Exploring drivers of pre-exposure prophylaxis uptake among gay, bisexual, and other men who have sex with men in Malaysia

Abstract

Background:

Pre-exposure prophylaxis (PrEP) is a valuable HIV prevention strategy, particularly among men who have sex with men (MSM); however, PrEP uptake is below the threshold needed to curb the HIV epidemic among this group, especially in settings like Malaysia, where same-sex sexual behavior is illegal.

Methods:

A sample of 355 participants completed an online survey between June and July 2020, recruited through geosocial networking apps for MSM and social networking websites (e.g. Facebook). We used descriptive and multivariable analyses to examine correlates of PrEP use within this population.

Results:

The sample was predominantly Malay (53.5%), had monthly incomes greater than RM 3000 (USD 730) (52.7%), and a tertiary level of education (84.5%). About 80% of participants heard of PrEP prior to the survey, with significantly less (18.3%) having ever taken PrEP. In the adjusted multivariable logistic model, using drugs before or during sexual intercourse (“chemsex”) (AOR: 3.37; 95% CI: 1.44–7.89), being diagnosed with a sexually transmitted infection in the last 12 months (AOR: 2.08; 95% CI: 1.13–3.85), HIV testing in the previous 6 months (AOR: 3.23; 95% CI: 1.74–5.99), and disclosure of sexual orientation (AOR: 1.85; 95% CI: 1.02–3.34) were associated with having taken PrEP in the past.

Conclusions:

This study revealed that PrEP use among Malaysian MSM is relatively low, despite high awareness, and is associated with healthcare engagement and high-risk behaviors. These results highlight the need to tailor outreach activities for individuals at increased risk for HIV and those disengaged with the health system.

Background

Pre-exposure prophylaxis (PrEP) for HIV is highly effective at preventing sexually acquired HIV infections, especially among men who have sex with men (MSM) ¹ For this reason, the World Health Organization (WHO) recommends that PrEP be used as a global prevention strategy to decrease the burden of HIV among high-risk groups, including MSM.² While the incidence of HIV in the general population has been stable since 2005, MSM continue to be disproportionately affected by new HIV infections, regardless of targeted prevention programs ^3,4

Though the higher rates of HIV in this group have been attributed to high-risk sexual practices, including the frequent use of recreational drugs prior to sexual intercourse, and lack of testing and PrEP awareness, the disproportionate burden of infections on MSM is not solely due to individual-level factors.^5,6 The risk of incident HIV infection is much higher among MSM living in countries like Malaysia, where same-sex sexual behavior is criminalized, and lesbian, gay, bisexual, and transgender (LGBT) people face high levels of stigmatization.^7,8 Recent reports indicate that the HIV epidemic among MSM in Malaysia is prolific, with prevalence increasing from 3.9% in 2009 to 21.6% in 2017.^9,10 Although difficult to estimate the precise number of MSM in Malaysia with high accuracy, the country’s 2019 Joint United Nations Programme on HIV/AIDS (UNAIDS) Progress Report on HIV/AIDS projected that MSM will bear the greatest burden of HIV over the next decade.⁹ Likewise, the use of recreational drugs common among MSM, such as amphetamine-type stimulants and opioids, is criminalized.^11,12 Stigmatization of LGBT people and drug use have been associated with low uptake of preventive services for HIV (e.g. PrEP, testing), exacerbating increases in incidence and morbidity.¹³

Despite advances in awareness of PrEP and its inclusion in Malaysia’s National Strategic Plan to end AIDS by 2030, awareness about and willingness to initiate PrEP among MSM remains severely under-scaled.¹⁴ Studies of acceptability to initiate PrEP in Malaysia have found positive associations between having multiple sex partners, prior knowledge of PrEP, lack of confidence in practicing safer sex, having ever paid for sex with a male partner, and a greater willingness to take PrEP.¹⁴ However, no studies have yet reported correlates of actual PrEP use in this group. Given the increasing HIV vulnerability among Malaysian MSM, it is crucial to understand what individual, community, and structural factors drive uptake of PrEP in this population. Therefore, this study aims to assess the use of PrEP among Malaysian MSM, including factors associated with its uptake, to better tailor and strengthen HIV prevention efforts nationwide.

Methods

This cross-sectional study utilized an online survey of Malaysian MSM conducted in June and July 2020. The survey sought to assess attitudes toward participation in an app-based mobile health (mHealth) HIV prevention program. Eligibility criteria were: (i) being 18 years or older; (ii) identifying as male; (iii) self-reported HIV status as negative or unknown; (iv) reporting recent (in the last 6 months) substance use or condomless sex; and (v) ability to read and understand English or Bahasa Malaysia.

