Effectiveness of onsite and online education in enhancing knowledge and use of human immunodeficiency virus pre- and post-exposure prophylaxis

Abstract

BACKGROUND

Enhancing awareness and use of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) is vital to curb human immunodeficiency virus (HIV) spread. High-risk behaviors prevalent among sexually transmitted infection clinic outpatients underscore the need for increased PrEP/PEP education in this group.

AIM

To investigate the effects of both onsite and online health education on the knowledge of, and willingness to use, PrEP and PEP among individuals receiving PEP services.

METHODS

Participants were drawn from a cohort study on PEP service intervention at an STD/AIDS outpatient clinic in designated HIV/AIDS hospitals in Beijing, conducted from January 1 to June 30, 2022. Health education was provided both onsite and online during follow-up. Surveys assessing knowledge of, and willingness to use, PrEP/PEP were administered at baseline and again at 24 wk post-intervention.

RESULTS

A total of 112 participants were enrolled in the study; 105 completed the follow-up at week 24. The percentage of participants with adequate knowledge of, and willingness to use, PrEP significantly increased from 65.2% and 69.6% at baseline to 83.8% and 82.9% at the end of the intervention (both P < 0.05). Similarly, those with adequate knowledge of, and willingness to use, PEP increased from 74.1% and 77.7% at baseline to 92.4% and 89.5% at week 24 (P < 0.05). Being between 31 years and 40 years of age, having a postgraduate degree or higher, and reporting a monthly expenditure of RMB 5000 or more were found to be significantly associated with knowledge of PrEP and PEP (both P < 0.05).

CONCLUSION

The findings show that both onsite and online health education significantly improved the knowledge of, and increased willingness to use, PrEP and PEP in individuals utilizing PEP services.

Key Words: Human immunodeficiency virus, Pre-exposure prophylaxis, Post-exposure prophylaxis, Health education, Intervention

Core Tip: The study aimed to assess the impact of onsite and online health education on the awareness and adoption of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) by PEP service users at a Beijing STD/AIDS clinic. Between January and June 2022, 112 participants were enrolled, and 105 completed the study. Education efforts led to a significant increase in the knowledge of and willingness to use PrEP and PEP, with adequate understanding of PrEP increasing from 65.2% to 83.8%, and PEP from 74.1% to 92.4%. The study concluded that both education methods effectively improved PrEP and PEP uptake by high-risk individuals.

INTRODUCTION

The epidemic of human immunodeficiency virus (HIV) remains a major global public health challenge. In 2021, an estimated 38.4 (33.9–43.8) million people were living with HIV, with approximately 1.5 million new infections and 650000 acquired immunodeficiency syndrome (AIDS)-related deaths reported[1]. By October 2020, 1.045 million people were reported living with HIV/AIDS across China[2]. In addition to scaling up testing and antiretroviral therapy, HIV prevention is a crucial component of the strategy to end HIV/AIDS as a public health threat by 2030[3].

Pre-exposure prophylaxis (PrEP) is a promising strategy for HIV prevention and involves the use of antiretroviral drugs by HIV-uninfected individuals to prevent infection. PrEP was first approved for HIV prevention by the US Food and Drug Administration in 2012 and has been recommended by the World Health Organization for individuals at high risk of HIV infection[4]. PrEP has been shown to significantly reduce the risk of HIV infection in HIV-negative individuals who adhere to the regimen[5-7]. Post-exposure prophylaxis (PEP) consists of a short-term course of HIV medicine taken soon after a potential exposure to HIV. If initiated promptly, within 72 h after exposure, PEP is effective in preventing HIV infection[8-10] and has become the standard of care following occupational and sexual exposure to the virus[11]. According to recent studies, the rate of PrEP use was 9.2%-13.8%, and the rate of PEP use was 8.7%-9.2%[12-14].

As there is no available HIV vaccine, these two biomedical interventions, based on antiretroviral therapy, are considered critical for HIV prevention. High levels of knowledge, acceptability, and use of PrEP and PEP are necessary to reduce HIV transmission within the general population. Outpatients visiting sexually transmitted infection clinics often engage in behaviors associated with a high risk of HIV infection. The aim of this study was to assess the level of knowledge and willingness to use PrEP and PEP, as well as the impact of health education on the use of PrEP and PEP by patients receiving PEP services.

MATERIALS AND METHODS

Cohort study design

The participants came from a cohort enrolled in the PEP study at a STD/AIDS clinic within one of the HIV/AIDS designated hospitals in Beijing, from January 1^st to June 30^th, 2022. All participants were on PEP and were provided with the co-formulated regimen of bictegravir/emtricitabine/tenofovir alafenamide, along with health education on both PrEP and PEP. This study was approved by the ethics committee of Beijing Youan Hospital, Capital Medical University. Informed consent was obtained from all participants. A total of 112 participants were enrolled at baseline.

