Exploring and Predicting HIV Preexposure Prophylaxis Adherence Patterns Among Men Who Have Sex With Men: Randomized Controlled Longitudinal Study of an mHealth Intervention in Western China

Abstract

Background: Preexposure prophylaxis (PrEP) is an effective strategy to reduce the risk of HIV infection. However, the efficacy of PrEP is highly dependent on adherence. Meanwhile, adherence changes over time, making it difficult to manage effectively.

Objective: Our study aimed to explore and predict the patterns of change in PrEP adherence among men who have sex with men (MSM) and evaluate the impact of the WeChat-based reminder intervention on adherence, thus providing more information for PrEP implementation strategies.

Methods: From November 2019 to June 2023, in a randomized controlled longitudinal study of the PrEP demonstration project in Western China (Chongqing, Sichuan, and Xinjiang) based on a mobile health (mHealth) reminder intervention, participants were randomly divided into reminder and no-reminder groups, with those in the reminder group receiving daily reminders based on the WeChat app. Participants were followed up and self-reported their medication adherence every 12 weeks for a total of 5 follow-up visits. We used the growth mixture model (GMM) to explore potential categories and longitudinal trajectories of adherence among MSM, and patterns of change in PrEP adherence were predicted and evaluated based on the decision tree.

Results: A total of 446 MSM were included in the analysis. The GMM identified 3 trajectories of adherence: intermediate adherence group (n=34, 7.62%), low adherence ascending group (n=126, 28.25%), and high adherence decline group (n=286, 64.13%). We included 8 variables that were significant in the univariate analysis in the decision tree prediction model. We found 4 factors and 8 prediction rules, and the results showed that HIV knowledge score, education attainment, mHealth intervention, and HIV testing were key nodes in the patterns of change in adherence. After 10-fold cross-validation, the final prediction model had an accuracy of 75%, and the classification accuracy of low and intermediate adherence was 78.12%.

Conclusions: The WeChat-based reminder intervention was beneficial for adherence. A short set of questions and prediction rules, which can be applied in future large-scale validation studies, aimed at developing and validating a short adherence assessment tool and implementing it in PrEP practices among MSM.

Keywords: adherence; decision tree; mHealth; mHealth intervention; men who have sex with men; mobile health; preexposure prophylaxis; trajectory analysis.

Figure 1.. Flowchart for the screening of study participants. MSM: men who have sex with men; GMM: growth mixture model.

Figure 2.. Trajectory of PrEP adherence potential categories in the MSM population. A, B, C, and D correspond to schemes with 1, 2, 3, and 4 adherence potential categories, respectively. PrEP: preexposure prophylaxis; MSM: men who have sex with men.

Figure 3.. Analytical results of the decision tree prediction model.

Figure 4.. Two prediction rules of the decision tree prediction model. “A” indicates the description of the prediction path, and “B” indicates the prediction path in the decision tree.