Discussion
WeChat-based PrEP
This pilot RCT with 70 Chinese GBMSM shows that compared to standardized HIV prevention care, the WeChat-based PrEP mini-app exhibits modest yet non-significant potential to facilitate PrEP uptake. The mini-app shows promise in reducing delays within the PrEP care cascade, while also increasing PrEP use intentions and self-efficacy among the sample. It also fosters more positive attitudes toward PrEP, and addressing some aspects of PrEP-related stigma.Overall, GBMSM sampled in this study evaluated the PrEP mini-app as acceptable and helpful in HIV prevention, but the lack of content updates and limited variety in how content was presented (i.e. primarily text-heavy articles) discouraged frequent use. Compared to standard HIV prevention care, the PrEP mini-app showed the most potential for behavioral change within the first four weeks of the intervention. The features of a centralized space to provide essential PrEP-related information (the Mini-classroom) and online appointment scheduling for the initial PrEP clinical counseling through the mini-app helped shorten participants’ wait times from study enrollment to the initial PrEP visit and their first PrEP prescription. As participants in our study moved back and forth across different stages of change towards PrEP initiation, having continued access to tailored information at their fingertips and the ability to act on that information when they were ready are two strengths of this mHealth intervention. In this regard, digital health interventions offer the ability for real-time assessment, ongoing evaluation of an individual’s behavioral change progress, and personalized feedback with appropriate designs [While about half of study participants indicated at baseline some level of interest or intention to start PrEP (i.e. the “Preparation” stage), less than 20% (n = 13) actually filled an initial PrEP prescription by the end of active intervention. Notably, only three people who started PrEP refilled their prescription during the study. Drop-off at this stage in the cascade could be partly explained by financial burden and the fact that most participants who started PrEP chose event-driven dosing strategy (11/13), such that they might not need to refill within the study course. In addition, GBMSM’s perceived burden of ongoing PrEP clinical care and concerns over long-term cost and potential side effects likely also contributed to the attrition. A systematic review of global PrEP clinical trials and real-world studies showed that over 40% of PrEP users discontinued PrEP within 6 months [Our results also indicated that the PrEP mini-app did not significantly increase the number of participants who initiated PrEP compared to the control group. Potential explanations may be the structural or logistical barriers that include the financial cost of PrEP medicines even after reimbursement, required clinical procedures at the study hospital for PrEP initiation, which require structural changes to make PrEP more easily accessible [Our study has several limitations. First, the convenience sample enrolled in our study may have introduced self-selection bias to the results such that before exposure to any intervention, our participants were more interested or willing to use PrEP than the general GBMSM population. Second, we had a relatively small sample size that limited our statistical power to detect differences. Given the exploratory nature of a pilot design, the main goal of our study was to evaluate acceptability of the PrEP mini-app among target user communities, to identify barriers to implementation, and to obtain preliminary estimates of variance in outcome measures of interest to inform future larger scale trials. Third, we were not able to track individual participant’s mini-app usage due to limited access to the mini-app backend data. We addressed this limitation by corroborating participants’ self-reported mini-app usage with qualitative interviews and solicited their feedback on intervention improvement. However, future iterations of the PrEP mini-app will seek to include a more robust para-data capture system in order to more accurately measure intervention exposure and explore patterns of intervention use [Our study also has several important implications for future research and policy reform in HIV prevention and care in China. First, the strong preference for event-driven PrEP among Chinese GBMSM that we found should be considered in the design of future mHealth interventions in this setting to ensure that adherence and refill supportive features can be tailored for various dosing strategies. Second, future iterations of the PrEP mini-app development–as well as other mHealth research projects for PrEP promotion—may consider adding participants’ suggested features, pill taking assistance or tracker, an interactive forum for users, and more timely updates to information about PrEP, HIV, and general sexual health. Third, further investigation into how to maximize the benefits of digital technologies in public health intervention for PrEP uptake is warranted. Provider training for both PrEP care provision and digital health-based practice is also critical [