BACKGROUND:Long-acting injectable cabotegravir (CAB-LA) as pre-exposure prophylaxis (PrEP), given once every 8 weeks, has been found to have superior efficacy over oral PrEP among men who have sex with men (MSM). We compared the epidemiologic impact of expanding CAB-LA to current oral PrEP users with different levels of adherence, and non-PrEP users among MSM in the Netherlands. METHODS:An MSM HIV transmission model was calibrated to the Dutch MSM HIV epidemic. The real-world effectiveness of daily oral-PrEP was assumed to decrease by users' adherence levels: High (defined as >75% of the days covered, 93% effectiveness), medium (50%-74% covered, 69%), and low (<50% covered, 18%), respectively. CAB-LA effectiveness was assumed as 91%. CAB-LA was targeted to current oral-PrEP users by their use adherence and non-PrEP-using MSM in 2025. The epidemiologic impact of CAB-LA targeting strategies was evaluated for 5, 15, and 25 years. RESULTS:Assuming 100% coverage, providing CAB-LA to MSM with low oral PrEP adherence would avert 862 (19.7%) new HIV infections among all MSM for 25 years. Expanding CAB-LA to MSM with medium/high oral PrEP adherence and non-PrEP users did not show a substantial epidemiologic impact. Moreover, our model suggested that the epidemiologic impact would decrease with a lower real-world CAB-LA effectiveness. CONCLUSIONS:Our model showed that CAB-LA can be an important addition to ending the HIV epidemic by 2030. To optimize the full potential of CAB-LA at the beginning stage of CAB-LA introduction, we suggest prioritizing the transition of current oral PrEP users with low adherence to CAB-LA to reduce HIV transmissions more efficiently.

BACKGROUND:Long-acting injectable pre-exposure prophylaxis (LAI-PrEP) offers potentials for expanding PrEP coverage and improving public health outcomes. This study synthesizes evidence on the prevalence and determinants of interest in and preference for LAI-PrEP among men who have sex with men (MSM), trans* individuals, and heterosexual women. METHODS:We conducted this systematic review and meta-analysis building on quantitative studies from a previous review and new studies published in PubMed, Web of Science, and Embase up to December 31, 2023. We used a random-effects meta-analysis to pool the prevalence of LAI-PrEP interest and preference, and narratively synthesized their determinants across all key populations. FINDINGS:We included 41 articles. Seventy-four percentage (95% CI: 71 to 78) of MSM showed interest in using LAI-PrEP, and 37% (95% CI: 29 to 44) of them preferred LAI-PrEP over other HIV prevention methods. The prevalence of interest and preference were even higher among current oral PrEP users [77% (95% CI: 70 to 84) and 43% (95% CI: 28 to 58), respectively]. Interest in LAI-PrEP among trans* individuals was similarly high at 72% (95% CI: 67 to 78), with 1 study reporting that 57% of transgender women preferred LAI-PrEP. Cisgender heterosexual women also showed a high preference for LAI-PrEP (55%, 95% CI: 40 to 70). No significant differences were found between low-/middle-income countries and high-income countries across any key populations. Overall, people with more resources and who are already aware of and using oral PrEP are likely more interested in LAI-PrEP when it becomes available. CONCLUSIONS:Continued research is essential to effectively deploy LAI-PrEP and address HIV prevention gaps. Because more countries adopt LAI-PrEP, understanding its impact and reaching underserved populations will be critical to maximizing public health benefits.