Onsite and online health education

Nurses, who were trained to provide information about PrEP and PEP, conducted health education onsite at the baseline, week 2, and week 4 visits. The information provided details on: “What are PrEP and PEP? What is on-demand PrEP? How can I start PrEP? How long does it take for PrEP to become effective? What is the maximum allowable delay in starting PEP? How long should the PEP regimen be taken? What behaviors increase the risk of contracting HIV? Are there any side effects?” This information was available to the participants on the WeChat and the Haodaifu Websites. If the participants had any questions, they could communicate with physicians online. For example, a participant inquired on the web about the steps to take after potential exposure to HIV through anal sex in the third week of the PEP course. The participant was advised to complete the remaining PEP medication, as this protocol aligns with the on-demand PrEP strategy.

Data collection and variable definition

A questionnaire was administered to assess the knowledge of and willingness to use PrEP and PEP among outpatients receiving PEP services at baseline and at week 24. Demographic information collected included age, sex, education level, sexual orientation, history of drug use, and history of STD infections. The questionnaire was derived and from previous literature and adapted to fit our study design[15-17]. It comprised 15 items on knowledge about PrEP and another 15 on PEP, Knowledge. Questions were scored equitably, with one point awarded for each correct response. A good knowledge level was defined as correctly answering more than 70% of the questions and scoring less than 70% correct answers was considered a poor knowledge level.

Statistical analysis

Data were analyzed with IBM SPSS 17.0 for Windows (SPSS Inc., Chicago, IL, United States). Continuous variables were reported as medians and interquartile range. Categorical variables were reported as counts and percentages. Group comparisons were made using the χ² test. A P value of < 0.05 was indicated statistical significance. Factors associated with knowledge of PrEP and PEP were determined by univariate and multivariate logistic regression.

RESULTS

Demographic characteristics

A total of 112 participants completed the survey at baseline. The demographic characteristics of the participants are shown in Table 1. The majority (97.3%) were men, and 83.0% were between 20 years and 40 years of age. Approximately four-fifths (85.7%) had attained at least a college education and about half (51.9%) reported a monthly income of 5000 RMB or more. The majority identified as homosexual (61.6%), had no history of STD infection (85.7%), and no history of drug use (91.1%). At the 24-wk follow-up, only 105 participants responded and completed the survey.

Table 1 Baseline demographic and sexual behavior characteristics of participants in Beijing.

Variables	Frequency, n = 112	%
Age in yr
20-30	49	43.7
31-40	44	39.3
41-50	15	13.4
51-60	4	3.6
Sex
Male	109	97.3
Female	3	2.7
Education level
High school or below	16	14.3
College and undergraduate	68	60.7
Postgraduate or above	28	25
Monthly expenditure in RMB
Less than 1000	8	7.5
1000-2999	25	22.6
3000-4999	20	17
5000 and above	59	51.9
Sexual orientation
Heterosexual	29	25.9
Homosexual	69	61.6
Bisexual	14	12.5
History of STD
Yes	16	14.3
No	96	85.7
History of drug use
Yes	10	8.9
No	102	91.1

STD: Sexually transmitted disease.

Knowledge and willingness to use PrEP

At baseline, 65.2% of participants had a good knowledge of PrEP, and 69.6% were willing to use PrEP. At. Following the health education intervention, at week 24, the percentages of participants with good knowledge and those willing to use PrEP had increased to 83.8% and 82.9%, respectively (both P < 0.05) (Table 2).

Table 2 Comparison of knowledge of and willingness to use human immunodeficiency virus pre-exposure prophylaxis before and after intervention.

Variable	Before intervention	After intervention	χ²	P value
	n = 112, n (%)	n = 105, n (%)
Knowledge level of PrEP			8.846	0.003
Good	73 (65.2)	88 (83.8)
Poor	39 (34.8)	17 (16.2)
Willingness to use PrEP			4.556	0.033
Yes	78 (69.6)	87 (82.9)
No	34 (30.4)	18 (17.1)

PrEP: Pre-exposure prophylaxis.

Knowledge and willingness to use PEP

At baseline, 74.1% of participants had good knowledge of PEP, and 77.7% were willing to use PEP. After the health education intervention, at week 24, the percentages of participants with good knowledge and those willing to use PEP had increased to 92.4% and 89.5%, respectively (both P < 0.05) (Table 3).

