From Acceptability to Affordability: A Decision Cascade Analysis of Long-Acting Injectable HIV Pre-Exposure Prophylaxis (Lenacapavir) Among HIV-Negative Men Who Have Sex with Men in Bali, Indonesia

From Acceptability to Affordability: A Decision Cascade Analysis of Long-Acting Injectable HIV Pre-Exposure Prophylaxis (Lenacapavir) Among HIV-Negative Men Who Have Sex with Men in Bali, Indonesia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Acceptability to Affordability: A Decision Cascade Analysis of Long-Acting Injectable HIV Pre-Exposure Prophylaxis (Lenacapavir) Among HIV-Negative Men Who Have Sex with Men in Bali, Indonesia Ngakan Putu Anom Harjana, Pande Putu Ida Oktayani, Brigitta Dhyah Kunthi Wardhani, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8727712/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Long-acting injectable HIV pre-exposure prophylaxis (PrEP) using lenacapavir (LEN) may reduce adherence challenges associated with daily oral PrEP. However, evidence remains limited on how populations at risk progress from acceptability to preference and affordability of LEN. We examined a sequential decision cascade for LEN among HIV-negative men who have sex with men (MSM) in Bali, Indonesia. Methods We conducted a cross-sectional survey among 116 HIV-negative MSM in Bali. Data included awareness of LEN, willingness to use LEN, preferred PrEP modality under hypothetical availability (LEN versus oral PrEP), and willingness to pay (WTP). Descriptive analyses characterised each cascade stage, and multivariable logistic regression identified factors associated with preference for LEN. Results Participants had a median age of 32 years (IQR 26.8–37.3), and 52.6% had ever used oral PrEP. Awareness of LEN was low, with only 28.4% having heard of LEN. Despite this, acceptability was high: 50.8% reported being willing or very willing to use LEN. Only 45.7% of respondents preferred LEN compared with oral PrEP, indicating attrition at the modality choice stage.. In multivariable analyses, perceived convenience of the six-monthly injection schedule was the only factor independently associated with preference for LEN (unadjusted OR 5.68, 95% CI 1.97–16.39; adjusted OR 4.91, 95% CI 1.65–14.59). No significant associations were observed for age, education level, prior oral PrEP use, perceived effectiveness, stigma-related concern, or concern about side effects. Willingness to pay further declined at > IDR 500.000 higher price thresholds, highlighting affordability as an additional barrier despite high acceptability. Conclusion Among HIV-negative MSM in Bali, acceptability of LEN was high, but preference and affordability were more selective. Considering the full decision cascade, from acceptability to affordability, is essential when planning the introduction of long-acting injectable PrEP. Health Economics & Outcomes Research Epidemiology HIV pre-exposure prophylaxis long-acting injectable PrEP lenacapavir men who have sex with men decision cascade Indonesia Figures Figure 1 Introduction Recent national surveillance data (SIHA) indicate that men who have sex with men (MSM) and transgender women continue to bear a disproportionate burden of HIV in Indonesia, with HIV prevalence of 24.4% among MSM and 28.9% among transgender women, based on IBBS 2024, substantially higher than prevalence observed among other key populations, including female sex workers (2.5%), and people who inject drugs (17.1%) [ 1 ]. Moreover, a study concudted in Jakarta and Bali also shows that high HIV prevalence 23.2% and 21.9%, respectively [ 2 ]. Pilot study in Indonesia reveals low retention of oral PrEP, due to poor adherence and high discontinuation rates in real-world settings, particularly men who have sex with men (MSM).[ 3 ] This persistent disparity underscores the ongoing vulnerability of MSM to HIV acquisition in Indonesia and other low- and middle-income countries. Although oral pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV when taken consistently, its real-world impact has been limited by challenges related to daily adherence, stigma, and discontinuation over time [ 3 , 4 ]. These constraints have intensified interest in long-acting HIV prevention technologies that may better align with the preferences, circumstances, and lived realities of populations at highest risk. Long-acting injectable PrEP represents a potential paradigm shift in HIV prevention. Lenacapavir (LEN), a capsid inhibitor with a six-monthly dosing interval, offers the prospect of reducing pill burden and mitigating adherence challenges associated with daily or event-driven oral PrEP [ 5 , 6 ]. Clinical trials have demonstrated high efficacy of long-acting injectable PrEP agents, and modelling studies suggest that such formulations could substantially enhance population-level impact if widely adopted [ 7 ]. However, biomedical efficacy alone does not guarantee public health effectiveness. Uptake and sustained use of long-acting PrEP depend on a sequence of behavioural, perceptual, and structural decisions made by individuals, including awareness of the intervention, acceptability, modality preference, and affordability [ 8 , 9 ]. Existing research on long-acting PrEP has largely focused on hypothetical acceptability or willingness to use, often treating these constructs as endpoints rather than intermediate stages [ 10 ]. Evidence remains limited on how individuals progress, or drop out, across successive decision points, particularly in LMIC settings where cost considerations and health system constraints may be pronounced. Moreover, few studies have empirically examined how perceptions of convenience, effectiveness, stigma, and side effects interact to shape preference for injectable PrEP relative to oral modalities among MSM with prior exposure to PrEP programmes [ 11 , 12 ]. Conceptualising PrEP uptake as a decision cascade, rather than a single outcome, provides a more nuanced framework for understanding implementation barriers. Similar cascade approaches have been instrumental in HIV testing and treatment research, revealing critical points of attrition that are obscured when outcomes are examined in isolation [ 13 ]. Applying this framework to long-acting injectable PrEP may help identify where potential users are lost between initial acceptability and feasible uptake, thereby informing more realistic introduction and pricing strategies. In this study, we examined a sequential decision cascade for long-acting injectable PrEP using lenacapavir among HIV-negative MSM in Bali, Indonesia. Specifically, we assessed awareness of LEN, willingness to use LEN, preference for LEN relative to oral PrEP under hypothetical availability, and willingness to pay. We further identified factors independently associated with preference for LEN using multivariable analysis. By integrating behavioural, perceptual, and economic dimensions within a single analytic framework, this study aims to generate policy-relevant evidence to inform the potential introduction and scale-up of long-acting injectable PrEP in Indonesia and similar settings. Methods Study Design and Settings The study employed a cross-sectional design among HIV-negative men who have sex with men (MSM), gay and transgender in Bali, Indonesia. Data were obtained from a larger survey on HIV prevention behaviours, includes topics related to long-acting injectable PrEP (LEN). Participants were recruited using snowball sampling initiated with six seeds in October 2025, through collaboration with community-based organisations and clinical service sites providing HIV prevention and care. Data collection was conducted at four community-based and clinical settings in Bali as part of a community-based assessment of HIV prevention preferences. Eligible participants were aged 18 years or older, self-identified as MSM/gay/transgender, reported HIV-negative status, and provided informed consent. Study Variables, Tools, and Measurement Data were collected using a structured, self-administered questionnaire developed in Bahasa Indonesia. The instrument was designed to capture a sequential decision cascade for long-acting injectable PrEP using LEN, encompassing four domains: awareness, acceptability, preference, and affordability. Awareness of LEN was assessed by asking participants whether they had ever heard of lenacapavir as a long-acting injectable option for HIV prevention. Acceptability was measured using a Likert-scale item assessing willingness to use LEN, with response options ranging from very unwilling to very willing. Preference was assessed by asking participants to indicate their preferred PrEP modality under a hypothetical scenario in which multiple options were available, including daily oral PrEP, on-demand oral PrEP, and long-acting injectable PrEP (LEN). Participants who reported no intention to use PrEP were excluded from analyses of modality preference. Affordability was measured using willingness-to-pay (WTP) questions that assessed the maximum monthly amount participants would be willing to pay for LEN if it were not provided free of charge. Independent variables included sociodemographic characteristics (age, education level, and monthly income), prior experience with oral PrEP (ever use), and perceptual factors related to LEN. Perceptual variables comprised perceived effectiveness of LEN relative to oral PrEP, perceived convenience of the six-monthly dosing interval, concern about potential side effects, and concern about stigma if others were aware of LEN use. These constructs were measured using categorical response options and were subsequently collapsed into analytically meaningful categories based on their distribution and conceptual relevance for analysis. Statistical Analysis Descriptive analyses were used to summarise participant characteristics and each stage LEN decision cascade. Categorical variables were summarised using frequencies and percentages, and continuous variables using medians and interquartile ranges. Willingness to use LEN was assessed on an ordered Likert scale and additionally dichotomised into high versus low or neutral willingness for selected analyses. Preference for PrEP modality was evaluated under a hypothetical scenario in which multiple PrEP options were available, excluding participants who reported no intention to