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Introduction <p>Implementing pre-exposure prophylaxis (PrEP) is hindered by a significant “PrEP Cliff”, a sharp decline from willingness to uptake and adherence. This study aimed to integrate status quo bias theory with a dual-process model, seeking to understand how this bias influences the PrEP cascade among men who have sex with men (MSM) in China.</p> Methods <p>A cross-sectional survey was conducted among 1022 MSM across six provinces in China from November 2024 to February 2025. Through regression models, we tested a moderated mediation framework to examine how status quo bias influenced PrEP willingness, uptake, and adherence, focusing on the mediating role of PrEP resistance intention and the moderating role of condom-use inertia.</p> Results <p>Participants were generally young (≤ 30&#xa0;years; 63.1%), mostly unmarried (88.5%), and well-educated (89% with a bachelor’s degree or higher). The “PrEP Cliff” was evident, characterized by high awareness (91.3%) and willingness among non-users (58.9%), but low uptake (46.2%) and poor adherence, with 53.4% of users self-reporting lower adherence. In the initiation phase (willingness and uptake), PrEP resistance intention significantly mediated the associations of transition costs and social norms on PrEP cascade outcomes. Condom-use inertia significantly moderated this mediation pathway by strengthening the associations of transition costs (<i>β</i> = 0.06, 95%&#xa0;CI 0.01 to 0.11) and social norms (<i>β</i> = −&#xa0;0.05, 95%&#xa0;CI −&#xa0;0.10 to 0.00) on PrEP resistance intention. However, the mechanism shifted during the adherence phase. Adherence was instead predominantly predicted by the direct associations of transition costs (<i>β</i> = −&#xa0;0.44, 95%&#xa0;CI −&#xa0;0.64 to −&#xa0;0.23) and social norms (<i>β</i> = 0.56, 95%&#xa0;CI 0.38 to 0.74).</p> Conclusion <p>This study provides an evidence-based framework for clinicians and public health programs to design stage-specific interventions tailored to the distinct psychological barriers that dominate each phase.</p>

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How Status Quo Bias Shapes Willingness, Uptake, and Adherence to PrEP Among Chinese MSM: A Behavioral Economics Perspective

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年1月23日

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  • Min Zhao,
  • Xiang Zhao,
  • Ye Zhang,
  • Zhuoheng Yin,
  • Fanpu Ji,
  • Jason J. Ong,
  • Weiming Tang,
  • Lei Zhang

摘要

Introduction

Implementing pre-exposure prophylaxis (PrEP) is hindered by a significant “PrEP Cliff”, a sharp decline from willingness to uptake and adherence. This study aimed to integrate status quo bias theory with a dual-process model, seeking to understand how this bias influences the PrEP cascade among men who have sex with men (MSM) in China.

Methods

A cross-sectional survey was conducted among 1022 MSM across six provinces in China from November 2024 to February 2025. Through regression models, we tested a moderated mediation framework to examine how status quo bias influenced PrEP willingness, uptake, and adherence, focusing on the mediating role of PrEP resistance intention and the moderating role of condom-use inertia.

Results

Participants were generally young (≤ 30 years; 63.1%), mostly unmarried (88.5%), and well-educated (89% with a bachelor’s degree or higher). The “PrEP Cliff” was evident, characterized by high awareness (91.3%) and willingness among non-users (58.9%), but low uptake (46.2%) and poor adherence, with 53.4% of users self-reporting lower adherence. In the initiation phase (willingness and uptake), PrEP resistance intention significantly mediated the associations of transition costs and social norms on PrEP cascade outcomes. Condom-use inertia significantly moderated this mediation pathway by strengthening the associations of transition costs (β = 0.06, 95% CI 0.01 to 0.11) and social norms (β = − 0.05, 95% CI − 0.10 to 0.00) on PrEP resistance intention. However, the mechanism shifted during the adherence phase. Adherence was instead predominantly predicted by the direct associations of transition costs (β = − 0.44, 95% CI − 0.64 to − 0.23) and social norms (β = 0.56, 95% CI 0.38 to 0.74).

Conclusion

This study provides an evidence-based framework for clinicians and public health programs to design stage-specific interventions tailored to the distinct psychological barriers that dominate each phase.