Acceptability and feasibility of HIV pre-exposure prophylaxis (PrEP) in Southeast Asia: A scoping review

Abstract

Background

The availability of HIV pre-exposure prophylaxis (PrEP) in Southeast Asia remains limited compared to regions like Western Europe or North America. Additionally, little is known about how key populations in Southeast Asia perceive the use of PrEP as a prevention tool for HIV. This scoping review aims to provide an overview of the literature on the acceptability and feasibility of HIV PrEP programs in Southeast Asia.

Methods

We conducted a systematic search using nine electronic databases, gray literature searches, and hand searches of references in included full-text articles. Following PRISMA guidelines for scoping reviews, we focused on original research articles published in English from July 2012 to December 2022. A narrative synthesis was used to summarize the findings.

Results

We identified 8,871 articles through the database search, removed 1,094 duplicates, and excluded 7,745 articles after title and abstract screening. Over 28 articles met the inclusion criteria. The use of PrEP was found to be highly acceptable, with participants showing a willingness to use and pay for it, moderate usage rates, convenience, and preference over other prevention methods. It was also considered highly feasible due to its effectiveness and successful program implementation. However, barriers included risk compensation, concerns about side effects, the burden of daily pill administration, and, most commonly noted in studies, cost.

Conclusion

HIV PrEP has been shown to be both acceptable and feasible. The necessity for direct efforts to expand PrEP access in Southeast Asia and address barriers to its uptake and adherence underscores the importance of ongoing monitoring and implementation.

Keywords

Acceptability feasibility HIV pre-exposure prophylaxis Southeast Asia

Introduction

Human Immunodeficiency Virus (HIV) is one of the most extensively studied viruses in history. Significant investments in research have led to remarkable advancements in our understanding of its biology and pathogenesis and the development of life-saving antiretroviral therapies (ART).¹

The 90-90-90 targets, introduced by UNAIDS in 2014, have significantly influenced HIV testing and treatment efforts. These targets aim for at least 73% of all individuals living with HIV to achieve reduced viral levels, ensuring their health and preventing further transmission.² Initially dismissed as unrealistic, they were later endorsed by the UN General Assembly as a global goal for 2020. By the deadline, eight nations had fully met the targets, with 11 others achieving 73% viral load suppression.² In 2021, UNAIDS launched the 95-95-95 targets, aiming to identify 95% of people living with HIV, provide antiretroviral therapy (ART) to 95% of them, and achieve viral suppression in 95% of treated cases by 2030.³ Despite advancements, numerous countries, including those in Southeast Asia, continue to fall short of HIV treatment goals.

The Southeast Asia Region, comprising 11 countries - Brunei, Burma (Myanmar), Cambodia, Timor-Leste, Indonesia, Laos, Malaysia, the Philippines, Singapore, Thailand, and Vietnam – had an estimated 5.8 million people living with HIV/AIDS in 2022.⁴ Key populations at heightened risk include sex workers and their clients, men who have sex with men (MSM), transgender individuals, and people who inject drugs (PWID). These groups also face disproportionately high rates of sexually transmitted infections.⁴

The Joint United Nations Programme on HIV/AIDS has supported comprehensive epidemiological surveillance across the region, enabling more targeted prevention efforts, including expanding pre-exposure prophylaxis (PrEP) availability to vulnerable populations. Despite these efforts, as of 2023, approximately 84,000 individuals in Southeast Asia died from HIV-related causes, and around 140,000 people acquired HIV.⁵ Although there have been ongoing initiatives to reduce these figures, progress remains slow, particularly among key populations such as MSM, PWID, and sex workers.⁵ A significant number of new infections occur in men, underscoring the urgent need to scale up preventive measures, including PrEP, to curb the epidemic effectively.

In 2012, WHO published the first clinical practice guideline for PrEP, and the United States became the first nation to approve tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for HIV prevention. By December 2018, 44 nations including Brazil, Malawi, Thailand, and South Africa, had approved TDF/FTC for PrEP. In 2015, WHO released guidelines recommending antiretroviral PrEP as an additional HIV prevention measure for those at high risk.⁶ Thailand has prioritized making PrEP accessible to MSM, while Vietnam has focused its efforts on increasing PrEP access for PWID.⁷

In recent years, significant progress has been made in developing PrEP. These advancements include compelling evidence of its effectiveness in reducing HIV risk, regulatory approval of the oral combination drug TDF/FTC as the first PrEP medication for sexual HIV prevention, and the establishment of clinical prescribing guidelines.⁸ However, many PrEP programs incorporate acceptability assessments, acknowledging that not all participants may adhere to the regimen during trials. Additionally, some individuals may choose not to use PrEP even when it is accessible due to personal preferences.^9,10 This highlights the importance of feasibility and adherence in maximizing PrEP’s effectiveness and positioning it as a critical prevention strategy.

