Preferences for pre-exposure prophylaxis for HIV among men who have sex with men and transgender women in 15 countries in Asia and Australia: a discrete choice experiment

Abstract

Background: Scaling up pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) and transgender women (TGW) in the Asia-Pacific region has been slow. We evaluated the drivers of PrEP use and forecasted PrEP uptake given different PrEP programs for MSM and TGW living in 15 countries and territories in Asia and Australia. Methods: Separate online discrete choice experiment (DCE) surveys for MSM and TGW were distributed in 15 Asian countries and territories and Australia between May-November 2022. We used random parameters logit models to estimate the relative importance of service attributes and predicted PrEP uptake for different program configurations. Findings: Among 21,943 participants included in the MSM survey and 1,522 in the TGW survey, the mean age was 31.7 (± 9.5) years and 28.1 (± 7.0) years, respectively. Despite variations in the relative importance of service attributes across countries, cost emerged as the primary driver of PrEP use for MSM and TGW, followed by the type of PrEP. The predicted PrEP uptake could improve by over 50% for MSM and 37% for TGW when switching from the least preferred PrEP service program (i.e., very high cost, PrEP implant, rare kidney problems as side effects, and a two-monthly clinic visit) to an optimal program (i.e., free access to PrEP via peer-led community clinics which offered STI testing, and a 6–12 monthly visit). Compared to those at less risk of HIV, free access was more preferred by MSM at a substantial risk of HIV, while telehealth was more preferred by TGW at a substantial risk of HIV. Interpretation: Tailoring services to local contexts, including ensuring affordability, preferred type of PrEP and providing differentiated services, could accelerate the uptake of PrEP among MSM and TGW in Asia and Australia.