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

Background Daily oral pre-exposure prophylaxis (PrEP) provides effective protection against HIV. Since September 2019, the costs of PrEP have been covered 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 among PrEP-eligible MSM. Methods Based on the PrApp online cross-sectional study, we analyzed 1,027 PrEP users and 431 PrEP non-users. A PrEP indication was assumed for cis-MSM with a diagnosis of a bacterial STI (syphilis, gonorrhea, chlamydia) or hepatitis C (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 PrEP non-users were more likely to be aged 18–29 years old (P < 0.05, reference group: 30–39 years) and to engage in sexualized drug use (P < 0.001). The highest HIV-specialists density (P < 0.01, reference group: 6–9 HIV-specialists per 10,000 gay men) was associated with PrEP use. Persons with sexualized drug use were more likely to report daily PrEP use as a barrier (34.3% vs. 16.9%, adjusted P < 0.05). Fear of side effects (54.5%) was the most common barrier and might be more pronounced in PrEP non-users living in a federal state with a high HIV-specialists density (67.9% vs. 51.8%, adjusted P = 0.08). PrEP non-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%, adjusted P = 0.08) as a reason for PrEP non-use. 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), fear of side effects could potentially be addressed by effective risk communication.