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Who says romance is dead? He's supposed to be Bourne with a smile but he's more like the Milk Tray man as an international date rapist. His upcoming film may be titled ' Reborn ' but it may actually mark the birth of the new Hollywood 'It Boy'. Almost half of the participants were ethnic Chinese and most completed the survey in English. The mean age was The majority of participants were single, identified themselves as gay, highly educated and working full time see Table 1. Participants came from all states of Malaysia including East Malaysia. The majority of participants reported having confidence in maintaining safer sex and most were not comfortable in talking about sexual behaviors with their health providers.
About one third of participants had never tested for HIV. In terms of sexual behaviors, Close to two thirds had 2 or more sexual partners in the last 6 months and half engaged in inconsistent condom use. Ten participants reported to have ever used PrEP and four were currently using it at the time of completing the survey. A small minority 1. About one third of participants indicated willingness to pay out-of-pocket for PrEP. The majority of participants believed that the government should cover the cost of PrEP.
The three preferred facilities to access PrEP, in rank order, were community-based organizations, general practitioners private physicians , and government clinic or hospitals. Close to half of the participants reported that they would only take PrEP as contingency for high-risk sex. The means of individual scale items ranged from 3.
In the bivariate analysis, ethnicity, gay sexual identity, multiple male sexual partners, having any inconsistent condom use in the past 6 months, lack of confidence in practising safer sex, having heard of PrEP, and ever paid for sex with a male partner were significantly associated with willingness to use PrEP. In the multiple logistic regression model, Malay ethnicity, gay sexual identity, having 2 or more male sex partners in the past 6 months, having heard of PrEP, having a lack of confidence in practising safer sex, and having ever paid for sex with a male partner were independently associated with willingness to use PrEP Table 4.
This is the first study to assess willingness to use PrEP among a key population in Malaysia. The present study found that willingness to use it was related to multiple factors, including demographic characteristics, sexual identity, HIV risk behaviors and prior awareness of PrEP.
These ethnic differences in willingness to use PrEP could not be explained by socio-economic factors such as education level, age or income. Other studies have found ethnic differences in health profiles of Malaysians [ 64 , 65 ], which have been attributed to cultural, health-seeking and lifestyle differences [ 64 — 66 ]. However, the extent to which these factors contribute to our observed differences in willingness to use PrEP is not clear.
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Other social, ethno-cultural and religious factors should be explored in future studies to understand factors contributing to differential willingness to use PrEP among different ethnic MSM populations. However, the positive relationship between outness and uptake of health services is dependent on the context within which sexual minorities live [ 68 ]. In contrast, two studies from China did not find an independent association between sexual orientation and willingness to use [ 44 , 47 ].
Hence, identifying potential high-risk users may require a wide variety of ways to reach both homosexual and bisexually active men. The present study found that risk behaviors such as having more male sexual partners and paying for sex were independently associated with willingness to use PrEP, echoing findings from China [ 47 ]. It must be noted that the variability of level of willingness to use PrEP among MSM in various countries may be due to the variability in measurement [ 54 ].
Most of previous studies measured willingness to use PrEP based on one single question and have generally yielded higher percentage of acceptability [ 54 ]. Interestingly, the level of willingness to use PrEP of the present study is higher than Holt et al. Our results have several implications for eventual demonstration and subsequent widespread implementation of PrEP.
Framing PrEP prevention messages appropriately based on accurate information with support of community partners will be crucial to raise awareness and interest among MSM. Evidence of PrEP efficacy and safety should be widely disseminated to allay concerns held by MSM about potential side effects. Local guidelines and policies are needed to determine eligibility criteria for PrEP and to ensure that antiretroviral drugs are licensed for prevention and can be prescribed safely.
Furthermore, it may be useful to position PrEP as a prevention strategy for all populations at risk for HIV infection, including serodiscordant heterosexual couples, in order to avoid further stigmatization of MSM and other key populations. In our study, the majority of respondents were not willing to pay for PrEP out of pocket. Currently, in Malaysia, available PrEP formulations of emtricitabine and tenofovir disoproxil fumarate e. Similar to reports from other Asian settings [ 48 , 52 , 69 ], the cost of medications and routine testing may remain a significant barrier to uptake of PrEP in Malaysia.
A previous study documented high levels of stigma toward MSM among future healthcare providers in Malaysia [ 70 ]. In a global survey of MSM, homophobia, stigma, and service provider stigma were significantly associated with reduced access to services [ 43 ]. Prevention strategies such as PrEP may further fuel the perceptions of MSM engaging in condomless sex as selfish, irresponsible, and reckless. A qualitative study from India showed that a major barrier to potential use PrEP among MSM was fear of being stigmatized and labelled as promiscuous by their peers [ 69 , 71 ].
Therefore, HIV care providers need training not only to increase their knowledge and competency regarding PrEP, but also to dispel negative stigma against potential PrEP users.
HIV providers are not the only important constituency. Training and competency development in relation to PrEP would also be valuable to primary care providers and other sexual health clinic staff. As highlighted in a recent discussion paper on the rollout of PrEP in the Asia Pacific region [ 4 ], the epidemic-limiting potential of this new prevention intervention will only be realized with significant health system investment and with the participation of MSM organizations in the design and delivery of PrEP related policies and programmes.
Several limitations need to be acknowledged. The study also excluded transgender participants, although we recommend targeted research among this distinct key population to adequately address their specific perspective and needs. In addition, online participation may have excluded MSM without access to internet sites on which the study was advertised.
Our sample differed from other MSM nationally in regard to ethnic profile as well as several HIV risk characteristics. In terms of ethnicity, Chinese MSM were over-represented in the sample even though ethnic Malay is the majority ethnic group in Malaysia. In terms of HIV risk characteristics, In addition, the national survey found However it is important to note that deviations from national data may have arisen due to our sampling strategy. While not representative of all MSM in Malaysia, our sample is nevertheless important given the large sample size and their higher risk profiles, which can inform implementation of PrEP and other HIV prevention interventions.
Post-survey measures to verify the self-report information were not employed, and would have had additional ethical implications.
For instance, some participants may have misrepresented themselves as Malaysian citizens. In terms of analysis, the dichotomization of continuous variables adopted in our study could have reduced the power to identify associations, between willingness to use PrEP and dichotomized variables [ 73 ].
However, this strategy was only employed in three attitudinal and non-biological measures, i. When preparing sexual health and harm reduction interventions for men who use drugs, it is important to take into account differences in motivation, psychological effect, and impact on sexual behavior risk taking between these drugs [ 74 , 75 ], which was inadequately accounted for in our study.
A more granulated approach to the use of drugs during sex should be used in future research. In our multivariable analysis, we included paying for sex but excluded selling sex to men, in light of the results from bivariate analysis.
However, selling sex to men may place male sex workers at heightened risk of HIV [ 76 ]. Future research should explore PrEP specifically among this sub-group of MSM, as has been the case in other countries [ 77 ]. In the context of civil law penal code and sharia law against homosexuality in Malaysia [ 58 ], MSM are criminalized and stigmatized.