use PrEP. Bivariate analyses examined associations between participant characteristics and preference for LEN versus oral PrEP, as well as willingness to use LEN, using Pearson’s chi-square or Fisher’s exact tests as appropriate. Multivariable logistic regression models were fitted to identify factors independently associated with each outcome, with Model 1 including core behavioural and perceptual predictors and Model 2 additionally adjusting for sociodemographic characteristics. Results were reported as odds ratios with 95% confidence intervals. Attrition across sequential decision stages, from awareness to acceptability, preference, and affordability, was visualised using a decision cascade diagram. All analyses were conducted using R (version 2025.05.0 + 496), and a two-sided p value of less than 0.05 was considered statistically significant. Ethical consideration This study received ethical approval from the Health Research Ethics Committee of the Faculty of Medicine, Udayana University/Ngoerah Hospital, Bali, Indonesia (Protocol No. 1856/UN14.2.2.VII.14/LT/2025). All participants provided written informed consent prior to enrolment, and participation was voluntary. Participant confidentiality and anonymity were rigorously protected, and the study was conducted in accordance with the principles of the Declaration of Helsinki. Results Characteristics of the Study Population The study included 116 HIV-negative MSM from a total of 186 valid responses were included in the analysis, with a median age of 32 years (IQR 26.75–37.25), most of whom were aged 25 years or older (Table 1 ). Educational attainment was generally low, with 67.2% having completed senior high school or less, and over half reported a monthly income below IDR 3,000,000. More than half of participants had ever used oral PrEP (52.6%), although current use was lower (39.7%), indicating attrition between initiation and continued use. Table 1 Sociodemographic Characteristics and PrEP Experience (n = 116) Characteristic n (%) Age (years) Median (IQR) 32 (26.75–37.25) 18–24 22 (19.0) 25–34 50 (43.1) ≥ 35 44 (37.9) Education level ≤ Senior high school 78 (67.2) Diploma 17 (14.7) Bachelor or higher 21 (18.1) Monthly income IDR 6 million 21 (18.1) Ever used oral PrEP Yes 61 (52.6) No 55 (47.4) Currently using oral PrEP Yes 46 (39.7) No 70 (60.3) Awareness and Perceptions of Long-Acting Injectable PrEP (Lenacapavir) Awareness of long-acting injectable PrEP using lenacapavir was low (Table 2 ), with fewer than one-third of participants reporting prior knowledge of LEN. Despite this limited awareness, perceptions of LEN were generally favourable. Nearly two-thirds of participants considered the six-monthly injection schedule more convenient than daily oral PrEP, while only a small minority perceived it as less convenient. Perceived effectiveness was mixed: half of the participants reported uncertainty, reflecting limited familiarity with LEN, while nearly one-third believed it was more effective than oral PrEP. Concerns about potential side effects were moderate overall, with most participants reporting low to moderate concern and relatively few expressing high concern. Stigma-related concerns were minimal, with over 80% reporting little or no concern about others knowing they used LEN. Table 2 Awareness and Perceptions of Long-Acting Injectable PrEP (Lenacapavir) (n = 116) Characteristic n (%) Aware/ever heard of lenacapavir (long-acting injectable PrEP) Yes 33 (28.4) No 83 (71.6) Perceived effectiveness of lenacapavir compared with oral PrEP More effective 33 (28.4) Equally effective 22 (19.0) Less effective 2 (1.7) Do not know 59 (50.9) Perceived convenience dosing interval of 6-monthly injection vs daily oral PrEP More convenient 75 (64.7) No difference 32 (27.6) Less convenient 9 (7.8) Concern about potential side effects of lenacapavir Very unconcerned 16 (13.8) Unconcerned 31 (26.7) Moderately concerned 40 (34.5) Very concerned 16 (13.8) Do not know 13 (11.2) Concern about stigma if others know about lenacapavir use Very unconcerned 36 (31.0) Unconcerned 58 (50.0) Moderately concerned 15 (12.9) Very concerned 2 (1.7) Do not know 5 (4.3) Willingness to Use and Preference for Lenacapavir Willingness to use lenacapavir was high (Table 3 ), with just under half of participants reporting willingness or strong willingness, and only a small minority expressing unwillingness. However, this high acceptability did not fully translate into preference for LEN as the preferred PrEP modality. Fewer than half of participants selected long-acting injectable PrEP over oral options, with a substantial proportion preferring on-demand or daily oral PrEP, and a minority reporting no interest in PrEP use. This divergence between willingness and preference suggests attrition at the modality-choice stage of the decision process. Among those considering LEN, convenience, specifically the avoidance of daily pill-taking, was the most frequently cited factor influencing decision-making, whereas cost, provider recommendation, and concerns about side effects were less commonly prioritised. Table 3 Willingness to Use and Preference for Lenacapavir (n = 116) Characteristic n (%) Willingness to use LEN Very unwilling 1 (0.9) Unwilling 10 (8.6) Neutral 46 (39.7) Willing 18 (15.5) Very willing 41 (35.3) Preferred PrEP modality Long-acting injectable PrEP (LEN) 53 (45.7) On-demand / event-driven PrEP (oral) 29 (25.0) Daily oral PrEP 19 (16.4) Do not want to use PrEP 15 (12.9) Most important factor in deciding to use LEN Convenience (no daily pill) 74 (63.8) Effectiveness 30 (25.9) Cost 5 (4.3) Recommendation from the healthcare provider 3 (2.6) Side effects 4 (3.4) Associations Between Participant Characteristics and Preference for LEN Bivariate analyses demonstrated that preference for LEN varied across behavioural and perceptual characteristics (Table 4 ). Prior experience with oral PrEP was not significantly associated with a preference for LEN, although participants without prior oral PrEP use were more likely to prefer LEN than those with prior experience, suggesting that familiarity with daily or event-driven PrEP may influence modality choice. In contrast, perceptions related to LEN itself were more strongly associated with preference. Perceived effectiveness of LEN relative to oral PrEP showed a significant association with modality preference, with participants expressing uncertainty about LEN’s effectiveness more likely to prefer LEN, whereas those perceiving LEN as equally or more effective tended to favour oral PrEP. Perceived convenience of the six-monthly injection schedule emerged as the strongest correlate of preference for LEN. Participants who perceived LEN as no different or less convenient than oral PrEP were significantly more likely to prefer LEN, whereas those who perceived it as more convenient predominantly preferred oral PrEP, highlighting heterogeneity in how convenience is interpreted and weighed in decision-making. Stigma-related concerns were not significantly associated with a preference for LEN, although a trend toward greater preference among participants with higher concerns was observed. Although concern about potential side effects was not statistically associated with preference for LEN, participants reporting little or no concern tended to show a higher preference for LEN. Table 4 Bivariate Associations Between Participant Characteristics and Preference for LEN (n = 101) Variable Prefer LEN (n = 53) Prefer oral PrEP (n = 48) p-value n (%) n (%) Ever used oral PrEP No 27 (62.8) 16 (37.2) 0.142 Yes 26 (44.8) 32 (55.2) Perceived effectiveness of LEN vs oral PrEP More or equally effective 19 (37.3) 32 (62.7) 0.001 Less effective or do not know 34 (68.0) 16 (32.0) Perceived convenience dosing interval of LEN More convenient 25 (37.9) 41 (62.1) < 0.001 Less convenient or no difference 28 (80.0) 7 (20.0) Concern about stigma of using LEN Very unconcerned or unconcerned 42 (48.3) 45 (51.7) 0.079 Moderately or very concerned 11 (78.6) 3 (21.4) Concern about side effects Very unconcerned or unconcerned 24 (64.9) 13 (35.1) 0.371 Moderately or very concerned 29 (45.3) 35 (54.7) Note: This table excludes those who do not want to use PrEP (n = 15) Factors Associated with Preference for LEN Multivariable analyses (Table 5 ) demonstrated that perceived convenience of the six-monthly LEN dosing interval was the only factor independently associated with preference for long-acting injectable PrEP. Participants who perceived LEN as more convenient than oral PrEP had markedly higher odds of preferring LEN in unadjusted analyses (OR 5.68, 95% CI 1.97–16.39), and this association remained strong after adjustment for age, education, and prior oral PrEP use (aOR 4.91, 95% CI 1.65–14.59). In contrast, sociodemographic characteristics, including age and educational attainment, were not significantly associated with preference for LEN, indicating that modality choice was not strongly patterned by background characteristics. Prior experience with oral PrEP was also not independently associated with preference for LEN, despite point estimates suggesting higher odds among previous users. Notably, perceived effectiveness of LEN relative to oral PrEP was not associated with preference in either model, suggesting that beliefs about comparative efficacy alone did not drive modality choice once convenience was accounted for. Similarly, concerns related to stigma and potential side effects were not independently associated with preference, and their inclusion did not materially alter other associations Table 5 Factors Associated with Preference for LEN (n = 101) Predictor Model 1 Model 2 OR (95% CI) p-value aOR (95% CI) p-value Age category Senior high Ref. Ever used oral PrEP No Ref. Ref. Yes 1.83 (0.76–4.42) 0.181 1.93 (0.78–4.79) 0.155 Perceived effectiveness of LEN Less effective or do not know Ref. Ref. More or Equally effective 1.25 (0.43–3.60) 0.686 1.61 (0.51–5.07) 0.411 Convenience of LEN dosing interval Less convenient or no difference Ref. Ref. More convenient 5.68 (1.97–16.39) 0.001 4.91 (1.65–14.59) 0.004 Stigma-related concern Very unconcerned or unconcerned Ref. Ref. Moderately or very concerned 0.42 (0.09–1.93) 0.267 0.43 (0.09–1.98) 0.281 Concern about side effects Low concern Ref. Ref. High concern 1.21 (0.46–3.16) 0.703 1.19 (0.44–3.20) 