Barriers and facilitators to engagement with the PrEP care continuum among sexual minority men in China: a systematic review

Abstract

Sexual minority men (SMM) in China are disproportionately affected by the HIV epidemic, yet utilization of HIV prevention services, such as pre-exposure prophylaxis (PrEP), remains low. This systematic review summarizes the barriers and facilitators to the PrEP care continuum among Chinese SMM using thematic analysis. Following PRISMA guidelines, a comprehensive literature search was conducted in English and Chinese databases, including PubMed, EMBASE, Web of Science, PsycINFO, CINAHL, CNKI and WanFang. From 820 records, 50 studies met inclusion criteria, revealing five key themes: (1) sexual behaviors and perceived HIV risk; (2) PrEP-related stigma and homophobia; (3) history of HIV and other STI care engagement; (4) perceptions of PrEP efficacy, side-effects and adherence, and (5) structural and access barriers, including cost, health insurance and residential status. Improving PrEP uptake among Chinese SMM requires addressing sexual risk behaviors, societal stigma and structural barriers. Comprehensive education around PrEP, stigma reduction and financial support are crucial. Targeted public health initiatives and policy changes are necessary to enhance PrEP awareness, accessibility and adherence among Chinese SMM. Additionally, integrating PrEP education into existing HIV/STI care frameworks, and fostering supportive environments within healthcare settings can further mitigate barriers. There is a need to explore and promote alternative PrEP modalities, including on-demand (event-driven) PrEP and long-acting injectable PrEP, to better meet the diverse needs of Chinese SMM. Collaboration between government, healthcare providers and community organizations is essential to develop and implement effective strategies for increasing PrEP uptake and ensuring sustained HIV prevention efforts among Chinese SMM.

Introduction

Sexual minority men (SMM) are the most vulnerable population who bear the highest burden of HIV in China, attributing to approximately 21.4–23.4% of HIV incidence. A systematic review found that HIV prevalence among SMM in China significantly increased from 2001 to 2018, ranging from 3.7% (95% CI: 3.0–4.5%) to 10.7% (95% CI: 12.8–14.9%).¹ Although this upward trend reflects an increased burden of HIV among SMM, it is also important to acknowledge that the observed rise was likely influenced, at least in part, by China’s extensive efforts to expand HIV testing capacity. These public health efforts may have led to higher detection rates and improved case identification. Nonetheless, multilevel factors, such as low awareness of HIV knowledge, inconsistent condom use, and substance use, and social stigma, pose significant challenges for HIV prevention among this population and contribute to an elevated risk of HIV incidence among SMM in China.^2–4

Despite the high burden, HIV prevention service utilization among SMM remains suboptimal. For example, a study in western China indicated that 42.42% of SMM had reported inconsistent condom use during anal sex in the past 6 months, and the rate was even lower among Chinese SMM living in rural areas.⁵ A recent study also found nearly 30% of sexually active SMM had never been tested for HIV, and individuals still experience multilevel barriers to regular HIV testing.⁶ To combat the HIV epidemic and address this public health threat, it is imperative to implement a holistic approach that combines socio-behavioral strategies, as well as biomedical interventions, such as pre-exposure prophylaxis (PrEP), to support multifaceted HIV prevention.

PrEP is an effective biomedical HIV prevention intervention when taken as prescribed.^7–9 It was first approved by the US Food and Drug Administration in 2012, then subsequently recommended by the World Health Organization for HIV prevention among priority populations, including SMM, in 2015.¹⁰ Globally, it is estimated that >6.5 million individuals have been prescribed PrEP cumulatively by the first quarter of 2024,¹¹ and empirical studies confirmed the population-level impact of reducing HIV incidence among SMM across different regions, such as Australia, France and Scotland.^12–14

In China, a modeling study suggested that a 50% PrEP coverage in ‘high-risk’ SMM might avert 170,000–320,000 new HIV cases over 20 years.¹⁵ However, real-world PrEP scale-up and implementation in China has been slow – PrEP was not approved by the China National Medical Products Administration until 2020.¹⁶ Overall, PrEP care engagement among Chinese SMM remains low. Our meta-analysis on studies published in the past 10 years found low PrEP awareness (32.4%, 95% CI: 25.1–40.7) and uptake (4.9%, 95% CI: 1.4–15.8%) relative to willingness (54.5%, 95% CI: 41.9–66.5) and adherence (40.7%, 95% CI: 20.0–65.2%), indicating the initial exposure to PrEP and linkage to service as potential barriers to engagement with PrEP care continuum.¹⁷ For example, researchers found only 25.6% of sexually active SMM had ever heard of PrEP in a study with a large online sample of >4000 individuals in China.¹⁸ Similarly, in a study involving a substantial amount of SMM men in Shanghai, China, researchers found that of the 197 (19.1%) participants that expressed a willingness to use PrEP for HIV prevention, only 26 (2.5%) of them actually started taking one tenofovir disoproxil fumarate tablet daily, which represents the actual uptake of PrEP.¹⁹ To enhance the overall engagement of the PrEP care continuum among Chinese SMM, it is of paramount importance to gain insights into the multifaceted factors influencing PrEP use with this population.