Several studies have explored HIV PrEP awareness and usage in countries such as Thailand,^9–11 Myanmar,¹² and Vietnam.^8,13 In Thailand, PrEP services have been implemented as a pilot program funded by both public and private sectors, including the Joint United Nations Program on HIV/AIDS, the Thai Red Cross Princess Soamsawali HIV Prevention Program (also known as the “Princess PrEP Program”), and the Global Fund to Fight AIDS, Tuberculosis, and Malaria.¹⁴ Cross-sectional surveys have shown that willingness to use PrEP ranged from 36% to 41% among Thai MSM and transgender individuals.^15,16 In Myanmar, reported awareness of PrEP was only 5% among a group of 326 MSM and 103 transgender individuals. However, the overall willingness to take PrEP was high, with 62% of MSM and 66% of transgender individuals expressing interest.¹⁷ These findings highlight the variability in PrEP awareness and interest among key populations in Southeast Asian countries.

PrEP availability in Southeast Asia is more limited compared to regions like Western Europe or North America.¹² For instance, in Thailand, only 35% of the 44,697 individuals targeted in the 2022 PrEP implementation goal were accessing PrEP.¹⁸ In contrast, 1.2 million Americans could benefit from a PrEP prescription, with 36% accessing PrEP in 2022.¹⁹ In England, 86,324 people started or continued PrEP, representing 85.4% of those with an identified need, marking a 40.3% increase from 2021.²⁰

Given these variations in PrEP awareness, interest, and availability, understanding the factors influencing the acceptability and feasibility of PrEP programs in Southeast Asia is crucial. Therefore, this scoping review aims to examine the state of HIV PrEP programs in the region, focusing on two key objectives: (1) to assess the acceptability and feasibility of HIV PrEP programs in Southeast Asia and (2) to identify the factors influencing these outcomes.

Methods

We carried out this scoping review following the Preferred Reporting Items for Systematic Review and Meta Analyses extension for Scoping Reviews (PRISMA – ScR) 2020 Checklist (Supplementary file 1). We established and registered a protocol in the Open Science Framework (doi.org/10.17605/OSF.IO/976ZV) (Supplementary file 2).

Patient and public involvement

There was no patient or public involvement because the scoping review method was focused on studying and gathering data from publicly accessible literature.

Study design

To meet the study’s objectives, this scoping review was conducted following the Arksey and O'Malley framework. This framework includes five stages: identifying the research question, identifying relevant studies, selecting the studies, charting the data, and collating, summarizing, and reporting the results.²¹

Types of sources

We utilized primary sources, including original research articles published in peer-reviewed journals. These studies were supplemented by secondary sources comprising review articles, editorials, and other literature reviews. Moreover, gray literature was also used in the conduct of this study to ensure comprehensive analysis pertinent to the acceptability and feasibility of HIV PrEP.

Search strategy

We developed a thorough and systematic search strategy using both keywords and MeSH terms relevant to HIV PrEP (Supplementary file 3). This approach ensured that we captured the broadest range of relevant studies, which were then carefully selected for inclusion in the review based on predefined eligibility criteria. The search for relevant studies was conducted with a date restriction between July 1, 2012, and December 21, 2022. This period starts from when the U.S. FDA approved the first HIV PrEP medication. To ensure comprehensive coverage of relevant literature, the search strategy was facilitated by the research supervisor (RRC), who accessed multiple electronic databases including Medline/PubMed, Web of Science, Academic Search Premier, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Psychology and Behavioral Sciences Collection, SocINDEX, PsycInfo, PsycArticles, and the Cochrane Library. In addition to these databases, gray literature was identified through health websites (e.g., WHO, UNAIDS), and a hand-search of references was also conducted to include potentially relevant articles during the full-text screening process.

Study selection

Articles that addressed the objective and intervention of this study were retrieved and reviewed in full text. The literature articles from digital search process were collected and exported using EndNote, a reference management software.

Inclusion criteria

Population

This study involved people who are at risk of acquiring HIV, as well as people who are part of the key population, such as MSM, women who work in the sex industry, pregnant women, transgender women (TGW), teenagers, PWID, and people who have multiple sexual partners.

Intervention

The intervention used in the study is HIV PrEP.

Comparison

The comparators of the study are condom use and non-HIV PrEP users. However, studies that do not contain a reference to the comparison groups are also included in this review.

Outcomes

This study focused on the outcomes pertaining to the acceptability and feasibility of HIV PrEP. The concept of ‘acceptability’ refers to the degree to which an intervention is likely to be accepted by the target population, and whether or not the component of the intervention are likely to meet the needs of the target population and organizational setting.²² The following parameters were used to assess the acceptability of HIV PrEP: willingness to use and pay, number of participants who use HIV PrEP, convenience of use, and preference over other types of prevention. On the other hand, ‘feasibility’ is defined as the practicality and likelihood of successful implementation of HIV PrEP in real-world settings.²³ Feasibility was evaluated by the effectiveness of the intervention and implementation of HIV PrEP. We also included in the synthesis the factors influencing the acceptability and feasibility of HIV PrEP in Southeast Asia.

