Study setting and participants
Between May and November 2022, two separate online cross-sectional surveys were distributed: 1) the survey for MSM via dating apps (e.g., Grindr and Scruff), social media platforms (e.g., WeChat and Facebook) and local and regional MSM community networks via social media and mailing lists, and 2) the survey for TGW via social media influencers and local and regional TGW community networks via social media and mailing lists.. We included MSM and TGW aged 18 years and above, reporting no prior HIV diagnosis and living in the participating high- (HIC) (only MSM) or middle-income Asian countries and territories (MIC) (MSM and TGW), or Australia (only MSM). MICs included Cambodia, China, India, Indonesia, Laos, Malaysia, Myanmar, Nepal, the Philippines, Thailand, and Vietnam. HIC included China SAR (Special administrative regions) Hong Kong, Taiwan (China), Japan, and Singapore. MSM self-identified as gay, bisexual or other men who have sex with men. TGW self-identified as transgender women. Respondents who completed the survey could enter a prize draw, with the prize values set at 3.5% of each country's median monthly income for both MSM and TGW groups.
Data analysis
We included respondents who answered at least one DCE question in the analyses. The respondents’ demographic characteristics were presented using descriptive statistics. Random parameters logit (RPL) models with 1,000 Halton draws were used to estimate the relative importance of attributes for each country/territory.17 All attribute levels were effects coded.18 All parameters were initially assumed to follow a normal distribution. Some parameters were set as non-random parameters to achieve a better model fit according to the Akaike information criteria and log-likelihood function. A simulation model using RPL was used to predict PrEP uptake, comparing “the least preferred PrEP program” (including attribute levels least wanted), “the optimal PrEP program” (including attribute levels most wanted), and “status quo” (including attribute levels currently offered). PrEP uptake percentage is the proportion of people accepting PrEP when offered a specific PrEP service program.
RPL with interaction models were used to explore the heterogeneity of preferences of those who would most benefit from PrEP (i.e., at substantial risk of HIV acquisition and naïve-PrEP users). We defined substantial risk as individuals in the last six months who were either involved in commercial sex, had condomless anal sex, drug use before or during sex (i.e. chemsex), had multiple sexual partners, shared injecting equipment, were diagnosed with an STI, or took PrEP.19 We defined naïve-PrEP users as individuals who had never heard of or used PrEP, and experienced PrEP users as individuals who used PrEP in the past or were currently using PrEP. The results were presented as coefficients, with a positive coefficient interpreted as a desired attribute level and a negative coefficient interpreted as a less preferred level. The standard deviations (SD) reported from RPL models demonstrate the level of heterogeneity for each attribute level: a statistically significant SD indicates heterogeneity in respondents’ preferences for that attribute level. We calculated each attribute's relative importance using the coefficient range of each attribute divided by the sum of ranges from all attributes.20 NLOGIT (version 6, Econometric Software Inc, USA) was used for all model estimations.
This study was approved by the University of New South Wales (UNSW) Human Research Ethics Committee (HC210729). It was exempted from review by the WHO Ethics Review Committee. Family Health International (FHI) 360 agreed that the UNSW Human Review Ethics Committee could act as the institutional review board.
Findings
Of 62,000 people who clicked on a survey link, 40,038 provided consent and completed 132,087 choice sets. Of these, 23,465 respondents, including 21,943 MSM and 1,522 TGW, completed at least one choice set and were included in the analyses. Ninety per cent (19,644/21,943) of MSM and 93% (1,422/1,522) of TGW completed all six choice sets in the DCE. Among respondents included in the analyses, the mean age of MSM and TGW was 31.7(± 9.6) and 28.1 (± 7.0) years, respectively. All TGW were recruited from only MIC, while 66% of MSM were from MIC. Regarding PrEP use, 8% of MSM and 11% of TGW reported taking PrEP in the past but not currently, while 19% of MSM and 35% of TGW reported currently taking PrEP. In the past six months, 15% of MSM reported chemsex, 8% reported an STI diagnosis, 9% were involved in commercial sex, 59% had multiple partners, and 1% shared injecting equipment. Meanwhile, 28% of TGW reported chemsex, 16% reported an STI diagnosis, 34% were involved in paid sex, 54% had multiple partners, and 4% shared injecting equipment in the last six months (Table 1).
Among MSM, cost was the most important attribute in all countries, followed by the type of PrEP. There were significant variations in the relative importance of other PrEP service attributes, including side effects, service locations and clinic visit frequency, across the region. However, service locations and clinic visit frequency were generally the least important attributes for PrEP use among MSM. (Fig. 1, Figure S1, Table S1 and Table S2).