Table 3 Comparison of knowledge of and willingness to use human immunodeficiency virus post-exposure prophylaxis before and after intervention.

Variable	Before intervention	After intervention	χ²	P value
	n = 112, n (%)	n =105, n (%)
Knowledge level of PEP			11.574	0.001
Good	83 (74.1)	97 (92.4)
Poor	29 (25.9)	8 (7.6)
Willingness to use PEP			4.634	0.031
Yes	87 (77.7)	94 (89.5)
No	25 (22.3)	11 (10.5)

PEP: Post-exposure prophylaxis.

Factors associated with knowledge of PEP and PrEP

As knowledge of PrEP and use of PEP are positively correlated with the use of PrEP and PEP[18], we assessed factors related to the knowledge of PrEP and PEP. The results of univariate and multivariate logistic regression are shown in Tables 4 and 5. Table 4 details findings regarding the knowledge of PrEP and Table 5 details findings regarding the knowledge of PEP.

Table 4 Factors associated with knowledge of pre-exposure prophylaxis.

Parameters	OR (95%CI)	P value	AOR (95%CI)	P value
Age in yr
20-30	Reference category
31-40	0.326 (0.114, 0.929)	0.036a	0.268 (0.088, 0.817)	0.021a
41-50	0.147 (0.018, 1.221)	0.147	0.335 (0.082, 1.375)	0.129
51-60	2.062 (0.266, 16.004)	0.489	1.779 (0.303, 10.430)	0.523
Sex
Male	Reference category
Female	4.253 (0.252, 71.662)	0.550	1.938 (0.128, 29.374)	0.633
Education level
High school or below	Reference category
College and undergraduate	0.920 (0.191, 4.432)	0.917	0.325 (0.089, 1.181)	0.088
Postgraduate or above	0.131 (0.023, 0.757)	0.023a	0.196 (0.044, 0.873)	0.032a
Monthly expenditure in RMB
Less than 1000	Reference category
1000-2999	0.706 (0.170, 2.923)	0.631	0.511 (0.085, 3.086)	0.464
3000-4999	0.447 (0.119, 1.669)	0.231	0.747 (0.121, 4.628)	0.754
5000 and above	0.126 (0.019, 0.827)	0.031a	0.142 (0.024, 0.850)	0.035a
Sexual orientation
Heterosexual	Reference category
Homosexual	0.650 (0.197, 2.138)	0.478	0.986 (0.324, 3.006)	0.981
Bisexual	1.625 (0.326, 8.095)	0.553	1.785 (0.223, 14.275)	0.585
History of STD
Yes	Reference category
No	1.445 (0.255, 8.205)	0.678	1.027 (0.259, 4.075)	0.970
History of drug use
Yes	Reference category
No	0.540 (0.104, 2.798)	0.463	0.769 (0.121, 4.870)	0.780

^aP < 0.05. STD: Sexually transmitted disease.

Table 5 Factors associated with knowledge of post-exposure prophylaxis.

Factors	OR (95%CI)	P value	AOR (95%CI)	P value
Age in yr
20-30	Reference category
31-40	0.210 (0.045, 0.983)	0.047a	0.167 (0.033, 0.842)	0.030a
41-50	0.671 (0.143, 3.151)	0.613	0.886 (0.212, 3.708)	0.869
51-60	1.857 (0.168, 20.511)	0.615	1.147 (0.365, 3.601)	0.814
Sex
Male	Reference category
Female	11.940 (0.523, 272.777)	0.120	10.813 (0.460, 254.122)	0.139
Education level
High school or below	Reference category
College and undergraduate	0.591 (0.126, 2.781)	0.506	0.564 (0.127, 2.499)	0.451
Postgraduate or above	0.045 (0.003, 0.678)	0.025a	0.103 (0.021, 0.513)	0.005a
Monthly expenditure in RMB
Less than 1000	Reference category
1000-2999	0.394 (0.055, 2.815)	0.353	0.435 (0.095, 1.996)	0.435
3000-4999	0.421 (0.070, 2.550)	0.347	0.473 (0.147, 1.522)	0.209
5000 and above	0.101 (0.016, 0.654)	0.016a	0.140 (0.028, 0.690)	0.017a
Sexual orientation
Heterosexual	Reference category
Homosexual	0.424 (0.056, 3.215)	0.262	0.460 (0.063, 3.356)	0.444
Bisexual	1.815 (0.366, 8.996)	0.462	1.487 (0.187, 11.808)	0.708
History of STD
Yes	Reference category
No	3.264 (0.361, 29.482)	0.292	2.221 (0.260, 18.957)	0.466
History of drug use
Yes	Reference category
No	0.832 (0.122, 5.656)	0.851	0.804 (0.122, 5.308)	0.821

^aP < 0.05. STD: Sexually transmitted disease.