Study setting

Southeast Asia, which is composed of Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, Timor-Leste and Vietnam.

Exclusion criteria

All publications not written in English/or and published before July 1, 2012, were excluded in this review.

Data extraction

We created data extraction tables and obtained the following: author name(s), date and title, location of study, research design, population observed, intervention of the study, comparators, acceptability of PrEP programs, feasibility to implement and monitor PrEP programs and key findings that were related to the study objective. Three authors (CAR, EGS, and CMS) independently conducted the data extraction, which was subsequently cross-checked for accuracy by one author (JRE). A tabular framework was used to organize the quantitative and qualitative data that were taken from the articles. Consistency issues were addressed with the research supervisor (RRC).

Collating, summarizing, and reporting the results

We used categories to chart data, mapping gaps and findings on HIV PrEP acceptability in Southeast Asia. Descriptive numerical summaries of included studies’ characteristics were reported, along with a narrative synthesis, which proved beneficial for synthesizing evidence across various literature on HIV PrEP programs’ acceptability and feasibility. As scoping review, we did not conduct a risk of bias assessment, focusing instead on comprehensively mapping existing literature. Recommendations were provided to enhance the current status of HIV PrEP in Southeast Asia.

Results

Out of the 8,871 reports identified through the database search, 1,094 duplicate records were removed, and 7,745 articles were excluded after title and abstract screening. A total of 32 studies were successfully retrieved and screened in full text. After the assessment for eligibility of each study, 10 articles were excluded for reasons listed in Supplementary file 4. 17 relevant studies from reference lists of the eligible studies were screened in full text, 11 studies were excluded for reasons stated in Supplementary file 4. In total, 28 studies were included in this review (Figure 1). Tables 1 and 2 summarize the characteristics of the included studies. For a detailed PICO, please refer to Supplementary file 5. Furthermore, the barriers influencing acceptability and feasibility were identified as follows: risk compensation, concerns about side effects, the burden of daily pill administration, adherence issues, and cost.

Figure 1.

Flow diagram of the process of article selection.

Table 1.

Characteristics of included studies reporting acceptability of HIV PrEP in Southeast Asia.

