Preferred service model and other factors associated with pre-exposure prophylaxis willingness among Indonesian men who have sex with men: analysis of PrEP APPEAL survey

BACKGROUND: Men who have sex with men (MSM) are disproportionately affected by HIV in Indonesia. To prevent transmission, there is a need to scale-up HIV prevention, especially pre-exposure prophylaxis (PrEP). This analysis aims to identify the preferred service model and factors associated with PrEP willingness among MSM. METHODS: PrEP APPEAL was an online cross-sectional survey conducted among MSM in 15 Asian countries/territories, including Indonesia, about preferences for PrEP service delivery. Participants included MSM aged >18 years who believed themselves to be HIV-negative. This analysis is limited to Indonesian participants. Participants were asked about their preferences for the PrEP regimen, willingness to pay and whether they would prefer healthcare workers who are MSM. A discrete choice experiment was also conducted to identify preferences for PrEP service models across six attributes (regimen, location, cost, visit frequency, side-effects and extra services), each with three to five levels. Logistic regression was conducted to identify factors associated with willingness to use PrEP, and latent class analysis was conducted to identify classes with similar service model preferences. RESULTS: The analysis included 1139 participants with a mean age of 30.6 years (s.d. 7.5). Service model preferences associated with PrEP willingness included accepting (but not preferring) either oral PrEP regimen (aOR 1.78, 95% CI 1.15-2.74) or preference for event-driven (aOR 1.49, 95% CI 1.04-2.12) compared with accepting neither; willingness to pay IDR150,001-300,000 (aOR 2.61, 95% CI 1.50-4.55); and preference for MSM providers (aOR 2.41, 95% CI 1.80-3.23). The largest class identified through latent class analysis (79%) were more likely to identify as gay, have higher education and were PrEP-enthusiastic with a preferred PrEP service model that included: event-driven regimen (utility coefficient 0.31, P < 0.001); access at MSM-run private community clinics (0.16, P < 0.001); PrEP availability at no cost (0.65, P < 0.001), up to IDR100,000 (0.16, P < 0.001), with declining preference at IDR200,000 (-0.17, P < 0.001) or more; and with STI testing (0.12, P < 0.001). CONCLUSIONS: We identified a preferred service model for MSM that includes event-driven PrEP, ideally free or under IDR200,000, accessible from MSM-run community clinics. Cost and preferred regimens were salient factors for PrEP willingness. These findings suggest the potential for an affordable, community-friendly and differentiated care model for PrEP scale-up in Indonesia.