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

Analysis of potential barriers for non-PrEP users among MSM in Germany | 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 Analysis of potential barriers for non-PrEP users among MSM in Germany Helena Waldorf, Ulrich Marcus, Sara Iannuzzi, Stefan Albrecht, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8163580/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Mar, 2026 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background. Daily oral pre-exposure prophylaxis (PrEP) provides effective protection against HIV. Since September 2019, the costs of PrEP have been reimbursed by statutory health insurance in Germany. While a considerable fraction of PrEP-eligible individuals receives PrEP, coverage is inhomogeneous across Germany. This study aims to identify potential barriers associated with PrEP non-use. Methods. Based on the PrApp online cross-sectional study, we analyzed 1,027 PrEP users and 431 non-PrEP users. A PrEP indication was assumed for cis-MSM with an STI diagnosis (12 months), ≥ 2 sex partners or sexualized drug use (6 months). Characteristics between PrEP users and PrEP non-users were compared descriptively and using multivariable logistic regression. Results. Non-PrEP users were more likely to be aged 18-29 years old (P < 0.05) and to use drugs during sex (P < 0.01). The highest HIV-specialists density (P < 0.01) was associated with PrEP use. Fear of side effects (54.5%) was the most common barrier and more pronounced in non-PrEP users living in a federal state with a high HIV-specialists density (67.9% vs. 51.8%) as well as low HIV-risk perception (35.8% vs. 24.1%). Non-PrEP users living in a federal state with a low HIV-specialists density described not wanting to discuss their sex life with their doctor (29.5% vs. 16.0%) as a reason for PrEP non-use. Persons with sexualized drug use were more likely to report daily PrEP use as a barrier (34.3% vs. 16.9%, P < 0.01, adjusted P < 0.05). Conclusions. Our analyses indicated structural barriers to PrEP use in federal states with a low HIV-specialists density (physician density, non-anonymity). For those with theoretical PrEP access (high HIV-specialists density), underestimation of HIV risk and fear of side effects could potentially be overcome by effective risk communication. HIV prevention barriers PrEP TDF/FTC MSM uptake Full Text Additional Declarations No competing interests reported. Supplementary Files PrAppBMCSupplementv2.pdf Cite Share Download PDF Status: Published Journal Publication published 27 Mar, 2026 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 12 Jan, 2026 Reviews received at journal 27 Dec, 2025 Reviews received at journal 22 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 28 Nov, 2025 Reviewers invited by journal 28 Nov, 2025 Editor assigned by journal 28 Nov, 2025 Editor invited by journal 26 Nov, 2025 Submission checks completed at journal 25 Nov, 2025 First submitted to journal 25 Nov, 2025 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. 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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-8163580","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":552411170,"identity":"2d75d158-1511-4e01-b826-e520786909b1","order_by":0,"name":"Helena Waldorf","email":"","orcid":"","institution":"Robert Koch Institute","correspondingAuthor":false,"prefix":"","firstName":"Helena","middleName":"","lastName":"Waldorf","suffix":""},{"id":552411171,"identity":"0df22129-23cc-4eb9-9d7a-71331b8c19d0","order_by":1,"name":"Ulrich Marcus","email":"","orcid":"","institution":"Robert Koch 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Germany","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HIV prevention, barriers, PrEP, TDF/FTC, MSM, uptake","lastPublishedDoi":"10.21203/rs.3.rs-8163580/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8163580/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground. \u003c/strong\u003eDaily oral pre-exposure prophylaxis (PrEP) provides effective protection against HIV. Since September 2019, the costs of PrEP have been reimbursed by statutory health insurance in Germany. While a considerable fraction of PrEP-eligible individuals receives PrEP, coverage is inhomogeneous across Germany. This study aims to identify potential barriers associated with PrEP non-use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods.\u003c/strong\u003e Based on the PrApp online cross-sectional study, we analyzed 1,027 PrEP users and 431 non-PrEP users. A PrEP indication was assumed for cis-MSM with an STI diagnosis (12 months), ≥ 2 sex partners or sexualized drug use (6 months). Characteristics between PrEP users and PrEP non-users were compared descriptively and using multivariable logistic regression.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults. \u003c/strong\u003eNon-PrEP users were more likely to be aged 18-29 years old\u0026nbsp;(P \u0026lt; 0.05) and to use drugs during sex (P \u0026lt; 0.01). The highest HIV-specialists density (P \u0026lt; 0.01) was associated with PrEP use. Fear of side effects\u0026nbsp;(54.5%) was the most common barrier and more pronounced in non-PrEP users\u0026nbsp;living in a federal state with a high HIV-specialists density (67.9% vs. 51.8%) as\u0026nbsp;well as low HIV-risk perception (35.8% vs. 24.1%). Non-PrEP users living in a\u0026nbsp;federal state with a low HIV-specialists density described not wanting to discuss\u0026nbsp;their sex life with their doctor (29.5% vs. 16.0%) as a reason for PrEP non-use.\u0026nbsp;Persons with sexualized drug use were more likely to report daily PrEP use as\u0026nbsp;a barrier (34.3% vs. 16.9%, P \u0026lt; 0.01, adjusted P \u0026lt; 0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions. \u003c/strong\u003eOur analyses indicated structural barriers to PrEP use in federal\u0026nbsp;states with a low HIV-specialists density (physician density, non-anonymity). For\u0026nbsp;those with theoretical PrEP access (high HIV-specialists density), underestimation of HIV risk and fear of side effects could potentially be overcome by effective\u0026nbsp;risk communication.\u003c/p\u003e","manuscriptTitle":"Analysis of potential barriers for non-PrEP users among MSM in Germany","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 15:51:19","doi":"10.21203/rs.3.rs-8163580/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-12T10:11:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-27T19:34:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T18:55:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260585166595938929723557920431783328871","date":"2025-12-03T15:06:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"42252849927645813993882885392164324028","date":"2025-11-28T17:27:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-28T15:31:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-28T15:26:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-26T11:07:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-25T09:37:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-25T09:35:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ddb7734b-245a-40f6-8fdc-60df04eddc9a","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T16:34:15+00:00","versionOfRecord":{"articleIdentity":"rs-8163580","link":"https://doi.org/10.1186/s12889-026-27039-3","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-03-27 16:12:40","publishedOnDateReadable":"March 27th, 2026"},"versionCreatedAt":"2025-12-01 15:51:19","video":"","vorDoi":"10.1186/s12889-026-27039-3","vorDoiUrl":"https://doi.org/10.1186/s12889-026-27039-3","workflowStages":[]},"version":"v1","identity":"rs-8163580","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8163580","identity":"rs-8163580","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}