Author, Year Location	Study design	Study setting	Study population	Sample size	Intervention	Comparator	Reported outcomes
Bourne, 2017 Malaysia	Qualitative	Kuala Lumpur, Malaysia	Biological male, MSM	19	Truvada®	Condom use	Many participants viewed PrEP as an additional layer of protection. It was also perceived as more valuable to “at-risk” men, such as those in HIV sero-discordant relationships or those with a higher number of sexual partners.
Cempaka, 2020 Indonesia	Cross-sectional	Clinic in Denpasar, Bali, Indonesia	MSM and TGW (known locally as “waria”) attending a non-government HIV testing and treatment clinic	220	Truvada®	No comparison group	Interested in using PrEP (74.5%); willing to do the PrEP procedure (60.9%); willing to pay 500-600k Indonesian Rupiah for PrEP (38.2%).
Chautrakarn, 2022 Thailand	Cross-sectional	Hospital and KPLHS settings in Thailand	Heterosexuals, bisexuals, MSM, transgender people, pansexual lesbians, and others from active PrEP service centers	513	Truvada®	No comparison group	The majority of hospital respondents who continued taking PrEP (63.7%) and followed by newly offered and agreed to initiate PrEP (20.3%); PrEP discontinuous due to low risk behaviors or do not want to continue taking PrEP for any reason (17.7%).
Draper, 2017 Myanmar	Cross-sectional	Yangon and Mandalay, Myanmar	HIV undiagnosed TGW	434	HIV PrEP	No comparison group	PrEP awareness was low (5%). PrEP acceptability was high, with 270 (62%) GMT classified as willing to use PrEP.
Galka, 2020 Malaysia	Cross-sectional	Selangor, Penang, and Negri Sembilan, and in Kuantan, Pahang, in East Malaysia	TGW	361	HIV PrEP	No comparison group	The majority (82.5%) expressed high willingness to take PrEP and most participants met the world health organization (WHO) indication for PrEP (82.3%).
Green, 2021 Vietnam	Qualitative	Three KP-led clinics and four public district hospital HIV OPCs in Ho Chi Minh	MSM and TGW	1069 MSM, 62 TGW	RICOVIR-EM (fixed-dose tenofovir disoproxil fumarate (TDF) 300 mg/emtricitabine (FTC) 200 mg – TDF/FTC)	No comparison group	PrEP is highly acceptable among MSM and moderately acceptable among TGW.
Khawcharoenporn, 2015 Thailand	Cross-sectional	Public University in Thailand	Thai University students	641	HIV PrEP	Condom use	Taking PrEP once a week was the most acceptable option (75%), while taking PrEP once a day was the least accepted option (43%).
Lim, 2017 Malaysia	Cross-sectional	All states of Malaysia including East Malaysia	MSM	990	HIV PrEP	No comparison group	Fewer than half of participants (44%) knew about PrEP before completing the survey. Over- all, 39% of the sample were interested to take PrEP.
Nguyen, 2021 Vietnam	Qualitative	Hanoi, Vietnam	MSM	30	HIV PrEP	Condom use	Most of the participants perceived PrEP as a promising intervention tool given its effectiveness in HIV transmission reduction and expressed their interest in using PrEP in the future.
Oldenburg, 2014 Vietnam	Qualitative	Ho Chi Minh City, Vietnam	MSW	281	HIV PrEP	No comparison group	MSW who reported previous contact with a PE (AOR 2.28, 95% CI 1.25–4.14) indicated increased willingness to use PrEP.
Oldenburg, 2018 Vietnam	Cross-sectional	Ho Chi Minh City, Vietnam	HIV- negative TGW	168	TDF-FTC	No comparison group	Participants who were willing to pay more for PrEP had reduced odds of indicating rectal microbicides to be their preferred PrEP modality (AOR 0.81 per one-unit increase in amount willing to pay for PrEP, 95% CI 0.72–0.92).
Plotzker, 2017 Thailand	Observational cohort	Four Thai urban community clinics in Thailand	MSM and TGW at a community-based health service	297	Emtricitabine/tenofovir (FTC/TDF)	No comparison group	Accepted PrEP (48% of MSM and 54% of TG). The vast majority of participants did not feel embarrassed to take PrEP (93.1%), and under one-third (31.8%) reported anxiety toward taking PrEP.
Ramautarsing, 2020 Thailand	Cross-sectional	Bangkok, Chonburi, Chiang Mai, Chiang Rai, Songkhla, and Ubonratchathani, Thailand	MSM and TGW who received HIV testing in Princess PrEP	6287 MSM and 900 TGW	HIV PrEP	No comparison group	(48%) participants accepted PrEP. When disaggregated by age, MSM younger than 25 years old had lower acceptance of PrEP compared to MSM aged 25 years or older. TGW younger than 25 years old had lower acceptance of PrEP compared to those aged 25 years or older.
Restar, 2020 Philippines	Cross-sectional	Manila and Cebu, Philippines	cis-MSM	179	HIV PrEP	No comparison group	Most of the participants were aware of PrEP (74.9%) and were interested in taking PrEP (88.8%).
Restar, 2020 Philippines	Cross-sectional	Metro Manila / National Capital region (NCR) and Central Visayas, Philippines	Filipina TGW	139	HIV PrEP	No comparison group	53% of Filipina transwomen were unaware of PrEP, but almost all (93%) expressed interest in taking PrEP once learning about it.
Sineath, 2013 Thailand	Cross-sectional	Thailand	MSM	404	TDF/FTC FDC, Truvada	Condom use	Of 144 PrEP-interested men, top reasons included extra protection from HIV (75%, past/future unprotected sex (65%), and having partners of unknown HIV status (53%).
Tan, 2018 Singapore	Cross-sectional	Singapore	Gay, bisexual, MSM	1098	TDF-FTC	No comparison group	Of those who had ever taken PrEP, 59.6% had obtained PrEP from overseas or other unofficial sources. Of those who had heard of but never taken PrEP, 73.3% reported that they would consider taking PrEP.
Wheelock, 2013 Thailand	Cross-sectional	Non-governmental organizations (NGO), nightclubs, red-light districts, saunas, streets, and universities in Bangkok and Chiang Mai, Thailand	MSM and TGW	259 MSM and 1 TGW	Truvada	No comparison group	Participants’ willingness to use PrEP remained high even after learning of potential mild side effects (56.5%), having to pay 150 Baht/month for it (58.8%). Yet, most participants felt that PrEP would give them hope for new possibilities in their lives (55.8%).
Wong, 2019 Singapore	Qualitative	Public HIV and sexual health clinics in Singapore	Cis-gender men	33	HIV PrEP	Condom use	PrEP was regarded by participants as a novel alternative to condoms and considered to be more convenient and allowed for more sexual spontaneity.
Yang, 2013 Thailand	Cross-sectional	PIMAN clinic in Chiang Mai, Thailand	MSM and TGW	131 MSM and 107 TGW	TDF-FTC	No comparison group	66% of both MSM and TGW respondents had prior knowledge of PrEP. Acceptability was 41% among MSM and 37% among TGW.

Cis-MSM, cisgender men who have sex with men; FDC, fixed-dose combination; GMT, gay men transgender; HIV PrEP, HIV pre-exposure prophylaxis; KP, key population; KPLHS, Key Population-Led Health Services; MSM, men who have sex with men; MSW, male sex workers; NCR, National Capital Region; PE, peer educator; TDF-FTC, tenofovir disoproxil fumarate and emtricitabine; TGW, transgender women.

Table 2.