The historical treatment of homosexuality in psychoanalysis has ranged from pathologization to discrimination. Despite recent attempts at inclusion, gay analysts and patients still report bias within the field. This study explored the experiences of gay and heterosexual psychoanalysts regarding the discipline's attitude towards homosexuality. Semi-structured interviews with nine analysts (four gay men, four heterosexual men, one heterosexual woman) from different theoretical traditions and countries were analysed using Interpretative Phenomenological Analysis. The sample's diversity offered a rare opportunity to compare the perspectives of gay and heterosexual analysts within the same professional community. Four major themes emerged: (1) 'It's not a problem', (2) experiences of discrimination, (3) critiques of psychoanalysis and its institution and (4) positive change in terms of acceptance of sexual diversity. Gay analysts reported discrimination, rejection and a sense of being wronged, while heterosexual analysts tended to lack emotional empathy and regarded discrimination as a problem of the past. Both groups acknowledged psychoanalysis as a valuable therapeutic tool but emphasized the urgency of systemic change to ensure its ethical integrity and inclusivity. The findings highlight the importance of fostering inclusive practices, addressing entrenched biases and maintaining the psychoanalytic attitude, the discipline's core, when working on issues related to homosexuality.

Background European men who have sex with men (MSM), trans* and non-binary individuals experience unique sexual health challenges and are disproportionally affected by HIV. Despite efforts to improve sexual health among these communities, gaps remain in the coverage of HIV prevention strategies at a population level. Methods An online cross-sectional survey was conducted across 20 European countries from October 2023 to April 2024. The survey was translated into 22 local and migrant languages. The survey was designed to understand the sociodemographic characteristics, sexual behavior, sexual health and the use of HIV prevention strategies among MSM, trans* and non-binary individuals in Europe. Participants were recruited mainly from gay dating apps and through a social media campaign. Results A total of 15,458 MSM, trans* and non-binary individuals participated in the survey and were included in this sample. Overall, the sample was sexually active in the past 6 months (96.4%), engaged in condomless anal intercourse in the past 6 months (83.4%), had more than 10 partners in the past 6 months (57.6%) and was PrEP naïve (51.4%). Conclusions MSM, trans* and non-binary individuals in Europe are sexually active and are employing a range of strategies to protect themselves from HIV, including oral PrEP, however gaps remain in HIV prevention coverage, which new PrEP modalities, such as long-acting injectable PrEP, could help to fill.

INTRODUCTION:In border regions like the EuRegio Meuse-Rhine (EMR), mobility does not stop at the border. HIV risk may therefore not only be determined by within-country factors but also by between-country differences. We explored between-country differences in HIV indicators in the EMR using two complementary data-driven approaches. METHODS:First, we used 2019-2021 surveillance data from the German Robert Koch Institute, the Belgian Health Institute Sciensano and the Dutch HIV Monitoring Foundation to report on the EMR-specific 95-95-95 goals. Second, we used the cross-sectional EMIS-2017 survey, including (trans)men who have sex with men (MSM), to report on determinants of HIV testing in the EMR. We employed multilevel multinomial regression modelling to identify sociodemographic factors associated with recent (<1 year), non-recent (≥1 year) and never testing for HIV, with a random effect for between-country effects. RESULTS:Based on 2021 surveillance data, the estimated number of individuals with HIV is 24 895, with 2236 individuals undiagnosed (9%). Countries differ most on the first pillar of the 95-95-95 goals: 95-93-96 in the Dutch, 90-98-96 in the German and 96-94-97 in the Belgian EMR-region, respectively. In EMIS-2017, half of MSM (n = 1335/2669) tested recently, 26% tested not-recently (n = 693) and 24% (n = 641) never tested for HIV; with 8% of HIV-testing variance explained by between-country differences. Non-recent and never-testing were both associated with socio-demographic factors, suggesting that some key populations (e.g., with transgender identity) and lack of resources determined differences in HIV testing. CONCLUSION:Targeted approaches to address regional and socio-demographic differences are urgently needed, especially to tackle HIV-testing barriers and reach individuals undiagnosed.

