The unseen impact of affordability: copayment sensitivity for long-acting PrEP among MSM in six European Countries, October 2023-April 2024

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 < <euro>50/month to <euro>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 <euro>250/month in all countries. MSM with high income showed significantly higher intention when copayment was under <euro>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 <euro>250, stressing the need for availability under insurance plans, or with limited copayments.