Characteristics of included studies reporting feasibility of HIV PrEP in Southeast Asia.

Author, Year Location	Study design	Study setting	Study population	Sample size	Intervention	Comparator	Reported outcomes
Chemnasiri, 2020 Thailand	Qualitative	HIV prevention trial Network 067 (HPTN 067) site in Bangkok, Thailand	MSM	179	Oral TDF-FTC PrEP dosing regimens	Oral TDF-FTC taken daily, time-driven, and event-driven	Concern about PrEP efficacy, and to some extent safety, were barriers to adherence. Participants recommended offering both daily and non-daily PrEP regimens in practice.
Choopanya, 2013 Thailand	RCT	17 drug-treatment clinics in densely populated urban communities of Bangkok, Thailand	Injecting drug users	2413	Tenofovir	Placebo	Efficacy rose from 46% to 56% in pre-protocol analysis with observed adherence and to 74% in participants with detectable tenofovir concentrations. Women (79%) and participants aged 40+ (89%), both high adherers, showed higher efficacy.
Colby, 2015 Thailand	Qualitative	Chiang Mai and Bangkok, Thailand	MSM and TGW	Varies per study mentioned	TDF-FTC taken daily	TDF-FTC taken intermittently; intermittent rectal gel	Oral PrEP has been proven to be effective at reducing HIV transmission among MSM, as well as among heterosexuals and PWID.
Doan, 2022 Vietnam	Cross-sectional	Clinics in Vietnam	TGW	124	Long-acting cabotegravir	No comparison group	A cumulative transgender women’s PrEP increased 46 in 2018 to 638 participants in 2021 as they implemented an outreach for transgender women-led communications campaign on PrEP use and hormones to address concerns expressed by the community.
Galka, 2020 Malaysia	Cross-sectional	Selangor, Penang, and Negri Sembilan, and in Kuantan, Pahang, in East Malaysia	TGW	361	HIV PrEP	No comparison group	High willingness among TGW to use PrEP, along with positive associations between PrEP hormone use, and willingness highlight its potential as an effective HIV prevention strategy.
Green, 2021 Vietnam	Qualitative	Three KP-led clinics and four public district hospital HIV OPCs in Ho Chi Minh	MSM and TGW	1069 MSM, 62 TGW	RICOVIR-EM (fixed-dose tenofovir disoproxil fumarate (TDF) 300 mg/emtricitabine (FTC) 200 mg – TDF/FTC)	No comparison group	Average monthly PrEP enrolment among MSM increased five- fold from the first 3 months (Mar–Jun 2017) to the last 3 months of active enrolment (Mar–Jun 2018), whereas for TGW, no increased trend in PrEP enrolment per quarter was seen.
Nittaya, 2018 Thailand	Quantitative	Thailand	MSM and TGW	1697	Tenofovir disoproxil fumarate (TDF) 300 mg/Emtricitabine (FTC) 200 mg	No comparison group	Among clients who attended clinic visits and reported currently taking PrEP, adherence to at least four PrEP pills per week was reported by 97.4%, 96.8%, 96.5%, 97.5% and 99.5% at Months 3, 6, 9 and 12 respectively.
Oldenburg, 2018 Vietnam	Cross-sectional	Ho Chi Minh City, Vietnam	HIV-negative TGW	168	TDF-FTC	No comparison group	Implementation programs in Vietnam may benefit from offering a variety of PrEP modalities, should they be shown to be effective.
Seekaew, 2019 Thailand	Cross-sectional	Bangkok, Chonburi, Chiang Mai, and Songkhla	MSM and TGW	564 MSM and 89 TGW	TDF-FTC	No comparison group	Urgent, innovative strategies for PrEP adherence and retention support for vulnerable sub-populations such as younger users, transgender women, and new clients.

HIV PrEP, HIV pre-exposure prophylaxis; MSM, men who have sex with men; OSS, one-stop shop; PWID, people who inject drugs; TDF-FTC, tenofovir disoproxil fumarate and emtricitabine; TGW, transgender women.

Acceptability of HIV PrEP

In most studies, HIV PrEP was highly acceptable as listed in Table 1. Four key factors were identified as crucial in determining the high acceptability rates of HIV PrEP: convenience, availability, increased awareness, and growing interest in HIV PrEP.

