Awareness and Knowledge of HIV Pre-Exposure Prophylaxis among Gay, Bisexual, and Other Men Who Have Sex with Men in Colombia

1. Introduction

Pre-exposure prophylaxis (PrEP) for human immunodeficiency virus is one of the most important advances in biomedical HIV prevention. The iPrEx, PROUD, and IPERGAY trials demonstrated a substantial reduction in the risk of HIV acquisition among MSM and showed that protection increases with adequate drug exposure [1,2,3,4]. Demonstration projects and implementation cohorts confirmed a very low incidence of HIV during appropriate use and supported both daily oral PrEP and, for eligible MSM, event-driven PrEP [5,6,7,8]. PrEP should therefore be understood as an effective strategy that expands opportunities for care rather than as an intervention that restricts sexual autonomy.

The value of PrEP extends beyond its pharmacological efficacy. The literature on user-reported outcomes indicates reduced HIV-related anxiety, a greater sense of control, improved communication with partners, and greater sexual enjoyment and intimacy [31,32,33]. These benefits are relevant from a person-centered public health perspective because sexual health is not limited to the absence of infection. At the same time, stigmatization of PrEP users may hinder acceptance, encourage concealment, and deepen inequities in access [48,49].

PrEP prevents HIV acquisition but does not provide direct protection against syphilis, gonorrhea, chlamydia, or other STIs. The WHO therefore recommends integrating it with condoms when individuals choose to use them, vaccination, periodic HIV and STI testing, timely diagnosis and treatment, and other combination-prevention interventions [50,51,52,53,54,55,56]. Understanding this distinction is essential for informed decision-making. Having heard of PrEP does not necessarily mean understanding its indication, the need to rule out HIV infection before initiation, the importance of adherence, clinical monitoring, or the conditions for safely discontinuing and restarting it.

International reviews have shown a persistent gap between awareness, accurate knowledge, willingness, initiation, and continuation. Although awareness and willingness to use PrEP have increased, actual use remains shaped by health coverage, provider availability, perceived need, stigma, cost, social networks, and service quality [18,19,20,21,22,23,24,25,35,36,37,38,39,40,46,47]. These differences are particularly important among populations facing structural barriers, including young people, individuals experiencing financial hardship, residents of areas with limited service availability, transgender people, and sex workers [42,43,44,45].

Another area of debate concerns changes in condom use and the occurrence of STIs after PrEP initiation. Meta-analyses and cohort studies have documented decreased condom use and high STI rates among some groups of users [10,11,12,13,14,15,16,17]. However, this relationship should not automatically be interpreted as causal. Individuals who initiate PrEP may have had greater exposure before initiation; moreover, periodic follow-up increases the likelihood of detecting asymptomatic infections, especially when extragenital testing is performed. Some trials also found no uniform increases in sexual practices [9,14]. Evaluations must distinguish among behavioral change, user selection, and greater diagnostic intensity.

In Latin America, the regulatory adoption of PrEP has advanced, but differences persist among the existence of guidelines, availability, and sustained access [22,30,58]. In Colombia, the incorporation of this strategy is relatively recent. National studies have examined knowledge, motivation, self-efficacy, awareness, eligibility, intention to use, and early program experiences [26,27,28,29]. However, evidence comparing objective knowledge among users and non-users while also describing preventive practices, screening, access pathways, and psychosocial experiences among current or former PrEP users remains limited.

Against this background, this study aimed to characterize the extent of PrEP awareness and knowledge among gay, bisexual, and other men who have sex with men in Colombia, including current users, former users, and non-users. Secondarily, we explored sources of information and consideration of use and, among those who currently or previously used PrEP, access pathways, condom-related practices, STI screening, and psychosocial experiences associated with this prevention strategy.

2. Materials and Methods

2.1. Study Design

We conducted an exploratory, descriptive, cross-sectional observational study using a self-administered web survey. This design was selected to provide an initial assessment of the reach of PrEP information and knowledge among users and non-users in a population that is difficult to access through conventional sampling frames. Experiences of use were explored as a secondary objective. The study was not intended to produce estimates representative of all gay, bisexual, and other MSM in the country or to establish causal relationships.