To address this critical gap, we conducted a systematic review to summarize the empirical evidence in the literature, and synthesize the overarching themes related to the barriers and facilitators to PrEP utilization among this particular population in China. The results of the review will elucidate the factors influencing PrEP utilization, help to identify areas for improvement, and the potential public health effects and policy changes of enhancing PrEP to combat the HIV epidemic in China.

Methods

Study design and literature search

We followed the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA).²⁰ A comprehensive search strategy was developed to identify relevant studies. Electronic databases for English and Chinese languages, including PubMed, EMBASE, Web of Science, PsycINFO, CINAHL, the China National Knowledge Infrastructure and WanFang Database, were systematically searched for relevant studies. The search was conducted using a combination of relevant keywords and Medical Subject Headings (MeSH) terms, such as ‘HIV,’ ‘pre-exposure prophylaxis,’ ‘PrEP,’ ‘sexual minority men,’ ‘gay,’ ‘homosexual,’ ‘China and Chinese,’ and related synonyms. We also manually searched the references cited in the included studies to identify any pertinent articles that may have been overlooked during the initial search. Additionally, we utilized Google Scholar to search for these keywords, further expanding our search for additional relevant studies.

Study selection and inclusion criteria

Studies were eligible for inclusion in this systematic review if they met the following criteria: (1) conducted in mainland China, (2) focused on SMM, (3) discussed biological, psychological or social factors that related to PrEP use and adherence, or willingness to use PrEP, and (4) published in English or Chinese. We included studies that presented empirical outcomes, regardless of their study designs, including both quantitative, qualitative and mixed-methods studies. Therefore, systematic reviews, commentary and other types of studies that did not contain original data were excluded. Given that PrEP was first approved for HIV prevention in 2012, we limited our search to studies published from 2012 onward. Three reviewers independently conducted the initial screening of search results based on titles and abstracts. Subsequently, full-text records that met the inclusion criteria were processed for data extraction and were included in this review. Any disparities were resolved through discussions among the three reviewers.

Data extraction and synthesis

Data extraction was performed using a standardized form, capturing the general study bibliographic information, such as author, year of publication, region/province and study design, as well as key findings related to barriers and facilitators, and relevant contextual information. A thematic synthesis approach was used to analyze and synthesize findings from the included studies, followed by previous studies.^21,22 Initially, individual codes were generated from the extracted data, and these codes were then grouped into higher-order themes. Any discrepancies in coding and the development of overarching themes were resolved through discussions and consultations with a senior author.

Results

Study selection and characteristics

A total of 865 records were identified through database searches, 695 of which were published in English, and 170 were published in Chinese. After removing duplicates, 583 studies were processed to title and abstract screening. Among these, 193 studies were included in the full-text review. Finally, 50 studies met the eligibility criteria and were included in this review.^19,23–71 Fig. 1 presents the PRISMA flowchart of study selection and Table 1 presents the characteristics and key findings of these studies. Through thematic analysis, we identified the following overarching themes relevant to the barriers and facilitators to PrEP among SMM in China across included studies, including: (1) sexual behaviors and perceived HIV risk; (2) PrEP-related stigma and homophobia; (3) history of HIV and other STI care engagement; (4) perceptions of PrEP efficacy, side-effects and adherence, and (5) access barriers, including cost, health insurance and residential status.

Fig. 1.

PRISMA flowchart of study selection.

Table 1.

Key findings of barriers and facilitators to HIV pre-exposure prophylaxis among Chinese sexual minority men among included studies (n = 50).