Willingness to use

Nine studies indicated high levels of willingness in taking PrEP. These studies were conducted in Indonesia, Myanmar, Malaysia, Thailand, Singapore, and the Philippines. Two quantitative studies in the Philippines represent the first effort to characterize PrEP awareness and willingness to take PrEP among a sample of Filipino cisgender Men who have sex with Men (cis-MSM) and TGW. It was found that 92.8% TGW were interested in taking PrEP.²⁴ However, in Malaysia, men who identified as heterosexual were less willing to use PrEP.²⁵

Notably, a qualitative study conducted in Vietnam reported that MSW who had previous contact with a peer educator indicated increased willingness to use PrEP.⁸ Additionally, three cross-sectional studies in Indonesia, Myanmar, and Singapore showed that MSM and TGW had high interest in using PrEP after having the attributes of PrEP explained.^17,26,27 In Bali, Indonesia, 74.5% of MSM and TGW expressed interest in using PrEP.²⁶ Similarly, in Myanmar, 62% of gay men, MSM, and TGW indicated a willingness to use PrEP.¹⁷ In Singapore, 70% of HIV-negative participants showed interest in using PrEP.²⁷

Willingness to pay

Five quantitative studies conducted in Malaysia, Vietnam, and Thailand explored the willingness to pay for PrEP. In Malaysia, most TGW were willing to pay an average of US$17.50 per month for PrEP.²⁸ Additionally, about one-third of 990 MSM indicated they would be willing to pay out-of-pocket for the medication, with a preference for a cost below 200 Malaysian Ringgit (RM; approximately US$50) per month.²⁵ In Vietnam, a study found that most TGW were willing to pay at least a small amount, specifically 100,000 Vietnam Dong (VND; about US$4).²⁹ In Thailand, the majority of MSM and TGW expressed a willingness to pay a reasonable price, with the minimum amount indicated being 750 Thai Baht (around US$25) per month.^16,30 However, a cross-sectional study in Indonesia revealed that MSM had a lower willingness to pay, with only 38.2% willing to do so when the average cost for a 1-month supply of PrEP ranged between US$33.48 and 40.17.²⁶

Number of participants who use HIV PrEP

Three cross-sectional studies reported on the number of participants who had used HIV PrEP. In Singapore, 15.0% (n = 154) of homosexual, bisexual, and MSM individuals reported having used PrEP, with 59.6% (n = 90) of these users obtaining it from overseas or other unofficial sources.²⁷ Meanwhile, in Thailand, hospital-based respondents continued to use PrEP at a rate of 63.8%.³¹

Convenience of use

Two studies highlighted the convenience of using HIV PrEP. In Singapore, a qualitative study found that most cis-MSM participants viewed PrEP as a novel alternative to condoms, citing its convenience and ability to facilitate greater sexual spontaneity.³² Additionally, a cross-sectional study in Thailand indicated that 67% of students preferred a weekly administration of PrEP over a daily regimen due to the increased convenience.³³

Preference for PrEP regimens and other types of prevention

Three cross-sectional studies conducted in Malaysia, Thailand, and Vietnam examined preferences for PrEP regimens and other HIV prevention methods. In Vietnam, HIV-negative younger TGWs preferred rectal microbicides and daily oral pills, whereas older TGWs favored long-acting injectables over rectal microbicides.²⁹ Similarly, a significant proportion of TGW in Malaysia indicated a preference for oral PrEP (83.1%) compared to a bimonthly injectable formulation (16.9%).²⁸ In Thailand, the majority of MSM and TGW preferred using condoms in conjunction with PrEP rather than relying on condoms alone.³⁰

Feasibility of HIV PrEP

HIV PrEP has demonstrated feasibility (Table 2) among key populations, with studies showing its effectiveness and successful implementation across various settings. These findings indicate that PrEP can play a crucial role in comprehensive HIV prevention strategies.

Effectiveness of HIV PrEP

Four studies in Thailand and Vietnam showed efficacy of HIV PrEP. In an RCT conducted in Thailand, the study primarily assessed the efficacy of PrEP in reducing HIV incidence as its primary endpoint.³⁴ This was achieved through a randomized, double-blind, placebo-controlled Phase 3 trial that included monthly HIV testing for participants who received either tenofovir or a placebo. The statistical findings indicated that tenofovir reduced the risk of HIV infection by 48.9% in the intention-to-treat analysis, demonstrating a significant impact on reducing HIV incidence among PWID. In the per-protocol analysis based on observed adherence, efficacy increased from 46.0% to 56.0%. Notably, the study found higher efficacy rates in women (79.0%) and participants aged 40 years and older (89.0%).³⁴

A qualitative study in Thailand highlighted both completed and ongoing PrEP clinical trials and demonstration projects. The iPrEx study was the first clinical trial to demonstrate the efficacy of oral PrEP, showing a 44.0% reduction in HIV infection across all sites with TDF/FTC combination.¹⁰ In Vietnam, a study found that among TGW, self-reported adherence to taking seven pills a week was 70.9% at month 3, 68.2% at month 6, 87.0% at month 9, 84.2% at month 12, 11.1% at month 15, and 88.9% at month 18.³⁵ However, another cross-sectional study reported that 37.4% of MSM and TGW indicated low adherence to services, defined as taking three pills per week or missing a clinic appointment at 1 month.³⁶