2.2. Population, Eligibility Criteria, and Setting

The population of interest comprised gay, bisexual, and other men who have sex with men who resided in or had social ties to Colombia. To access the form, each participant was required to declare Colombian nationality, an age of 18 years or older, that they had read the study information, and that they voluntarily agreed to participate. The questionnaire included questions about sex assigned at birth, gender identity, sexual orientation or identity, and sexual contact with men during the preceding 12 months, allowing characterization of the correspondence between the reached and target populations.

Records without consent were excluded from the analysis, and responses with insufficient information to establish eligibility, clearly duplicated records, and patterns incompatible with valid completion were scheduled for review. Because the form was anonymous and did not collect direct identifiers, duplicate detection was limited to the joint assessment of timestamps and response patterns; multiple entries submitted from different devices cannot be reliably identified.

2.3. Sampling and Recruitment

Non-probability convenience sampling was used, supplemented by chain-referral dissemination. The Google Forms link was distributed through social media and WhatsApp groups belonging to LGBTIQ+ community networks, collectives, and groups. Recipients could share the invitation with members of their networks who met the eligibility criteria. No sampling frame was available, and no random selection was performed.

Because this was an exploratory study, no a priori sample-size calculation was performed. We sought to include all eligible responses received during the dissemination period. This procedure precluded calculation of a response rate because the number of unique individuals who viewed the invitation or received the link was unknown.

2.4. Instrument and Variables

A structured questionnaire was developed in Google Forms. Its primary component measured the reach of PrEP awareness and basic knowledge across the entire sample rather than only among individuals with experience of use. All participants completed the sociodemographic, prior-awareness, information-source, objective-knowledge, and PrEP-status modules. Only current or former users completed secondary modules on use, preventive practices, STI screening, and perceived psychosocial effects. The exported file contains 52 fields, including the timestamp and consent; skip logic prevented non-users from receiving experience-related questions.

Table 1. Structure of the data collection instrument.

Module	Length	Main Constructs
Consent and eligibility	1 statement	Review of information, voluntary participation, Colombian nationality, and legal age.
Sociodemographic and relationship characteristics	12 questions	Age, racial/ethnic identification, education, employment status, financial hardship, health coverage, sex assigned at birth, gender identity, sexual orientation, sexual contact with men, steady relationship, and sexual agreements.
Awareness and sources of information	2 questions	Prior awareness of PrEP and information channels.
Objective knowledge	15 statements	Mechanism, indication, absence of curative effect, limitations regarding other STIs, prior HIV testing, follow-up, effectiveness/adherence, distinction from PEP, combination prevention, modalities, initiation/discontinuation, and resistance.
PrEP status	1 question	Current use, former use, consideration of use, no consideration, or uncertainty.
Use characteristics	3 conditional questions	Most recent modality, source of access, and reasons for initiation.
Condoms and decision-making	3 conditional questions	Change since initiation, influence attributed to PrEP, and factors associated with non-use.
STI screening and diagnoses	5 conditional questions	Frequency before/during PrEP, diagnosed episodes, and type of STI.
Psychosocial experience and combination prevention	9 Likert statements	Concern about HIV, control, anxiety, communication, engagement with services, follow-up visits, concern about other STIs, importance of screening, and consideration of STIs in condom decisions.

Table 1. Structure of the data collection instrument.

Module	Length	Main Constructs
Consent and eligibility	1 statement	Review of information, voluntary participation, Colombian nationality, and legal age.
Sociodemographic and relationship characteristics	12 questions	Age, racial/ethnic identification, education, employment status, financial hardship, health coverage, sex assigned at birth, gender identity, sexual orientation, sexual contact with men, steady relationship, and sexual agreements.
Awareness and sources of information	2 questions	Prior awareness of PrEP and information channels.
Objective knowledge	15 statements	Mechanism, indication, absence of curative effect, limitations regarding other STIs, prior HIV testing, follow-up, effectiveness/adherence, distinction from PEP, combination prevention, modalities, initiation/discontinuation, and resistance.
PrEP status	1 question	Current use, former use, consideration of use, no consideration, or uncertainty.
Use characteristics	3 conditional questions	Most recent modality, source of access, and reasons for initiation.
Condoms and decision-making	3 conditional questions	Change since initiation, influence attributed to PrEP, and factors associated with non-use.
STI screening and diagnoses	5 conditional questions	Frequency before/during PrEP, diagnosed episodes, and type of STI.
Psychosocial experience and combination prevention	9 Likert statements	Concern about HIV, control, anxiety, communication, engagement with services, follow-up visits, concern about other STIs, importance of screening, and consideration of STIs in condom decisions.