At least a 50% absolute increase in PrEP uptake was found when switching from the least preferred PrEP programs (including very high cost, PrEP implants, rare kidney problems as side effects, and visiting service locations every two months) to the optimal PrEP service program (including free, available in peer-led community clinics, visiting the clinic every 6 or 12 months, and STI testing as an additional service) among MSM in the following countries: Australia, China, Hong Kong SAR China, Japan, the Philippines, Taiwan (China), and Thailand. The details of the uptake of PrEP among MSM, given different PrEP program configurations in each country, are shown in Table 2.
Table 2
Demographic characteristics and risk behaviours of the study population (MSM, N = 21,943 and TGW, N = 1,522)
| MSM | TGW |
| n | % | n | % |
Mean age | Mean 31·7 | SD 9·6 | Mean 28·1 | SD 7·0 |
Sex at birth | | | | |
Male | 21,383 | 97·5 | 1357 | 89·2 |
Female | 151 | 0·7 | 40 | 2·6 |
Others | 409 | 1·9 | 125 | 8·2 |
Sexual identity | | | | |
Gay or homosexual | 15,123 | 68·9 | 631 | 41·5 |
Bisexual or pansexual | 4,703 | 21·4 | 196 | 12·9 |
Heterosexual or straight | 465 | 2·1 | 258 | 17·0 |
I don't usually use a term | 1,280 | 5·8 | 304 | 20·0 |
I use a different term | 372 | 1·7 | 133 | 8·7 |
Country | | | | |
Asian middle-income countries | 14,529 | 66·2 | 1,522 | 100·0 |
• Thailand | 1,552 | 7·1 | 256 | 16·8 |
• Vietnam | 1,451 | 6·6 | 253 | 16·6 |
• Indonesia | 1,428 | 6·5 | 80 | 5·3 |
• The Philippines | 2,289 | 10·4 | 98 | 6·4 |
• China | 1,853 | 8·4 | 28 | 1·8 |
• Malaysia | 1,035 | 4·7 | 13 | 0·9 |
• Myanmar | 561 | 2·6 | 145 | 9·5 |
• India | 2,768 | 12·6 | 145 | 9·5 |
• Cambodia | 821 | 3·7 | 127 | 8·3 |
• Laos | 312 | 1·4 | 34 | 2·2 |
• Nepal | 459 | 2·1 | 343 | 22·5 |
Asian high-income countries | 7,414 | 33·8 | - | - |
• Taiwan (China) | 2,564 | 11·7 | - | - |
• Singapore | 770 | 3·5 | - | - |
• Hong Kong SAR, China | 646 | 2·9 | - | - |
• Japan | 1,540 | 7·0 | - | - |
Australia | 1,894 | 8·6 | - | - |
Education level | | | | |
No schooling | 120 | 0·6 | 57 | 3·8 |
Up to high school or equivalent | 7,515 | 34·3 | 984 | 64·7 |
At least undergraduate degree | 13,372 | 60·9 | 460 | 30·2 |
Other* | 936 | 4·3 | 3 | 0·2 |
Employment | | | | |
Full time | 13,931 | 63·5 | 617 | 40·5 |
Part time | 2,257 | 10·3 | 272 | 17·9 |
Unemployed | 1,894 | 8·6 | 318 | 20·9 |
Student | 2,912 | 13·3 | 177 | 11·6 |
Retired | 242 | 1·1 | 17 | 1·1 |
Other | 532 | 2·4 | 78 | 5·1 |
Missing | 175 | 0·8 | 43 | 2·8 |
PrEP awareness and use | | | | |
Never heard of PrEP | 4,214 | 19·2 | 300 | 19·7 |
Heard of PrEP but never used PrEP | 10,961 | 49·8 | 457 | 30·0 |
Used in the past but not currently | 1,768 | 8·1 | 166 | 10·9 |
Currently using PrEP | 4,098 | 18·7 | 531 | 34·9 |
Missing | 902 | 4·3 | 68 | 4·5 |
Chemsex in the last 6 months | | | | |
No sexual partner | 838 | 38·2 | 59 | 3·9 |
No chemsex | 15,463 | 70·5 | 924 | 60·7 |
Had chemsex | 3,378 | 15·4 | 421 | 27·7 |
Missing | 2,264 | 10·3 | 118 | 7·8 |
STI diagnosis in the last 6 months | | | | |
No | 17,101 | 77·9 | 1103 | 72·5 |
Yes | 1,712 | 7·8 | 249 | 16·4 |
Missing | 3,130 | 14·3 | 170 | 11·2 |
Involvement in commercial sex in the last 6 months | | | | |
No | 17,259 | 78·7 | 867 | 57·0 |
Yes | 1,989 | 9·1 | 518 | 34·0 |
Missing | 2,695 | 12·3 | 137 | 9·0 |
Sexual partner in the last 6 months | | | | |
Single | 2,188 | 10·0 | 180 | 11·8 |
One partner | 3,751 | 17·1 | 237 | 15·6 |
Multiple partners | 13,028 | 59·4 | 826 | 54·3 |
Missing | 2,976 | 13·6 | 149 | 9·8 |
Condomless anal sex in the last 6 months | | | | |
No sex | 3,481 | 15·9 | 210 | 13·8 |
Always used condoms | 5,250 | 23·9 | 402 | 26·4 |
Not always used condoms | 10,094 | 46·0 | 742 | 48·8 |
Missing | 3,118 | 14·2 | 168 | 11·0 |
Sharing injecting equipment in the last 6 months | | | | |
Not injecting drugs | 17,599 | 80·2 | 1,110 | 72·9 |
Injecting drug without sharing equipment | 1,074 | 4·9 | 174 | 11·4 |
Injecting drug and sharing equipment | 173 | 0·8 | 54 | 3·6 |
Missing | 3,097 | 14·1 | 175 | 11·5 |
MSM = men who have sex with other men, PrEP = pre-exposure prophylaxis, SD = standard deviation, STI = sexually transmitted infection, TGW = Trans women |
