HIV Risk Profiles and Pre-Exposure Prophylaxis and Postexposure Prophylaxis Uptake Among Men Who Have Sex With Men in China: Cross-Sectional Latent Class Analysis.

Background: Men who have sex with men remain disproportionately affected by HIV globally and in China. Despite the availability of pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP), their uptake remains suboptimal. Previous studies have rarely integrated both sexual behavioral factors and prevention-related cognitive factors. A clearer understanding of heterogeneity in HIV exposure and prevention literacy is needed to inform targeted HIV prevention strategies. Objective: This study aimed to identify latent subgroups of men who have sex with men based on sexual behaviors and prevention-related cognition and to examine differences in PrEP and PEP uptake across these subgroups. Methods: An online community-recruited cross-sectional survey was conducted among men who have sex with men in Hangzhou, China, from January 2024 to August 2024. A total of 3267 eligible participants (male at birth, aged ≥16 years, and history of sex with men) completed the structured self-administered questionnaires. Measures included sociodemographic characteristics, sexual behaviors within the past 3 months, exposure to HIV-related information, HIV testing history, and PrEP or PEP awareness and use. Latent class analysis was used to identify behavioral-cognitive subgroups. Multinomial logistic regression examined sociodemographic predictors of class membership, and binary logistic regression assessed associations between latent classes and PrEP or PEP use. A 2-sided α of .05 was used. Results: Four latent subgroups were identified: low-risk and well-informed (n=1219, 37.3%), high-risk and well-informed (n=735, 22.5%), moderate-risk and poorly informed (n=830, 25.4%), and high-risk and poorly informed (n=483, 14.8%). Overall, PrEP use was 7.81% (n=255; 95% CI 6.93%-8.78%) and PEP use was 4.74% (n=155; 95% CI 4.07%-5.53%). Compared with the low-risk, well-informed group, the high-risk, well-informed group had higher PrEP use (n=99, 13.48%; odds ratio [OR] 4.89, 95% CI 3.22-7.42) and PEP use (n=69, 9.40%; OR 3.04, 95% CI 1.93-4.77). The high-risk, poorly informed group also showed elevated PrEP use (n=65, 13.55%; OR 5.42, 95% CI 11.52%-15.87%) and PEP use (n=31, 6.41%; OR 2.57, 95% CI 1.67-3.98). The moderate-risk, poorly informed subgroup had the lowest uptake of PrEP (n=19, 2.30%; OR 0.89, 95% CI 1.35%-3.90%) and PEP (n=9, 1.06%; OR 0.39, 95% CI 0.49%-2.30%). Membership in poorly informed subgroups was associated with lower education, lower income, living in a rural area, and short-term residence. Conclusions: Distinct behavioral-cognitive typologies exist among men who have sex with men in Hangzhou, with substantial gaps between HIV risk exposure and prevention uptake. A large subgroup characterized by moderate behavioral risk but very low prevention literacy showed minimal PrEP or PEP use. These findings suggest that knowledge alone does not determine prevention utilization and highlight the need for integrated education, low-threshold counseling, and improved service access for underserved men who have sex with men. Linking behavioral-cognitive profiles to prevention outcomes provides actionable evidence for designing targeted and equitable HIV prevention strategies in real-world public health settings.