2.4.1. Measurement of PrEP Knowledge

The core of the instrument consisted of 15 statements with “True,” “False,” and “I don’t know” response options. Content was selected for its relevance to informed and safe use: preventive purpose; use by people without HIV; absence of a curative effect; lack of direct protection against gonorrhea, syphilis, and chlamydia; need to confirm an HIV-negative result before initiation; clinical follow-up; relationship between effectiveness and adherence to the prescribed regimen; distinction between PrEP and PEP; possibility of acquiring other STIs; combination with other strategies; availability of daily, event-driven, and injectable modalities; risks of discontinuing or restarting without guidance; effects of missed doses; drug resistance when PrEP is initiated during an undetected infection; and the need to discuss other STIs even when a partner uses PrEP.

For analysis, one point will be assigned to each correct response and zero points to incorrect or “I don’t know” responses, yielding a score from 0 to 15, with higher values indicating greater knowledge. The primary outcome will be analyzed as a continuous variable and as the proportion of correct responses. Secondarily, the following predefined descriptive categories may be used: low (<60%; 0–8 points), intermediate (60%–79%; 9–11 points), and high (≥80%; 12–15 points). Because these cutoffs do not belong to a validated diagnostic scale, they will be presented as an operational classification, and a sensitivity analysis without categorization will be conducted.

2.4.2. Experience of Current and Former Users

Participants who reported current or former PrEP use answered questions about the regimen, source of access, and reasons for initiation. Change in condom use was measured on an ordinal scale, followed by attribution of that change to PrEP and a multiple-response question about reasons for not using condoms. The frequency of gonorrhea, chlamydia, or syphilis testing and the number of diagnosed episodes were assessed for the 12 months before initiation and the most recent 12 months of use. This self-reported comparison does not constitute longitudinal follow-up and may be affected by differences in screening intensity.

Emotional, personal, and relational experiences were assessed using nine statements and five response options ranging from “Strongly disagree” to “Strongly agree.” Items addressed reduced concern and anxiety, control over prevention, partner communication, engagement with services, the usefulness of follow-up visits, and continued concern and preventive action regarding other STIs. Given the small expected number of users, these items will be analyzed individually; any composite score will require assessment of conceptual and internal consistency before use.

2.5. Data Collection Procedure

The invitation included a brief explanation of the study purpose and a link to the form. Participation was voluntary, and the questionnaire was completed without an interviewer using an internet-connected device. Before viewing the questions, participants were required to provide informed consent. Google Forms automatically recorded the submission date and time. Names, identification numbers, and email addresses were not requested as part of the analyzed dataset.

Responses were exported to a spreadsheet for quality control and analysis.

2.6. Quality Control and Management of Missing Data

An unaltered copy of the original dataset will be retained, and an analytical dataset will be created with a data dictionary and traceability of transformations. Ranges, consistency between screening questions and conditional modules, unexpected categories, multiple responses, and missing data will be reviewed. Values absent because of skip logic will be classified as “not applicable” rather than missing responses. True missing data will be reported for each variable.

Given the exploratory sample size, no data imputation will be performed. Each analysis will use available cases and report its denominator. Multiple-response questions will be disaggregated into binary variables. Open-ended responses or participant-added categories will be reviewed and recoded only when clear semantic equivalence exists; every decision will be documented in the analysis code.

2.7. Statistical Analysis Plan

The primary analysis will describe the reach of PrEP across the entire sample using three indicators: prior awareness of its existence, sources of information—allowing multiple responses—and the objective knowledge score. Categorical variables will be summarized using absolute frequencies, percentages, and exact 95% confidence intervals when informative; quantitative variables will be summarized using the mean and standard deviation or the median and interquartile range. These percentages characterize only the reached sample and will not be interpreted as national coverage or prevalence. The internal consistency of the 15 dichotomous items will be explored using KR-20; factor analysis will not be performed because of the insufficient ratio of sample size to number of items.