Sampling method

Participants were recruited using advertisements on geosocial networking apps (GSN) frequently used by MSM (e.g. Grindr, Hornet) and popular social networking websites for the general population (e.g. Facebook). A convenience sampling method was used to recruit MSM. The GSN apps pushed the advertisement to the chat inboxes of all users in Malaysia while targeted banner advertisements were used on Facebook. These banners could show up either as a static ad on the right-hand pane of the website or an ad that resembled a standard post that users could encounter while scrolling through their feed. Clicking on the advertisements directed interested persons to an eligibility screening tool and a brief online consent form hosted by Qualtrics.

The consent form indicated that interested persons could enter a drawing to win one of 10 vouchers worth 635 Malaysian Ringgit (RM) [equivalent to 150 U.S. dollars (USD)] and that there was “no participation necessary” to enter the random draw. The average completion time for the anonymous online survey was 10–12 minutes. The study protocol was approved by the institutional review boards of the University of Malaya and Yale University.

Study measures

Awareness of PrEP was assessed via the question “Before participating in this survey, have you ever heard about PrEP, also known as pre-exposure prophylaxis?”, with the outcome variable of interest being participants’ use of PrEP. To assess PrEP use, participants were asked if they had ever used PrEP, with “Yes” or “No” as available responses. Predictor variables were dichotomized (“Yes” or “No”) HIV risk behaviors of the participants in the past 6 months: (i) sexual intercourse with another man; (ii) engagement in condomless sex; (iii) engagement in group sex (i.e. sex with more than one other man); (iv) engagement in commercial (transactional) sex; (v) consistent condom use (defined as always using condoms during anal sex); (vi) use of injection drugs; (vii) engagement in chemsex (i.e. the use of recreational drugs (e.g. crystal methamphetamine/i.e. ketamine, ecstasy, and gamma-hydroxybutyrate “G”) before or during sex; and (viii) the number of sexual partners, coded as none, one, and more than one.

Perceived likelihood of HIV acquisition was assessed by asking: “What do you think is your current risk of getting HIV?” Responses were dichotomized as “Low” and “High.” Participants were also asked if they had ever tested for HIV, including in the past 3, 6, and 12 months. Recent sexually transmitted infection (STI) diagnosis was also assessed (in the past 12 months). All responses were dichotomized as “Yes” or “No.” Sociodemographic data of the participants included age, ethnicity, income, relationship status, educational attainment, sexual orientation, and disclosure of sexual orientation to family. All sociodemographic variables except age were dichotomized, as shown in Table 1.

Table 1.

Sociodemographic characteristics of Malaysian MSM, stratified by PrEP use (N = 355)^a.

Sociodemographic characteristics	Total n (%)b	Never used PrEP n (%)b	Used PrEP n (%)b	χ2	Df	P
Age (years): Mean (±SD)	33.1 (±8.9)	32.7 (±9.0)	35.1 (±8.2)	—	353	.129
Ethnicity
Malay	190 (53.5)	158 (83.2)	32 (16.8)	1.972	2	.373
Chinese	106 (29.9)	82 (77.4)	24 (22.6)
Other	59 (16.6)	50 (84.7)	9 (15.3)
Income
< RM 3000	168 (47.3)	144 (85.7)	24 (14.3)	3.453	1	.074
≥ RM 3000	187 (52.7)	146 (78.1)	41 (21.9)
Educationc
Secondary and below	55 (15.5)	48 (87.3)	7 (12.7)	1.356	1	.342
Tertiary	300 (84.5)	242 (80.7)	58 (19.3)
Relationship status
Single	238 (67.0)	198 (83.2)	40 (16.8)	1.091	1	.309
In a relationship	117 (33.0)	92 (78.6)	25 (21.4)
Sexual orientation
Gay	263 (74.1)	212 (80.6)	51 (19.4)	2.365	2	.307
Bisexual	77 (21.7)	67 (87.0)	10 (13.0)
Other	15 (4.2)	11(73.3)	4 (26.7)

MSM: men who have sex with men; PrEP: pre-exposure prophylaxis; p: p-value; SD: Standard Deviation; RM: Malaysian Ringgit.

^aTable values are n and (%) for categorical variables and mean and standard deviation (SD) for continuous variables.

