Preferences for emerging modalities of HIV pre-exposure prophylaxis among sexual and gender diverse populations in Malaysia: implications for person-centred HIV prevention

BACKGROUND: In Malaysia, HIV pre-exposure prophylaxis (PrEP) uptake remains low. Emerging formulations (e.g. injectable, long-acting oral, and event-driven PrEP) may help overcome barriers such as daily pill burden and adherence. This study examined PrEP preferences among men who have sex with men (MSM), transgender women, and gender-diverse individuals, and assessed how socio-demographic, sexual history, and substance use influence these preferences. METHODS: We conducted the PrEP APPEAL survey among 663 individuals in Malaysia from 10 May 2022 to 30 November 2022. Multivariable binary and multinomial logistic regressions identified factors associated with PrEP preferences, including 6-monthly injection, monthly oral pill and, event-driven (ED-PrEP) oral pill relative to the bi-monthly injection, yearly slow-releasing removable implant, daily oral pill, and other options. RESULTS: Our findings showed diverse PrEP preferences: 167 (25.2%) preferred monthly oral; 138 (20.8%) preferred event-driven; 137 (20.7%) preferred 6-monthly injectable; and 82 preferred daily oral pill (12.4%). PrEP profiles (relative risk ratios (RRR) 2.47-9.54, P < 0.05), education (RRR 2.00, P = 0.005), the number of sexual partners (RRR 1.75, P = 0.03), and willingness-to-pay (RRR 3.13-6.45, P < 0.05) were significant predictors of these preferences. CONCLUSIONS: These findings highlight the importance of diverse, person-centred PrEP delivery models to improve uptake and affordability. Strategies should reflect differences in education, sexual behaviour, and willingness to pay. Limitations include self-reported data, sample variability, cross-sectional design, and potential selection bias, which should be considered when interpreting results.