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Eligibility criteria included being biological male, Malaysian citizen, 18 years of age or above, identifying as MSM, and being HIV negative or unknown status. Bivariate analysis and logistic regression were performed to determine factors associated with willingness to use PrEP. Multivariate logistic regression indicated that Malay men AOR: 1.

Majority of participants preferred to access PrEP at affordable cost below Malaysian Ringgit USD25 per month from community based organisations followed by private or government hospitals. There is a need to provide PrEP at affordable cost, increase demand and awareness of PrEP, and to provide access to this preventative medication via diverse, integrated and tailored sexual health services. This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose.

The work is made available under the Creative Commons CC0 public domain dedication. Data Availability: In keeping with ethical restrictions imposed by the Medical Ethics Committee of University of Malaya Medical Center, data related to this study cannot be made publicly available, primarily due to social stigma and criminalisation of homosexual relations. Some authors GM, BW, MC were employed by the funder during the conduct of this research; however, the views expressed in this paper are those of the authors and not necessarily those of the funder.

Lim Sin How, Dr. Jeffrey A Wickersham. Competing interests: The authors have declared that no competing interests exist. The safety and efficacy of oral antiretroviral drugs in reducing the risk of HIV infection has been demonstrated in 15 randomized control trials and 3 observational studies across different populations globally [ 1 ].

Other countries, particularly in the Asia Pacific region, have embarked on several PrEP implementation projects [ 4 ]. The success of PrEP implementation will depend on its widespread acceptability and access among those who need it. In recent years, research on the acceptability of PrEP has increased ificantly. Two systematic reviews identified more than 30 quantitative studies on acceptability or willingness to use PrEP [ 56 ]. Other studies have assessed acceptability of PrEP using surveys that included MSM from multiple countries [ 4243 ].

The rising prevalence among MSM can be explained by both high levels of risk behaviors [ 5657 ], and a low uptake of HIV testing [ 57 ] in this population. Therefore, many MSM may not be aware of their infection and are not initiated on antiretroviral treatment.

In addition, the Malaysian law, specifically the Section of its Penal Code, criminalizes same sex intercourse: introduction of the penis into the anus or mouth of the other person is classified as carnal intercourse against the order of nature, which is punishable with imprisonment of up to twenty years, and is liable to whipping [ 58 ].

Although numerous acceptability studies have been conducted among MSM, research in this area is still in its infancy in Asian countries, including Malaysia. In addition, a consistent finding in existing PrEP research is that demographic as well as contextual socio-economic, cultural, and structural factors may influence the acceptability and potential uptake of PrEP among MSM in Asia and globally [ 754 ], which limits universal generalisability of findings from existing studies. In the Malaysian context, PrEP can be a useful intervention for MSM who experience problems using condoms, or struggle to use them consistently, as well as those who engage in risky behaviors such as multiple casual sex partners [ 57 ] and recreational drug use in the context of sex [ 59 ].

Despite the inclusion in of PrEP in the National Strategic Plan to End AIDS byPrEP implementation projects are not due to start until latepartly due to uncertainties regarding potential demand, cost implications, and implementation modalities. Therefore, the aim of this study was to assess willingness to use PrEP among MSM, as well as factors associated with such willingness. The second phase of the study involved focus group discussions among a sub-sample of survey participants [ 60 ].

This paper presents data only from the first phase of the study. The study was advertised through a banner on Grindr, a popular social networking app for MSM in Malaysia. Apart from recruitment through gay mobile apps, outreach workers and staff members of community based organization CBO additionally promoted the study to MSM in their social networks to encourage participation. The anonymous self-administered online questionnaire took approximately 15—20 minutes to complete. Participants were eligible if they self-reported to be male, a Malaysian citizen, 18 years old or above, negative or unknown HIV status, and identified as men who have sex with other men.

Participants who did not report sex with other men or self-identify as MSM were excluded from the survey. The survey was programmed and delivered via Survey Monkey [ 61 ]. During the one-month recruitment period, 2, participants entered the survey and 1, Of 1, men, 1, identified themselves as Malaysian citizens. The sample was further limited to men who reported to be HIV-negative or of unknown status. Of the men, two were excluded because they were under the age of The final sample consisted of MSM who fulfilled the eligibility criteria.

The participant selection is shown in Fig 1. The following definitions were used for analyses: knowledge of PrEP was defined as having known that PrEP was an effective HIV prevention intervention prior to survey participation; ever received HIV testing was defined as having been HIV tested at least once in their lifetime; had a serodiscordant sexual partner was defined as having engaged in sexual activity with a man you knew to have diagnosed HIV in the last 6 months; STI diagnosis was defined as having been diagnosed with any STI other than HIV in the last 12 months; inconsistent condom use was defined as having any insertive or receptive anal intercourse without a condom in the last 6 months, and as a result, MSM who did not have any anal sex male partners were included under the converse category of consistent condom users.

