AIDS and Behavior

, Volume 23, Issue 10, pp 2784–2794 | Cite as

Risk Behavior Not Associated with Self-Perception of PrEP Candidacy: Implications for Designing PrEP Services

  • Lu Xie
  • Yumeng Wu
  • Siyan Meng
  • Jianhua Hou
  • Rong Fu
  • Huang Zheng
  • Na He
  • Min Wang
  • Kathrine MeyersEmail author
Original Paper


In a study of sexually-active HIV-negative men who have sex with men (MSM) in China, we compared behavioral indication for pre-exposure prophylaxis (PrEP) based on risk criteria to self-perception of PrEP candidacy (SPC) and explored factors associated with SPC. Of 708 MSM surveyed, 323 (45.6%) were behaviorally-indicated for PrEP, among whom 42.1% self-perceived as appropriate PrEP candidates. In a multivariable model we found no association between sexual behavior nor HIV risk perception and SPC but found that higher perceived benefits of PrEP, increased frequency of HIV testing, and low condom use self-efficacy were positively-associated with SPC. In a sub-analysis restricted to MSM behaviorally-indicated for PrEP, relationship-factors were also significant. Our findings suggest that PrEP implementers should look beyond risk criteria to consider shared decision-making tools that support individuals to assess whether they are appropriate PrEP candidates based on their existing HIV prevention strategies, sexual health goals, and relationship dynamics.


Pre-exposure prophylaxis PrEP candidacy Risk perception HIV prevention Men who have sex with men 



The study was supported by the Good Participatory Practice Program of the Aaron Diamond AIDS Research Center. Dr. Meyers is also supported by Grant # UL1TR001866 from the National Center for Advancing Translational Sciences, National Institutes of Health Clinical and Translational Science Award program. The authors would like to acknowledge all the GPP team members and collaborators: Weibin Cheng, Yuzhou Gu, and Huifang Xu (Guangzhou Center for Disease Control and Prevention, Guangzhou, China), Xiaojie Huang (Beijing You’an Hospital, China) and the following community-based organizations: Changsha Zonda-sunshine Social Work Center, QingCai Volunteer Centre, Lingnan Partners, Zhitong, Tianyuan. We thank all our participants for their responses and their time.


This study is funded by GlaxoSmithKline. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in this study were in accordance with the ethical standards of the Ethics Review Committee of Fudan University, Shanghai, China (IRB00002408 & FWA00002399) and with the 1964 Helsinki declaration and its later amendments.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

10461_2019_2587_MOESM1_ESM.xlsx (93 kb)
Supplementary material 1 (XLSX 93 kb)