Author (year)	Study design	Language	Sample size	Key findings
Cao et al.43	Quantitative	English	n = 689	Factors associated with PrEP pay willingness: PrEP awareness; acceptability; perceived PrEP adherence; perceived PrEP benefit in reducing condom use; full disclosure of sexual orientation to health professionals; high HIV literacy; a high degree of HIV disclosure with sex partners.
Chen et al.25	Quantitative	English	n = 550	MSM who had university degrees or above, used condoms during past anal sex and tested three times or more for HIV were more likely to be aware of PrEP. MSM who had use of gay dating apps, ever participated in HIV- or sexually transmitted disease-related studies and had heard of PrEP were more willing to use any regimen of PrEP. MSM at high risk of HIV infection had low awareness of PrEP and moderate willingness to use PrEP.
Cui et al.38	Quantitative	English	n = 495	PrEP awareness was associated with higher education level, previous HIV testing. PrEP willingness was associated with Internet-based partner-seeking. The main barriers influencing those who knew about PrEP, but refused to use it were the high price of PrEP, the need to use condoms consistently, and concerns about side-effects and effectiveness of prevention (22.6%).
Ding et al.19	Quantitative	English	n = 1033	Higher willingness to use PrEP was associated with being aged ≥45 years, non-local residents, having more male sex partners in the past 6 months and not using condom during past anal sex with man. Actual uptake of PrEP was associated with having ≥11 male sex partners in lifetime and reporting no female sex partners in lifetime.
Fu et al.30	Quantitative	English	n = 969	MSM with higher education levels were less likely to show a willingness to use LAI-PrEP. Participants who had a history of HIV test, were willing to use daily oral PrEP, had multiple male sexual partners, who used rush poppers and who were aware of PEP were more likely to show willingness to use LAI-PrEP.
Fu et al.50	Quantitative	English	n = 829	Factors associated with a higher willingness to use PrEP included Zhuang or Han ethnic origin, recruitment through peer introduction or gay venues, pursuit of a higher education level, previous HIV testing and oral sex with a man. Conversely, having casual sex in the past 6 months was associated with a lower willingness to use PrEP.
Gao et al.49	Quantitative	English	n = 791	Factors correlated with poor PrEP adherence during the COVID-19 included not being tested for HIV, using condoms consistently with regular partners and being married or cohabitating with a woman.
Guan et al.68	Quantitative	English	n = 1915	Age, living alone and occupation were associated with the objective needs. Age, income and sexual behavior were associated with actual usage.
Guo et al.57	Quantitative	English	n = 3337 (2019) n = 5313 (2021) n = 15,758 (2022)	A positive correlation between PrEP use and PrEP awareness, as well as between PEP use and PrEP knowledge awareness, and between PEP use and PrEP use.
Guo et al.69	Quantitative	English	n = 608	Experiences of sexual perpetration was negatively associated with the willingness to use on-demand PrEP and the overall willingness to use any type of PrEP. The willingness to use LAI-PrEP also had negative associations with any type of monitoring IPV, controlling victimization and emotional victimization.
Hong et al.37	Quantitative	English	n = 956	Awareness of on-demand PrEP was associated with having anal sex with both a main partner and casual partners, substance use, and recent HIV testing and higher perceived PrEP efficacy. Similarly, greater willingness to use on-demand PrEP was associated with being gay (compared with bisexual), higher education level, having engaged in group sex, used substances and receiving an HIV test in the past 6 months. In the multi-variable model, greater willingness to use on-demand PrEP was associated with being gay (compared with bisexual), engaged in group sex, and recent HIV testing and greater perceived daily oral PrEP efficacy.
Hu et al.54	Quantitative	English	n = 411	The medication rate was higher among MSM who were divorced (compared with those who were unmarried). MSM with more positive expectations as to the efficacy of the drugs showed higher rates of medication, whereas those who were more worried about side-effects had a lower medication rate.
Huang et al.46	Quantitative	English	n = 1045	Men who had ever heard about PrEP, men who had sought sexual partners online in the past 12 months, men who had multiple male sexual partners in the past 3 months and men who had a higher level of community engagement in sexual health were more likely to be interested in oral PrEP. Men who had sought sexual partners online, men who had multiple sexual partners, men who had multiple HIV tests in the past year and men who had a higher level of community engagement in sexual health were more likely to be interested in injectable PrEP. Participants who had ever heard about PrEP and who had multiple HIV tests in the past year were more likely to rank injectable PrEP as their most preferred PrEP formulation. Men who only had recent receptive anal sex were more likely to prefer injectable PrEP compared with men who had both recent receptive and insertive anal sex.
Jackson et al.66	Quantitative	English	n = 570	A higher willingness group was predicted by previous consultation about HIV, more reported barriers to using condoms and elevations in depressive symptoms. Independent of these factors, higher willingness to use HIV PrEP was predicted by beliefs that the intervention was low in stigma and high in potential benefits.
Li et al.58	Qualitative	English	n = 31	Major barriers to PrEP uptake among MSM in the sample included uncertainty about PrEP efficacy and lack of PrEP education (information), concerns over potential side effects and cost (motivation), and difficulties in identifying authentic PrEP medications, and managing PrEP care (behavioral skills). Facilitators include the perceived benefit of PrEP in improving the quality of sex life and control over health. At the contextual level, the authors identified barriers to PrEP access from a thriving informal PrEP market and stressors related to being MSM.
Li et al.71	Qualitative	English	n = 793	Willingness to use PrEP was associated with higher education, multiple sexual partners. Higher levels of perceived HIV stigma was also associated with higher levels of willingness to use PrEP.