0.735 Note: This table excludes those who do not want to use PrEP (n = 15); Odds Ratio (OR); Adjusted Odds Ratio (aOR), and 95% Confidence Interval (CI) Figure 1 summarises the sequential decision cascade for LEN, integrating findings from Tables 2 – 5 . While awareness and willingness to use LEN were relatively high, substantial attrition was observed at the stages of modality preference and willingness to pay. Fewer than one-third of participants were aware of LEN, yet over half expressed willingness to use LEN, indicating that acceptability was not solely driven by prior awareness. However, this willingness did not consistently translate into preference for LEN over oral PrEP, with a marked reduction at the modality choice stage. Affordability further narrowed the cascade, as a considerable proportion of participants who preferred LEN reported limited willingness to pay, particularly at higher price thresholds. The cascade highlights progressive attrition from acceptability to preference and affordability, underscoring that high willingness alone is insufficient to ensure uptake of long-acting injectable PrEP in the absence of favourable modality and cost considerations. This pattern was similar among all participants (Panel A) as weel as among participants that aware of LEN (Panel B). Discussion In this study, we examined the potential uptake of LEN among HIV-negative MSM in Bali, Indonesia, through a sequential decision cascade framework spanning awareness, acceptability, preference, and affordability. Our findings demonstrate that while acceptability of LEN was high, substantial attrition occurred at the stages of modality preference and willingness to pay. These results underscore the importance of conceptualising PrEP uptake not as a single behavioural endpoint, but as a multi-stage process shaped by distinct and interacting determinants. A key finding was the disconnect between low awareness and high willingness to use LEN. Fewer than one-third of participants had previously heard of LEN, yet more than half reported being willing or very willing to use it. This pattern suggests that acceptability was driven less by prior knowledge and more by perceived attributes of the intervention once introduced, particularly its long dosing interval [ 14 ]. Similar findings have been reported in studies of other long-acting PrEP modalities, where hypothetical acceptability remains high even in contexts of limited baseline awareness [ 9 ]. This has important implications for implementation, in which increasing awareness alone may not be sufficient to ensure uptake, but targeted messaging that clearly communicates the practical benefits of long-acting PrEP could rapidly translate into demand once such products become available [ 15 , 16 ]. Despite high acceptability, preference for LEN over oral PrEP was more selective, with fewer than half of participants indicating LEN as their preferred modality. This attrition at the modality choice stage highlights a critical juncture in the decision cascade. Our multivariable analyses identified perceived convenience of the six-monthly injection schedule as the only factor independently associated with preference for LEN, even after adjustment for sociodemographic characteristics and prior oral PrEP use. Participants who perceived LEN as more convenient than oral PrEP had nearly five-fold higher odds of preferring LEN. In contrast, perceived effectiveness, stigma-related concerns, and concerns about side effects were not independently associated with preference once convenience was accounted for. These findings suggest that, among MSM with exposure to PrEP services, modality choice is driven primarily by how well an intervention fits into daily life rather than by abstract assessments of biomedical efficacy [ 17 , 18 ]. Notably, sociodemographic characteristics, including age and educational attainment, were not significantly associated with preference for LEN. This lack of social patterning contrasts with some oral PrEP studies, where uptake and persistence have been stratified by age, education, or socioeconomic status [ 19 , 20 ]. Our findings imply that long-acting injectable PrEP may have the potential to transcend some of the social gradients observed with daily oral PrEP, provided that access barriers are addressed. Similarly, prior experience with oral PrEP was not independently associated with preference for LEN, suggesting that injectable PrEP may appeal both to PrEP-experienced individuals seeking an alternative and to those who have not successfully engaged with oral PrEP regimens. Affordability emerged as the final and most restrictive stage of the decision cascade. Even among participants who preferred LEN, willingness to pay declined sharply as hypothetical costs increased, with a substantial proportion reporting unwillingness to pay at higher price thresholds. This finding is particularly salient in the Indonesian context, where PrEP is currently provided free of charge through public and community-based programmes, and out-of-pocket payment for prevention services remains uncommon [ 21 ]. Without substantial price subsidies or inclusion within national health financing schemes, the public health impact of LEN is likely to be limited, regardless of its acceptability or perceived convenience [ 5 , 22 ]. In global markets, current commercial prices of LEN remain extremely high, with list prices for twice-yearly injections exceeding US $ 25,000– $ 40,000 per person-year, far above typical incomes in low- and middle-income settings [ 23 ]. Although projections and agreements with generic manufacturers aim for much lower pricing (e.g., around US $ 35– $ 46 per year in some LMICs under licensing partnerships), these reduced costs are contingent on volume, licensing reach, and manufacturing scale [ 24 , 25 ]. In our study context, the hypothetical willingness-to-pay cut-off of 500,000 IDR (≈ US $ 30–35) is still roughly on par with optimistic generic price targets but well below present commercial prices, and does not capture additional service costs for injection delivery. This suggests that, under an out-of-pocket model without insurance or subsidy, affordability challenges could significantly constrain actual uptake even when acceptability and preference are high. Our cascade analysis therefore illustrates that high willingness and preference do not automatically translate into feasible uptake in the absence of affordability. These findings extend the existing evidence base on long-acting PrEP by empirically illustrating how engagement diminishes across successive stages of the decision-making process. Whereas much of the prior literature has emphasised willingness or acceptability as primary indicators of potential uptake [ 26 , 27 ], the decision cascade framework applied in this study demonstrates that such measures may substantially overestimate real-world utilisation when downstream barriers are not explicitly accounted for. This has important implications for policy and programme design. To achieve meaningful population-level impact, the implementation of long-acting injectable PrEP in Indonesia and comparable settings will require integrated strategies that concurrently address demand generation, support informed modality choice, and ensure financial accessibility [ 24 ]. This study has several limitations. First, the cross-sectional design precludes causal inference and captures stated preferences under hypothetical scenarios rather than observed behaviour. Second, the sample was recruited using snowball sampling and may not be fully representative of all MSM in Bali, particularly those not engaged with community-based services. Third, willingness to pay was assessed hypothetically and may not reflect actual payment behaviour if LEN becomes available. Nevertheless, the study provides timely and policy-relevant insights into how MSM in a low- and middle-income setting navigate decisions around emerging HIV prevention technologies. Conclusions In conclusion, our findings indicate that while long-acting injectable PrEP using lenacapavir is highly acceptable among HIV-negative MSM in Bali, substantial attrition occurs at the stages of modality preference and affordability. Perceived convenience is the dominant driver of preference, whereas demographic factors, prior PrEP use, and concerns about stigma or side effects play a more limited role. Framing PrEP uptake as a decision cascade highlights critical points where potential users are lost and underscores the need for integrated strategies that address not only acceptability but also preference formation and financial access. Such an approach will be essential to ensure that the promise of long-acting injectable PrEP translates into equitable and sustained HIV prevention impact. Declarations Acknowledgments The authors express their sincere appreciation to the HIV-negative men who have sex with men who participated in this study for generously sharing their time and perspectives. We are grateful to the staff of community-based organisations and health facilities in Bali for their collaboration and support during participant recruitment and data collection. We also acknowledge the contributions of the research assistants and field coordinators whose dedication was essential to the successful implementation and management of this study. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Author contributions All authors contributed substantially to this study. NPAH led the conceptualization and design of the study, conducted the data analysis, interpreted the findings, and drafted the manuscript. PPIO and BDKW were responsible for data acquisition. PPIO, BDKW, NKS, GBSW, and PPJ critically reviewed and revised the manuscript for important intellectual content. All authors read and approved the final version of the manuscript. Funding We gratefully acknowledge the support of the Ministry of Higher Education, Science, and Technology of Indonesia (Kementerian Pendidikan Tinggi, Sains, dan Teknologi) for funding this research and the PUI-PT Center for Public Health Innovation (CPHI), Udayana University for facilitating this research. Data availability The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request, subject to ethical approval and data protection regulations. References Ministry of Health Republic of Indonesia. Survei Terpadu Biologis dan Perilaku (STBP) Populasi Kunci Tahun 2023. Jakarta: 2024. Wardhani BDK, Grulich AE, Kawi NH, Prasetia Y, Luis H, Wirawan GBS, et al. 