  1. 1.
    Sullivan P, Smith K, Mera-Giler R, Siddiqi A, Gunnels B, Harris N, et al. The impact of pre-exposure prophylaxis with TDF/FTC on HIV diagnoses, 2012–2016, United States. Abstract number: LBPEC036. 22nd International AIDS Conference (AIDS 2018); Amsterdam, the Netherlands 2018.Google Scholar
  2. 2.
    San Francisco Department of Public Health. HIV Epidemiology Annual Report 2017. Population Health Division SF. 2017.Google Scholar
  3. 3.
    The New York City Department of Health and Mental Hygiene. Bureau of Sexually Transmitted Disease Control Quarterly Report (2017: 4th Quarter). 2018.Google Scholar
  4. 4.
    Grulich AE, Guy R, Amin J, Jin F, Selvey C, Holden J, et al. Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study. Lancet HIV. 2018;5(11):e629–37.Google Scholar
  5. 5.
    Brown A, Kirwan P, Chau C, Khawam J, Gill N, Delpech V. Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK. In: Public Health England, Editor. 2017.Google Scholar
  6. 6.
    Coleman R. Setting the scene, setting the targets. The Joint United Nations Programme on HIV/AIDS prevention targets of 2016 and estimating global pre-exposure prophylaxis targets. CSIRO Sex Health. 2018;15(6):485–8.Google Scholar
  7. 7.
    Aghaizu A, Mercey D, Copas A, Johnson AM, Hart G, Nardone A. Who would use PrEP? Factors associated with intention to use among MSM in London: a community survey. Sex Transm Infect. 2013;89(3):207–11.Google Scholar
  8. 8.
    Allen E, Gordon A, Krakower D, Hsu K. HIV preexposure prophylaxis for adolescents and young adults. Curr Opin Pediatr. 2017;29(4):399–406.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Calabrese SK, Underhill K. How stigma surrounding the use of HIV preexposure prophylaxis undermines prevention and pleasure: a call to destigmatize “Truvada Whores”. Am J Public Health. 2015;105(10):1960–4.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Eaton LA, Kalichman SC, Price D, Finneran S, Allen A, Maksut J. Stigma and conspiracy beliefs related to pre-exposure prophylaxis (PrEP) and interest in using PrEP among black and white men and transgender women who have sex with men. AIDS Behav. 2017;21(5):1236–46.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Golub SA, Gamarel KE, Rendina HJ, Surace A, Lelutiu-Weinberger CL. From efficacy to effectiveness: facilitators and barriers to PrEP acceptability and motivations for adherence among MSM and transgender women in New York City. AIDS Patient Care STDs. 2013;27(4):248–54.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Grov C, Whitfield THF, Rendina HJ, Ventuneac A, Parsons JT. Willingness to take PrEP and potential for risk compensation among highly sexually active gay and bisexual men. AIDS Behav. 2015;19(12):2234–44.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Haire BG. Preexposure prophylaxis-related stigma: strategies to improve uptake and adherence—a narrative review. HIV/AIDS (Auckl). 2015;7:241–9.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Plotzker R, Seekaew P, Jantarapakde J, Pengnonyang S, Trachunthong D, Linjongrat D, et al. Importance of risk perception: predictors of PrEP acceptance among Thai MSM and TG women at a community-based health service. J Acquir Immune Defic Syndr. 2017;76(5):473–81.Google Scholar
  15. 15.
    Underhill K, Guthrie KM, Colleran C, Calabrese SK, Operario D, Mayer KH. Temporal fluctuations in behavior, perceived HIV risk, and willingness to use pre-exposure prophylaxis (PrEP). Arch Sex Behav. 2018;47(7):2109–21.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Van der Elst EM, Mbogua J, Operario D, Mutua G, Kuo C, Mugo P, et al. High acceptability of HIV pre-exposure prophylaxis but challenges in adherence and use: qualitative insights from a phase I trial of intermittent and daily PrEP in at-risk populations in Kenya. AIDS Behav. 2013;17(6):2162–72.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Ware NC, Wyatt MA, Haberer JE, Baeten JM, Kintu A, Psaros C, et al. What’s love got to do with it? Explaining adherence to oral antiretroviral pre-exposure prophylaxis for HIV-serodiscordant couples. J Acquir Immune Defic Syndr. 2012;59(5):463–8.Google Scholar
  18. 18.
    Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12(1):38–48.Google Scholar
  19. 19.