Abstract In October 2025, mpox virus clade I infections have been detected among men who have sex with men (MSM) in the EU/EEA, suggesting local transmission in MSM sexual networks. Given the large outbreak of mpox among MSM in 2022 and the uncertain transmission parameters of clade I in the European context, clade I poses a public health concern to the EU/EEA. This work assesses the potential effect of increasing the mpox vaccine uptake among MSM via two contributions. First, building on the European MSM and Trans Persons Internet Survey 2024, we estimate the mpox vaccine uptake among MSM as well as the proportion who are unvaccinated but willing to get vaccinated for 28 countries in the EU/EEA. Specifically, we fit Bayesian mixed-effects models for the vaccine and recovery status of an individual depending on their number of sexual partners and country. Second, we develop a susceptible-infectious-recovered model on a sexual contact network to estimate the reduction of the reproduction number if vaccines are provided to MSM who are willing to get vaccinated. Our results suggest a substantial willingness for mpox vaccination among MSM if mpox cases increase and a large reduction of the effective reproduction number if this willingness is met. These findings highlight a large potential of increasing mpox vaccine uptake among MSM and preventing future mpox outbreaks in the EU/EEA.

BACKGROUND:Migrant women account for a substantial proportion of new HIV diagnoses in Europe, yet remain underrepresented in HIV prevention research. Little is known about how legal status and national policy context shape engagement with PrEP among migrant women, particularly those without secure documentation. We assessed the PrEP cascade and HIV prevention preferences among migrant women, examining how legal status, sex work engagement and national reimbursement policies drive inequities in access. METHODS:We conducted a community-led, cross-sectional survey (June-July 2025) of 521 HIV-negative migrant women recruited offline via community-based organisations. Multivariable logistic regression examined associations between legal status, sex work, country-level PrEP reimbursement policies and PrEP cascade outcomes. RESULTS:Among 521 participants, 259 (49.7%) lacked secure legal status (119 asylum seekers, 89 refugees and 51 undocumented migrants) and 90 (17.3%) were engaged in sex work. Overall, 40.1% (95% CI 35.9-44.5) were aware of PrEP and 24.6% (20.9-28.6) intended to use it, yet only 6.0% (4.1-8.4) were current users; 36.7% (23.8-51.7) of PrEP-experienced women had discontinued use. Compared with naturalised citizens or documented residents, undocumented migrants (aOR = 2.57, 95% CI = 1.19-5.64), asylum seekers (3.67, 1.98-6.93) and refugees (2.28, 1.22-4.31) had higher odds of PrEP awareness. Sex workers had higher odds of current PrEP use (5.50, 1.61-20.42). Residing in countries with full PrEP reimbursement was independently associated with higher uptake (4.96, 1.30-26.11). Although condoms were the most preferred method (60.3%), interest in daily oral and long-acting injectable PrEP was evident, particularly among undocumented women and sex workers. CONCLUSION:A four-fold gap between PrEP intention and actual uptake among migrant women reflects a failure of universal health coverage, driven by restrictive migration governance and health financing. Achieving HIV equity requires decoupling PrEP eligibility from documentation status and expanding community-led delivery.