Lin et al.42	Quantitative	Chinese	n = 622	Perceived candidacy for PrEP was associated PEP use, PrEP availability, a greater number of PrEP-using friends, PrEP knowledge, multiple sexual partnership and a perceived higher risk of HIV infection.
Lin et al.42	Mixed-methods	English	n = 489	Employment, disclosure of MSM status and mental health issues were associated with PrEP acceptability. The challenges of using PrEP included high cost, low accessibility and stigma in clinic settings.
Liu et al.40	Quantitative	English	n = 496	Poor PrEP adherence was associated with on-demand PrEP medication, students at school, occasional condom use and good HIV knowledge.
Liu et al.55	Qualitative	English	n = 32	Perception of low HIV risk, mistrust of the national PrEP program and concerns of side-effects were the main reasons for not wanting to use PrEP. Also, lack of main sexual partner’s support, difficulties in adhering to the daily tenofovir disoproxil fumarate regimen and the inconvenient schedules in securing the medicine were the major reasons for not wanting to use or quitting the use of PrEP. In contrast, perceived high HIV risk, beliefs in efficacy of PrEP and worries of transmitting HIV to families were the major motives for PrEP uptake.
Liu et al.56	Quantitative	Chinese	n = 330	MSM with good awareness of PrEP had relatively better compliance to PrEP compared with those with poor awareness of PrEP.
Liu et al.59	Quantitative	English	n = 689	PrEP self-efficacy was directly associated with PrEP behaviors, cues to action were directly associated with PrEP behaviors, perceived benefits were directly associated with PrEP behaviors, and perceived susceptibility was directly associated with PrEP behaviors.
Luo et al.64	Quantitative	Chinese	n = 513	The confidence in PrEP had direct influence on the willingness; the degree of influence from sex partners, the attitude of sex partner to PrEP and the positive emotions not only had direct effects on willingness of PrEP use, but also had indirect effects on willingness of PrEP use by affecting the confidence to it; the role in sexual behavior, AIDS severity, HIV prevention behavior had direct effects on willingness of PrEP use. The proportion of HIV infection in the population had no direct effects on willingness of PrEP use, but had indirect effects on willingness of PrEP use by affecting the confidence in it.
Mao et al.23	Quantitative	Chinese	n = 292	Factors independently associated with those ‘on-demand’ would include having more than two male sexual partners during the past 6 months, concerns about the positive effect of PrEP (vs side-effects), having HIV-infected sexual partners and self-reported high risk for HIV.
Meyers et al.35	Quantitative	English	n = 412	Higher levels of education, lower PrEP use stigma and higher perceived benefits of PrEP were associated with greater PrEP uptake. More frequent sex, higher PrEP adherence self-efficacy, higher endorsement of the belief in elevated efficacy of daily over on-demand PrEP and lower endorsement of a desire for a PrEP method that is only taken when needed led to greater odds of choosing the daily PrEP regimen.
Meyer et al.70	Quantitative	English	n = 200	Partnership factors differentiated those who would be willing to use only LAI-PrEP versus any PrEP modality, whereas higher self-perception of risk was associated with interest in LAI-PrEP versus no PrEP.
Pan et al.33	Quantitative	Chinese	n = 2447	PrEP use among MSM in 24 cities was statistically associated with age, monthly income, ever having unprotected anal sex in the past year, used sexual drugs and sexually transmitted disease (STD) diagnosis in the past year. Compared with MSM aged 18–24 years, the proportion of MSM was relatively lower among those aged 25–44 years, who discontinued the PrEP or never used PrEP. The proportion of unprotected anal sex among MSM currently on PrEP was higher than those who have stopped PrEP and never used PrEP. Those MSM group, with monthly income >5000 Yuan, used sexual drugs and STD diagnosis in the past year were more likely to have a higher rate for PrEP usage.
Peng et al.41	Quantitative	English	n = 524	Participants were less likely to say that they would use PrEP if they used a condom consistently with their regular partners. However, participants were more likely to say that they would use PrEP if they had casual partners in the past month and had higher HIV prevention literacy.
Qu et al.63	Quantitative	English	n = 331	The main objective reasons for non-adherence were ‘forgetting to take medicine’, ‘too busy’, ‘worrying about side-effects’ and ‘too much trouble’.
Shi et al.60	Quantitative	Chinese	n = 622	Utilization of PrEP can improve the self-efficacy of using PrEP, which increased by 0.14 times and 0.07 times with the increase of one score of the awareness of PrEP-related knowledge and concern about using PrEP, respectively. The main concerns about using PrEP were side-effects, HIV prevention effect and its expense.
Sun et al.47	Quantitative	English	n = 608	Greater odds of PrEP awareness were associated with higher education level, greater HIV-related knowledge, HIV testing and sexually transmitted infections. Lower odds of PrEP awareness were associated with higher stigma score.
Sun et al.61	Quantitative	English	n = 622	Facilitative factors of PrEP willingness included migrant status, sexual risk and prior PrEP use, whereas barriers included concerns over being treated as an HIV/AIDS patient, recent HIV testing, identity concealment and HIV prevention service usage. Adherence self-efficacy was associated with PrEP knowledge and confidence in PrEP efficacy of HIV prevention.
Wang et al.67	Quantitative	English	n = 487	The most commonly reported reasons for being willing to use PrEP were preventing HIV infection, taking responsibility for own sexual health and protecting family members from harm. The main reasons for being unwilling to use PrEP were being worried about side-effects, the necessity of taking PrEP for long periods of time and cost. 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 number of casual sex partners.
Wang et al.34	Quantitative	English	n = 1530	Adherence, defined as the proportion of self-reported days with sexual intercourse in which PrEP was taken according to prescription of at least 90%, increased over time among ED-PrEP users and decreased over time among D-PrEP users. Daily PrEP users reported fewer adverse events than ED-PrEP users.