^bNumbers may not sum to total due to missing data, and percentages may not sum to 100% due to rounding.

^cSecondary education is defined as post-primary education ending in 5 years (ages 13–18); tertiary education is any education post-secondary education, such as university.

Data analysis

We followed a protocol based on published standards for removing potentially duplicate cases while erring on the side of keeping rather than removing data in cases where a determination could not be made. We first identified potential duplicates based on age, sexual orientation, and ethnicity. All cases sharing those features were manually examined, focusing on responses to other questions such as education, relationship status, income, and device and browser information, including survey duration.

We used IBM SPSS v27.0 for all data analyses. Frequencies and percentages were used to describe categorical variables and means and standard deviations to describe continuous variables. Bivariate Chi-square tests were used to compare differences between the outcome (participants’ use of PrEP) and predictor variables. The statistical significance level was set at 0.10 in the bivariate analyses testing sociodemographic and additional factors hypothesized to be related to PrEP use.^14–16 The final multivariable model included variables with statistically significant p-values (i.e. p < .10) from the bivariate analysis, barring awareness of PrEP which was removed from the final multivariable analysis due to complete separation of data. Multicollinearity of the predictor variables was assessed, and the assumption was not violated. Statistical significance in the final multivariable logistic model was set to p < .05, with odds ratios, p-values, and corresponding confidence intervals used as indicators of significance. The goodness-of-fit of the final model was assessed using Nagelkerke’s R square (R²) Test.¹⁷

Results

The recruitment period lasted for one month, and 1259 individuals engaged with the survey, of which 592 (47.0%) consented and completed the screening tool. Two hundred and twenty-seven (38.3%) out of the 592 who completed screening and met inclusion criteria did not complete the survey; there was no significant difference between completers and non-completers on any demographic factors. Four out of the 365 who completed the survey failed attention and consistency validation checks (e.g. survey duration) and were eliminated. Another six identified as female and were excluded from the analysis. The final sample size was 355.

Participants’ characteristics

Table 1 provides information on the sociodemographic and personal characteristics of the sample. The mean age of participants was 33.1 (SD = 8.9) years. More than half of the participants were Malays, and about 30% were Chinese. Most participants had a tertiary level of education (84.5%), but only slightly more than half earned ≥3000 RM monthly (approximately USD 730). About three-quarters of participants identified as gay, and two-thirds were currently single. Almost 37% of the study population disclosed their sexual orientation to their family members. A vast majority (77.2%) had ever tested for HIV, while roughly 57% had been tested for HIV within the previous 6 months. Meanwhile, 27.0% of participants had been diagnosed with a STI, other than HIV, in the last year and over one-third (34.9%) considered themselves at risk of acquiring HIV. Among sociodemographic characteristics, only income slightly related to PrEP use (p = .074).

As shown in Table 2, a majority of participants were aware of PrEP (80.8%) before study enrollment, and all individuals that used PrEP in the past heard of it previously (p < .001). Most participants (83.7%) engaged in anal intercourse with another man in the past 6 months, but among these individuals, 55.6% did not use condoms during the intercourse. More than half of the participants had multiple sexual partners; however, only 35.2% engaged in transactional anal sex. A small percentage (16.9%) of participants had been involved in group sex in the past 6 months. The use of injection drugs (in the past 6 months) was reported among 3.9% of participants, and about 12% used drugs before sexual intercourse (“chemsex”).

Table 2.

Behavioral correlates of PrEP use among Malaysian MSM^a.