Individuals between 31 years and 40 years of age demonstrated a significant increase in knowledge of PrEP compared with those younger than 30 years of age (AOR 0.268; 95%CI: 0.088-0.817). In addition, a postgraduate degree or higher (AOR 0.196; 95%CI: 0.044-0.873) and reporting a monthly expenditure of RMB 5000 or more (AOR 0.142; 95%CI: 0.024-0.850) were also linked to greater knowledge of PrEP.

Similar patterns were observed for PEP, and several factors were significantly associated with reported knowledge (Table 5). Being between 31 years and 40 years of age (AOR 0.167; 95%CI: 0.033-0.842), having a postgraduate degree or higher (AOR 0.103; 95%CI: 0.021-0.513), and reporting a monthly expenditure of RMB 5000 or more (AOR 0.140; 95%CI: 0.028-0.690) were associated with increased knowledge of PEP.

DISCUSSION

The outcomes of this study underscore the significant impact that both onsite and online health education have on increasing the knowledge of individuals regarding PrEP and PEP. Face-to-face interaction with participants allowed for a deeper understanding of the complexities of PrEP and PEP[19,20], and the flexibility of an online platform facilitated convenient access to information and communication with healthcare providers[20,21]. The study findings revealed an increase in the participants’ knowledge from a baseline of 65.2% and 74.1% to 84.1% and 92.5% at week 24 for PrEP and PEP, respectively. This highlights the importance of incorporating both onsite and online health education to improve knowledge acquisition for PrEP and PEP.

Despite the proven effectiveness of PrEP and PEP in preventing HIV infection in high-risk populations[5,22], their implementation in China has been less than optimal[23]. Our study found that the initial willingness to use PrEP and PEP was 69.6% and 77.7%, respectively, which is consistent with recent studies in China[24,25]. Following the health education interventions, there was a notable improvement in the willingness to use these preventive measures. Thus, it is evident that both onsite and online health education have a crucial role in promoting the acceptance of PrEP and PEP by those at high risk for HIV.

Moreover, our study indicates that participants who experienced PEP services gained a better understanding of the safety and tolerability of the medications used in HIV prevention. This understanding is instrumental in alleviating concerns about the adverse reactions associated with these medications, thereby facilitating the uptake of PrEP and PEP. Knowing that the side effects are manageable may decrease the hesitancy of users to initiate these preventive measures and enhance their confidence in the preventive interventions.

The study results show that being between 31 years and 40 years of age, having a postgraduate degree or higher, and reporting a monthly expenditure of RMB 5000 or more, were significantly associated with knowledge of PrEP and PEP. Considering our findings that young people between 31 years and 40 years of age had better PrEP and PEP knowledge, there appears to be a disparity in knowledge linked to age[26,27]. Previous studies have shown that high income and a high education level were associated with high HIV knowledge[28,29]. High income and a high education level have also been associated with having knowledge about PrEP and PEP[30-33]. These findings are consistent with our study results. Generally, income and expenditure are balanced, with higher expenditure indicating higher income.

We must some study limitations. Firstly, being a single-center study with a relatively small sample size may have affected the generalizability of our findings. Secondly, the study did not explore differences in the impact of online vs physical health education for PrEP/PEP, as both approaches were used for the same participants. Thirdly, the potential for selection bias in participant recruitment could have affected the universality of our results. Future multicenter studies across diverse regions and backgrounds with larger sample sizes are needed to increase the representativeness of the study and would be able explore the differences between online and physical health education for PrEP/PEP.

In the dissemination of PrEP and PEP strategies, a variety of educational channels and strategies should be considered. These include, but are not limited to, onsite education, online learning, community support, and the active engagement of healthcare professionals. Educational programs that address different cultural and societal contexts may prove more effective. For example, targeting younger populations might benefit from the use of modern technological methods such as social media and mobile applications to disseminate knowledge and services related to PrEP and PEP[34,35].

Finally, future studies should explore the long-term effects of different types of health education on PrEP and PEP knowledge and willingness to use these medications and to investigate how these methods might vary in impact in different populations. Through this research, we can gain a better understanding of how to effectively promote PrEP and PEP in high-risk populations and reduce HIV transmission.

CONCLUSION

In summary, knowledge of and willingness to use PrEP and PEP significantly improved after health educational intervention. Onsite and online health education need to be a priority for improving HIV prevention and control in HIV high-risk populations.