BACKGROUND:Italy has recently expanded access to oral pre-exposure prophylaxis (PrEP) and made rapid progress in long-acting PrEP (LA-PrEP) availability. These developments create a unique opportunity to assess population-level readiness for LA-PrEP and identify gaps that may limit its public health impact. AIM:To assess an extended PrEP cascade, quantify unmet prevention needs that LA-PrEP could mitigate, and identify determinants of LA-PrEP intention across key populations (KPs) in Italy. METHODS:We analysed data from the PROTECT cross-sectional survey (October 2023-April 2024), including participants without HIV in Italy (n = 2215): 1707 MSM, 32 trans* individuals, 267 cis-men, and 209 cis-women. We described PrEP cascades (oral PrEP awareness, uptake, adherence, discontinuation; LA-PrEP awareness, interest, intention), unmet prevention needs potentially addressable by LA-PrEP ( defined as no current oral PrEP use or suboptimal oral PrEP adherence combined with LA-PrEP intention), and regional differences. Open-ended responses on LA-PrEP perceptions were analysed. Determinants of LA-PrEP intention and unmet PrEP needs were explored using multivariable logistic regression. RESULTS:Overall, 19.0% (95%CI = 17.3-20.6) reported current oral PrEP use, of whom 19.8% (95%CI = 15.8-24.3) reported suboptimal adherence and 10.0% (95%CI = 8.3-13.9) had discontinued. Nearly half (47.0%, 95%CI = 44.9-49.8) expressed LA-PrEP intention. Unmet prevention needs potentially addressable by LA-PrEP were identified in 34.8% (95%CI = 32.8%-36.8%). MSM showed the highest PrEP engagement, whereas cisgender men had the lowest; unmet needs were greater in less-urbanised areas. Qualitative data reflected a positive outlook, framing LA-PrEP as safe, convenient, and empowering sexual freedom. Among MSM, unmet prevention needs potentially addressable by LA-PrEP were substantial among PrEP-naïve and discontinued users, although intention to use LA-PrEP was comparatively lower in these groups, indicating a mismatch between prevention need and acceptability. CONCLUSIONS:Despite low awareness, LA-PrEP intention is high in Italy, indicating strong readiness for rollout. However, a mismatch between prevention need and intention, particularly among PrEP-naïve individuals, may limit population-level impact. Yet, these findings should be interpreted considering the potential for selection bias associated with online convenience sampling and recruitment through social media and dating applications. Targeted, equity-oriented implementation strategies are required to ensure that LA-PrEP reaches populations experiencing substantial unmet HIV prevention needs.

BACKGROUND:Long-acting injectable PrEP (LA-PrEP) is a novel HIV prevention modality recently approved in Europe, offering an important addition to HIV prevention options. Understanding user perceptions early is critical for anticipating uptake, addressing barriers, and shaping implementation. This study aimed to identify the latent qualitative themes surrounding LA-PrEP among Dutch-speaking men-who-have-sex-with-men (MSM) in the Netherlands and Belgium, and to assess how these perceptions associate with their intention to use LA-PrEP. METHODS:We utilised data from the cross-sectional PROTECT survey (October 2023-April 2024). Before questioning, participants were provided a standardised, objective explanation of LA-PrEP's efficacy, dosing schedule, and potential side effects to ensure a baseline understanding. MSM without HIV who completed the Dutch-language survey answered a single open-ended question: 'What does LA-PrEP mean to you?' Participants could provide multiple short terms or phrases. Responses were analysed directly in Dutch using Structural Topic Modelling (STM), an unsupervised machine learning approach, to estimate latent topics and their regression with LA-PrEP use intention. RESULTS:We analysed qualitative responses from 1,472 Dutch-speaking MSM without HIV. Overall expectations were highly positive. Six distinct conceptual topics were identified: empowerment (29% of the topic proportion), superiority (24%), concerns and uncertainties (13%), convenience and reliability (12%), peace of mind (12%), and ideal regimen (11%). While dominant themes emphasised freedom, safety, and reassurance, a notable subset expressed ambivalence. Topic regression revealed that responses strongly aligned with the concerns and uncertainties topic were significantly associated with a lower intention to use LA-PrEP (β = -0.021; 95%CI: -0.042 to -0.001). CONCLUSIONS:LA-PrEP is widely perceived as a promising and convenient HIV prevention option among Dutch-speaking MSM, but concerns about safety and necessity remain for a subset of individuals. Addressing these concerns through targeted, evidence-based communication will be essential to support informed choice and maximise uptake.