HIV risk behaviors (In the past 6 months)	Total	Never used PrEP n (%)b	Used PrEP n (%)b	χ2	df	p c
Anal sex with another man
No	85 (16.3)	74 (87.1)	11 (12.9)	2.154	1	.152
Yes	270 (83.7)	216 (80.0)	54 (20.0)
Condomless sex
No	120 (44.4)	98 (81.7)	22 (18.3)	0.375	1	.646
Yes	150 (55.6)	118 (78.7)	32 (21.3)
Consistent condom use
No	150 (55.6)	118 (78.7)	32 (21.3)	0.375	1	.646
Yes	120 (44.4)	98 (81.7)	22 (18.3)
Number of sexual partners
0	85 (23.9)	74 (87.1)	11 (12.9)	3.617	2	.164
1	72 (20.3)	61 (84.7)	11 (15.3)
>1	198 (55.8)	155 (78.3)	43 (21.7)
Transactional sex
No	230 (64.8)	186 (80.9)	44 (19.1)	0.294	1	.667
Yes	125 (35.2)	104 (83.2)	21 (16.8)
Group sex
No	295 (83.1)	249(84.4)	46 (15.6)	8.612	1	.006
Yes	60 (16.9)	41(68.3)	19 (31.7)
Injection drug use
No	341 (96.1)	282 (82.7)	59 (17.3)	5.872	1	.027
Yes	14 (3.9)	8 (57.1)	6 (42.9)
Chemsexd
No	313 (88.2)	267 (85.3)	46 (14.7)	23.094	1	<.001
Yes	42 (11.8)	23 (54.8)	19 (45.2)
Perceived likelihood of HIV acquisition
No	231 (65.1)	191 (82.7)	40 (17.3)	0.437	1	.565
Yes	124 (34.9)	99 (79.8)	25 (20.2)
Disclosed sexual orientation to family
No	224 (63.1)	191 (85.3)	33 (14.7)	5.195	1	.032
Yes	131 (36.9)	99 (75.6)	32 (24.4)
Testing behaviors
HIV Tested – lifetime
No	81 (22.8)	80 (98.8)	1 (1.2)	20.457	1	<.001
Yes	274 (77.2)	210 (76.6)	64 (23.4)
HIV Tested – last 3 months
No	281 (79.1)	238 (84.7)	43 (15.3)	8.151	1	.007
Yes	74 (20.9)	52 (70.3)	22 (29.7)
HIV Tested – last 6 months
No	204 (57.5)	183 (89.7)	21 (10.3)	20.602	1	<.001
Yes	151(42.5)	107 (70.9)	44 (29.1)
HIV Tested – last 12 months
No	140 (39.4)	132 (94.3)	8 (5.7)	24.519	1	<.001
Yes	215 (60.6)	158 (73.5)	57 (26.5)
STI diagnosis – last 12 months
No	259 (73.0)	222 (85.7)	37 (14.3)	10.369	1	.002
Yes	96 (27.0)	68 (70.8)	28 (29.2)
Aware of PrEP
No	68 (19.2)	68 (100.0)	0 (0.0)	18.85	1	<.00
Yes	287 (80.8)	222 (77.4)	65 (22.6)

MSM: men who have sex with men; PrEP: preexposure prophylaxis; df: degrees of freedom; χ²: chi-square; p: p-value.

^aTable values are n and (%) for categorical variables.

^bNumbers may not sum to total due to missing data, and percentages may not sum to 100% due to rounding.

^cp-value is for the chi-square (χ2) test.

^dChemsex is defined as the use of recreational drugs before anal sex.

Correlates of PrEP use

In this sample, PrEP had only ever been used by 18.3% of total participants. At the bivariate level, group sex in the past 6 months (p = .006; OR: 2.51, 95% CI: 1.34–4.70), injection drug use in the past 6 months (p = .027; OR: 3.59, 95% CI: 1.20–10.72), chemsex in the past 6 months (p < .001; OR: 4.80, 95% CI: 2.42–9.50), disclosure of sexual orientation to family (p = .032; OR: 1.87, 95% CI: 1.08–3.22), HIV testing within the last 6 months (p < .001; OR: 3.58, 95% CI: 2.02–6.35), and STI diagnosis in the last 12 months (p = .002; OR: 2.47, 95% CI: 1.41–4.33), were significantly associated with lifetime PrEP use (Table 2 and Table 3).

Table 3.

Results of Multivariable Logistic Regression Model Predicting PrEP use among Malaysian MSM^a.

Variables	OR (95% CI)	AOR (95% CI)	P c
Group sex in past 6 months	2.51 (1.34–4.70)	1.25 (0.61–2.57)	.548
Injection drug use in past 6 months	3.59 (1.20–10.72)	1.52 (0.38–6.04)	.556
Chemsexb in past 6 months	4.80 (2.42–9.50)	3.37 (1.44–7.89)	.005
STI diagnosis – last 12 months	2.47 (1.41–4.33)	2.08 (1.13–3.85)	.019
HIV tested – last 6 months	3.58 (2.02–6.35)	3.23 (1.74–5.99)	<.001
Disclosed sexual orientation to family	1.87 (1.08–3.22)	1.85 (1.02–3.34)	.042
Income > RM 3000	0.59 (0.34–1.03)	0.71 (0.39–1.30)	.266
Nagelkerke’s R2 d	—	0.21	—

MSM: men who have sex with men; PrEP: pre-exposure prophylaxis; OR: unadjusted odds ratio; CI: confidence interval; AOR: adjusted odds ratio; p: p-value.