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Equity of PrEP uptake by race, ethnicity, sex and region in the United States in the first decade of PrEP: a population-based analysis. The Lancet Regional Health–Americas 2024;33. Pillay D, Stankevitz K, Lanham M, Ridgeway K, Murire M, Briedenhann E, et al. Factors influencing uptake, continuation, and discontinuation of oral PrEP among clients at sex worker and MSM facilities in South Africa. PLoS One 2020;15:e0228620. Siregar AYM, Juwita MN, Hardiawan D, Akbar A, Rachman ZH, Haekal MDF, et al. Cost of implementing HIV pre‐exposure prophylaxis at community‐based clinics in Indonesia. Tropical Medicine & International Health 2024;29:13–22. Wu L, Kaftan D, Wittenauer R, Arrouzet C, Patel N, Saravis AL, et al. Health impact, budget impact, and price threshold for cost-effectiveness of lenacapavir for HIV pre-exposure prophylaxis in eastern and southern Africa: a modelling analysis. Lancet HIV 2024;11:e765–73. Adepoju VA, Abdulrahim A. Dollars and dilemmas: lenacapavir’s pricing, patents, and the path to affordability. Int J Equity Health 2025;24:270. Schmidt HA, Prochazka M, Ingold H, Reza‐Paul S, Chidarikire T, Romyco I, et al. Seizing the moment: the potential of PrEP choice and innovation to transform HIV prevention. J Int AIDS Soc 2025;28:e26498. Wu L, Kaftan D, Wittenauer R, Arrouzet C, Patel N, Saravis AL, et al. Health impact, budget impact, and price threshold for cost-effectiveness of lenacapavir for HIV pre-exposure prophylaxis in eastern and southern Africa: a modelling analysis. Lancet HIV 2024;11:e765–73. Adepoju VA, Abdulrahim A, Jamil S. Breaking barriers for key populations in the lenacapavir era. Decoding Infection and Transmission 2026;4:100075. Kityo C, Cortes CP, Phanuphak N, Grinsztejn B, Venter F. Barriers to uptake of long-acting antiretroviral products for treatment and prevention of HIV in low-and middle-income countries (LMICs). Clinical Infectious Diseases 2022;75:S549–56. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8727712","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":582214772,"identity":"d88fb479-bf4b-4a8c-931d-ac9e20698402","order_by":0,"name":"Ngakan Putu Anom Harjana","email":"","orcid":"https://orcid.org/0000-0002-4649-7185","institution":"Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia ² Center for Public Health Innovation (PUI PT CPHI), Udayana University, Denpasar, Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Ngakan","middleName":"Putu Anom","lastName":"Harjana","suffix":""},{"id":582214773,"identity":"840737e0-6cba-4889-aa7c-07ed3c0a3933","order_by":1,"name":"Pande Putu Ida Oktayani","email":"","orcid":"https://orcid.org/0009-0003-7220-5515","institution":"PUI-PT Center for Public Health Innovation (CPHI), Udayana University, Bali, Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Pande","middleName":"Putu Ida","lastName":"Oktayani","suffix":""},{"id":582214774,"identity":"d8cf08c5-df39-4c8c-b2e5-cc703f7f2f60","order_by":2,"name":"Brigitta Dhyah Kunthi Wardhani","email":"","orcid":"https://orcid.org/0000-0002-7504-2032","institution":"PUI-PT Center for Public Health Innovation (CPHI), Udayana University, Bali, Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Brigitta","middleName":"Dhyah Kunthi","lastName":"Wardhani","suffix":""},{"id":582214775,"identity":"d96b05b9-b438-484c-abc7-5acd95f99d1d","order_by":3,"name":"Ni Kadek Sudastri","email":"","orcid":"https://orcid.org/0009-0001-6267-3468","institution":"PUI-PT Center for Public Health Innovation (CPHI), Udayana University, Bali, Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Ni","middleName":"Kadek","lastName":"Sudastri","suffix":""},{"id":582214776,"identity":"7c9f465d-7409-49ad-9413-7d33059e0698","order_by":4,"name":"Gede Benny Setia Wirawan","email":"","orcid":"https://orcid.org/0000-0002-0477-5749","institution":"The Kirby Institute, UNSW, Sydney, Australia","correspondingAuthor":false,"prefix":"","firstName":"Gede","middleName":"Benny Setia","lastName":"Wirawan","suffix":""},{"id":582214777,"identity":"98a1e2b3-09eb-48c3-ab1c-1f1baf020b95","order_by":5,"name":"Pande Putu Januraga","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYBACxgYogx9E8IAIZgYD4rRINhCrBQ4MDsC0MBDQwtx+9ph0RU2tvPGN3GMSbxjs5BnYmTfgd1hPXprkmWPHDbfdADLmMCQbNjCzFeDX0pBjJtnAdoxx240cM2keBuYEBmYeAt7vfwPU8u+Y/eYZYC31RGgBqpRsbKtJ3CAB1nKYGC1vjC0b+w4kzzgDZMwxOG7YRsgvhv05hjcbvtXZ9rfnGN54U1Etz89/GH+IGTaAqcNQLtBJbHjVA4E8hKojpG4UjIJRMApGMgAA4eY9tba6Q7oAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-2926-0856","institution":"Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia ² Center for Public Health Innovation (PUI PT CPHI), Udayana University, Denpasar, Indonesia","correspondingAuthor":true,"prefix":"","firstName":"Pande","middleName":"Putu","lastName":"Januraga","suffix":""}],"badges":[],"createdAt":"2026-01-29 06:22:12","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8727712/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8727712/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101485246,"identity":"376617ae-9057-44b8-9378-1bc6b9c603c4","added_by":"auto","created_at":"2026-01-30 08:58:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":210518,"visible":true,"origin":"","legend":"\u003cp\u003eDecision cascade for long-acting injectable PrEP Lenacapavir among MSM. Panel A shows the cascade for all participants, while Panel B shows among participants that aware of LEN\u003c/p\u003e","description":"","filename":"Figure1PrepLEN.png","url":"https://assets-eu.researchsquare.com/files/rs-8727712/v1/d3c401792d461552956c1ba0.png"},{"id":101485256,"identity":"6e693601-a31b-44d5-b874-d892d54f9b55","added_by":"auto","created_at":"2026-01-30 08:58:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1093634,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8727712/v1/54286b01-5441-4df7-9908-7d204df87f51.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eFrom Acceptability to Affordability: A Decision Cascade Analysis of Long-Acting Injectable HIV Pre-Exposure Prophylaxis (Lenacapavir) Among HIV-Negative Men Who Have Sex with Men in Bali, Indonesia\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRecent national surveillance data (SIHA) indicate that men who have sex with men (MSM) and transgender women continue to bear a disproportionate burden of HIV in Indonesia, with HIV prevalence of 24.4% among MSM and 28.9% among transgender women, based on IBBS 2024, substantially higher than prevalence observed among other key populations, including female sex workers (2.5%), and people who inject drugs (17.1%) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Moreover, a study concudted in Jakarta and Bali also shows that high HIV prevalence 23.2% and 21.9%, respectively [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Pilot study in Indonesia reveals low retention of oral PrEP, due to poor adherence and high discontinuation rates in real-world settings, particularly men who have sex with men (MSM).[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] This persistent disparity underscores the ongoing vulnerability of MSM to HIV acquisition in Indonesia and other low- and middle-income countries. Although oral pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV when taken consistently, its real-world impact has been limited by challenges related to daily adherence, stigma, and discontinuation over time [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These constraints have intensified interest in long-acting HIV prevention technologies that may better align with the preferences, circumstances, and lived realities of populations at highest risk.\u003c/p\u003e \u003cp\u003eLong-acting injectable PrEP represents a potential paradigm shift in HIV prevention. Lenacapavir (LEN), a capsid inhibitor with a six-monthly dosing interval, offers the prospect of reducing pill burden and mitigating adherence challenges associated with daily or event-driven oral PrEP [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Clinical trials have demonstrated high efficacy of long-acting injectable PrEP agents, and modelling studies suggest that such formulations could substantially enhance population-level impact if widely adopted [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, biomedical efficacy alone does not guarantee public health effectiveness. Uptake and sustained use of long-acting PrEP depend on a sequence of behavioural, perceptual, and structural decisions made by individuals, including awareness of the intervention, acceptability, modality preference, and affordability [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eExisting research on long-acting PrEP has largely focused on hypothetical acceptability or willingness to use, often treating these constructs as endpoints rather than intermediate stages [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Evidence remains limited on how individuals progress, or drop out, across successive decision points, particularly in LMIC settings where cost considerations and health system constraints may be pronounced. Moreover, few studies have empirically examined how perceptions of convenience, effectiveness, stigma, and side effects interact to shape preference for injectable PrEP relative to oral modalities among MSM with prior exposure to PrEP programmes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConceptualising PrEP uptake as a decision cascade, rather than a single outcome, provides a more nuanced framework for understanding implementation barriers. Similar cascade approaches have been instrumental in HIV testing and treatment research, revealing critical points of attrition that are obscured when outcomes are examined in isolation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Applying this framework to long-acting injectable PrEP may help identify where potential users are lost between initial acceptability and feasible uptake, thereby informing more realistic introduction and pricing strategies.