* diploma/trade/vocational certificate/Singapore education |
Table 3
The predicted uptake of the worst and best PrEP service package among MSM and TGW in 15 Asian countries and Australia
| Scenario | Uptake (%) | Increase in uptake (%)* | Type of PrEP | Service location | Cost | Side effects | Visit frequency | Extra service |
TGW | | | | | | | | | |
Asia | Worst | 50 | | Implant | Hospital | Very high | Rare chance of kidney problems | Every 2 months | None |
| Status quo | 60 | 10 | | | | | | |
| Best | 87 | 37 | Injectable | Community clinic run by MSM/TG | Free | No side effects | Every 6 or 12 months | STI testing |
MSM | | | | | | | | | |
Australia | Worst | 48 | | Implant | Hospital | Very high | Rare chance of kidney problems | Every 2 months | None |
| Status quo | 86 | 38 | | | | | | |
| Best | 100 | 52 | Long-acting oral | Pharmacy | Free | No side effects | Once a year | STI testing |
Cambodia | Worst | 67 | | Implant | Pharmacy | Very high | Rare chance of kidney problems | Every 2 months | Mental health counselling |
| Status quo | 88 | 21 | | | | | | |
| Best | 97 | 30 | On-demand | Private community clinic (incl. GP) | Free | No side effects | Every 3 months | STI testing |
China | Worst | 49 | | Implant | STI clinic | Very high | Rare chance of kidney problems | Every 2 months | Mental health counselling |
| Status quo | 87 | 38 | | | | | | |
| Best | 100 | 51 | On-demand | Private community clinic (incl. GP) | Free | No side effects | Once a year | STI testing |
Hong Kong SAR, China | Worst | 37 | | Implant | STI clinic | Very high | Rare chance of kidney problems | Every 2 months | Mental health counselling |
| Status quo | 96 | 59 | | | | | | |
| Best | 100 | 63 | Long-acting oral | Telehealth | Free | Mild pain at the injection site | Once a year | STI testing |
India | Worst | 48 | | Implant | Telehealth | Very high | Rare chance of kidney problems | Every 2 months | None |
| Status quo | 80 | 32 | | | | | | |
| Best | 95 | 47 | Long-acting oral | Community clinic run by MSM/TG | Free | No side effects | Once a year | STI testing |
Indonesia | Worst | 76 | | Daily oral | Hospital | Very high | Rare chance of kidney problems | Every 2 months | Mental health counselling |
| Status quo | 91 | 15 | | | | | | |
| Best | 100 | 24 | On-demand | Community clinic run by MSM/TG | Free | No side effects | Every 6 months | STI testing |
Japan | Worst | 47 | | Implant | STI clinic | Very high | Rare chance of kidney problems | Every 2 months | Mental health counselling |
| Status quo | 94 | 47 | | | | | | |
| Best | 100 | 53 | Long-acting oral | Community clinic run by MSM/TG | Free | No side effects | Every 6 months | STI testing |
Laos | Worst | 92 | | Implant | Pharmacy | Very high | Mild | Once a year | None |
| Status quo | 92 | 0 | | | | | | |
| Best | 100 | 8 | On-demand | Private community clinic (incl. GP) | Free | Mild pain at the injection site | Every 3 months | STI testing |
Malaysia | Worst | 78 | | Implant | Private community clinic (incl. GP) | Very high | Rare chance of kidney problems | Every 2 months | Mental health counselling |
| Status quo | 93 | 15 | | | | | | |
| Best | 100 | 22 | On-demand | Community clinic run by MSM/TG | Free | No side effects | Once a year | STI testing |
Myanmar | Worst | 97 | | Implant | Hospital | Very high | Rare chance of kidney problems | Every 2 months | None |
| Status quo | 99 | 2 | | | | | | |
| Best | 100 | 3 | On-demand | Community clinic run by MSM/TG | Free | No side effects | Every 6 months | STI testing |
Nepal | Worst | 70 | | Implant | Private community clinic (incl. GP) | Very high | Rare chance of kidney problems | Once a year | STI testing |
| Status quo | 86 | 16 | | | | | | |
| Best | 100 | 30 | Injection | Community clinic run by MSM/TG | Free | No side effects | Every 6 months | None |
Philippines | Worst | 48 | | Implant | Telehealth | Very high | Rare chance of kidney problems | Every 6 months | Mental health counselling |
| Status quo | 89 | 41 | | | | | | |
| Best | 100 | 52 | On-demand | Community clinic run by MSM/TG | Free | No side effects | Once a year | STI testing |
