Analysis of potential barriers for non-PrEP users among MSM in Germany

Background. Daily oral pre-exposure prophylaxis (PrEP) provides effective protection against HIV. Since September 2019, the costs of PrEP have been reimbursed by statutory health insurance in Germany. While a considerable fraction of PrEP-eligible individuals receives PrEP, coverage is inhomogeneous across Germany. This study aims to identify potential barriers associated with PrEP non-use. Methods. Based on the PrApp online cross-sectional study, we analyzed 1,027 PrEP users and 431 non-PrEP users. A PrEP indication was assumed for cis-MSM with an STI diagnosis (12 months), ≥ 2 sex partners or sexualized drug use (6 months). Characteristics between PrEP users and PrEP non-users were compared descriptively and using multivariable logistic regression. Results. Non-PrEP users were more likely to be aged 18-29 years old (P < 0.05) and to use drugs during sex (P < 0.01). The highest HIV-specialists density (P < 0.01) was associated with PrEP use. Fear of side effects (54.5%) was the most common barrier and more pronounced in non-PrEP users living in a federal state with a high HIV-specialists density (67.9% vs. 51.8%) as well as low HIV-risk perception (35.8% vs. 24.1%). Non-PrEP users living in a federal state with a low HIV-specialists density described not wanting to discuss their sex life with their doctor (29.5% vs. 16.0%) as a reason for PrEP non-use. Persons with sexualized drug use were more likely to report daily PrEP use as a barrier (34.3% vs. 16.9%, P < 0.01, adjusted P < 0.05). Conclusions. Our analyses indicated structural barriers to PrEP use in federal states with a low HIV-specialists density (physician density, non-anonymity). For those with theoretical PrEP access (high HIV-specialists density), underestimation of HIV risk and fear of side effects could potentially be overcome by effective risk communication.