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Participants were also reminded of potential side effects and the need for regular follow up and adherence to medication for PrEP to be successful. The secondary outcomes of the study include variables related to the access and delivery of PrEP services.

For example, the amount of money participants were willing to spend on PrEP and the venue they would prefer to access it. Moreover, participants were asked about their preferred dosing strategy daily versus event-basedand their understanding of the difference between PrEP and PEP. Multicollinearity of the predictor variables were assessed and assumption of multicollinearity was not violated.

All statistical analyses were conducted using SPSS version Each participant completed an online informed consent form by acknowledging that they understood the purpose, eligibility criteria, risks and benefits of the study. Almost half of the participants were ethnic Chinese and most completed the survey in English.

The mean age was The majority of participants were single, identified themselves as gay, highly educated and working full time see Table 1. Participants came from all states of Malaysia including East Malaysia. The majority of participants reported having confidence in maintaining safer sex and most were not comfortable in talking about sexual behaviors with their health providers. About one third of participants had never tested for HIV. In terms of sexual behaviors, Close to two thirds had 2 or more sexual partners in the last 6 months and half engaged in inconsistent condom use. Ten participants reported to have ever used PrEP and four were currently using it at the time of completing the survey.

A small minority 1. About one third of participants indicated willingness to pay out-of-pocket for PrEP. The majority of participants believed that the government should cover the cost of PrEP. The three preferred facilities to access PrEP, in rank order, were community-based organizations, general practitioners private physiciansand government clinic or hospitals.

Close to half of the participants reported that they would only take PrEP as contingency for high-risk sex.

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The means of individual scale items ranged from 3. In the bivariate analysis, ethnicity, gay sexual identity, multiple male sexual partners, having any inconsistent condom use in the past 6 months, lack of confidence in practising safer sex, having heard of PrEP, and ever paid for sex with a male partner were ificantly associated with willingness to use PrEP. In the multiple logistic regression model, Malay ethnicity, gay sexual identity, having 2 or more male sex partners in the past 6 months, having heard of PrEP, having a lack of confidence in practising safer sex, and having ever paid for sex with a male partner were independently associated with willingness to use PrEP Table 4.

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This is the first study to assess willingness to use PrEP among a key population in Malaysia. The present study found that willingness to use it was related to multiple factors, including demographic characteristics, sexual identity, HIV risk behaviors and prior awareness of PrEP. These ethnic differences in willingness to use PrEP could not be explained by socio-economic factors such as education level, age or income.

Other studies have found ethnic differences in health profiles of Malaysians [ 6465 ], which have been attributed to cultural, health-seeking and lifestyle differences [ 64 — 66 ]. However, the extent to which these factors contribute to our observed differences in willingness to use PrEP is not clear. Other social, ethno-cultural and religious factors should be explored in future studies to understand factors contributing to differential willingness to use PrEP among different ethnic MSM populations.

However, the positive relationship between outness and uptake of health services is dependent on the context within which sexual minorities live [ 68 ]. In contrast, two studies from China did not find an independent association between sexual orientation and willingness to use [ 4447 ].

Hence, identifying potential high-risk users may require a wide variety of ways to reach both homosexual and bisexually active men. The present study found that risk behaviors such as having more male sexual partners and paying for sex were independently associated with willingness to use PrEP, echoing findings from China [ 47 ]. It must be noted that the variability of level of willingness to use PrEP among MSM in various countries may be due to the variability in measurement [ 54 ]. Most of studies measured willingness to use PrEP based on one single question and have generally yielded higher percentage of acceptability [ 54 ].

Interestingly, the level of willingness to use PrEP of the present study is higher than Holt et al. Our have several implications for eventual demonstration and subsequent widespread implementation of PrEP. Framing PrEP prevention messages appropriately based on accurate information with support of community partners will be crucial to raise awareness and interest among MSM. Evidence of PrEP efficacy and safety should be widely disseminated to allay concerns held by MSM about potential side effects. Local guidelines and policies are needed to determine eligibility criteria for PrEP and to ensure that antiretroviral drugs are d for prevention and can be prescribed safely.

Furthermore, it may be useful to position PrEP as a prevention strategy for all populations at risk for HIV infection, including serodiscordant heterosexual couples, in order to avoid further stigmatization of MSM and other key populations.

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