In European countries with stratified educational trajectories, in which adolescents are separated into vocational and academic tracks, studies have shown that there are educational differences in adolescent sexual health. However, due to heterogeneity of the existing literature in terms of national educational systems and dimensions of sexual health being studied, uncertainty remains about the strength of the association between educational track and adolescent sexual health. The current meta-analysis synthesizes the available evidence on educational differences in sexual health among adolescents in Europe. Further, it tests the extent to which findings vary according to the (sub)domain of sexual health being studied, and study and sample characteristics such as study quality, gender and ethnic background of participants. This meta-analysis included 47 studies, with 159 effect sizes, and 177,169 adolescents (Mage = 16.59, SD = 2.17). Results revealed a significant association between educational track and adolescent sexual health (g = 0.279, 95

BACKGROUNDDoxycycline post-exposure prophylaxis (doxy-PEP) has been shown to reduce the incidence of chlamydia and syphilis among men who have sex with men (MSM) at high risk of sexually transmitted infections (STIs). However, doxy-PEP adds antibiotic exposure and may select for tetracycline resistance in both target and bystander bacteria, raising concerns about antimicrobial resistance (AMR). Quantifying additional antibiotic consumption from doxy-PEP is important for assessing its potential AMR impact at population level.AIMWe estimated the potential increase in doxycycline consumption attributable to doxy-PEP among MSM using HIV pre-exposure prophylaxis (PrEP) in the European Union and European Economic Area (EU/EEA) and compared it with overall doxycycline and tetracycline-class consumption.METHODSWe used Monte Carlo simulation to estimate annual doxycycline use from doxy-PEP among MSM using PrEP. We estimated population size from the 2024 European MSM Internet Survey and derived doxy-PEP uptake and prescribing frequency from expert elicitation. Estimated consumption in defined daily doses (DDD) per year was compared with tetracycline-class and doxycycline antibiotic use reported by the European Surveillance of Antimicrobial Consumption Network.RESULTSDoxy-PEP among MSM using PrEP in the EU/EEA could result in an estimated 4.4 million DDDs of doxycycline annually (95% credible interval (CrI): 0.5–18.1 million), corresponding to a 1.9% increase (95% CrI: 0.2–7.7) relative to 2023 doxycycline consumption.CONCLUSIONThe estimated Doxy-PEP use constitutes a non-negligible share of total doxycycline consumption in the EU/EEA. Monitoring doxy-PEP uptake and AMR indicators will be essential as more countries consider integrating this intervention into STI prevention strategies.

OBJECTIVE:To examine the awareness, usage and perceptions of doxycycline post-exposure prophylaxis (doxyPEP) for sexually transmitted infection (STI) prevention among gay and bisexual men and transgender (trans) and gender diverse people in Australia. DESIGN:Cross-sectional online survey. SETTING, PARTICIPANTS:National multi-site survey in Australia from 1 July 2024 to 30 November 2024, recruiting from 13 sexual health and community clinics, 6 general practices, social media, dating applications, and university portals. Gay and bisexual men and trans and gender diverse people aged ≥ 18 years living in Australia were included in the study. MAIN OUTCOME MEASURES:DoxyPEP awareness, ever use, recent use (past 12 months), dosage regimens, sourcing methods and planned future use. RESULTS:Among 2095 participants, half (1080/2095, 51.6%) had heard of doxyPEP. Of those aware, 323/1080 (29.9%) had ever used doxyPEP, and 306/1080 (28.3%) were recent users. DoxyPEP awareness and usage varied by HIV status and pre-exposure prophylaxis (PrEP) use (p < 0.0001). Nearly two-thirds of users had taken the recommended 200 mg within 72 h after sex (205/323, 63.5%). Among recent users, 29/306 (9.5%) reported recent syphilis diagnoses, and 85/306 (27.8%) had ≥ 2 STI diagnoses in the past 12 months. Of those who had ever used doxyPEP, 135/323 (41.8%) obtained prescriptions from clinicians, 17/323 (5.3%) obtained it online, and 28/323 (8.7%) purchased it in person overseas without a prescription. Of those aware of doxyPEP, 490/1080 (45.4%) planned to use doxyPEP in the next 12 months, primarily to prevent chlamydia (460/490, 93.9%), gonorrhoea (422/490, 86.1%) or syphilis (386/490, 78.8%). Some intended to prevent Mycoplasma genitalium (92/490, 18.8%) or mpox (36/490, 7.4%). Among non-users, 306/756 (40.5%) worried about antibiotic resistance. CONCLUSIONS:DoxyPEP use was happening quickly but often involved non-recommended regimens and unsupervised sourcing. Urgent educational interventions and improved clinical access are needed for safe implementation.