Wang et al.48	Quantitative	English	n = 773	Being willing to pay for PrEP and PEP uptake was associated with conducting HIVST, and initiations of two HIV prevention methods, PrEP and PEP uptake were significantly associated with each other.
Wei et al.39	Quantitative	Chinese	n = 650	For those who refused to use it, most of them said that were afraid of the side-effects and doubted the effectiveness of PrEP. Those who had found partners through friends and those who would advise his friend to use PrEP were more likely to accept PrEP. Those who thought they could protect themselves from HIV infection or not having sex with the ones who refused to use a condom were less likely to accept PrEP.
Wu et al.27	Quantitative	English	n = 856	MSM who were in the event-driven PrEP group had fewer male sexual partners in the past 2 weeks, were 1 year older on average, considered that medication kept them safe, were less worried about others knowing they took medicine and were more likely to have high adherence.
Xia et al.31	Quantitative	Chinese	n = 1147	Logistic regression analysis revealed that compared with those who used no PrEP/PEP, those who used PrEP/PEP were more likely to have unprotected anal sex in the past month, and more likely to have multiple homosexual partners in the past month, and compared with those who used no rush poppers or drugs in the past month, those who used rush poppers or drugs in the past month were more likely to have unprotected anal sex in the past month, and more likely to have multiple homosexual partners.
Xie et al.24	Quantitative	Chinese	n = 301	Among those who had regular homosexual partners, results suggested that those who were married/cohabiting were more likely to report a willingness to use PrEP compared with unmarried/divorced or widowed, compared with homosexuality, heterosexuality was associated with decreased odds of willingness to use PrEP, compared with HIV status of sexual partner was negative or uncertain, positive infection status was associated with increased odds of willingness to use. Compared with MSM who have not regular homosexual partners, those who were married/cohabiting were more likely to report a willingness to use PrEP compared with unmarried/divorced or widowed, compared with those who think they have risk of infection, those who do not think they have risk of infection was associated with decreased odds of willingness to use PrEP, compared with those with a high frequency to seek sexual partners, those not often to seek was associated with decreased odds of willingness to use PrEP.
Xie et al.28	Quantitative	English	n = 708	Higher perceived benefits of PrEP, increased frequency of HIV testing and low condom use self-efficacy were positively-associated self-perceptions of PrEP candidacy. In a sub-analysis restricted to MSM behaviorally-indicated for PrEP, relationship factors were also significant.
Xue et al.65	Quantitative	Chinese	n = 760	In the univariate analysis, the willingness of taking PrEP was lower among those annual income l<60,000 yuan than those annual income higher; the willingness was significantly higher among those understanding PrEP than those not understanding. In multivariate logistic regression analysis, it suggested that annual income <60,000 yuan and understanding PrEP were influencing factors for usage of PrEP among MSM.
Yu et al.26	Quantitative	English	n = 255	Higher self-rated risk and fear of contracting HIV, awareness of PrEP, sharing one’s own sexual orientation with parents or siblings and having a university education or above were associated with willingness to use PrEP.
Zhang et al.32	Quantitative	Chinese	n = 2815	Factors associated with high likelihood of PrEP use in MSM included age ≤30 years, self-perceived lower risk of HIV infection, group sex and commercial sex in the past 6 months, new-type drug use, receiving peer education, other people using PrEP, and being HIV negative. Factor associated with low likelihood of PrEP use in MSM was anal sex with casual partner. Factors associated with high likelihood of PEP use in MSM included aged <50 years, no self-perceived risk for HIV infection, group sex in the past 6 months, new-type drug use and receiving no peer education.
Zhang et al.32	Quantitative	English	n = 309	Willingness to use PrEP was positively associated with having a college degree or higher and higher anticipated HIV stigma. Facilitators of intention to adhere included higher education levels and higher anticipated HIV stigma, whereas a primary barrier was community homophobia.
Zhang et al.51	Quantitative	English	n = 595	PrEP after the COVID-19 outbreak was associated with higher HIV testing utilization.
Zhang et al.52	Quantitative	English	n = 1865	PrEP was used by those who were aged ≥26 years, had a master’s degree or above, had unstable work, had tested five or more HIV times in the past year, had consulted PrEP and had PrEP knowledge awareness.
Zhang et al.53	Quantitative	English	n = 1402	The predictors of willingness to use PrEP included lower education, moderate income compared with the lowest income, never or rarely finding sexual partners through the Internet in the past 6 months, sexually transmitted infection history, more knowledge of AIDS, worrying about HIV as a threat to themselves and their family, having previously heard of PrEP, and believing that PrEP was effective in preventing HIV.
Zhang et al.62	Quantitative	English	n = 541	Compared with MSM with a basic level of PrEP comprehension, MSM with a high level were more likely to report clear choices: a willingness or unwillingness to use PrEP. Among 350 MSM willing to use PrEP or uncertain about uptake, those with a high level of PrEP comprehension were more likely to use PrEP daily and to use PrEP with mild or other side-effects. A high level of PrEP comprehension is a key factor in urging MSM to use PrEP under varying conditions.
Zhou et al.29	Quantitative	English	n = 152	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 and having ever heard of the side-effects of antiretroviral drugs were independently associated with willingness to accept PrEP.
Zhou et al.45	Quantitative	English	n = 541	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 and having ever heard of the side-effects of antiretroviral drugs were independently associated with willingness to accept PrEP.