Implementation of the program

Four studies reported implementation of the HIV PrEP program. A qualitative study in Thailand included open-label PrEP extensions for TGW and MSM after the efficacy trials were finished, providing initial experience in implementing PrEP.¹⁰ This study emphasizes strong community engagement and comprehensive health systems that integrate PrEP into broader HIV prevention strategies, addressing the needs of key populations. MSM participants from Bangkok, Thailand, recommended the availability of both daily and non-daily PrEP regimens, allowing customization based on individual patterns of sexual events.³⁷ This approach highlights the importance of tailoring adherence strategies to offer flexibility in PrEP regimens. Hence, it will help improve adherence to taking HIV PrEP. Additionally, a cross-sectional study in Vietnam involving TGW found that having primary healthcare that is gender-competent can enhance PrEP enrollment and adherence, serving as an important entry point for patients seeking care at primary healthcare clinics.³⁸ However, three studies, also in Vietnam, reported a lack of awareness about oral PrEP among MSM and TGW, coupled with low interest in utilizing oral PrEP.^8,29,35

Factors influencing the acceptability and feasibility of PrEP

Risk compensation

Individuals often adjust their behavior based on a perceived decrease in risk associated with their use of PrEP. For instance, someone on PrEP might engage in riskier sexual behavior, believing they are effectively protected from HIV. This concern aligns with findings from an observational study conducted in Singapore, where 16 participants (12.4%) expressed worries about the potential for risk compensation within the community.²⁷ Additionally, a qualitative study in Vietnam highlighted that clinic offering PrEP services included counseling on risk compensation as part of their service delivery approach.³⁵

Worry about side effects

In an observational cohort study conducted in Thailand, participants expressed concerns about the potential side effects of PrEP, which is a common apprehension associated with any medication.³⁷ The most frequently reported side effects of PrEP include gastrointestinal symptoms; however, PrEP is generally considered safe and well-tolerated among the target population. Some participants noted experiencing minimal side effects, with these symptoms typically resolving within about 2 weeks.³⁷ Additionally, a cross-sectional study conducted in Thailand found that participants had a positive attitude towards PrEP use, with 52.7% expressing willingness to use PrEP even after learning about its potential mild side effects.¹⁶

Burden of daily pill administration

A cross-sectional study conducted in Thailand reported that participants preferred daily pills and longer-lasting injections in the arm as the primary routes of PrEP administration.¹⁶ Among the options for administration (e.g., a daily pill, a pill before and after sex, a monthly injection in the arm, or a bi-monthly injection in the buttocks), a daily pill was the most preferred, followed by a monthly injection in the arm.¹⁶

Cost

A cross-sectional study conducted in Thailand used a structured questionnaire to determine the participants willingness to pay for PrEP. Among the 260 participants, the results showed that 58.8% responded ‘Yes, definitely’ to the survey question regarding their willingness to pay for PrEP, with costs ranging from around 750 Thai Baht (approximately US$25) per month.¹⁶ In a qualitative study from Vietnam, 76.1% of MSM indicated a willingness to pay for PrEP, with a median of US$21.7 per month.³⁵ This highlights a significant portion of the population that finds the cost of PrEP prohibitive. Additionally, 23.9% of participants expressed that they were unwilling or unable to pay, indicating a substantial financial barrier for some individuals.³⁵ Furthermore, four studies reported that there is a gap between willingness to use PrEP and its uptake attributed to cost.^10,27,39,40

Preferred site for HIV PrEP delivery

In a cross-sectional survey conducted in Malaysia, the preferred venues for obtaining PrEP-related medical care and picking up medication were government clinics (32.7%), community-based NGOs (25.3%), and private clinics (23%).²⁸ TGW primarily favored government clinics, citing convenience (40.0%) and trustworthiness (26.8%) as their main reasons for preference.²⁸ A qualitative study in Thailand found that PWID preferred to receive PrEP at drug treatment centers and correctional facilities.¹⁰ In contrast, MSM preferred community-based clinics or NGOs for PrEP delivery.³⁹

Discussion

This scoping review provides a comprehensive collection and summary of the latest research on the acceptability and feasibility of HIV PrEP in Southeast Asia. Most studies indicate that PrEP is generally well-accepted among key populations at high risk for HIV, such as MSM, TGW, and PWID. Many participants perceive PrEP as a crucial tool for self-protection, mainly when used in conjunction with existing prevention strategies like condom use. Despite its effectiveness in reducing the risk of HIV infection, perceived barriers still influence the acceptability and feasibility of the intervention among these key populations. Addressing these barriers is essential to maximizing the potential benefits of PrEP.

One of the barriers identified in this study is the burden of daily pill administration. A study conducted in Thailand noted that non-daily regimens of HIV PrEP are more relevant for individuals who have infrequent sex. In contrast, daily regimens are better suited for those with frequent sexual activity.¹⁰ However, non-daily regimens come with precautions; it is advised not to exceed seven doses per week to avoid potential risks and adverse effects. Exceeding the prescribed dosage with non-daily regimens does not provide additional protection against HIV and may increase the likelihood of side effects. In contrast, daily regimens are designed for regular use and offer consistent protection without the same concerns regarding dosage frequency.³⁷ This review suggests that the choice between daily and non-daily regimens of HIV PrEP should be tailored to an individual’s sexual activity patterns, with careful adherence to prescribed dosages to minimize risks and ensure adequate protection.