Men-who-have-sex-with-men (MSM), as well as transgender and non-binary individuals, continue to face a disproportionate burden of stigma, mental health challenges, HIV, and other sexually transmitted infections. To address their needs, public health planners require reliable and comparable data. Monitoring behaviours in these populations also supports the evaluation of health policies. The European-MSM-Internet-Survey (EMIS-2024) builds on our international surveys conducted in 2010 and 2017, expanding its scope to include explicitly transgender women and non-binary people. It provides much-needed data for planning interventions, promoting health, and harmonising behavioural surveillance. A key strength of EMIS-2024 is the use of a shared sampling frame and a core questionnaire across all participating countries. This approach allows meaningful cross-national comparisons, unlike many national surveys with varying methods. The three core consortium partners (Deutsche Aidshilfe, Robert Koch Institute and Maastricht University) led the revision of the EMIS-2017 questionnaire. Over 60 partners from 40 countries played a key role in the survey’s success, providing high-quality translations in 35 languages and actively promoting the survey. National partners ensured the survey’s visibility, credibility, and relevance once dating app advertisements or invitations appeared. The survey ran online during the first half of 2024. Overall, 165,380 responses were received, of which 50,330 qualified for the analytic sample. EMIS-2024 demonstrates that large-scale, multi-country sexual health surveys are feasible with public funding. A harmonised questionnaire, shared sampling strategy, and meaningful community involvement were key to generating robust, comparable data across Europe.

Background HIV self-testing (HIVST) has the potential to increase testing uptake among populations underserved by facility/clinic-based services, including African migrants in Europe. However, research on HIVST among African migrants in Europe and other high-income countries remains limited. Objective To explore perspectives on HIVST, identify barriers and facilitators to uptake, and provide recommendations to inform effective implementation among African migrants in the Netherlands. Methods Between February 2021 and May 2023, semi-structured interviews were conducted with 26 African migrants and 13 key informants, including healthcare providers (general practitioners, HIV specialists, testing service providers), policy and research professionals, and migrant community representatives. Data were analyzed using an inductive thematic approach. The Consolidated Framework for Implementation Research (CFIR) was applied post hoc to contextualize study findings within a broader implementation context. Results Participants’ perspectives on HIVST centered on three themes: enhanced autonomy in decision-making and testing processes; navigating autonomy and support for self-testing and care linkage; and HIVST within the Dutch context and prevention landscape. Factors potentially influencing successful uptake and implementation were identified across multiple CFIR domains, including perceived relative advantage over facility/clinic-based testing, evidence on reliability, and procedural complexity (Innovation Characteristics); low self-efficacy, self-testing and linkage to care support needs (Individual Characteristics); HIV stigma, limited awareness and low visibility of HIVST (Outer Setting); and perceived incompatibility with existing healthcare systems (Inner Setting). Conclusions Although HIVST can address key testing barriers among African migrants, targeted implementation strategies are needed to guarantee equitable access, proper use, and optimal outcomes. These include enhanced dissemination of HIVST information, normalization of HIV testing and self-testing, provision of person-centered support, and establishing clear pathways for timely care linkage when required.

OBJECTIVE:Individuals seeking HIV protection can choose from various strategies (e.g. condoms, PrEP). Thus, individuals may engage in informed decision making, balancing risks and benefits with their values. This study examines how different levels of informed decision making affect the relationship between individuals' momentary prioritization of HIV safety and the perceived safety of their choices. Additionally, it investigates the relationship between informed decision-making levels and choice variability. METHODS AND MEASURES:105 participants (104 cisgender men, 1 intersex man) provided safety evaluations for different sexual scenarios involving various HIV prevention strategies. Over six biweekly follow-ups, implemented strategies were reported and matched with safety evaluations, while assessing informed decision-making levels, impulsivity, and personal priority of safety. RESULTS:Higher levels of informed decision making were associated with a weaker positive relationship between momentary prioritization of HIV safety and perceived safety of the chosen strategy, suggesting that perceived safety was less dependent on momentary prioritization of HIV safety. Further, informed decision-making levels were not associated with choice variability. CONCLUSIONS:Our findings suggest that informed HIV prevention decisions are associated with higher perceived safety and act compensatory towards low personal safety prioritizations. This highlights the importance of supporting informed HIV prevention decisions.