PrEP status will initially be described in five categories: current use, former use, no use with prior consideration, no use without prior consideration, and uncertainty. The score and each knowledge item will be presented overall and by these categories. Comparisons will use Fisher’s exact test for categorical variables and the Kruskal–Wallis test for scores or ordinal variables; when counts require it, categories will be transparently collapsed into any experience of use versus none or uncertain, and the Mann–Whitney test will be used. Exploratory differences and measures of association will be reported with confidence intervals, prioritizing magnitude and precision over statistical significance. Consideration of use among non-users will be described as an indicator of potential reach, not as a validated measure of behavioral intention.

Among current or former users, screening and diagnosis frequencies before and during use will be analyzed as paired self-reported measures. The Wilcoxon signed-rank test will be used for ordinal variables and exact tests for categorical changes when data permit. These results will be interpreted as differences within recalled experience, not as incidence or a causal effect of PrEP.

Adjusted models will be limited to outcomes with sufficient observations and events. If high knowledge or experience of use is explored as an outcome, parsimonious models will be preferred and, in the presence of separation or small cells, Firth penalized logistic regression will be used. Automated variable-selection procedures will not be applied. All tests will be two-sided; given the exploratory design, exact p values will be reported without making them the sole criterion for interpretation, and the risk of error due to multiple comparisons will be acknowledged.

2.8. Ethical Considerations

Under Resolution 8430 of 1993 of the Colombian Ministry of Health, the study was observational and non-interventional and involved no physical procedures, medication administration, or intentional modification of biological, physiological, psychological, or social variables. However, the questionnaire addressed sexual practices, PrEP use, and STI history and therefore included sensitive behavioral information. Although foreseeable risks were low and primarily informational or psychosocial, the research was not formally evaluated or classified by an ethics committee, and it is not retrospectively described as “risk-free” research.

To reduce risks, participation was voluntary and preceded by electronic informed consent; only persons aged 18 years or older were included; the form was anonymous and collected no names, identity documents, email addresses, or other direct personal identifiers; and information was stored and analyzed in aggregate. These safeguards were consistent with the principles of dignity, autonomy, privacy, and well-being under Colombian regulations but do not substitute for formal approval or exemption.

2.9. Reporting Guidelines

The study will be reported in accordance with STROBE recommendations for cross-sectional observational studies and, because it used a web survey, will incorporate the relevant CHERRIES elements: form description, recruitment channels, voluntary participation, prevention and assessment of multiple entries, management of incomplete questionnaires, and denominators for each analysis.

3. Projected Results

3.1. PrEP Awareness and Use Status

In the projected scenario, 194 of 278 participants (69.8%) would have heard of PrEP before completing the form; 79 (28.4%) would not have heard of it, and 5 (1.8%) would be unsure. The main information channels would be social media or websites (104; 37.4%), friends, partners, or acquaintances (103; 37.1%), health professionals (69; 24.8%), community organizations or activists (60; 21.6%), and dating applications (38; 13.7%). A total of 84 projected participants (30.2%) would report having received no prior information about PrEP. Because this was a multiple-response question, percentages for sources do not total 100%.

Table 2. PrEP awareness and use status in the projected scenario (n = 278).

Projected Indicator	n	%
Had heard of PrEP	194	69.8
Current user	60	21.6
Former user	19	6.8
Never used it but had considered using it	79	28.4
Never used it and had not considered using it	101	36.3
Was unsure of their status	19	6.8

Table 2. PrEP awareness and use status in the projected scenario (n = 278).

Projected Indicator	n	%
Had heard of PrEP	194	69.8
Current user	60	21.6
Former user	19	6.8
Never used it but had considered using it	79	28.4
Never used it and had not considered using it	101	36.3
Was unsure of their status	19	6.8

Overall, 79 projected participants (28.4%) would be current or former users. Among the 180 individuals who had never used PrEP and expressed a definite position, 79 (43.9%) would have considered using it. This indicator represents prior consideration and is not a validated measure of behavioral intention.