^aOR predictions are predicting lifetime PrEP use.

^bChemsex is defined as the use of recreational drugs before anal sex.

^cp-value for the final adjusted multivariable model.

^dR² is for the final adjusted multivariable model.

Additionally, we examined the significant covariates independently associated with PrEP use through multivariable logistic modeling (Table 3). Those who participated in chemsex were 3.4 times as likely to have used PrEP (AOR: 3.37, 95% CI: 1.44–7.89) compared to MSM who had not participated in chemsex. Participants who tested for HIV within the last 6 months were over three times as likely to have used PrEP (AOR: 3.23, 95% CI: 1.74–5.99) than those who were not tested for HIV within the same period. Disclosure of sexual orientation to family increased the likelihood of using PrEP almost twofold (AOR: 1.85, 95% CI: 1.02–3.34), as opposed to non-disclosure. Compared to those MSM that were not diagnosed with an STI in the past 12 months, respondents diagnosed with an STI were twice as likely to have used PrEP (AOR: 2.08, 95% CI: 1.13–3.85).

Discussion

This is the first study to assess factors related to PrEP use among MSM in Malaysia. Individual behaviors, such as sexual practices, drug use, and health services utilization, played the largest role in engagement with PrEP, which aligns well with prior studies examining willingness to use PrEP in this population.¹⁴ Unlike previous studies, however, social and ethnocultural factors hypothesized as significant predictors of PrEP use were not related to PrEP uptake in this sample.¹⁸

Although chemsex is traditionally associated with increased sexual risk-taking (e.g. group sex, condomless sex) and STIs, including HIV, this study revealed that participants who engage in chemsex are more likely to use PrEP.¹⁹ Interestingly enough, group sex (another high-risk sexual practice) was also significantly associated with PrEP uptake in the bivariate analysis, although insignificant in the final model. Despite mixed findings on the associations between chemsex and PrEP use, this is not the first study to find a higher utilization of health services for MSM engaging in chemsex.²⁰ Multiple studies of MSM across Europe revealed that most MSM that engaged in chemsex had attended a sexual health clinic and had an HIV test done in the last year.^21,22 Another study of GSN users on Hornet (a GSN app marketed for gay men) in Mexico found a threefold higher odds of PrEP use among chemsex participating users.²³ Therefore, the finding that chemsex is associated with PrEP uptake is encouraging and not unfounded. Those individuals engaging in the highest-risk sexual practices, such as condomless sex or group sex, were the most likely to use PrEP to prevent HIV. A prior study done in France and Canada, for example, revealed that participants reporting chemsex had a higher HIV risk perception, which may lend itself to this finding.²⁴ While perceived risk does not always translate into changed behavior,²⁵ it was clear that there was some association with actual risk and PrEP uptake. It appears that MSM who engage in chemsex may have a high degree of self-awareness of their risk behavior, particularly their drug use, which may motivate them to engage in health services and get a PrEP prescription.

Similar to other studies, those who recently received health care services, such as through an HIV test in the previous 6 months, were significantly more likely to have used PrEP – a medication that requires a provider prescription.^{26, 27} Prior research has shown that engagement with health care services is associated with positive or improved HIV prevention and treatment outcomes.²⁶ Unfortunately, uptake of HIV testing among Malaysian MSM has remained relatively modest (~70.4%), well below the 90% target declared by the United Nations.²⁸ In our study, recent HIV testing (in the past 6 months or earlier) was markedly lower, indicating a potentially lower uptake of health services in general. While we cannot determine the temporal relationship between HIV testing and PrEP use – for example, if testing to initiate or remain on PrEP was the cause of this association – this finding still emphasizes the importance of expedited engagement to care for marginalized populations, such as MSM.