BackgroundTransgender men face barriers to gynecological care, and data from Brazil are scarce. Understanding their health needs is essential to removing barriers and improving healthcare access.ObjectivesTo assess the prevalence of gynecological conditions among trans men in Rio de Janeiro, Brazil, and examine access to care within a culturally safe clinic.MethodsWe conducted a prospective, observational study of 100 trans men on hormone therapy, followed for 12 months at a university-affiliated clinic. Clinical evaluations, laboratory testing, and structured questionnaires were used to determine the prevalence of gynecological conditions.ResultsEighty-four percent of participants reported prior gynecological evaluation, yet only 49% had cytological testing, markedly lower than coverage in cisgender Brazilian women. At least one gynecological symptom was reported by 71%, most frequently dysmenorrhea (43.7%), dyspareunia (32.4%), and vaginal discharge (16.9%). Clitoromegaly was nearly universal (97%). Novel papillary clitoral lesions were observed, and there was one case of primary syphilis. Adherence to visits was high (99%), supported by a culturally safe clinic environment with trained and gender-diverse staff.ConclusionsGynecological conditions are common among trans men in Brazil, and uptake of preventive screening remains suboptimal. Inclusive, patient-centered services can promote retention in care, even in stigmatizing contexts.ImplicationsReducing disparities requires integration of transgender-specific training in medical curricula, expansion of culturally adequate clinics, and further research on determinants of morbidity in this population.

This study investigated the clustering of psychosocial adversities and their synergistic effect with depression on suicidality in a 12-month prospective cohort (N = 214) of YMSM living with HIV in Bangkok, Thailand. Latent class analysis identified subgroups with distinct combinations of adversities, including bullying, intimate partner violence, substance use, HIV stigma, low social support, histories of sex work, and below-income status. Significant interactive synergism were found as hypothesized, supporting a syndemic effect with qualitatively increasing levels of adversities on suicidality (score range: 3–17) over the 12 months. The interaction between moderate adversity clustering and depression (βow = 2.50, 95

BACKGROUND:Suboptimal adherence to PrEP limits its global impact, with current evidence mostly from the Global North and lacking Global South perspectives. This meta-analysis synthesises the rates and determinants of suboptimal adherence to oral PrEP among MSM in both regions. METHODS:We searched for literature describing PrEP adherence and its determinants among MSM globally up until October 2024 to conduct a meta-analysis on the rate and determinants of suboptimal adherence in both regions. The definition of (sub-)optimal adherence were study-based. RESULTS:We included 82 studies in the meta-analysis, with 24, 53, and 5 stemmed from the Global South, North, and global multicentre studies, respectively. Oral PrEP suboptimal adherence is prevalent among MSM PrEP-users globally (rate=0.33, 95%CI:0.28-0.38) with a significantly higher rate (p=0.021) in the Global South (rate=0.41, 95%CI:0.33-0.50) compared to the Global North (rate=0.29, 95%CI:0.23-0.35). In the Global South, older age (OR=0.57, 95%CI:0.37-0.87), alcohol use (OR=1.28, 95%CI:1.02-1.60) and presenting depressive symptoms (OR=1.47, 95%CI:1.01-2.16) were associated with suboptimal adherence. In the Global North, MSM self-identified as Black (OR=2.27, 95%CI:1.31-3.95) or Other (OR=1.36, 95%CI:1.02-1.81), having a university degree (OR=0.50, 95%CI:0.34-0.73), and presenting depressive symptoms (OR=2.26, 95%CI:1.35-3.78) were associated with suboptimal adherence. On-demand PrEP-users globally demonstrated a higher likelihood of suboptimal adherence (OR=1.59, 95%CI:1.18-2.14). CONCLUSIONS:Suboptimal adherence to oral PrEP is prevalent among MSM globally, particularly higher in the Global South. Regional differences in determinants highlight the need for tailored interventions. Tailored interventions are required to address mental health with tailored efforts to younger MSM in the Global South, while interventions in the Global North should be tailored to specific sub-groups.