3.2. Knowledge of PrEP

The projected knowledge score would have a mean of 8.67 out of 15, a median of 12, and an interquartile range of 0–14. Knowledge would be classified as high in 149 participants (53.6%), intermediate in 18 (6.5%), and low in 111 (39.9%). The distribution would be markedly polarized, with clusters of high scores and “I don’t know” responses among individuals unfamiliar with the strategy.

Table 3. Projected knowledge score by PrEP-use status.

PrEP status	n	Mean	Median
Current user	60	13.90	14
Former user	19	13.05	13
Non-user who had considered using it	79	10.18	12
Non-user who had not considered using it	101	5.19	0
Unsure	19	0.00	0

Table 3. Projected knowledge score by PrEP-use status.

PrEP status	n	Mean	Median
Current user	60	13.90	14
Former user	19	13.05	13
Non-user who had considered using it	79	10.18	12
Non-user who had not considered using it	101	5.19	0
Unsure	19	0.00	0

The largest gaps would concern knowledge of the risk of resistance when PrEP is initiated during undetected HIV infection (28.1% correct), discontinuation and restarting without clinical guidance (45.3%), the distinction between PrEP and PEP (48.2%), and the availability of different modalities (48.2%). Overall, 63.3% would recognize that PrEP does not directly protect against gonorrhea, syphilis, or chlamydia, and 63.7% would know that other STIs can still be acquired while using it.

3.3. Projected Experience of Current and Former Users

All 79 projected current or former users would currently or previously have used daily oral PrEP. Access would be through a Health Promoting Entity or Health Service Provider (EPS or IPS) in 65 cases (82.3%), through purchase or acquisition without clinical follow-up in 9 (11.4%), and through private consultation or insurance in 5 (6.3%). The uniformity of the regimen reflects replication of the original responses and does not support the conclusion that other modalities are absent in Colombia.

Condom use would have decreased somewhat in 28 participants (35.4%) and greatly in 19 (24.1%); thus, 47 of 79 (59.5%) would report some decrease. It would have increased in 14 (17.7%), remained unchanged in 14 (17.7%), and 4 (5.1%) used condoms neither before nor during PrEP. Sixty participants (75.9%) would attribute the change partly or mainly to PrEP. Reasons for not using condoms would include PrEP use (55; 69.6%), a recent HIV-negative test result (34; 43.0%), pleasure or comfort (33; 41.8%), trust or agreement with a steady partner (27; 34.2%), and the partner also using PrEP (27; 34.2%).

Quarterly testing for gonorrhea, chlamydia, or syphilis would increase from 19 participants (24.1%) before initiation to 33 (41.8%) during use. Fifteen individuals (19.0%) would report at least one STI diagnosis before initiating PrEP and five (6.3%) during the most recent 12 months of use. This difference does not represent incidence or a protective effect: some participants had less than 12 months of exposure, some were not tested, and comparisons are retrospective, self-reported, and synthetically replicated.

Regarding psychosocial experiences, 50 projected users (63.3%) would feel greater control over HIV prevention; 46 (58.2%) would enjoy their sex life with less anxiety, and 46 (58.2%) would feel more able to discuss prevention with their partners. Furthermore, 56 (70.9%) would reject the idea that PrEP use makes concern about other STIs unnecessary, 46 (58.2%) would consider STI testing important, and 51 (64.6%) would take other STIs into account when deciding about condom use.

4. Discussion

The projected scenario suggests that PrEP would have achieved substantial recognition in the surveyed population, although its reach would be far from universal: nearly three in ten participants would have received no prior information. This pattern is consistent with the reported gap among general awareness, willingness, and actual PrEP initiation [18,19,20,21,22,23,24,25,35,36,37,38,39,40]. In Colombia, where programmatic incorporation is recent, awareness of the strategy cannot be assumed to be firmly established; moreover, recognizing its name is not equivalent to understanding its indications, limitations, and follow-up requirements [26,27,28,29,30].