\u003c/p\u003e \u003cp\u003eIn this study, we examined a sequential decision cascade for long-acting injectable PrEP using lenacapavir among HIV-negative MSM in Bali, Indonesia. Specifically, we assessed awareness of LEN, willingness to use LEN, preference for LEN relative to oral PrEP under hypothetical availability, and willingness to pay. We further identified factors independently associated with preference for LEN using multivariable analysis. By integrating behavioural, perceptual, and economic dimensions within a single analytic framework, this study aims to generate policy-relevant evidence to inform the potential introduction and scale-up of long-acting injectable PrEP in Indonesia and similar settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Settings\u003c/h2\u003e \u003cp\u003eThe study employed a cross-sectional design among HIV-negative men who have sex with men (MSM), gay and transgender in Bali, Indonesia. Data were obtained from a larger survey on HIV prevention behaviours, includes topics related to long-acting injectable PrEP (LEN). Participants were recruited using snowball sampling initiated with six seeds in October 2025, through collaboration with community-based organisations and clinical service sites providing HIV prevention and care. Data collection was conducted at four community-based and clinical settings in Bali as part of a community-based assessment of HIV prevention preferences. Eligible participants were aged 18 years or older, self-identified as MSM/gay/transgender, reported HIV-negative status, and provided informed consent.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Variables, Tools, and Measurement\u003c/h3\u003e\n\u003cp\u003eData were collected using a structured, self-administered questionnaire developed in Bahasa Indonesia. The instrument was designed to capture a sequential decision cascade for long-acting injectable PrEP using LEN, encompassing four domains: awareness, acceptability, preference, and affordability.\u003c/p\u003e \u003cp\u003eAwareness of LEN was assessed by asking participants whether they had ever heard of lenacapavir as a long-acting injectable option for HIV prevention. Acceptability was measured using a Likert-scale item assessing willingness to use LEN, with response options ranging from very unwilling to very willing. Preference was assessed by asking participants to indicate their preferred PrEP modality under a hypothetical scenario in which multiple options were available, including daily oral PrEP, on-demand oral PrEP, and long-acting injectable PrEP (LEN). Participants who reported no intention to use PrEP were excluded from analyses of modality preference. Affordability was measured using willingness-to-pay (WTP) questions that assessed the maximum monthly amount participants would be willing to pay for LEN if it were not provided free of charge.\u003c/p\u003e \u003cp\u003eIndependent variables included sociodemographic characteristics (age, education level, and monthly income), prior experience with oral PrEP (ever use), and perceptual factors related to LEN. Perceptual variables comprised perceived effectiveness of LEN relative to oral PrEP, perceived convenience of the six-monthly dosing interval, concern about potential side effects, and concern about stigma if others were aware of LEN use. These constructs were measured using categorical response options and were subsequently collapsed into analytically meaningful categories based on their distribution and conceptual relevance for analysis.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive analyses were used to summarise participant characteristics and each stage LEN decision cascade. Categorical variables were summarised using frequencies and percentages, and continuous variables using medians and interquartile ranges. Willingness to use LEN was assessed on an ordered Likert scale and additionally dichotomised into high versus low or neutral willingness for selected analyses. Preference for PrEP modality was evaluated under a hypothetical scenario in which multiple PrEP options were available, excluding participants who reported no intention to use PrEP.\u003c/p\u003e \u003cp\u003eBivariate analyses examined associations between participant characteristics and preference for LEN versus oral PrEP, as well as willingness to use LEN, using Pearson\u0026rsquo;s chi-square or Fisher\u0026rsquo;s exact tests as appropriate. Multivariable logistic regression models were fitted to identify factors independently associated with each outcome, with Model 1 including core behavioural and perceptual predictors and Model 2 additionally adjusting for sociodemographic characteristics. Results were reported as odds ratios with 95% confidence intervals. Attrition across sequential decision stages, from awareness to acceptability, preference, and affordability, was visualised using a decision cascade diagram. All analyses were conducted using R (version 2025.05.0\u0026thinsp;+\u0026thinsp;496), and a two-sided p value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical consideration\u003c/h3\u003e\n\u003cp\u003eThis study received ethical approval from the Health Research Ethics Committee of the Faculty of Medicine, Udayana University/Ngoerah Hospital, Bali, Indonesia (Protocol No. 1856/UN14.2.2.VII.14/LT/2025). All participants provided written informed consent prior to enrolment, and participation was voluntary. Participant confidentiality and anonymity were rigorously protected, and the study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the Study Population\u003c/h2\u003e \u003cp\u003eThe study included 116 HIV-negative MSM from a total of 186 valid responses were included in the analysis, with a median age of 32 years (IQR 26.75\u0026ndash;37.25), most of whom were aged 25 years or older (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Educational attainment was generally low, with 67.2% having completed senior high school or less, and over half reported a monthly income below IDR 3,000,000. More than half of participants had ever used oral PrEP (52.6%), although current use was lower (39.7%), indicating attrition between initiation and continued use.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic Characteristics and PrEP Experience (n\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (26.75\u0026ndash;37.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (19.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50 (43.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44 (37.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le; Senior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78 (67.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (18.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; IDR 3,000,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65 (56.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIDR 3\u0026ndash;6 million\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (25.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; IDR 6 million\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (18.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver used oral PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61 (52.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55 (47.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrently using oral PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (39.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70 (60.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAwareness and Perceptions of Long-Acting Injectable PrEP (Lenacapavir)\u003c/h3\u003e\n\u003cp\u003eAwareness of long-acting injectable PrEP using lenacapavir was low (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), with fewer than one-third of participants reporting prior knowledge of LEN. Despite this limited awareness, perceptions of LEN were generally favourable. Nearly two-thirds of participants considered the six-monthly injection schedule more convenient than daily oral PrEP, while only a small minority perceived it as less convenient. Perceived effectiveness was mixed: half of the participants reported uncertainty, reflecting limited familiarity with LEN, while nearly one-third believed it was more effective than oral PrEP. Concerns about potential side effects were moderate overall, with most participants reporting low to moderate concern and relatively few expressing high concern. Stigma-related concerns were minimal, with over 80% reporting little or no concern about others knowing they used LEN.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAwareness and Perceptions of Long-Acting Injectable PrEP (Lenacapavir) (n\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAware/ever heard of lenacapavir (long-acting injectable PrEP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (28.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83 (71.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived effectiveness of lenacapavir compared with oral PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (28.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEqually effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (19.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59 (50.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived convenience dosing interval of 6-monthly injection vs daily oral PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore convenient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75 (64.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (27.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess convenient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcern about potential side effects of lenacapavir\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery unconcerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (13.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnconcerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31 (26.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately concerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (34.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery concerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (13.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (11.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcern about stigma if others know about lenacapavir use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery unconcerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (31.