission and continuing the treatment for a total of 28 days [1]. nPEP is recommended when a person’s sexual partner is HIV-positive with a detectable or unknown viral load or there was condomless anal sex with men who have sex with men (MSM) of unknown HIV status [1]. nPEP programs have been implemented in many resource-rich countries to complement other effective HIV prevention strategies [2]. The World Health Organization has also provided guidance on the use of nPEP [3]. Studies reported that the use of antiretrovirals after a high risk exposure can reduce the likelihood of HIV infection by 79–81% [4] and nPEP is cost-effective when targeted to high-risk populations [5, 6]. However, there is a perception that nPEP might exacerbate high-risk sexual activities, also called sexual risk behavior disinhibition [7, 8]. In this regard, studies to estimate potential nPEP effects on sexual behaviors among key populations, such as MSM, are warranted.

The current literature show that the relationship between nPEP and sexual risk behavior is not conclusive. Some studies confirm that disinhibition of sexual risk behavior is a concern for individuals taking nPEP. A study from the United States (US) found a significant proportion (21%) of MSM reported condomless sex and 11% of MSM reported condomless sex with HIV-positive or HIV status unknown partners during nPEP use [9]. A longitudinal study in the Netherlands found that the majority of the HIV seroconverters reported ongoing risk behavior after nPEP prescription [10]. Another longitudinal study in Australia reported an association between nPEP use and high risk of subsequent HIV infection among MSM [11]. A retrospective study in Australia also confirmed that nPEP users had a higher number of male partners, less consistent condom use, and injecting drug use history [12]. However, there are other studies that reported different results. A study in San Francisco reported that knowledge about the availability of nPEP did not lead to an increase in condomless anal sex among gay men [13]. Another longitudinal study also reported that most MSM (73%) had a decrease in high-risk sexual behaviors and most of them (85%) had no change in incident sexually transmitted infections (STI), indicating a lack of behavioral disinhibition [14]. Another randomized HIV-prevention trial among MSM in the US observed that, although nPEP users were a riskier group at baseline, previous nPEP use was not associated with higher odds of high risk sex at follow-up [15]. In Brazil, a cohort study also reported that nPEP use was not associated with increases in reported high-risk behavior [4]. These discrepancies require further exploration, which is a significant contribution of the current study.

Recently, China’s 13th Five-Year Action Plan for HIV/AIDS Containment and Prevention examined the feasibility of including nPEP as one of the strategies for HIV prevention. Yet, in China, there are few nPEP studies to date. One study published in a Chinese journal explored factors related to the need of nPEP and reported only 22.1% of MSM had heard about nPEP [16]. Another study described the introduction of nPEP services in an acquired immune deficiency syndrome (AIDS) designated hospital in Beijing, but did not report any impact of nPEP use on sexual risk behaviors [17]. In the English literature, nPEP studies from China are largely absent. This might be because nPEP is not a conventional service widely available in China yet, although some AIDS-designated hospitals provide nPEP on a case-by-case basis. Before nPEP is routinized nationwide, it is necessary to examine the potential for nPEP use to change sexually risky behaviors. The current study aims to explore the potential effects of nPEP use on individual and population sexual behaviors from the perspective of MSM if nPEP is routinized nationally.

The current study is guided by social cognitive theory, which conceptualizes an interactional causal structure as triadic reciprocal causation of behavior that involves a dynamic interplay among personal determinants, behavior and environmental influences [18]. Therefore, we modelled the relationships among personal determinants (e.g., age, education, HIV knowledge, nPEP knowledge), behavior (e.g., using nPEP, looking for male sexual partners through the Internet), and environmental factors (e.g., city of residence, duration of local residence in the current city) in the current study. We hypothesize that nPEP use and related knowledge might be related to MSM’s sexual risk behavior. Moreover, previous studies reported that nPEP use was associated with inconsistent condom use [12] and more sexual partners among MSM [19], supporting our hypothesis that MSM’s behaviors regarding condom use and number of sexual partners might change if nPEP is widely available. A study has reported a significant discrepancy between people’s actual risk behavior and their perception [20]. However, there are very few HIV studies examining anticipated behavioral discrepancy between individual and population. We adopted this concept from studies that examined perceived/anticipated behavioral or cognitive/emotion discrepancy in other health-related models [21, 22]. We hypothesize that nPEP use might influence nPEP knowledge, and it might influence anticipated individual and population behavioral changes and discrepancy directly and indirectly. People generally first learn about HIV, and then nPEP [23], and HIV and nPEP knowledge were associated with an intention to use nPEP [24]. In this regard, we hypothesize that HIV knowledge might have an effect on nPEP knowledge, and it might influence anticipated individual and population behavioral changes and discrepancy directly and indirectly.

A cross-sectional study that explored Chinese MSM’s awareness, knowledge, and perceived need of nPEP, willingness to use nPEP, and sociodemographic factors was conducted in November and December, 2018. Two big cities in China, Shijiazhuang in the north and Xiamen in the south, were selected given that MSM populations are large and accessible in these two cities, and local centers for disease control and prevention and community-based organizations (CBOs) were able to help with the data collection. Local CBOs helped recruit participants. Inclusion criteria were: (1) biological males (assigned male sex at birth) aged 18 years and over; (2) had sex with another male in the past 12 months; (3) self-reported negative or were unaware of their HIV status; and (4) provided written informed consent and participated voluntarily in the survey. Exclusion criteria were: (1) self-reported HIV positive; (2) not able to complete the survey due to health problems (e.g., mental illness); and (3) unable to provide written informed consent.