ED-PrEP, event-driven PrEP; HIVST, HIV self-testing; LAI-PrEP, long-acting injectable PrEP.

Perceived HIV risk and sexual behaviors

One theme that emerged from included studies was the impact of sexual behaviors and perceived HIV risk on PrEP uptake. Chinese SMM across studies consistently reported that their decisions to use PrEP for HIV prevention were largely linked to their sexual behaviors and perceived vulnerability to HIV.^23–33 SMM in China who engaged in condomless anal sex or had multiple casual sexual partners were more inclined to consider PrEP as a preventive strategy.^{19,30,31,33–36} Individuals consider these behaviors as indicators that increase their risks of HIV acquisition and, therefore, expressed a greater willingness to utilize PrEP for HIV prevention. Similarly, engagement in group sex and substance use was also found to be associated with greater willingness to use PrEP for HIV prevention among Chinese SMM.^32,37 Conversely, SMM who reported consistent condom use during anal sex were less willing to use PrEP.^19,38,39 In addition to individuals’ sexual behaviors, perceived HIV risk was also influenced by one’s HIV knowledge and their fear of contracting HIV.^27,30,40 For example, one study assessing HIV knowledge among SMM found that a point increase in the HIV knowledge score was associated with a 1.4-fold higher likelihood of using PrEP.¹⁹ Similarly, researchers conducting a study in western China also found SMM were more likely to be willing to use PrEP if they had higher HIV prevention literacy.⁴¹

Stigma toward homosexuality, gay sex and PrEP

Another theme featured the enduring impact of stigma and homophobia as a major barrier to PrEP uptake among Chinese SMM. In a mixed-methods study, Lin et al. found that SMM in China frequently experienced discrimination when accessing PrEP services, even in specialized care settings.⁴² The concerns about confidentiality and the capacity of primary care providers, coupled with stigma and a lack of trust in healthcare privacy, contribute to a decreased willingness to seek PrEP uptake.^42,43 Notably, the same study also indicated that there was a negative association between concealment of one’s sexual orientation and the willingness to use PrEP.⁴² In another study, a high level of community homophobia was found to be associated with low intention to adhere to PrEP among Chinese SMM.⁴⁴ A cross-sectional study on SMM in Changsha, China, found that SMM who were open about their sexual orientation with close family members, such as parents or siblings, were more inclined to be willing to use PrEP, as evidenced by an odds ratio of 2.52 (95% CI: 1.54–7.20).²⁶ This suggested that social support is important in health-related decision-making.⁴⁵

History of HIV/STI care engagement

Past experience of HIV/STI care engagements strongly influences SMM’s acceptance and willingness to use PrEP. Experiences including routine HIV testing and STI diagnosis might make people more conscious of the high risk of HIV/STI themselves and, thus, be more eager to take PrEP for self-protection.^{23,30,37,38,45–51} For example, in a study conducted across multiple cities in China, SMM who had tested for HIV five or more times were significantly more likely of using PrEP for HIV prevention, compared with those who tested five times or less in the past year.⁵² Furthermore, receiving HIV/STI-related education and participating in corresponding studies in the past would contribute to higher adherence to PrEP.^25,53 For example, in a study among a large sample of Chinese SMM in Shandong Province, having received peer education was associated with higher likelihood of PrEP use.³²

Perceptions of PrEP efficacy, concerns about side-effects and low adherence

Another theme that influences PrEP use throughout included studies was Chinese SMM’s perceived PrEP efficacy, concerns about side-effects and perceived low adherence. Many studies consistently reported that negative perceptions of PrEP greatly prevent Chinese SMM from PrEP use because of their concerns about potential side-effects, whereas higher perceived PrEP efficacy was associated with greater willingness to use PrEP.^{25,36–38,52,54–63} Low perceived PrEP effectiveness also influenced Chinese SMM’s willingness to use PrEP. Limited perceived effectiveness of PrEP, the less-supportive attitudes of sex partners toward PrEP and SMM’s discriminatory experience of PrEP all contribute to suboptimal PrEP care engagement.⁶⁴ Furthermore, suboptimal adherence to PrEP and other medications, and lack of knowledge about PrEP were found to be highly associated with preventing participants from using PrEP for HIV prevention.^23,25,55 On the contrary, positive perceptions of PrEP might facilitate the PrEP uptake across our studies. SMM in China who had heard about the preventive effectiveness of PrEP,^{23,25,42,46,65} had known the ease and comfort of PrEP use previously^55,66 or had confidence in PrEP^53,64 were more likely to use PrEP for HIV prevention. Meanwhile, the spread of positive perceptions by advising each other about PrEP uptake might also further contribute to the increase of PrEP use among Chinese SMM.³⁹

Structural factors created additional barriers to accessing PrEP care

Finally, the engagement of Chinese SMM in the PrEP care continuum is significantly influenced by structural barriers. Among these barriers, high cost of medication, coupled with a lack of health insurance coverage, together pose significant challenges in the adoption of PrEP for HIV prevention.^25,38,42,67 For instance, 41% (79/188) of SMM in southern China expressed reluctance to use PrEP due to its prohibitive cost.²⁵ Echoing this, researchers also found nearly 70% of SMM in their studies declined PrEP use, primarily due to financial constraints.^25,42 Naturally, the role of income also emerged as a significant factor, with those earning moderate and higher incomes more likely to consider future PrEP use compared with their lower-income counterparts.^48,53,65,68 Additionally, willingness to use PrEP appears to be influenced by the level of education received.^{19,25,26,30,38,44,47,53,68–71} Higher education levels were associated with increased PrEP awareness, whereas lower educational levels were more inclined toward PrEP acceptance.^38,53 Through these findings, a complex interplay of structural factors, such as cost, education and income, subtly intertwined and collectively influenced the landscape of PrEP utilization among Chinese SMM.