Like participating in recent HIV testing, diagnosis with an STI was significantly related to uptake of PrEP in this population. Although not assessed through temporal mechanisms, we hypothesize that initial engagement with STI testing may lead individuals to be more involved in the health care system and subsequently more likely to speak to their providers about PrEP. On the other hand, it is possible that being on PrEP could have discouraged condom usage due to a perception that PrEP provides protection for other STIs, not just HIV.²⁹ While this is possible, the over-whelming benefits of PrEP cannot be overshadowed and further longitudinal research in this context must be conducted. As a preventive strategy, programs looking to optimize PrEP uptake among MSM in Malaysia may also highlight the importance of frequent STI testing while taking PrEP. Additionally, prior research has shown that being diagnosed with an STI is associated with recent and incident HIV infections.³⁰ This connection to HIV acquisition, in addition to associations with a greater number of sexual partners, group sex, and injection drug use might alert providers that PrEP may be warranted.²⁹ With this in mind, prioritizing connection to PrEP services for individuals that receive a positive diagnosis with an STI might be a meaningful strategy to ensure that high-risk MSM receive PrEP in a timely manner.³¹

As also found by How Lim et al., disclosure of sexual orientation was significantly associated with an increased likelihood of PrEP uptake.¹⁴ Outward disclosure of one’s sexual orientation may be associated with an increased likelihood of engaging with health services and making individuals more open to sharing their sexual practices with family, friends, and healthcare providers.³² It might also decrease reluctance to discuss PrEP use with partners and providers while diminishing the likelihood of engaging in unsafe behaviors.³³ MSM who do not hide their sexuality are reported to seek out less high-risk behaviors to engage in sexual practices favorable to them. Meanwhile, structural factors, such as the illegalization of same-sex sexual behavior in Malaysia, may impact the ability for men to disclose their sexual orientation.³⁴ Thus, not having the ability to disclose their sexual orientation in a safe environment could potentially be exacerbating the HIVepidemic within the MSM community in Malaysia.

As with any study, there were several limitations. Our study used convenience sampling through advertisements on GSN apps for MSM and social networking websites for the general population. This sampling method likely allowed us to get a relatively representative sample of MSM in Malaysia but may have missed individuals not involved in these platforms. Coupled with access issues, responses may have been influenced by social desirability or recall biases which are common issues relevant to cross-sectional studies. Likewise, due to the nature of the study, we could not assess causal mechanisms for PrEP uptake that would have been available in a longitudinal study. For example, we could not temporally assess the true association between STI diagnosis and PrEP use. Similarly, our survey only assessed lifetime PrEP uptake, which may have resulted in different findings than a study of recent or current PrEP use. Because we did not assess recent or current PrEP use, our conclusions may not translate well into determining factors that predict readiness or general willingness to initiate PrEP for the prevention of sexual risk. Overall, the small sample size and the small number of participants reporting PrEP use may have introduced type-2 errors (not detecting a significant, true association), which could have impacted our results. Although we slightly overrepresented individuals pursuing a tertiary level of education in Malaysia, which may have resulted in an artifactually high level of awareness, we still captured a substantial number of responses from individuals with lower educational attainment.³⁵ Despite these limitations, we believe that our study’s strengths far outweigh its limitations. The insights provided on the drivers of PrEP use among MSM in Malaysia will be profoundly valuable for alleviating the burden of the HIV epidemic and tailoring public health programs related to PrEP within this context.

Conclusion

As several countries in the Asia Pacific region embark on nationwide PrEP implementation, the implications for this study are paramount.³⁶ PrEP can be a valuable tool for preventing HIV among key populations, including MSM, who are at increased risk of HIV infection due to various individual (e.g. high-risk sexual practices), provider (e.g. stigmatization), and structural (e.g. the illegality of same-sex sexual behavior) factors. This study revealed that utilization of PrEP among MSM in Malaysia is alarmingly low, despite high awareness. It appears that awareness alone is insufficient in increasing PrEP uptake; however, targeted behavioral interventions could enhance the HIV prevention landscape in Malaysia. Our findings highlight the need for better public health programming around PrEP and other HIV risk reduction strategies among MSM in Malaysia and the need for tailored programs for individuals who may be at increased risk. Existing services should focus on strategies that will decrease stigma around PrEP and HIV-related services and provide an environment where MSM can disclose their sexuality. Ultimately, any national program to halt the HIV epidemic in Malaysia should focus on expediting care and testing for MSM with an elevated risk of HIV infection and the importance of inclusive educational programming that further empowers MSM to disclose their sexuality safely.

Abbreviations

AIDS

Acquired Immunodeficiency Syndrome

GSN

Geosocial Networking Apps

HIV

Human immunodeficiency virus

mHealth

Mobile Health

MSM

Men who have sex with men

OR

Odds ratio

PrEP

Pre-exposure prophylaxis for HIV

PWID

People who inject drugs

RM

Malaysian Ringgit

STI

Sexually transmitted infection

UMREC

University of Malaya Research Ethics Committee

USD

United States Dollar

WHO

World Health Organization