    Parsons JT, Rendina HJ, Lassiter JM, Whitfield TH, Starks TJ, Grov C. Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States: the motivational PrEP cascade. J Acquir Immune Defic Syndr. 2017;74(3):285.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Wu Y, Xie L, Meng S, Hou J, Fu R, Zheng H, et al. Mapping potential pre-exposure prophylaxis users onto a motivational cascade: identifying targets to prepare for implementation in China. LGBT Health. 2019. Scholar
  21. 21.
    Peng P, Su S, Fairley CK, Chu M, Jiang S, Zhuang X, et al. A global estimate of the acceptability of pre-exposure prophylaxis for HIV among men who have sex with men: a systematic review and meta-analysis. AIDS Behav. 2018;22(4):1063–74.Google Scholar
  22. 22.
    Yi S, Tuot S, Mwai GW, Ngin C, Chhim K, Pal K, et al. Awareness and willingness to use HIV pre-exposure prophylaxis among men who have sex with men in low-and middle-income countries: a systematic review and meta-analysis. J Int AIDS Soc. 2017;20(1):21580.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Bourne A, Cassolato M, Thuan Wei CK, Wang B, Pang J, Lim SH, et al. Willingness to use pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Malaysia: findings from a qualitative study. J Int AIDS Soc. 2017;20(1):21899.PubMedPubMedCentralGoogle Scholar
  24. 24.
    To KW, Lee SS. HIV pre-exposure prophylaxis in South East Asia: a focused review on present situation. Int J Infect Dis. 2018;77:113–7.Google Scholar
  25. 25.
    Chakrapani V, Newman P, Shunmugam M, Mengle S, Varghese J, Nelson R, et al. Acceptability of HIV Pre-exposure prophylaxis (prep) and implementation challenges among men who have sex with men in India: a qualitative investigation. AIDS Patient Care STDs. 2015;10:569–77.Google Scholar
  26. 26.
    Wang X, Bourne A, Liu P, Sun J, Cai T, Mburu G, et al. Understanding willingness to use oral pre-exposure prophylaxis for HIV prevention among men who have sex with men in China. PLoS ONE. 2018;13(6):e0199525.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Ding Y, Yan H, Ning Z, Cai X, Yang Y, Pan R, et al. Low willingness and actual uptake of pre-exposure prophylaxis for HIV-1 prevention among men who have sex with men in Shanghai China. Biosci Trends. 2016;10(2):113–9.Google Scholar
  28. 28.
    Draper BL, Oo ZM, Thein ZW, Aung PP, Veronese V, Ryan C, et al. Willingness to use HIV pre-exposure prophylaxis among gay men, other men who have sex with men and transgender women in Myanmar. J Int AIDS Soc. 2017;20(1):21885.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Hoagland B, De Boni RB, Moreira RI, Madruga JV, Kallas EG, Goulart SP, et al. Awareness and willingness to use pre-exposure prophylaxis (PrEP) among men who have sex with men and transgender women in Brazil. AIDS Behav. 2017;21(5):1278–87.Google Scholar
  30. 30.
    Jackson T, Huang A, Chen H, Gao X, Zhong X, Zhang Y. Cognitive, psychosocial, and sociodemographic predictors of willingness to use HIV pre-exposure prophylaxis among Chinese men who have sex with men. AIDS Behav. 2012;16(7):1853–61.Google Scholar
  31. 31.
    Young I, Li J, McDaid L. Awareness and willingness to use HIV pre-exposure prophylaxis amongst gay and bisexual men in Scotland: implications for biomedical HIV prevention. PLoS ONE. 2013;8(5):e64038.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Mimiaga MJ, Case P, Johnson CV, Safren SA, Mayer KH. 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. 2009;50(1):77–83.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Holt M, Murphy DA, Callander D, Ellard J, Rosengarten M, Kippax SC, et al. Willingness to use HIV pre-exposure prophylaxis and the likelihood of decreased condom use are both associated with unprotected anal intercourse and the perceived likelihood of becoming HIV positive among Australian gay and bisexual men. Sex Transm Infect. 2012;88(4):258–63.Google Scholar
  34. 34.
    Meyers K, Wu Y, Qian H, Sandfort T, Huang X, Xu J, et al. Interest in long-acting injectable PrEP in a cohort of men who have sex with men in China. AIDS Behav. 2018;22(4):1217–27.PubMedPubMedCentralGoogle Scholar
  35. 35.
    Eaton LA, Driffin DD, Smith H, Conway-Washington C, White D, Cherry C. Psychosocial factors related to willingness to use pre-exposure prophylaxis for HIV prevention among Black men who have sex with men attending a community event. Sex Health. 2014;11(3):244–51.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Dubin S, Goedel WC, Park SH, Hambrick HR, Schneider JA, Duncan DT. Perceived candidacy for pre-exposure prophylaxis (PrEP) among men who have sex with men in Paris France. AIDS Behav. 2018. Scholar
