Increasing awareness of HIV pre-exposure prophylaxis (PrEP) and willingness to use HIV PrEP among men who have sex with men: a systematic review and meta-analysis of global data

Zhishan Sun, Qianfei Gu, Yifan Dai, Huachun Zou, Bruce Agins, Qiaosen Chen, Peiyang Li, Junchun Shen, Yi Yang, Hongbo Jiang, Zhishan Sun, Qianfei Gu, Yifan Dai, Huachun Zou, Bruce Agins, Qiaosen Chen, Peiyang Li, Junchun Shen, Yi Yang, Hongbo Jiang

Abstract

Introduction: Integrated knowledge regarding pre-exposure prophylaxis (PrEP) awareness and willingness to use PrEP can be useful for HIV prevention in high incidence groups. This review summarizes the awareness of PrEP and willingness to use PrEP among men who have sex with men (MSM).

Methods: Online electronic databases were searched before 31 August 2021. A meta-analysis was conducted to pool studies analysing PrEP awareness and willingness to use PrEP. LOESS regression and linear regression were applied to fit the trends over time for the proportion of MSM aware of PrEP and willing to use PrEP. Dose-response meta-analysis (DRMA) was conducted by a restricted cubic spline model to explore the relationship between willingness to use PrEP and selected factors.

Results and discussion: A total of 156 articles involving 228,403 MSM were included. The pooled proportions of MSM aware of PrEP and willing to use PrEP were 50.0 (95% CI: 44.8-55.2) and 58.6% (95% CI: 54.8-62.4), respectively. PrEP awareness varied among countries with different economic status and different WHO regions, among different publication and research years, PrEP types and support policies. PrEP willingness differed among countries with different economic status and groups with different risks of HIV. The awareness of PrEP increased from 2007 to 2019 with a slope of 0.040260 (p<0.0001), while the proportion of MSM willing to use PrEP decreased from 2007 to 2014 (slope = -0.03647, p = 0.00390) but increased after 2014 (slope = 0.04187, p = 0.03895). The main facilitators of willingness to use PrEP were PrEP awareness, condomless sexual behaviours, high perceived risk of HIV infection and influence of social network. The main barriers were doubts about the efficacy and side effects of PrEP. DRMA results indicated that MSM with more sexual partners and lower level of education were more willing to use PrEP. No publication bias was observed.

Conclusions: The proportions of PrEP awareness and willingness to use PrEP among MSM have increased since 2014, although the awareness was low and the willingness was moderate. Improving awareness of PrEP through increasing access to PrEP-related health education and enhancing risk perceptions of HIV infection could have positive effects on the willingness to use PrEP among MSM.

Keywords: awareness; men who have sex with men; meta-analysis; pre-exposure prophylaxis; trend; willingness.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.

Figures

Figure 1
Figure 1
Flow diagram of search strategy and study selection.
Figure 2
Figure 2
Trend analysis for awareness of and willingness to use PrEP. Simple linear regression and loess regression are used to fit the proportion of PrEP awareness. Piecewise linear regression and loess regression are used to fit the proportion of PrEP willingness. The weights of all regression models are the sample size of every data point. 95% confidence intervals are illustrated as red and blue shade areas. The median research year of every study was selected as the estimated year.
Figure 3
Figure 3
Factors associated with willingness to use PrEP. The larger size of the dot refers to being more frequently reported in the literature.
Figure 4
Figure 4
Dose–response meta‐analysis for the associations between selected factors and willingness to use PrEP. 95% confidence intervals are illustrated as the grey shade areas.
Figure B1
Figure B1
Studies reporting both awareness and willingness to use PrEP.
Figure B2
Figure B2
Funnel plots for publication bias of awareness and willingness to use PrEP.
Figure B3
Figure B3
AIC result of PrEP willingness in two piecewise linear regression models. Node_1: The piecewise linear regression model has one turning year. Node_2: The piecewise linear regression model has two turning years. The red line shows the minimum value of AIC.

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