PrEP acceptability and self-efficacy in men who have sex with men: the roles of identity, trust and knowledge

Pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention for preventing human immunodeficiency virus (HIV) acquisition. Despite its clinical efficacy, uptake remains suboptimal among key populations, particularly men who have sex with men (MSM). This study investigates psychosocial and structural predictors of PrEP acceptability and self-efficacy, addressing the need for targeted interventions to improve PrEP uptake in the UK. A cross-sectional, online survey was conducted among UK-based MSM not currently using PrEP (N = 246). Participants completed validated measures assessing identity resilience, LGBTQ+ connectedness, outness, medical mistrust, perceptions of the NHS, and HIV knowledge. Structural equation modelling (SEM) was used to examine relationships between these psychosocial factors and PrEP acceptability and self-efficacy, while controlling for age, previous sexually transmitted infection (STI) diagnosis, and condomless sex. The SEM demonstrated excellent model fit (χ² (7, 246) = 4.974, p = .663, CFI = 1.000, TLI = 1.047, SRMR = 0.013). PrEP acceptability was positively associated with LGBTQ+ connectedness and negatively associated with medical mistrust. Conversely, PrEP self-efficacy was positively associated with identity resilience, outness, NHS perceptions, and HIV knowledge. Findings show that the predictors of PrEP acceptability and self-efficacy are different which should help inform interventions for promoting PrEP use in at-risk groups. Enhancing LGBTQ+ connectedness and reducing medical mistrust may increase PrEP acceptability, while fostering identity resilience, outness, and positive perceptions of the NHS could strengthen PrEP self-efficacy. This study identifies distinct yet complementary predictors of PrEP acceptability and self-efficacy, emphasising the necessity for tailored interventions.