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PrEP Product Awareness, Preferences, and Past Experiences among Transgender Women and Men Who Have Sex with Men in Asia and Australia

The challenge

Progress towards 2030 targets for ending HIV transmission in Asia and the Pacific has slowed. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention option and is initiated before a potential exposure to HIV. Across the Asia-Pacific region, access to and uptake of oral PrEP has been slow and there are multiple barriers to PrEP uptake. New PrEP products like long-acting Cabotegravir (CAB-LA) could address some of the challenges of oral PrEP and WHO has recommended long acting injectable cabotegravir (CAB-LA) as an additional PrEP option. Understanding awareness of and preferences for different PrEP products will help countries and programs better plan to provide the appropriate mix of options.

The project

PrEP Product Awareness, Preferences, and Past Experiences among Transgender Women and Men Who Have Sex with Men in Asia and Australia (PrEP APPEAL) was a survey study in 16 countries and territories in Asia and Australia. The overall goal of PrEP APPEAL was to identify values and preferences about PrEP, as well as barriers and facilitators to PrEP uptake, among men who have sex with men (MSM) and transgender women (TGW) in Asia and Australia.

The specific aims were:

  1. To determine awareness and use of each PrEP product among MSM and TGW in Asia and Australia
  2. To determine whether offering additional PrEP products would increase the total number of MSM and TGW who use PrEP in Asia and Australia
  3. To determine which PrEP products should be prioritised for which populations in Asia and Australia
  4. To ascertain the willingness of MSM and TGW in Asia and Australia to pay for PrEP.
The method

PrEP APPEAL was a cross-sectional survey of TGW in 11 countries and MSM in 16 countries and territories. Participants were recruited between May 2022 and November 2022 through community-based promotions and paid advertising. The survey explored: demographics; PrEP awareness, use, and preferences; future PrEP and service delivery preferences; attitudes towards PrEP; and sexual behaviour, drug use, and sexual health. A discrete choice experiment quantified preferences for different PrEP service delivery models and included attributes on type of PrEP, location of service, costs, side effects, service frequency, and extra services.

The results

1,260 TGW and 17,032 MSM completed the survey. Of the MSM, 10,689 were from Asian Low- and Middle-Income Countries (Asian LMIC), 4,656 were from Asian High-Income Countries and Territories (Asian HIC), and 1,687 were from Australia. Knowledge, experiences, and preferences differed between populations and countries but across the sample PrEP awareness was high: more than 80% of participants in each population had heard of PrEP. Preferences for PrEP modality varied across populations: TGW preferred daily oral PrEP and a six-monthly injection; MSM in Asian LMIC preferred daily oral PrEP, event-driven oral PrEP, monthly pill, and six-monthly injections; MSM in Asian HIC preferred event-driven oral PrEP and monthly pill; MSM in Australia preferred monthly pill 7 and six-monthly injection. In the discrete choice experiment examining preferences for PrEP services, cost was the most important driver of choice in all populations. Type of PrEP was the next most important driver of choice to use PrEP for TGW, MSM in Asian LMIC, and MSM in Australia. Side effects were the second most important driver of choice to use PrEP for MSM in Asian HIC, and the third most important for MSM in Asian LMIC and Australia.

The impact

There are several potential impacts of these results. Providing PrEP in settings outside of hospitals or general practices may be preferrable and facilitate a greater reach to those who would prefer receiving PrEP at community clinics run by peers or through a pharmacy. Preferences of PrEP service delivery must be used to guide the establishment of country-tailored PrEP service delivery guidelines, along with policy advocacy efforts to support demedicalization and simplification of certain elements of services. As new PrEP options emerge, developing decision aids will be needed to guide those wanting to initiate PrEP to choose the option that best suits their lifestyle and HIV prevention needs. As CAB-LA becomes available, policy and clinical infrastructure should prepare to adapt to implementing other PrEP options besides oral PrEP, and document changes to current systems to facilitate CAB-LA and prepare to apply those to other potential PrEP options in the future, such as the monthly pill, six-monthly injection, or removable implant. Further PrEP advocacy is needed to improve access to PrEP and address the unmet need for PrEP across Asia.

Project collaborators

UNAIDS Regional Office for Asia and the Pacific, Bangkok, Thailand; World Health Organization, Geneva, Switzerland; PATH, Hanoi, Vietnam; FHI 360, Hanoi, Vietnam; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia; Institute of HIV Research and Innovation, Bangkok, Thailand; APCOM Foundation, Bangkok, Thailand; Asia Pacific Transgender Network, Bangkok, Thailand; China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China; University of North Carolina, Chapel Hill, United States.

Project funding

This study was supported by funding from the World Health Organization, the Kirby Institute, and Outstanding Young Scholars Support Program. The Australian arm of the study was supported by funds from ViiV Healthcare, NSW Ministry of Health, MAC AIDS Fund, and the Australian Government Department of Health.