HIV Pre-Exposure Prophylaxis (PrEP) Access and Preference among Men who have Sex with Men in China Restricted; Files Only

Abstract

Preventing HIV transmission remains a public health focus in China, particularly among gay, bisexual, and other men who have sex with men (MSM). HIV pre-exposure prophylaxis (PrEP) is highly effective but not widely used by MSM in China. PrEP scale-up in China faces challenges at the healthcare system level and with both MSM and healthcare providers. To optimize the potential of implementation science to increase PrEP uptake, strategies such as evidence synthesis (i.e., literature review), stakeholders’ assessments (e.g., patients and providers), and strategies to explore user preferences are needed. In this dissertation, I employed Levesque’s patient-centred access to healthcare framework to guide the evaluation of demand-side and supply-side factors for access to health care. Specifically, in aim 1, I conducted a systematic review and meta-analysis of studies to assess the efficacy of technology-based HIV prevention interventions to increase HIV testing and consistent condom use. Technology-based HIV prevention interventions are found to be promising strategies to improve HIV testing uptake and consistent condom use among MSM in China. In aim 2, I conducted a qualitatively in-depth interview to explore barriers and facilitators of PrEP care access and provision from the perspective of MSM and healthcare providers. Findings from this study indicate that the challenges that both MSM and clinicians stated could be turned into opportunities by promoting PrEP through post-exposure prophylaxis, tailored messaging about PrEP, providing generic medicine and event-based packages, and training a broader array of clinicians to provide PrEP care. In aim 3, I conducted a discrete choice experiment (DCE) to quantitatively evaluate PrEP care access preference among MSM in China. This study found a strong and unique preference regarding accessing PrEP among Chinese MSM: cost is a critical variable, especially important because the medication and clinical care are currently entirely unsubsidized in China. Preferences for on-demand PrEP and home delivery indicate methods the healthcare system can utilize to best meet the needs of MSM, and factors that should be incorporated into future interventions. Findings from this mixed methods dissertation will inform the PrEP scale-up research and public health programs among MSM in China.

Table of Contents

Contents

Specific Aims ............................................................................................................................. 1

Chapter 1: Background and Significance ................................................................................... 5

HIV prevalence and interventions for MSM in China ............................................................... 5

Pre-exposure prophylaxis (PrEP) for HIV prevention .............................................................. 8

PrEP concerns from MSM and healthcare providers .............................................................10

Theory and conceptual model for scaling-up PrEP among MSM ...........................................12

Figure 1. Conceptual model for HIV PrEP access ..............................................................31

Chapter 2: Aim 1 .......................................................................................................................32

Abstract .................................................................................................................................32

Introduction ...........................................................................................................................34

Methods ................................................................................................................................36

Results ..................................................................................................................................39

Figure 1. PRISMA flow chart ..............................................................................................44

Discussion .............................................................................................................................44

References ............................................................................................................................48

Table 1. Study characteristics in reviewed literature ..............................................................57

Table 2. Association between study and intervention characteristics and study effect sizes ..........................................................................................................................................67

Figure 2. Forest plots of intervention effect on HIV testing uptake from Bayesian random effects meta-analysis .........................................................................................................68

Figure 3. Forest plots of intervention effect on consistent condom use from Bayesian hierarchical random effects model......................................................................................69

Figure 4. Contour-enhanced funnel plot for correlation between probability of publication and magnitude of effect for HIV testing uptake and consistent condom use .......................70

Appendix ...............................................................................................................................71

Appendix 1. Search terms ..................................................................................................71

Appendix 2. Bayesian hierarchical random effects model results .......................................72

Appendix 3. Sensitivity analysis .........................................................................................74

Appendix 4. Quality assessment ........................................................................................75

Chapter 3: Aim 2 .......................................................................................................................76

Abstract .................................................................................................................................76

Introduction ...........................................................................................................................78

Methods ................................................................................................................................80

Results ..................................................................................................................................82

Figure 1. Conceptualization of HIV PrEP access among MSM in China, adapted from the patient-centered health care access framework by Levesque et al.....................................83

Discussion .............................................................................................................................92

References ............................................................................................................................97

Table 1. Participants characteristics of MSM .................................................................... 103

Table 2. Themes for MSM accessing HIV PrEP guided by the five dimensions of accessibility of services and corresponding abilities in patient-centered access to health care framework ................................................................................................................ 104

Chapter 4: Aim 3 ..................................................................................................................... 110

Abstract ............................................................................................................................... 110

Introduction ......................................................................................................................... 112

Methods .............................................................................................................................. 114

Results ................................................................................................................................ 118

Discussion ........................................................................................................................... 121

References .......................................................................................................................... 125

Table 1. Attributes and attribute levels for PrEP access preference options in the survey 134

Figure 1. An example of a choice task in the survey viewing from mobile phone.............. 135

Table 2. Sociodemographic and behavioral characteristics of PrEP eligible MSM who never used PrEP and who ever used PrEP ................................................................................ 136

Table 3. Estimates of the mixed logit model for the preferences of PrEP access among Chinese MSM .................................................................................................................. 137

Figure 2. Predicted uptake of different PrEP modality with levels of subsidy .................... 138

Figure 3. Relative importance of PrEP access among Chinese MSM in four latent classes ........................................................................................................................................ 139

Appendix ............................................................................................................................. 140

Appendix 1. Attributes and attribute levels selection ........................................................ 140

Appendix 2. Description of attributes and attribute levels in the survey ............................ 141

Appendix 3. Quality control of the DCE design ................................................................. 143

Appendix 4. Sensitivity analysis ....................................................................................... 144

Appendix 5. Latent class analysis .................................................................................... 147

Chapter 5: Discussion ............................................................................................................. 149

Summary of Study Findings ................................................................................................. 149

Strengths and Limitations .................................................................................................... 151

Implications for Future Research and Practice .................................................................... 152

Conclusion .......................................................................................................................... 154

References .......................................................................................................................... 154

About this Dissertation

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School	Laney Graduate School
Department	Behavioral Sciences and Health Education
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Public Health
Mot-clé	men who have sex with men (MSM) China Pre-exposure prophylaxis (PrEP) patient-centered access to health care HIV prevention
Committee Chair / Thesis Advisor	Aaron J. Siegler, Emory University
Committee Members	Jessica M. Sales, Emory University Whitney S. Rice, Emory University Daniel Stegmueller, Duke University Jason J. Ong, Monash University

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