Discussion

We systematically reviewed published literature in English and Chinese, and identified five overachieving themes related to the barriers and facilitators to the engagement in PrEP care continuum among SMM in China. The findings of this review can be interpreted through the lens of the health belief model (HBM), which provides a useful framework for situating observed barriers and facilitators to PrEP engagement within established health behavior theories, despite not being used to guide data extraction or analysis.⁷² The HBM was originally developed to understand the adoption of preventive health behaviors, positing that health behaviors are influenced by various factors, such as perceived risk susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and health motivation.

Our study found Chinese SMM with higher perceived risk for HIV, indicated by self-reported sexual behaviors, HIV knowledge and fear of contracting HIV, were more willing to use PrEP for HIV prevention. This finding aligns with the HBM construct of risk susceptibility, which has frequently been targeted in HIV prevention interventions. For example, an intervention using motivational interview-based sessions among black SMM in the US increased perceived risk for HIV and willingness to initiate PrEP.⁷³ However, the aforementioned study did not find perceived HIV risk to be associated with willingness to initiate PrEP. The authors posited that the PrEP-related outcomes were perhaps better explained by other components of the intervention (e.g. active listening from a peer, adequate presentation of PrEP information), which map onto HBM elements, such as health motivation and perceived benefits. This suggested that perceived HIV risk alone might not be adequate to induce change in health behaviors. There is also evidence suggesting that actual HIV-related risk behaviors, such as condom use behaviors, rather than perceived HIV risk, were better predictors of PrEP willingness.⁷⁴ This indicates that interventions and providers may assess actual HIV risk behaviors as an important benchmark in addition to perceived HIV risk to more accurately gauge PrEP use willingness and provide linkage to care. More studies are needed to further our understanding of the role of sexual behavior, perceived HIV risk and the interplay with other factors to together influence willingness to use PrEP.

Although the HBM posits that perceived benefits must outweigh perceived barriers for health behavior change to occur, our review also underscores the salience of multilevel barriers – individual, interpersonal, community and structural – that may overshadow the perceived benefits of PrEP. Among the barriers, stigma related to being SMM and using PrEP plays a significant role in deterring Chinese SMM from inquiring about PrEP.

Stigma and discrimination toward SMM in China has been increasingly studied in recent years. Being SMM is still highly stigmatized in China, where individuals’ perceived and internalized stigma often inevitably leads to adverse mental health outcomes and engagement in prevention.⁷⁵ Stigma often leads individuals to conceal one’s identity, resulting in isolation from family and friends who are important sources of social support – a key motivational source for health behavior change.^76,77 Indeed, our review found Chinese SMM who are open about their sexuality and receive social support are more likely to express willingness to use and adhere to PrEP. Meanwhile, PrEP stigma intersects with and exacerbates existing stigma related to homosexuality and HIV. PrEP use can inadvertently ‘out’ individuals as SMM or as being at risk for HIV.⁷⁸ Additionally, PrEP use is often perceived as an indicator of engaging in ‘risky’ sexual practices or promiscuity. This perception can lead to judgment and discrimination from others, including healthcare providers.⁴⁷

In addition to addressing structural barriers by increasing insurance coverage and reducing PrEP-related cost, public education campaigns related to PrEP, health provider training and community support programs should be integrated to mitigate the negative impact of stigma, and enhance motivation to engage in PrEP care continuum.⁷⁹ It is also important to acknowledge that the landscape of PrEP access in China has been evolving. For example, since late 2021, the availability of lower-cost generic tenofovir disoproxil fumarate/FTC, the emergence of online PrEP pharmacies, flexible packaging options and rapid home delivery services have significantly reduced some structural barriers, such as geographic access and upfront medication costs. However, despite these advancements, associated costs – such as regular medical visits, laboratory monitoring and ongoing provider consultation – may continue to pose financial burdens and accessibility challenges for many. Future research should explore how these evolving changes impact PrEP utilization, and identify new or persistent barriers that require targeted intervention.

Health motivation as a key element of the HBM can be reflected by past engagement with health care, and subsequently predict development of or changes of health behaviors. Findings from our review suggested that individuals with a history of HIV/STI care engagement are more likely to access PrEP, suggesting that effort to remove barriers to engaging with HIV-prevention services and interventions in general, including testing and condom use, may have indirect effects on enhancing engagement with PrEP care continuum. HIV testing, specifically, can identify PrEP candidates, and may serve as an important target for interventions to increase linkage to PrEP care continuum.