Indonesia is a country deeply rooted in religion, faith, and spirituality. These aspects significantly determine individuals' decision-making and behavior, including health care decisions. Given the suboptimal attainment of the HIV-cascade targets in the country, we conducted a study to explore the role of religion, faith, and spirituality on antiretroviral therapy (ART) initiation. Our study involved individual interviews with 67 participants recruited from community health centers, public hospitals, and private clinics, predominantly Muslim, including 17 untreated people with HIV (ART-naïve), 30 people with HIV on treatment (ART-experienced), and 20 HIV service providers. Findings revealed that many individuals perceived HIV as a godly punishment related to individual failure (prior risk-prone behaviors), generating shame, guilt, and stigma. Perceiving religion as punitive and unforgiving and holding fatalistic beliefs was linked to postponed ART initiation. Conversely, perceiving religion as loving and forgiving, seeking forgiveness through religious practices, viewing ART intake as a "collaborative" effort with God, and engaging in righteous deeds facilitated ART initiation. These findings indicated that religion, faith, and spirituality can serve as both barriers and facilitators to ART initiation, depending on individuals' faith-based practices and perceptions of religion, whether punishing or forgiving. We recommend that people with HIV and health care providers better recognize the role of religion, faith, and spirituality in coping with shame, guilt, and stigma after an HIV diagnosis. This recognition can facilitate informed decisions regarding ART initiation, ultimately improving health outcomes for individuals with HIV in Indonesia.

BACKGROUND:Long-acting pre-exposure prophylaxis (LA-PrEP) is approved in Europe with promising HIV prevention potential. Currently, no data are available that examine intention to use LA-PrEP intention when it is not fully covered by healthcare/insurance programs. We investigated how the affordability of LA-PrEP impacts the intention to use LA-PrEP by men who have sex with men (MSM) in six European countries. METHODS:We included 10,592 HIV-negative MSM from an online cross-sectional survey (PROTECT, October 2023-April 2024), with participants from France (n = 1965), Germany (n = 2268), Italy (n = 1707), Spain (n = 1985), the United Kingdom (n = 1218) and the Netherlands (n = 1449). We investigated the intention to use LA-PrEP if one showed interest under different levels of affordability. For those who showed intention to use LA-PrEP when out-of-pocket copayments were required, we explored their intention by different copayments (ranging from < €50/month to €1000 + /month). We used multinomial regression to explore the impact of individual income on their intention to use LA-PrEP across different affordability/copayment scenarios. RESULTS:Of the included MSM, 59%-79% showed LA-PrEP interest in these six countries. Among them, a consistent decline in the LA-PrEP intention was observed as affordability decreased: from 44%(FR)-91%(NL) at high affordability to 10%(DE)-26%(NL) at low affordability. MSM with a high income showed significantly higher intention under medium and low affordability scenarios in all countries. Among those who showed intention with copayments, a strongly declining intention was observed and reached almost 0% when the copayment exceeded €250/month in all countries. MSM with high income showed significantly higher intention when copayment was under €250/month in all countries. CONCLUSIONS:LA-PrEP would be welcomed in Europe if affordable. When LA-PrEP is not fully-covered, MSM with a high income may be the early adopters. However, LA-PrEP may not be affordable for those with a reason to use LA-PrEP once monthly copayments exceed €250, stressing the need for availability under insurance plans, or with limited copayments.