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnconcerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately concerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (12.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery concerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eWillingness to Use and Preference for Lenacapavir\u003c/h3\u003e\n\u003cp\u003eWillingness to use lenacapavir was high (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), with just under half of participants reporting willingness or strong willingness, and only a small minority expressing unwillingness. However, this high acceptability did not fully translate into preference for LEN as the preferred PrEP modality. Fewer than half of participants selected long-acting injectable PrEP over oral options, with a substantial proportion preferring on-demand or daily oral PrEP, and a minority reporting no interest in PrEP use. This divergence between willingness and preference suggests attrition at the modality-choice stage of the decision process. Among those considering LEN, convenience, specifically the avoidance of daily pill-taking, was the most frequently cited factor influencing decision-making, whereas cost, provider recommendation, and concerns about side effects were less commonly prioritised.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWillingness to Use and Preference for Lenacapavir (n\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWillingness to use LEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery unwilling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnwilling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (8.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (39.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (15.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery willing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (35.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreferred PrEP modality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLong-acting injectable PrEP (LEN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53 (45.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn-demand / event-driven PrEP (oral)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily oral PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (16.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not want to use PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (12.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost important factor in deciding to use LEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConvenience (no daily pill)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74 (63.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffectiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (25.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecommendation from the healthcare provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (3.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAssociations Between Participant Characteristics and Preference for LEN\u003c/h2\u003e \u003cp\u003eBivariate analyses demonstrated that preference for LEN varied across behavioural and perceptual characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Prior experience with oral PrEP was not significantly associated with a preference for LEN, although participants without prior oral PrEP use were more likely to prefer LEN than those with prior experience, suggesting that familiarity with daily or event-driven PrEP may influence modality choice. In contrast, perceptions related to LEN itself were more strongly associated with preference. Perceived effectiveness of LEN relative to oral PrEP showed a significant association with modality preference, with participants expressing uncertainty about LEN\u0026rsquo;s effectiveness more likely to prefer LEN, whereas those perceiving LEN as equally or more effective tended to favour oral PrEP.\u003c/p\u003e \u003cp\u003ePerceived convenience of the six-monthly injection schedule emerged as the strongest correlate of preference for LEN. Participants who perceived LEN as no different or less convenient than oral PrEP were significantly more likely to prefer LEN, whereas those who perceived it as more convenient predominantly preferred oral PrEP, highlighting heterogeneity in how convenience is interpreted and weighed in decision-making. Stigma-related concerns were not significantly associated with a preference for LEN, although a trend toward greater preference among participants with higher concerns was observed. Although concern about potential side effects was not statistically associated with preference for LEN, participants reporting little or no concern tended to show a higher preference for LEN.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate Associations Between Participant Characteristics and Preference for LEN (n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrefer LEN (n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrefer oral PrEP (n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver used oral PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27 (62.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.142\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (55.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived effectiveness of LEN vs oral PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore or equally effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (37.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (62.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess effective or do not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (68.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (32.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived convenience dosing interval of LEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore convenient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (62.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess convenient or no difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcern about stigma of using LEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery unconcerned or unconcerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (48.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.079\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately or very concerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcern about side effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery unconcerned or unconcerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (35.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately or very concerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (45.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (54.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: This table excludes those who do not want to use PrEP (n\u0026thinsp;=\u0026thinsp;15)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFactors Associated with Preference for LEN\u003c/h2\u003e \u003cp\u003eMultivariable analyses (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) demonstrated that perceived convenience of the six-monthly LEN dosing interval was the only factor independently associated with preference for long-acting injectable PrEP. Participants who perceived LEN as more convenient than oral PrEP had markedly higher odds of preferring LEN in unadjusted analyses (OR 5.68, 95% CI 1.97\u0026ndash;16.39), and this association remained strong after adjustment for age, education, and prior oral PrEP use (aOR 4.91, 95% CI 1.65\u0026ndash;14.59). In contrast, sociodemographic characteristics, including age and educational attainment, were not significantly associated with preference for LEN, indicating that modality choice was not strongly patterned by background characteristics. Prior experience with oral PrEP was also not independently associated with preference for LEN, despite point estimates suggesting higher odds among previous users. Notably, perceived effectiveness of LEN relative to oral PrEP was not associated with preference in either model, suggesting that beliefs about comparative efficacy alone did not drive modality choice once convenience was accounted for. Similarly, concerns related to stigma and potential side effects were not independently associated with preference, and their inclusion did not materially alter other associations\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors Associated with Preference for LEN (n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eaOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.88 (0.71\u0026ndash;4.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.207\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le; Senior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.70 (0.28\u0026ndash;1.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.435\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; Senior high\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEver used oral PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.83 (0.76\u0026ndash;4.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.93 (0.78\u0026ndash;4.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived effectiveness of LEN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess effective or do not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore or Equally effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.25 (0.43\u0026ndash;3.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.686\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.61 (0.51\u0026ndash;5.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.411\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConvenience of LEN dosing interval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess convenient or no difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore convenient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.68 (1.97\u0026ndash;16.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.91 (1.65\u0026ndash;14.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStigma-related concern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery unconcerned or unconcerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately or very concerned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.42 (0.09\u0026ndash;1.