Pre-exposure prophylaxis (PrEP) is an effective means of HIV prevention for men who have sex with men (MSM), a key population whose engagement is crucial for achieving effective public health outcomes. An optimal service model would be important in planning the implementation of PrEP in places where such service has not been established.
Methods
A qualitative study was conducted to delineate the attributes of an optimal PrEP service model for MSM in Hong Kong, a city where no formal PrEP programs existed. Twenty purposively sampled MSM who were enrollees of two pilot PrEP projects participated in the semi-structured interviews promoting story-telling. The coded data were thematically analyzed following Grounded Theory approach, focusing on uncovering a typology of the essential attributes of an optimal PrEP service model, and the reasons for such preferences.
Results
Participating MSM were all ethnic Chinese and aged 26 to 52 years. All had received PrEP from pilot projects in conjunction with periodic screening of sexually transmitted infections (STI), HIV antibody, and plasma creatinine. Four major themes emerged as regards the attributes of a preferred PrEP service: (i) comprehensiveness of HIV/STI and safety monitoring; (ii) convenient unitary service; (iii) stigma-free PrEP access and protecting confidentiality; and (iv) affordable price. Whereas regular provision of PrEP was acceptable to MSM, unaffordability and related stigma were the anticipated challenges for potential service providers.
Conclusions
The qualitative assessment of MSM’s preference for PrEP service delivery has yielded important information on the many facets of a desirable service model.
GrantRMLamaJRAndersonPL, et al.Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med2010; 363(27): 2587–99.
2.
BaetenJMDonnellDNdaseP, et al.Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med2012; 367(5): 399–410.
3.
McCormackSDunnDTDesaiM, et al.Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet2016; 387(10013): 53–60.
4.
MolinaJMCharreauISpireB, et al.Efficacy, safety, and effect on sexual behaviour of on-demand pre-exposure prophylaxis for HIV in men who have sex with men: an observational cohort study. Lancet HIV2017; 4(9): e402–410.
5.
LiuAYCohenSEVittinghoffE, et al.Preexposure prophylaxis for HIV infection integrated with municipal- and community-based sexual health services. JAMA Intern Med2016; 176(1): 75–84.
6.
GrulichAEGuyRAminJ, 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 HIV2018; 5(11): e629–637.
7.
NwokoloNHillAMcOwanA, et al.Rapidly declining HIV infection in MSM in Central London. Lancet HIV2017; 4(11): e482–483.
Hodges-MameletzisIDalalSMsimanga-RadebeB, et al.Going global: the adoption of the World Health Organization's enabling recommendation on oral pre-exposure prophylaxis for HIV. Sex Health2018; 15(6): 489–500.
HanJBoueyJZWangL, et al.PrEP uptake preferences among men who have sex with men in China: results from a National Internet Survey. J Int AIDS Soc2019; 22(2): e25242.
12.
GrovCWhitfieldTHFRendinaHJ, et al.Willingness to take PrEP and potential for risk compensation among highly sexually active gay and bisexual men. AIDS Behav2015; 19(12): 2234–2244.
13.
YoungILiJMcDaidL. Awareness and willingness to use HIV pre-exposure prophylaxis amongst gay and bisexual men in Scotland: implications for biomedical HIV prevention. PLoS One2013; 8(5): e64038.
14.
GaleaJTKinslerJJSalazarX, et al.Acceptability of pre-exposure prophylaxis as an HIV prevention strategy: barriers and facilitators to pre-exposure prophylaxis uptake among at-risk Peruvian populations. Int J STD AIDS2011; 22(5): 256–62.
15.
YiSTuotSMwaiGW, 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 Soc2017; 20(1): 21580.
16.
Special Preventive Programme, Centre for Health Protection, Department of Health. FACTSHEET HIV/AIDS Situation in Hong Kong. Centre for Health Protection, 2019.
BrooksRALandovitzRJKaplanRL, et al.Sexual risk behaviors and acceptability of HIV pre-exposure prophylaxis among HIV-negative gay and bisexual men in serodiscordant relationships: a mixed methods study. AIDS Patient Care STDS2012; 26(2): 87–94.
19.
DubovAOgunbajoAAlticeFL, et al.Optimizing access to PrEP based on MSM preferences: results of a discrete choice experiment. AIDS Care2019; 31(5): 545–553.
20.
HillisAGermainJHibbertMPHopeVVan HoutMC. “Belt and braces approach; added benefit and … extra reassurance”: a multi-stakeholder examination of the challenges to effective provision of pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Northern and Central England. AIDS Care2021; 33(6): 736–745.
21.
RebeKHoosenNMcIntyreJA. Strategies to improve access for MSM in low-income and middle-income countries. Curr Opin HIV AIDS2019; 14(5): 387–392.
22.
SmithDKToledoLSmithDJ, et al.Attitudes and program preferences of African-American urban young adults about pre-exposure prophylaxis (PrEP). AIDS Educ Prev2012; 24(5): 408–21.
23.
JohnsonRWaterfieldJ. Making words count: the value of qualitative research. Physiother Res Int2004; 9(3): 121–31.
24.
CharmazK. Stories and silences: disclosures and self in chronic illness. Qual Inq2002; 8: 302–328.
25.
PalaciosJFSalemBHodgeFS, et al.Storytelling: a qualitative tool to promote health among vulnerable populations. J Transcult Nurs2015; 26(4): 346–53.
26.
LeeSSKwanTHWongNS, et al.Piloting a partially self-financed mode of human immunodeficiency virus pre-exposure prophylaxis delivery for men who have sex with men in Hong Kong. Hong Kong Med J2019; 25(5): 382–391.
27.
