Where you live matters, but action is personal: insights from multilevel analysis of pre-exposure prophylaxis awareness, willingness, and use among men who have sex with men in China.

Abstract

Background: Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy, yet its uptake among men who have sex with men (MSM) in China remains low. This study aimed to assess whether city-level differences influence the PrEP awareness, willingness, and ever-use among MSM in China.

Methods: A secondary analysis of a national cross-sectional survey of MSM (n = 5041) from 42 Chinese cities was conducted. We fitted generalized linear mixed models with city as a random intercept for awareness and ever-use. Willingness showed no significant clustering by city and was analyzed using logistic regression. Independent variables were grouped according to Andersen's Behavioral Model of Health Services Use into predisposing, enabling, and need-related factors. Interclass correlation (ICC) quantifies the variance between cities.

Results: The majority (87.2%) had heard of PrEP, 58.4% were willing to use it, and 13.0% had ever used it. In fully adjusted models, city-level clustering remained evident for PrEP awareness (ICC = 5.3%, P = 0.003) and ever-use (ICC = 8.1%, P = 0.011), indicating a measurable influence of place of residence. Willingness showed no significant between-city variation. PrEP awareness was higher among younger MSM (aOR = 0.98, P < 0.05) and those with lower income (< 3000 CNY: aOR = 0.67, P < 0.05), and not knowing partners' HIV status (aOR = 0.57, P < 0.001) was associated with reduced awareness. Willingness to use PrEP was lower among those earning < 3000 CNY (aOR = 0.75, P < 0.05), positively associated with higher per capita health expenditure (aOR = 1.02, P < 0.05), and negatively associated with higher HIV prevalence (aOR = 0.96, P < 0.01). Ever use of PrEP was associated with condomless sex (aOR = 1.62, P < 0.001), while lower income (< 3000 CNY: aOR = 0.45, P < 0.001) remained a significant barrier.

Conclusions: Place of residence affects PrEP awareness and use, but not willingness. However, actual use is primarily driven by individual-level factors. HIV prevention in China should combine city-level service expansion with targeted individual-level interventions to close the gap between PrEP awareness, willingness, and actual use.