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.43 (0.09\u0026ndash;1.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.281\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcern about side effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow concern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh concern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.21 (0.46\u0026ndash;3.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.703\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.19 (0.44\u0026ndash;3.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: This table excludes those who do not want to use PrEP (n\u0026thinsp;=\u0026thinsp;15); Odds Ratio (OR); Adjusted Odds Ratio (aOR), and 95% Confidence Interval (CI)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the sequential decision cascade for LEN, integrating findings from Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. While awareness and willingness to use LEN were relatively high, substantial attrition was observed at the stages of modality preference and willingness to pay. Fewer than one-third of participants were aware of LEN, yet over half expressed willingness to use LEN, indicating that acceptability was not solely driven by prior awareness. However, this willingness did not consistently translate into preference for LEN over oral PrEP, with a marked reduction at the modality choice stage. Affordability further narrowed the cascade, as a considerable proportion of participants who preferred LEN reported limited willingness to pay, particularly at higher price thresholds. The cascade highlights progressive attrition from acceptability to preference and affordability, underscoring that high willingness alone is insufficient to ensure uptake of long-acting injectable PrEP in the absence of favourable modality and cost considerations. This pattern was similar among all participants (Panel A) as weel as among participants that aware of LEN (Panel B).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we examined the potential uptake of LEN among HIV-negative MSM in Bali, Indonesia, through a sequential decision cascade framework spanning awareness, acceptability, preference, and affordability. Our findings demonstrate that while acceptability of LEN was high, substantial attrition occurred at the stages of modality preference and willingness to pay. These results underscore the importance of conceptualising PrEP uptake not as a single behavioural endpoint, but as a multi-stage process shaped by distinct and interacting determinants.\u003c/p\u003e \u003cp\u003eA key finding was the disconnect between low awareness and high willingness to use LEN. Fewer than one-third of participants had previously heard of LEN, yet more than half reported being willing or very willing to use it. This pattern suggests that acceptability was driven less by prior knowledge and more by perceived attributes of the intervention once introduced, particularly its long dosing interval [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Similar findings have been reported in studies of other long-acting PrEP modalities, where hypothetical acceptability remains high even in contexts of limited baseline awareness [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This has important implications for implementation, in which increasing awareness alone may not be sufficient to ensure uptake, but targeted messaging that clearly communicates the practical benefits of long-acting PrEP could rapidly translate into demand once such products become available [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite high acceptability, preference for LEN over oral PrEP was more selective, with fewer than half of participants indicating LEN as their preferred modality. This attrition at the modality choice stage highlights a critical juncture in the decision cascade. Our multivariable analyses identified perceived convenience of the six-monthly injection schedule as the only factor independently associated with preference for LEN, even after adjustment for sociodemographic characteristics and prior oral PrEP use. Participants who perceived LEN as more convenient than oral PrEP had nearly five-fold higher odds of preferring LEN. In contrast, perceived effectiveness, stigma-related concerns, and concerns about side effects were not independently associated with preference once convenience was accounted for. These findings suggest that, among MSM with exposure to PrEP services, modality choice is driven primarily by how well an intervention fits into daily life rather than by abstract assessments of biomedical efficacy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNotably, sociodemographic characteristics, including age and educational attainment, were not significantly associated with preference for LEN. This lack of social patterning contrasts with some oral PrEP studies, where uptake and persistence have been stratified by age, education, or socioeconomic status [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Our findings imply that long-acting injectable PrEP may have the potential to transcend some of the social gradients observed with daily oral PrEP, provided that access barriers are addressed. Similarly, prior experience with oral PrEP was not independently associated with preference for LEN, suggesting that injectable PrEP may appeal both to PrEP-experienced individuals seeking an alternative and to those who have not successfully engaged with oral PrEP regimens.\u003c/p\u003e \u003cp\u003eAffordability emerged as the final and most restrictive stage of the decision cascade. Even among participants who preferred LEN, willingness to pay declined sharply as hypothetical costs increased, with a substantial proportion reporting unwillingness to pay at higher price thresholds. This finding is particularly salient in the Indonesian context, where PrEP is currently provided free of charge through public and community-based programmes, and out-of-pocket payment for prevention services remains uncommon [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Without substantial price subsidies or inclusion within national health financing schemes, the public health impact of LEN is likely to be limited, regardless of its acceptability or perceived convenience [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn global markets, current commercial prices of LEN remain extremely high, with list prices for twice-yearly injections exceeding US \u003cspan\u003e$\u003c/span\u003e25,000\u0026ndash;\u003cspan\u003e$\u003c/span\u003e40,000 per person-year, far above typical incomes in low- and middle-income settings [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Although projections and agreements with generic manufacturers aim for much lower pricing (e.g., around US \u003cspan\u003e$\u003c/span\u003e35\u0026ndash;\u003cspan\u003e$\u003c/span\u003e46 per year in some LMICs under licensing partnerships), these reduced costs are contingent on volume, licensing reach, and manufacturing scale [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In our study context, the hypothetical willingness-to-pay cut-off of 500,000 IDR (\u0026asymp;\u0026thinsp;US \u003cspan\u003e$\u003c/span\u003e30\u0026ndash;35) is still roughly on par with optimistic generic price targets but well below present commercial prices, and does not capture additional service costs for injection delivery. This suggests that, under an out-of-pocket model without insurance or subsidy, affordability challenges could significantly constrain actual uptake even when acceptability and preference are high. Our cascade analysis therefore illustrates that high willingness and preference do not automatically translate into feasible uptake in the absence of affordability.\u003c/p\u003e \u003cp\u003eThese findings extend the existing evidence base on long-acting PrEP by empirically illustrating how engagement diminishes across successive stages of the decision-making process. Whereas much of the prior literature has emphasised willingness or acceptability as primary indicators of potential uptake [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], the decision cascade framework applied in this study demonstrates that such measures may substantially overestimate real-world utilisation when downstream barriers are not explicitly accounted for. This has important implications for policy and programme design. To achieve meaningful population-level impact, the implementation of long-acting injectable PrEP in Indonesia and comparable settings will require integrated strategies that concurrently address demand generation, support informed modality choice, and ensure financial accessibility [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the cross-sectional design precludes causal inference and captures stated preferences under hypothetical scenarios rather than observed behaviour. Second, the sample was recruited using snowball sampling and may not be fully representative of all MSM in Bali, particularly those not engaged with community-based services. Third, willingness to pay was assessed hypothetically and may not reflect actual payment behaviour if LEN becomes available. Nevertheless, the study provides timely and policy-relevant insights into how MSM in a low- and middle-income setting navigate decisions around emerging HIV prevention technologies.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, our findings indicate that while long-acting injectable PrEP using lenacapavir is highly acceptable among HIV-negative MSM in Bali, substantial attrition occurs at the stages of modality preference and affordability. Perceived convenience is the dominant driver of preference, whereas demographic factors, prior PrEP use, and concerns about stigma or side effects play a more limited role. Framing PrEP uptake as a decision cascade highlights critical points where potential users are lost and underscores the need for integrated strategies that address not only acceptability but also preference formation and financial access. Such an approach will be essential to ensure that the promise of long-acting injectable PrEP translates into equitable and sustained HIV prevention impact.