# Medication adherence and its associated factors among oral pre-exposure prophylaxis (PrEP) users in China: The Real-world E-consumer Cohort of PrEP study

## TL;DR

This study examines how well people in China follow their HIV prevention medication when buying it online, finding that most struggle with adherence.

## Contribution

The study provides the first real-world assessment of PrEP adherence among e-commerce users in China, focusing on event-driven and daily regimens.

## Key findings

- Event-driven PrEP users had low adherence, while daily users showed high adherence.
- Older age, higher self-efficacy, and fewer same-sex partners were linked to better adherence.
- PrEP-related stigma and chemsex were associated with lower adherence among event-driven users.

## Abstract

Medication adherence is the key to success of HIV pre-exposure prophylaxis (PrEP). In China, the majority of real-world users purchase PrEP through e-commerce platforms, yet their adherence remains unaddressed. This cohort study aimed to evaluate PrEP adherence and its associated factors among e-consumers in China.

Eligible participants who had purchased PrEP online in the past 3 months were enrolled in the Real-world E-consumer Cohort of PrEP (RECOPE) in December 2023. Anonymous self-administered e-questionnaires were used at baseline and 1-, 3-, and 6-month follow-ups to collect data on PrEP adherence and potentially associated factors. Optimal adherence was defined as full compliance with the ‘2-1-1’ dosing protocol for event-driven (ED) users and no missed pills in the past month for daily users. Generalized linear mixed-effects models and logistic regression were fitted to identify prognostic factors of PrEP adherence. Of 877 individuals invited, 680 were eligible and 657 completed the baseline survey (response rate 96.6%). The follow-up response rate at the 1-, 3-, and 6-month timepoints was 90.1% (592/657), 82.6% (543/657), and 80.1% (526/657), respectively. Among the 621 participants who had initiated PrEP at baseline, 529 (85.2%) used the ED regimen, and 92 (14.8%) used the daily regimen. Among ED users, the prevalence of optimal adherence at the four timepoints was 41.3% (154/373), 43.1% (146/339), 45.3% (139/307), and 52.6% (160/304), respectively. Among daily users, the prevalence of optimal adherence was 83.7% (77/92), 81.4% (83/102), 87.8% (86/98), 84.3% (75/89) at each survey wave, respectively. Within this group, the mean adherence rates in the past month ranged from 97.1% to 98.7% across waves. Among ED users, older age, receptive or versatile sexual role, and higher self-efficacy were positively associated with optimal adherence, while multiple same-sex partners, chemsex, and PrEP-related stigma were negatively associated factors. Selection bias, recall bias, social desirability bias, confounding bias, and limited representativeness were the main limitations of the study.

The study found PrEP adherence was low among ED PrEP users who account for the majority of real-world e-consumers in China. Targeted interventions are suggested to prioritize enhancing users’ understanding of medication instructions, promoting self-efficacy of maintaining adherence, and alleviating PrEP-related stigma. Additional attention should be given to ED users who have chemsex, insertive anal sex, multiple sexual partners, or a younger age.

Oral HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition only when users maintain optimal medication adherence.

Currently, the majority of real-world PrEP users in China buy the medication online, yet little is known about their medication adherence.

The cohort study aimed to evaluate the level and factors associated with PrEP adherence among real-world e-consumers in China.

We recruited 657 e-consumers of PrEP from the largest online platform for PrEP services in China and collected their baseline, 1-, 3-, and 6-month follow-up survey data.

We found that PrEP adherence was low among event-driven (ED) PrEP users who accounted for the majority of real-world e-consumers in China, while the adherence was high among daily PrEP users.

Age, sexual role, number of same-sex partners, chemsex, self-efficacy of maintaining PrEP adherence, and PrEP-related stigma were significantly associated with PrEP adherence among the ED users.

There is an urgent need to improve medication adherence among e-consumers of ED PrEP in China.

Future targeted interventions can incorporate components of enhancing users’ understanding of medication instructions, promoting self-efficacy of maintaining adherence, and alleviating PrEP-related stigma.

Selection bias, recall bias, social desirability bias, confounding bias, and limited representativeness were the main limitations of the study.

Qingyu Li and colleagues analyze data from survey responses of an e-consumer cohort in China to understand adherence to event-driven and daily HIV pre-exposure prophylaxis.