Singapore | Worst | 76 | | Implant | STI clinic | Very high | Interactions with other medications | Every 2 months | Mental health counselling |
| Status quo | 96 | 20 | | | | | | |
| Best | 100 | 24 | Long-acting oral | Community clinic run by MSM/TG | Free | No side effects | Once a year | STI testing |
Taiwan (China) | Worst | 20 | | Implant | STI clinic | Very high | Rare chance of kidney problems | Every 2 months | Mental health counselling |
| Status quo | 86 | 66 | | | | | | |
| Best | 100 | 80 | On-demand | Community clinic run by MSM/TG | Free | No side effects | Once a year | STI testing |
Thailand | Worst | 44 | | Implant | Hospital | Very high | Interactions with other medications | Every 2 months | Mental health counselling |
| Status quo | 87 | 43 | | | | | | |
| Best | 99 | 55 | Long-acting oral | Community clinic run by MSM/TG | free | No side effects | Every 6 months | STI testing |
Vietnam | Worst | 80 | | Implant | Telehealth | Very high | Mild | Every 2 months | Mental health counselling |
| Status quo | 94 | 14 | | | | | | |
| Best | 99 | 19 | Daily oral | Community clinic run by MSM/TG | Free | No side effects | Every 3 months | None |
*%increase in uptake is calculated from the difference in uptake between the best- and the worst PrEP program. |
The best PrEP programs included attribute levels most preferred by MSM or TGW in each country. |
The Worst PrEP programs included attribute levels least preferred by MSM or TGW in each country. |
status quo programs included daily oral PrEP, access via hospital, high-cost PrEP, mild side effects, clinic visit every 3 months, no additional service. MSM = men who have sex with other men, PrEP = pre-exposure prophylaxis, STI = sexually transmitted infection, TG = Trans women |
When examining preference for PrEP service programs among MSM with different levels of risk of HIV, MSM at substantial risk (15,841/21,943) had a greater preference for free long-acting oral PrEP and visiting the service location every six months compared to the low-risk group (6,102/21,943) who had a greater preference for PrEP without side effects and preferred to visit a service location once a year. The two groups showed no significant difference in preferences for service locations and extra services (Fig. 2 and Table S3). When comparing preferences for PrEP service programs between MSM who were experienced PrEP users (5,866/21,041) and naïve PrEP users (15,175/21,041), naïve PrEP users were more likely to use PrEP if the program offered free on-demand PrEP with no side effects, and the option for telehealth access (Fig. 3 and Table S4).
When examining drivers of PrEP use among TGW, the most important attribute of PrEP use was cost (62% relative importance), followed by the type of PrEP (10% relative importance), location (8% relative importance), extra services (8% relative importance), visit frequency (7% relative importance) and side effects (5% relative importance) (Fig. 1). We observed a 37% absolute increase in PrEP uptake when switching from the least preferred PrEP service (including very high cost, PrEP implants, a rare chance of kidney problems as side effects, a hospital as a service location, visits every two months, and no additional services) to the optimal PrEP service configuration (including no cost, injectable PrEP, no side effects, a peer-led clinic as a service location, six or 12 monthly visit, and additional STI testing services) (Table 2 and Figure S2).
When exploring preferences for PrEP service programs among TGW with different risk profiles for HIV, TGW at substantial risk had a greater preference to access PrEP through telehealth with additional STI testing. In contrast, low-risk TGW had a greater preference to access PrEP through a pharmacy with gender-affirming prescription hormones as an extra service. They had less preference to access PrEP through a private community clinic compared to the high-risk group (Fig. 2 and Table S5). When comparing preferences for PrEP service programs between experienced PrEP users (697/1,454) and naïve PrEP users (757/1,454) among TGW, naïve-PrEP users had less preference to use PrEP with a rare chance of kidney problems and preferred long-acting oral PrEP (Fig. 3 and Table S6).