Information would circulate primarily through social media, personal connections, and community organizations, whereas fewer than one quarter of participants would have received it from health professionals. This projected finding does not diminish community work; on the contrary, it confirms its capacity to reach historically stigmatized populations. However, it also suggests that the health system still plays a limited role in proactive outreach, education, and routine PrEP provision. When the strategy remains concentrated in infectious-disease services, specialized clinics, or pathways known only to people with greater social and health capital, access no longer depends solely on need but also on the ability to find an entry point.

Projected differences in knowledge between users and non-users reinforce the existence of an access cascade: those who have used PrEP have also had more opportunities to receive information and support. Nevertheless, gaps would persist regarding resistance, available modalities, the distinction between PrEP and post-exposure prophylaxis, and the conditions for discontinuing or restarting the medication. Approximately one third would also fail to identify correctly that PrEP provides no direct protection against other STIs. These gaps are clinically relevant because they may limit informed consent, foster inaccurate expectations, and increase the likelihood of use without professional support.

Among current and former users, a frequent reduction in condom use would be projected alongside an increase in quarterly STI screening. The literature has documented both phenomena but cautions against automatically interpreting STIs as a causal consequence of presumed risk compensation [9,10,11,12,13,14,15,16,17]. Individuals initiating PrEP may have greater baseline exposure, and periodic follow-up increases detection of asymptomatic infections. Changes in condom use should therefore be analyzed without moral judgment and within a combination-prevention perspective that recognizes sexual preferences, facilitates anatomically appropriate testing, vaccination, and timely diagnosis and treatment, and keeps condoms available to those who choose to use them [50,51,52,53,54,55,56].

The projected benefits would not be exclusively biomedical. A greater sense of control, reduced HIV-related anxiety, and more open communication with partners are consistent with studies describing PrEP as a technology that can expand autonomy, intimacy, and sexual enjoyment [31,32,33]. These results challenge approaches that value prevention only in terms of the absence of infection and support person-centered sexual health services. At the same time, possible access without clinical follow-up among more than one in ten projected users warns that overly restrictive medicalization may also create risks: when pathways are difficult, insufficiently confidential, or stigmatizing, some individuals may obtain medication outside the system or discontinue follow-up.

From an equity perspective, democratizing PrEP entails making it visible and competently available in primary care, general sexual health services, and territorial programs without losing the expertise of specialized teams. This requires training personnel, simplifying pathways, ensuring confidentiality, reducing administrative barriers, and coordinating culturally appropriate campaigns with community organizations. Provision should prioritize those facing the greatest access barriers—including young people, residents of areas with limited service availability, and sex workers—without turning membership in a population category into a source of stigma [42,43,44,45].

Overall, the projected scenario supports the hypothesis that PrEP may promote sexual experiences characterized by greater autonomy and less HIV-related anxiety, but it also shows that its population-level impact will depend on equitable dissemination, accurate knowledge, accessible support, and combination prevention.

5. Conclusions

PrEP is an effective HIV-prevention strategy and may contribute to sexuality experienced with greater autonomy, control, and less anxiety. Nevertheless, the projected scenario indicates that its reach would remain incomplete and unequal: a substantial proportion of participants would have received no prior information, and important gaps would persist between users and non-users regarding its limitations, modalities, and conditions for safe use.

The Colombian health system has an opportunity to take a more active role in this strategy. PrEP should not remain confined to highly specialized services or depend on individuals knowing specific networks, having private resources, or navigating the system on their own. Democratizing PrEP means integrating it into primary care and general sexual health services, training health personnel, simplifying access and follow-up pathways, ensuring confidentiality, and developing territorial actions in partnership with community organizations. This expansion must explicitly include populations that may fall outside conventional pathways, including sex workers and people living in areas with limited health-service availability.

The expansion of PrEP must maintain a combination-prevention approach free from moral judgment. The projected decrease in condom use does not invalidate the benefits of the strategy, but it does reinforce the need to communicate that PrEP protects against HIV and not directly against other STIs; to offer periodic screening, vaccination, and timely diagnosis and treatment; and to respect each person’s informed decisions. Accessible and non-stigmatizing pathways are also essential to reduce medication access without clinical support and promote continuity of follow-up.