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe authors express their sincere appreciation to the HIV-negative men who have sex with men who participated in this study for generously sharing their time and perspectives. We are grateful to the staff of community-based organisations and health facilities in Bali for their collaboration and support during participant recruitment and data collection. We also acknowledge the contributions of the research assistants and field coordinators whose dedication was essential to the successful implementation and management of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Competing Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eAll authors contributed substantially to this study. NPAH led the conceptualization and design of the study, conducted the data analysis, interpreted the findings, and drafted the manuscript. PPIO and BDKW were responsible for data acquisition. PPIO, BDKW, NKS, GBSW, and PPJ critically reviewed and revised the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eWe gratefully acknowledge the support of the Ministry of Higher Education, Science, and Technology of Indonesia (Kementerian Pendidikan Tinggi, Sains, dan Teknologi) for funding this research and the PUI-PT Center for Public Health Innovation (CPHI), Udayana University for facilitating this research.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request, subject to ethical approval and data protection regulations.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMinistry of Health Republic of Indonesia. Survei Terpadu Biologis dan Perilaku (STBP) Populasi Kunci Tahun 2023. 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Lancet HIV 2022;9:e254\u0026ndash;68.\u003c/li\u003e\n \u003cli\u003eHill A, Levi J, Fairhead C, Pilkington V, Wang J, Johnson M, et al. Lenacapavir to prevent HIV infection: current prices versus estimated costs of production. Journal of Antimicrobial Chemotherapy 2024;79:2906\u0026ndash;15.\u003c/li\u003e\n \u003cli\u003eGupta SK, Berhe M, Crofoot G, Sims J, Benson P, Ramgopal M, et al. Long-acting subcutaneous lenacapavir dosed every six months as part of a combination regimen in treatment-naive people with HIV: interim 16-week results of a randomized, open-label, phase 2 induction-maintenance study (CALIBRATE). J Int AIDS Soc 2021;24:13\u0026ndash;4.\u003c/li\u003e\n \u003cli\u003eSubramanian R, Tang J, Zheng J, Lu B, Wang K, Yant SR, et al. Lenacapavir: a novel, potent, and selective first-in-class inhibitor of HIV-1 capsid function exhibits optimal pharmacokinetic properties for a long-acting injectable antiretroviral agent. 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Long-acting HIV pre-exposure prophylaxis (PrEP) approaches: recent advances, emerging technologies, and development challenges. Expert Opin Drug Deliv 2022;19:1365\u0026ndash;80.\u003c/li\u003e\n \u003cli\u003eLorenzetti L, Dinh N, van der Straten A, Fonner V, Ridgeway K, Rodolph M, et al. Systematic review of the values and preferences regarding the use of injectable pre‐exposure prophylaxis to prevent HIV acquisition. J Int AIDS Soc 2023;26:e26107.\u003c/li\u003e\n \u003cli\u003eHumphries H, Knight L, Van Heerden A. The HIV prevention decision-making cascade: Integrating behavioural insights into HIV prevention efforts. Prev Med Rep 2024;46:102870.\u003c/li\u003e\n \u003cli\u003eAlford K, Sidat S, Bristowe K, Cicconi P, Vera JH, Cresswell F. Lenacapavir: Patient and healthcare provider perceptions and the potential role for a twice‐yearly injectable HIV treatment. HIV Med 2025;26:441\u0026ndash;50.\u003c/li\u003e\n \u003cli\u003eCelum C, Grinsztejn B, Ngure K. Preparing for long‐acting PrEP delivery: building on lessons from oral PrEP. J Int AIDS Soc 2023;26:e26103.\u003c/li\u003e\n \u003cli\u003eVenter WDF, Gandhi M, Sokhela S, Sikwese K, Bygrave H, Da Gama L, et al. The long wait for long-acting HIV prevention and treatment formulations. Lancet HIV 2024;11:e711\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eDe Vito A, Colpani A, Moi G, Minisci D, Foc\u0026agrave; E, Calcagno A, et al. Present and future of HIV pre-exposure prophylaxis: a narrative review. Future Virol 2025;20:397\u0026ndash;413.\u003c/li\u003e\n \u003cli\u003eGoswami S, Veeramachaneni S, Masurkar PP. Lenacapavir for HIV PrEP: Narrative review of clinical trials and implications for patient access. Curr Treat Options Infect Dis 2025;17:5.\u003c/li\u003e\n \u003cli\u003eSullivan PS, DuBose SN, Castel AD, Hoover KW, Juhasz M, Guest JL, et al. Equity of PrEP uptake by race, ethnicity, sex and region in the United States in the first decade of PrEP: a population-based analysis. The Lancet Regional Health\u0026ndash;Americas 2024;33.\u003c/li\u003e\n \u003cli\u003ePillay D, Stankevitz K, Lanham M, Ridgeway K, Murire M, Briedenhann E, et al. Factors influencing uptake, continuation, and discontinuation of oral PrEP among clients at sex worker and MSM facilities in South Africa. PLoS One 2020;15:e0228620.\u003c/li\u003e\n \u003cli\u003eSiregar AYM, Juwita MN, Hardiawan D, Akbar A, Rachman ZH, Haekal MDF, et al. Cost of implementing HIV pre‐exposure prophylaxis at community‐based clinics in Indonesia. Tropical Medicine \u0026amp; International Health 2024;29:13\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eWu L, Kaftan D, Wittenauer R, Arrouzet C, Patel N, Saravis AL, et al. Health impact, budget impact, and price threshold for cost-effectiveness of lenacapavir for HIV pre-exposure prophylaxis in eastern and southern Africa: a modelling analysis. Lancet HIV 2024;11:e765\u0026ndash;73.\u003c/li\u003e\n \u003cli\u003eAdepoju VA, Abdulrahim A. Dollars and dilemmas: lenacapavir\u0026rsquo;s pricing, patents, and the path to affordability. Int J Equity Health 2025;24:270.\u003c/li\u003e\n \u003cli\u003eSchmidt HA, Prochazka M, Ingold H, Reza‐Paul S, Chidarikire T, Romyco I, et al. Seizing the moment: the potential of PrEP choice and innovation to transform HIV prevention. J Int AIDS Soc 2025;28:e26498.\u003c/li\u003e\n \u003cli\u003eWu L, Kaftan D, Wittenauer R, Arrouzet C, Patel N, Saravis AL, et al. Health impact, budget impact, and price threshold for cost-effectiveness of lenacapavir for HIV pre-exposure prophylaxis in eastern and southern Africa: a modelling analysis. Lancet HIV 2024;11:e765\u0026ndash;73.\u003c/li\u003e\n \u003cli\u003eAdepoju VA, Abdulrahim A, Jamil S. Breaking barriers for key populations in the lenacapavir era. Decoding Infection and Transmission 2026;4:100075.\u003c/li\u003e\n \u003cli\u003eKityo C, Cortes CP, Phanuphak N, Grinsztejn B, Venter F. Barriers to uptake of long-acting antiretroviral products for treatment and prevention of HIV in low-and middle-income countries (LMICs). Clinical Infectious Diseases 2022;75:S549\u0026ndash;56.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Ministry of Higher Education, Science, and Technology of Indonesia (Kementerian Pendidikan Tinggi, Sains, dan Teknologi) ","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV pre-exposure prophylaxis, long-acting injectable PrEP, lenacapavir, men who have sex with men, decision cascade, Indonesia","lastPublishedDoi":"10.21203/rs.3.rs-8727712/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8727712/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLong-acting injectable HIV pre-exposure prophylaxis (PrEP) using lenacapavir (LEN) may reduce adherence challenges associated with daily oral PrEP. However, evidence remains limited on how populations at risk progress from acceptability to preference and affordability of LEN. We examined a sequential decision cascade for LEN among HIV-negative men who have sex with men (MSM) in Bali, Indonesia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a cross-sectional survey among 116 HIV-negative MSM in Bali. Data included awareness of LEN, willingness to use LEN, preferred PrEP modality under hypothetical availability (LEN versus oral PrEP), and willingness to pay (WTP). Descriptive analyses characterised each cascade stage, and multivariable logistic regression identified factors associated with preference for LEN.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eParticipants had a median age of 32 years (IQR 26.8\u0026ndash;37.3), and 52.6% had ever used oral PrEP. Awareness of LEN was low, with only 28.4% having heard of LEN. Despite this, acceptability was high: 50.8% reported being willing or very willing to use LEN. Only 45.7% of respondents preferred LEN compared with oral PrEP, indicating attrition at the modality choice stage.. In multivariable analyses, perceived convenience of the six-monthly injection schedule was the only factor independently associated with preference for LEN (unadjusted OR 5.68, 95% CI 1.97\u0026ndash;16.39; adjusted OR 4.91, 95% CI 1.65\u0026ndash;14.59). No significant associations were observed for age, education level, prior oral PrEP use, perceived effectiveness, stigma-related concern, or concern about side effects. Willingness to pay further declined at \u0026gt;\u0026thinsp;IDR 500.000 higher price thresholds, highlighting affordability as an additional barrier despite high acceptability.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAmong HIV-negative MSM in Bali, acceptability of LEN was high, but preference and affordability were more selective. Considering the full decision cascade, from acceptability to affordability, is essential when planning the introduction of long-acting injectable PrEP.\u003c/p\u003e","manuscriptTitle":"From Acceptability to Affordability: A Decision Cascade Analysis of Long-Acting Injectable HIV Pre-Exposure Prophylaxis (Lenacapavir) Among HIV-Negative Men Who Have Sex with Men in Bali, Indonesia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 08:57:37","doi":"10.21203/rs.3.rs-8727712/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"13cfed75-d3d8-4f3a-8cc0-65abd81ac00f","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":61941204,"name":"Health Economics \u0026 Outcomes Research"},{"id":61941205,"name":"Epidemiology"}],"tags":[],"updatedAt":"2026-01-30T08:57:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 08:57:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8727712","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8727712","identity":"rs-8727712","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}