PrEP use and willingness cascades among GBMSM in 15 Asian countries/territories: an analysis of the PrEP APPEAL survey

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INTRODUCTION: Despite the high HIV incidence among gay, bisexual and other men who have sex with men (GBMSM) and the demonstrated effectiveness of HIV pre-exposure prophylaxis (PrEP), PrEP is not accessible at scale across Asia. To help inform future scaling efforts, our study aimed to examine PrEP use and willingness to use among GBMSM to identify opportunities and target groups for upscaling PrEP. METHODS: The PrEP APPEAL survey was a cross-sectional survey, promoted through online advertising and community organizations, from May to November 2022. Eligible participants were adult GBMSM who self-identified as HIV negative residing in Asia. We constructed two cascades: PrEP use (comprising awareness, lifetime use and current use of PrEP) and PrEP willingness among participants who were aware of PrEP but had never used it (comprising HIV exposure risk, willingness in PrEP and willingness to pay for PrEP). Multivariable logistic regression models identified factors associated with lifetime PrEP use and PrEP willingness. RESULTS: Of 15,339 participants, 1440 were excluded due to missing data, leaving 13,899 for analysis. Most lived in large or capital cities (68.3%) and in lower-middle-income countries (45.1%). The median age was 30 (25-36) years old. For the PrEP use cascade, 82.2% (n = 11,427/13,899) of participants were aware of PrEP, 35.0% (n = 4000/11,427) had used it before and 70.1% (n = 2803/4000) of them were currently on PrEP. For the PrEP willingness cascade, 54.8% of (n = 4068/7427) PrEP-naïve participants engaged in one or more behaviours with a higher risk of HIV acquisition, 73.7% (n = 2996/4068) of them expressed willingness to use PrEP and 83.0% (n = 2487/2996) of them were willing to pay for PrEP. Multivariable logistic regression models identified system-level (PrEP availability, accessibility and affordability) predictors of PrEP use. Individual-level behaviours associated with higher HIV acquisition risks were associated with PrEP use and willingness. CONCLUSIONS: While PrEP uptake was suboptimal, there was high awareness and willingness in PrEP among GBMSM. This is encouraging for future scale-up efforts. Future PrEP programmes should address system-level barriers to support PrEP uptake.

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