To the best of our knowledge, this is the first study from China to explore anticipated behavioral change in terms of condom use and number of sexual partners from MSM’s perspective if nPEP were to be provided nationally. We found a significant proportion (50%) of participants reported their sexual behaviors may change. About 60% reported anticipated discrepancies between their personal behaviors and other men’s behaviors. nPEP use as well as HIV and nPEP knowledge were not significantly related to the anticipation of individual and population behavioral changes and discrepancy regarding condom use and number of sexual partners, which is consistent with previous studies reporting that nPEP would not lead to sexual risk behavior disinhibition [4, 13‐15].

Our study has found some factors related to the anticipation of individual and population behavioral changes. Age is an important factor, since older men were more likely to state they will use more condoms and have fewer sexual partners if nPEP is available. It is reasonable to assume that as these men get older, they may have more social and sexual experiences regarding condom use and sexual partners. As HIV/AIDS prevention and intervention programs continue to focus on key groups of men who have sex with men, these men are more likely to be exposed to health promotion messages regarding consistent condom use and reducing number of sexual partners, and are therefore more likely to perceive positive (i.e., less risky) behavioral changes [37, 38]. Also, when these men have longer duration of residence in these large metropolitan cities with comparatively more complex MSM networks and more likelihood to be exposed to HIV/AIDS campaigns and messages, they might be more likely to understand the importance of using more condoms and having fewer sexual partners. Participants with higher education were more likely to state they would use less condoms and have more sexual partners if nPEP is available, indicating that these well-educated MSM might be overly optimistic about the protective effect of nPEP. These findings are different from a study conducted in the US reporting no significant differences in age or education level between those who reported condomless anal sex during nPEP and those who did not [9]. HIV/AIDS treatment optimism may be a concern among Chinese MSM, particularly those who are well-educated [13]. This is consistent with foreign studies reporting a higher incidence of sexually transmitted diseases was associated with perceiving less HIV/AIDS threat since highly active antiretroviral therapy availability [39]. A longitudinal study reported that nPEP was more often prescribed for a sexual accident with a known HIV-positive sex partner in a later period, indicating treatment optimism is a concern (41.0 versus 24.5%, P < 0.01) [10].

Another interesting finding is that there are differences of anticipated behavioral changes in condom use and number of sexual partners between what men anticipate for themselves and how they believe other men would respond to the availability of nPEP. These men seem to have more positive anticipations about themselves, with more negative anticipations about how their peers in the wider MSM community would react to the availability of nPEP. In other words, these men may not trust their peers, which might be about an issue of stigma related to same-sex sexuality (e.g., spoiled identity) among these marginalized and stigmatized sexual minorities [40]. This is consistent with an ethnographic study among Chinese MSM reporting men internalized a stigma that MSM are bad and dangerous and MSM communities are disappointing and hopeless [41]. Participants whose ethnicity was not Han Chinese and participants who were never married to or cohabiting with a woman were more likely to report a discrepancy between anticipated individual and population behavioral changes. Being both an ethnic minority and an MSM may make these men even more distrustful toward their MSM peers in these metropolitan cities. For MSM who never get married and never cohabit with females, they may be more comfortable with their same-sex sexuality, which is a marginalized sexuality in China. A study reported that some MSM in metropolitan areas have tried to negotiate same-sex sexuality as a normal variation of human sexuality [42]. This practice of changing social norms is difficult, as another study reported that most (70%) MSM got married to females after the age of 30 [43]. It is therefore understandable that MSM who never get married and never cohabit with females might have more negative perceptions about the MSM population.

Our study has important public health implications. The real use of nPEP was not significantly associated with anticipated behavioral changes, indicating that providing nPEP to MSM may not lead to their negative behavioral change regarding less condom use and more sexual partners. HIV and nPEP knowledge were not related to anticipated behavioral changes from the individual or population perspectives, indicating that health behavior promotion for increasing condom use and reducing number of sexual partners cannot just rely on distribution of knowledge. Most participants reported discrepancies between anticipated individual and population behavioral changes, suggesting distrust and internalized stigma among the MSM communities. It is important to be reflective about previous HIV/AIDS prevention and intervention projects, which largely focused on technical issues, such as testing tools and treatment regimens, with much less attention paid to the active and positive development of the communities from the perspective of the key populations. In this regard, when nPEP is incorporated into public health services, it needs to be implemented as a means of community development for MSM. For example, community-based MSM organizations and related stakeholders should be actively recruited to play important roles in the development and implementation of nPEP services at every step.

The current study is subject to limitations. First, the use of convenience sampling and relatively small sample size would limit the generalizability of the findings. Second, regarding the outcomes of anticipated behavioral changes, these are self-reported data and social desirability may be a concern, although this may be mitigated by the anonymous nature of the survey. MSM-related stigma may not be the only potential cause of these men’s anticipated behavioral discrepancy, which needs further examinations in future studies. Also, the concept and measurement of anticipated behavioral discrepancy should be further developed and validated. Third, stated behaviors are different from actual behaviors. However, in the context of examining nPEP as a potential national strategy for HIV prevention, the investigation of anticipated behavioral changes can provide valuable data for strategy planning and policy development. Fourth, qualitative studies exploring the whole process and in-depth experiences of using nPEP services from users’ perspective are warranted, so that researchers can develop better knowledge of using nPEP services for health behavior promotion for the key population.

This study identified a high-risk subgroup of MSM who reported they would use condoms less and/or have more sexual partners when nPEP becomes available. These men were younger in age, had shorter duration of residence in the metropolitan city, and had higher education. Tailored health interventions might be needed to mitigate potential increases in sexual risk behaviors for this subgroup of MSM. Moreover, there is a clear discrepancy between anticipated individual and population behavioral changes regarding future routinization of nPEP services, suggesting the need to address the issue of distrust and internalized stigma among MSM population.