  37. 37.
    Gallagher T, Link L, Ramos M, Bottger E, Aberg J, Daskalakis D. Self-perception of HIV risk and candidacy for pre-exposure prophylaxis among men who have sex with men testing for HIV at commercial sex venues in New York City. LGBT Health. 2014;1(3):218–24.Google Scholar
  38. 38.
    Lockard A, Rosenberg ES, Sullivan PS, Kelley CF, Serota DP, Rolle CM, et al. Contrasting self-perceived need and guideline-based indication for HIV pre-exposure prophylaxis among Young, Black Men who have sex with men offered pre-exposure prophylaxis in Atlanta Georgia. AIDS Patient Care STDs. 2019;33(3):112–9.Google Scholar
  39. 39.
    Cohen SE, Vittinghoff E, Bacon O, Doblecki-Lewis S, Postle BS, Feaster DJ, et al. High interest in pre-exposure prophylaxis among men who have sex with men at risk for HIV-infection: baseline data from the US PrEP demonstration project. J Acquir Immune Defic Syndr (1999). 2015;68(4):439.Google Scholar
  40. 40.
    Cui Y, Guo W, Li D, Wang L, Shi CX, Brookmeyer R, et al. Estimating HIV incidence among key affected populations in China from serial cross-sectional surveys in 2010–2014. J Int AIDS Soc. 2016;19(1):20609.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Zhang W, Xu JJ, Zou H, Zhang J, Wang N, Shang H. HIV incidence and associated risk factors in men who have sex with men in Mainland China: an updated systematic review and meta-analysis. Sex Health. 2016;13(4):373–82.Google Scholar
  42. 42.
    Wang QQ, Chen XS, Yin YP, Liang GJ, Zhang RL, Jiang N, et al. HIV prevalence, incidence and risk behaviours among men who have sex with men in Yangzhou and Guangzhou, China: a cohort study. J Int AIDS Soc. 2014;17:18849.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Mao X, Wang Z, Hu Q, Huang C, Yan H, Wang Z, et al. HIV incidence is rapidly increasing with age among young men who have sex with men in China: a multicentre cross-sectional survey. HIV Med. 2018;19(8):513–22.Google Scholar
  44. 44.
    AIDS and Hepatitis C Professional Group, Society of Infectious Diseases, Chinese Medical Association; Chinese Center for Disease Control and Prevention. [Chinese guidelines for diagnosis and treatment of HIV/AIDS (2018)]. Zhonghua nei ke za zhi. 2018;57(12):867–84.Google Scholar
  45. 45.
    Study protocol: A multicenter, real-world study on two oral Truvada approaches to prevention HIV infection among men who have sex with men. 2017ZX10201101 2017.
  46. 46.
    Li L, Jiang Z, Song W, Ding Y, Xu J, He N. [Chinese] Constructing an HIV risk assessment tool for MSM using the Delphi method. Chin J Epidemiol. 2017;38(10):1426–30.Google Scholar
  47. 47.
    IBM. SPSS Statistics, Version 22.0. New York: IBM Corp. 2014.Google Scholar
  48. 48.
    Golub SA. PrEP stigma: implicit and explicit drivers of disparity. Curr HIV/AIDS Rep. 2018;15:1–8.Google Scholar
  49. 49.
    Dubov A, Galbo P Jr, Altice FL, Fraenkel L. Stigma and shame experiences by MSM who take PrEP for HIV prevention: a qualitative study. Am J Mens Health. 2018;12(6):1843–54.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Jaspal R, Nerlich B. Polarised press reporting about HIV prevention: social representations of pre-exposure prophylaxis in the UK press. Health (London). 2017;21(5):478–97.Google Scholar
  51. 51.
    Brooks RA, Landrian A, Nieto O, Fehrenbacher A. Experiences of anticipated and enacted pre-exposure prophylaxis (PrEP) stigma among Latino MSM in Los Angeles. AIDS Behav. 2019;23(7):1–10.Google Scholar
  52. 52.
    Spieldenner A. PrEP whores and HIV prevention: the queer communication of HIV pre-exposure prophylaxis (PrEP). J Homosex. 2016;63(12):1685–97.Google Scholar
  53. 53.
    Calabrese SK, Krakower DS, Willie TC, Kershaw TS, Mayer KH. US guideline criteria for HIV pre-exposure prophylaxis: clinical considerations and caveats. Clin Infect Dis. 2019. Scholar
  54. 54.
    Wang X, Wu Z, Tang Z, Nong Q, Li Y. Promoting HIV testing with home self-test kit among men who have sex with men in China: a feasibility study. The Lancet. 2015;386:S68.Google Scholar
  55. 55.