The majority of studies indicate that, despite the general acceptance of HIV PrEP in Southeast Asia, significant barriers to its uptake persist beyond the burden of daily pill administration. These barriers include concerns about side effects, risk of compensation, and most commonly, cost.³¹ In contrast to nine studies showing high willingness to take PrEP, a cross-sectional study in Singapore observed that the cost of PrEP and concerns about anonymity in healthcare settings contribute to the gap between willingness to actual uptake.²⁷ For PrEP to significantly impact Singapore’s HIV/AIDS response, national financial schemes are necessary to increase access. Our findings highlight various factors beyond daily pill administration that influence PrEP uptake, especially in Southeast Asia. They emphasize the importance of financial and policy interventions to overcome these barriers and improve access to PrEP.

Several studies have identified national PrEP programs as part of comprehensive HIV prevention strategies in Thailand, Malaysia, Cambodia, Singapore, Vietnam, Myanmar, and the Philippines. These programs are implemented through their respective Departments or Ministries of Health, along with the support of non-governmental organizations. However, Indonesia, Brunei, Laos, and Timor-Leste do not have national PrEP programs, although efforts to address HIV prevention and treatment are ongoing. Some NGOs and research projects in Indonesia have initiated PrEP demonstration projects.²⁶

Guidelines for PrEP provision have been established by both WHO and CDC, recommending its use among key populations. For PWID, PrEP is advised alongside harm reduction strategies, such as needle and syringe programs and opioid substitution therapy.⁴¹ For TGW, the guidelines address interactions with gender-affirming hormone therapy, advocating for tailored care.⁴² In Thailand, PrEP is recommended not only for PWID and TGW but also for people with multiple partners and MSM. The Thai Ministry of Public Health has implemented PrEP programs targeting these groups as part of its broader HIV prevention strategy.^10,37 Meanwhile, in Malaysia, the national guidelines support PrEP provision for sex workers, PWID, and TGW in high-risk environments, aligning with WHO recommendations.³⁹

The results from Southeast Asia provide further evidence of PrEP’s feasibility and acceptability. Factors that can increase PrEP uptake include ensuring availability, tailoring doses to individual lifestyles, adapting regimens to sexual activities, offering daily and non-daily options, and providing support.^38–40 These strategies highlight the need for enhanced efforts to encourage and attract more individuals to use PrEP.

The primary strength of this scoping review lies in its systematic approach, which features a comprehensive search strategy, clearly defined inclusion and exclusion criteria, and meticulous data extraction and synthesis. This design allows for a thorough mapping of the evidence regarding the acceptability and feasibility of PrEP in Southeast Asia. Furthermore, the review’s scope is inclusive, encompassing all sexual orientations without being limited to a single gender or classification.

However, several limitations emerged. This review is limited to English-language publications. Additionally, we did not include studies from outside this region because we focused on recommending future research in PrEP implementation within Southeast Asia. This exclusion restricts the transferability of findings to other contexts without further local research. Furthermore, the heterogeneity in study designs, populations, and methodologies employed in the included studies prevents the review from conducting a meta-analysis. We recommend conducting more RCTs and longitudinal studies to examine the impact of PrEP on key populations more effectively. Despite these limitations, this review illustrates the acceptability and feasibility of HIV PrEP through a diverse range of studies.

Conclusion

HIV PrEP has been shown to be both acceptable and feasible, with existing research indicating that it can significantly reduce the incidence of HIV/AIDS. Factors influencing its acceptability include perceived interest, increased awareness, convenience, and availability. This review also emphasizes the feasibility of PrEP programs, particularly regarding their effectiveness and integration into existing HIV prevention and healthcare services. However, challenges persist, such as risk compensation, concerns about side effects, the burden of daily pill administration, adherence issues, and cost. Adhering to WHO guidelines for enhancing PrEP strategies could maximize its benefits for key populations. Efforts to expand access to PrEP and address barriers to uptake and adherence underscore the need for ongoing monitoring and support, especially for marginalized and vulnerable groups. Effective implementation of PrEP programs requires raising public awareness and providing facilities that offer affordable or accessible PrEP.

Supplemental Material

Supplemental Material - Acceptability and feasibility of HIV pre-exposure prophylaxis (PrEP) in Southeast Asia: A scoping review

Supplemental Material for Acceptability and feasibility of HIV pre-exposure prophylaxis (PrEP) in Southeast Asia: A scoping review by Justitia Roma Espera, Chaia Alyssa Reyes, Erla Grace Sarmiento, Czarina Mae Sitchon, Roueline Zantua and Rogie Royce Carandang by International Journal of STD & AIDS

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Justitia Roma Espera

Supplemental Material

Supplemental material for this article is available online.

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