Willingness to use pre‐exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Malaysia: findings from a qualitative study

Abstract

Background: Men who have sex with men (MSM) continue to be disproportionately affected by HIV in Malaysia. Recent success has been observed within demonstration projects examining the efficacy of HIV pre-exposure prophylaxis (PrEP), an antiretroviral -based medication taken by HIV-negative men to prevent sero-conversion. In order for such promising findings to be translated in real-world settings, it is important to understand the acceptability of PrEP, including perceived barriers to access or uptake.Methods: As part of a larger mixed-methods study exploring acceptability and willingness to use PrEP among MSM in Malaysia, 19 men took part in audio-recorded focus group discussions hosted by a community-based HIV organization and facilitated by a trained researcher. Discussions focussed on awareness and potential information management, general perceptions of PrEP and potential motivations or barriers to the use of PrEP, including those at the personal, social, health system or structural level. Data were transcribed verbatim and underwent a detailed thematic analysis.Results: Rather than perceiving PrEP as a replacement for condoms in terms of having safer sex, many participants viewed it as an additional layer protection, serving as a crucial barrier to infection on occasions where condom use was intended, but did not occur. It was also perceived as more valuable to “at-risk” men, such as those in HIV sero-discordant relationships or those with a higher number of sexual partners. Elements of discussion tended to suggest that some men taking PrEP may be subject to stigma from others, on the assumption they may be promiscuous or engage in high-risk sexual behaviours.Conclusions: This qualitative study indicates that, broadly speaking, PrEP may be acceptable to MSM in Malaysia. However, in order for its potential to be realized, and uptake achieved, educative interventions are required to inform the target population as to the efficacy and potential, positive impact of PrEP. Given concerns for how those taking it may be stigmatized, it is crucial that the use of PrEP is presented as a responsible course of action, and one of a range of strategies that men can use to keep themselves safe from HIV.

Exploring acceptability of oral PrEP prior to implementation among female sex workers in South Africa

“…This translated into one of the key motivations for use of having an additional layer of protection and personal control, to safeguard against the unpredictable such as sexual violence at work or lack of condom use with main partners with an unknown HIV status. This notion of additional protection and the relevant reasons are fairly different than what has been articulated by MSM who have been more concerned with (lack of) accurate risk perception and stigma within their social circles , suggesting the need to carefully consider differences in population perspectives when planning to rollout PrEP. Interestingly, changes in condom use over time were primarily seen in the efficacy and implementation studies with MSM, as opposed to the studies with heterosexual men and women which may correlate with the different needs and desires of the populations.…”

“…Of particular note were the participants' worries and concerns in our study about the broader effects of PrEP and potential for misuse and misinterpretation. Their recognition, combined with the same awareness among other current and existing users in other parts of the world [36][37][38], should come as a reassurance to those with apprehensions that the introduction of PrEP could be mismanaged leading to declines in condom use [39]. Participants felt strongly that the addition of PrEP should be seen as a back-up for when condoms failed for the various reasons previously mentioned, but that PrEP was an important new option that should be offered to all HIV-negative women.…”

Awareness and willingness to use HIV pre‐exposure prophylaxis among men who have sex with men in low‐ and middle‐income countries: a systematic review and meta‐analysis

“…These 23 studies related to 22 distinct populations. Two Malaysian studies conducted by Lim et al [31] and Bourne et al [32] were linked in that participants of the quantitative study were invited to participate in follow-on qualitative interviews. All of the quantitative studies were cross-sectional surveys.…”

“…Although appropriate for identifying MSM who require PrEP, these strategies may exclude other MSM, for example those who are not living openly as MSM. A number of studies in Thailand [43], Malaysia [31,32], Kenya [51], and China [46], among others, started off by recruiting MSM and then screened them for eligibility based on age, HIV status, and availability and interest to participate in interviews, among other criteria, thereby limiting generalizability of findings to wider MSM populations. In addition, recruitment from rural areas across all studies was limited.…”

“…Definitions and general information regarding PrEP were provided by researchers or data collectors who were facilitating interviews, focus group discussions [32,49,50,52], or face-to-face quantitative questionnaires [33,34,47]. In other studies, this information was provided online as part of the study [31,35].…”