    Han L, Bien CH, Wei C, Muessig KE, Yang M, Liu F, et al. HIV self-testing among online MSM in China: implications for expanding HIV testing among key populations. J Acquir Immune Defic Syndr. 2014;67(2):216.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Tang W, Wei C, Cao B, Wu D, Li KT, Lu H, et al. Crowdsourcing to expand HIV testing among men who have sex with men in China: a closed cohort stepped wedge cluster randomized controlled trial. PLoS Med. 2018;15(8):e1002645.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Wei C, Yan H, Yang C, Raymond HF, Li J, Yang H, et al. Accessing HIV testing and treatment among men who have sex with men in China: a qualitative study. AIDS Care. 2014;26(3):372–8.Google Scholar
  58. 58.
    Liu C, Mao J, Wong T, Tang W, Tso LS, Tang S, et al. Comparing the effectiveness of a crowdsourced video and a social marketing video in promoting condom use among Chinese men who have sex with men: a study protocol. BMJ Open. 2016;6(10):e010755.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Saberi P, Gamarel KE, Neilands TB, Comfort M, Sheon N, Darbes LA, et al. Ambiguity, ambivalence, and apprehensions of taking HIV-1 pre-exposure prophylaxis among male couples in San Francisco: a mixed methods study. PLoS ONE. 2012;7(11):e50061.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Gamarel KE, Golub SA. Intimacy motivations and pre-exposure prophylaxis (PrEP) adoption intentions among HIV-negative men who have sex with men (MSM) in romantic relationships. Ann Behav Med. 2014;49(2):177–86.Google Scholar
  61. 61.
    Mitchell JW, Lee J-Y, Woodyatt C, Bauermeister J, Sullivan P, Stephenson R. HIV-negative male couples’ attitudes about pre-exposure prophylaxis (PrEP) and using PrEP with a sexual agreement. AIDS Care. 2016;28(8):994–9.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Lancki N, Almirol E, Alon L, McNulty M, Schneider J. PrEP guidelines have low sensitivity for identifying seroconverters in a sample of Young Black men who have sex with men in Chicago. AIDS. 2018;32(3):383–92.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Zarwell M, Ransome Y, Barak N, Gruber D, Robinson WT. PrEP indicators, social capital and social group memberships among gay, bisexual and other men who have sex with men. Cult Health Sex. 2019. Scholar
  64. 64.
    Phillips G, Neray B, Birkett M, Felt D, Janulis P, Mustanski B. Role of social and sexual network factors in PrEP utilization among YMSM and transgender women in Chicago. Prev Sci. 2019. Scholar
  65. 65.
    Dubov A, Altice FL, Fraenkel L. An information–motivation–behavioral skills model of PrEP uptake. AIDS Behav. 2018;22(11):3603–16.Google Scholar
  66. 66.
    Bitton A, Gaziano T. The Framingham Heart Study’s impact on global risk assessment. Prog Cardiovasc Dis. 2010;53(1):68–78.PubMedPubMedCentralGoogle Scholar
  67. 67.
    Blake GM, Fogelman I. The role of DXA bone density scans in the diagnosis and treatment of osteoporosis. Postgrad Med J. 2007;83(982):509–17.PubMedPubMedCentralGoogle Scholar
  68. 68.
    Noble D, Mathur R, Dent T, Meads C, Greenhalgh T. Risk models and scores for type 2 diabetes: systematic review. BMJ. 2011;343:d7163.PubMedPubMedCentralGoogle Scholar
  69. 69.
    Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97(18):1837–47.Google Scholar
  70. 70.
    Hoots BE, Finlayson T, Nerlander L, Paz-Bailey G, Group NHBSS, Wortley P, et al. Willingness to take, use of, and indications for pre-exposure prophylaxis among men who have sex with men—20 US cities, 2014. Clin Infect Dis. 2016;63(5):672–7.PubMedPubMedCentralGoogle Scholar
  71. 71.
    Blumenthal J, Jain S, Mulvihill E, Sun S, Hanashiro M, Ellorin E, et al. Perceived versus calculated HIV risk: Implications for Pre-exposure prophylaxis uptake in a randomized trial of men who have sex with men. J Acquir Immune Defic Syndr. 9000; Publish Ahead of Print.Google Scholar
  72. 72.
    Barry MJ, Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780–1.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Institute of HIV/AIDS, The First Hospital of ChangshaChangshaChina
  2. 2.Aaron Diamond AIDS Research Center, The Rockefeller UniversityNew YorkUSA
  3. 3.School of Public HealthFudan UniversityShanghaiChina
  4. 4.Center for Infectious DiseasesBeijing You’an Hospital, Capital Medical UniversityBeijingChina
  5. 5.Guangzhou Center for Disease Control and PreventionGuangzhouChina
  6. 6.Shanghai CSW & MSM CenterShanghaiChina

Personalised recommendations