Factors that motivate men who have sex with men in Berlin, Germany, to use or consider using HIV pre-exposure prophylaxis-A multi-methods analysis of data from a multicentre survey.

Background: While our knowledge of what motivates men who have sex with men (MSM) to use HIV pre-exposure prophylaxis (PrEP) has grown in recent years, quantitative survey-based studies have not asked MSM explicitly to name their motivations. We did so using a qualitative open-ended question and aimed to categorise the responses and explore whether these were related to where MSM were located along a conceptual continuum of PrEP care.

Methods: In a multicentre survey examining knowledge and use of PrEP among MSM in Berlin, Germany, we additionally asked an open-ended question about motivations for using or considering PrEP. Data were collected from 10/2017-04/2018. One researcher developed a thematic framework deductively from the literature and another did so inductively from the free-text data, and a merged framework was used to code responses independently. We used Fisher's exact test to assess whether the frequency of motivations differed significantly between respondents using or considering PrEP.

Results: Of 875 questionnaires, 473 were returned and 228 contained a free-text response. Motivations in the following categories were reported: (1) Safety/protection against HIV (80.2% of participants, including general safety; additional protection to condoms), (2) Mental well-being and quality of life (23.5%, including reduced anxiety; better quality of life), (3) Condom attitudes (18.9% intent not to use condoms), (4) Expectations about sexuality (14.4%, including worry-free sex or more pleasurable sex, with explicit mention of sex or sexuality), (5) Norms/social perspectives (0.8%). The difference in frequencies of motivations between those using or considering PrEP was not statistically significant.

Conclusions: Safety and protection against HIV, particularly having additional protection if condoms fail, were the most common motivations for using or considering PrEP, followed by mental well-being and quality of life. Many respondents reported several motivations, and responses overall were heterogeneous. This suggests that approaches to increase PrEP uptake that focus exclusively on its effectiveness in preventing HIV are unlikely to be as successful as a holistic approach that emphasises multiple motivations and how these fit into the broader sexual and psychological health of MSM.