A recent systematic review on the use of HIV self-testing to support PrEP engagement showed mixed findings, where some studies found slight increased PrEP adherence with HIV self-testing use between clinic visits, whereas other studies reported non-inferior results for adherence.⁸⁰ The increased adherence might be due to the biofeedback effect of HIV self-testing, as well as the psychological and emotional benefits of feeling empowered by the information of their HIV status and risk of transmission.⁸¹

However, even for individuals with a history of engaging with HIV prevention and care continuum, PrEP engagement may require additional support to help individuals to obtain accurate information of benefits, side-effects, options of regime and importance of adherence. Complementary services and community-led interventions that aim to support individuals to manage side-effects and adherence may also be beneficial to create the ecosystem for continued engagement with the care continuum. Indeed, in the guideline for countries to determine needs for scaled HIV prevention, UNAIDS emphasizes synergy among resources for comprehensive HIV response that strengthens prevention, testing and treatment.⁸²

The findings of this review highlight the urgent need to diversify and promote alternative PrEP modalities, such as on-demand (event-driven, or 2-1-1) PrEP and long-acting injectable PrEP, to meet the unique needs of Chinese SMM. These modalities can address several critical barriers identified in this review, including concerns about adherence and perceived stigma from providers, as well as concerns about medication cost. For example, on-demand PrEP provides a flexible, event-driven regimen that aligns more closely with the sexual behaviors of individuals who may not require daily prevention, but still engage in occasional sexual risk behaviors.⁸³

By offering a tailored approach, on-demand PrEP could reduce concerns related to daily adherence and associated stigma, and potential cost, making it a more acceptable option for some. Similarly, long-acting injectable PrEP represents a promising innovation to overcome challenges related to daily pill regimens and adherence fatigue.⁸⁴ The injectable approach administered less frequently (e.g. every 2 months) may alleviate the stigma associated with carrying or consuming oral medication, and mitigate adherence issues that arise from daily dosing. Furthermore, this modality may be particularly appealing to individuals who have concerns about forgetting doses or who prefer less frequent healthcare interactions. Previous research suggests that these approaches are acceptable among Chinese SMM.^30,37 Integrating these options into the existing PrEP program, accompanied by robust education campaigns and community-led support, can enhance the accessibility, appropriateness and acceptability of PrEP among Chinese SMM. Future studies should explore the acceptability and feasibility of these modalities in China, tailoring interventions to address the unique needs and preferences of diverse subgroups within this population.

This systematic review has several limitations. The review relied on published literature, which may be subject to publication bias, potentially overrepresenting positive or significant results. This bias could skew our understanding of the barriers and facilitators to PrEP use among SMM in China, as studies with null or negative findings might be underrepresented in the literature. Additionally, although this review aimed to synthesize evidence across the PrEP care continuum, most of the included studies focused on willingness to use PrEP, with limited empirical data on actual uptake, adherence or long-term persistence. As a result, our synthesis could not fully disentangle stage-specific factors that may influence different points of the PrEP continuum. Future research is needed to examine how barriers and facilitators may differ across behavioral stages – such as awareness, willingness, initiation and adherence – to support more targeted and stage-specific intervention strategies. Moreover, future studies would benefit from the consistent application and explicit reporting of behavioral theoretical frameworks, such as the Theory of Planned Behavior, the Information-Motivation-Behavioral Skills model, to better elucidate mechanisms driving PrEP-related behaviors and to inform the design of theory-driven interventions. The rapid evolution of PrEP policies, implementation strategies and social attitudes in China means that some of our findings may not fully reflect the current landscape of PrEP use among SMM in the country. Future reviews could examine the longitudinal changes as policies and services continue to develop in China. Such longitudinal analyses would provide valuable insights into the evolving nature of PrEP engagement, capturing how barriers and facilitators shift over time in response to policy changes, increased awareness, and expanding service availability. This approach would offer a more dynamic understanding of patterns of engagement with PrEP engagement, potentially informing more effective, time-sensitive interventions and policy adjustments.

Despite the limitations, the findings of this systematic review underscore the critical need for multifaceted approaches to enhance PrEP engagement among Chinese SMM, and provide implications for future research, practice and policy. First, future research should explore the nuanced interplay between multilevel factors associated with PrEP care engagement and other syndemic factors to better understand their collective impact on PrEP utilization and persistence. There is also a need for in-depth qualitative investigations and longitudinal studies to capture the evolving landscape of PrEP care engagement over time. This includes examining differences in geographic regions and cultures across these regions. From the policy perspective, future efforts should focus on addressing structural barriers, such as medication cost and health insurance coverage, to improve access. Health policy should also address the pervasive stigma related to same-sex behavior, homosexuality and PrEP use through health education campaigns and programs for healthcare providers. Finally, clinical practice should utilize community-led efforts to provide accurate information through best practices, such as information dissemination through key opinion leaders. Enhancing social support and connectedness to the LGBTQ+ community, and fostering an accepting environment that reduces stigma could also facilitate PrEP care engagement. Clinicians and providers should also consider comprehensive screening strategies to identify individuals who are eligible and might benefit from PrEP, and provide them with the necessary information and support.

Conclusion

This systematic review showed the multifaceted landscape of PrEP engagement among SMM in China, revealing a complex interplay of individual, social and structural factors. Our findings underscore the critical influence of perceived HIV risk, stigma, healthcare engagement history, PrEP-related perceptions and structural barriers on the PrEP care continuum. These insights call for a holistic approach to PrEP implementation that transcends individual-level interventions to address broader societal and systemic challenges. As China advances its PrEP rollout, tailored strategies that mitigate identified barriers while leveraging facilitators are imperative.

Data availability.

All data were extracted from published studies and are publicly available.