KwanTHLuiGCYLamTTN, et al.Comparison between daily and on-demand PrEP (pre-exposure prophylaxis) regimen in covering condomless anal intercourse for men who have sex with men in Hong Kong: a randomized, controlled, open-label, crossover trial. J Int AIDS Soc2021; 24: e25795.
28.
MolinaJMCharreauIChidiacC, et al.Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: an open-label randomised substudy of the ANRS IPERGAY trial. Lancet Infect Dis2018; 18(3): 308–317.
29.
CharmazKBelgraveLL. Grounded theory. In: RitzerG (ed). The Blackwell encyclopedia of sociology. Hoboken, NJ: Wiley-Blackwell; 2015, https://doi.org/10.1002/9781405165518.wbeosg070.pub2 (Accessed 12 April 2021).
30.
SineathRCFinneranCSullivanP, et al.Knowledge of and interest in using preexposure prophylaxis for HIV prevention among men who have sex with men in Thailand. J Int Assoc Provid AIDS Care2013; 12(4): 227–31.
31.
KarugaRNNjengaSNMulwaR, et al.“How I wish this thing was initiated 100 years ago!” Willingness to take daily oral pre-exposure prophylaxis among men who have sex with men in Kenya. PLoS One2016; 11(4): e0151716.
32.
RossIMejiaCMelendezJ, et al.Awareness and attitudes of pre-exposure prophylaxis for HIV prevention among physicians in Guatemala: implications for country-wide implementation. PLoS One2017; 12: e0173057.
33.
BlackstockOJMooreBABerkenblitGV, et al.A cross-sectional online survey of HIV pre-exposure prophylaxis adoption among primary care physicians. J Gen Intern Med2017; 32: 62–70.
34.
PleuhsBQuinnKGWalshJL, et al.Health care provider barriers to HIV pre-exposure prophylaxis in the United States: a systematic review. AIDS Patient Care STDS2020; 34(3): 111–123.
35.
KarrisMYBeekmannSEMehtaSR, et al.Are we prepped for preexposure prophylaxis (PrEP)? Provider opinions on the real-world use of PrEP in the United States and Canada. Clin Infect Dis2014; 58(5): 704–12.
36.
TellalianDMaznaviKBredeekUF, et al.Pre-exposure prophylaxis (PrEP) for HIV infection: results of a survey of HIV healthcare providers evaluating their knowledge, attitudes, and prescribing practices. AIDS Patient Care STDS2013; 27(10): 553–9.
37.
PintoRMBerringerKRMelendezR, et al.Improving PrEP implementation through multilevel interventions: a synthesis of the literature. AIDS Behav2018; 22: 3681–3691.
38.
OwensCHubachRDWilliamsD, et al.Exploring the pre-exposure prophylaxis (PrEP) health care experiences among men who have sex with men (MSM) who live in rural areas of the Midwest. AIDS Educ Prev2020; 32(1): 51–66.
39.
GolubSAMyersJE. Next-wave HIV pre-exposure prophylaxis implementation for gay and bisexual men. AIDS Patient Care STDS2019; 33(6): 253–261.
40.
CalabreseSKMagnusMMayerKH, et al.Putting PrEP into practice: lessons learned from early-adopting U.S. Providers' firsthand experiences providing HIV pre-exposure prophylaxis and associated care. PLoS One2016; 11(6): e0157324.
41.
MackNWongCMcKennaK, et al.Human resource challenges to integrating HIV pre-exposure prophylaxis (PrEP) into the public health system in Kenya: a qualitative study. Afr J Reprod Health2015; 19(1): 54–62.
42.
ReyniersTVuylstekeBPirotteB, et al.Physicians' preparedness for pre-exposure prophylaxis: results of an online survey in Belgium. Sex Health2018; 15(6): 606–611.
43.
Rosengren-HoveeALLelutiu-WeinbergerCWoodhouseEW, et al.A scoping review of HIV pre-exposure prophylaxis stigma and implications for stigma-reduction interventions for men and transwomen who have sex with men. AIDS Behav2021; 25: 1–7.
44.
HayesRSchmidtAJPharrisA, et al.Estimating the 'PrEP Gap': how implementation and access to PrEP differ between countries in Europe and Central Asia in 2019. Euro Surveill2019; 24(41): 1900598.
45.
LauJYHungCTLeeSS. A review of HIV pre-exposure prophylaxis (PrEP) programmes by delivery models in the Asia-Pacific through the healthcare accessibility framework. J Int AIDS Soc2020; 23(7): e25531.
46.
BauermeisterJAMeanleySPingelE, et al.PrEP awareness and perceived barriers among single young men who have sex with men. Curr HIV Res2013; 11(7): 520–7.
47.
World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a Public Health Approach - 2nd ed. World Health Organization. Published June 2016, https://www.ncbi.nlm.nih.gov/books/NBK374312/ (Accessed March 19, 2021).
YoungIFlowersPMcDaidLM. Barriers to uptake and use of pre-exposure prophylaxis (PrEP) among communities most affected by HIV in the UK: findings from a qualitative study in Scotland. BMJ Open2014; 4(11): e005717.
51.
GolubSAGamarelKERendinaHJ, et al.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 STDS2013; 27(4): 248–54.
52.
CahillSTaylorSWElsesserSA, et al.Stigma, medical mistrust, and perceived racism may affect PrEP awareness and uptake in black compared to white gay and bisexual men in Jackson, Mississippi and Boston, Massachusetts. AIDS Care2017; 29(11): 1351–1358.
53.
WheelockAEisingerichABAnanworanichJ, et al.Are Thai MSM willing to take PrEP for HIV prevention? An analysis of attitudes, preferences and acceptance. PLoS One2013; 8(1): e54288.
54.
ChakrapaniVNewmanPAShunmugamM, 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 STDS2015; 29(10): 569–77.
