Perceptions of Daily and On-Demand HIV Pre-Exposure Prophylaxis and Digital Adherence-Support Needs Among Cisgender Men in Brazil: Qualitative Interview and Focus Group Study.

Background: Pre-exposure prophylaxis (PrEP) is a proven effective preventive method in reducing the risk of HIV infection. While daily PrEP is well-established, the on-demand regimen remains less accessible, despite offering advantages, such as a reduced pill burden and lower risk of side effects, particularly for those with variable sexual activity patterns. Objective: This study explored, from the perspective of PrEP use trajectories, how cisgender men in Brazil choose and adhere to daily or on-demand regimens, and identified key user-informed requirements for designing a digital tool to support on-demand PrEP use. Methods: A qualitative study was carried out between July 2022 and December 2023 in 5 Brazilian cities. Overall, 19 individual interviews and 5 in-person focus groups were conducted (N=47). The sample was diverse by age, education, race/color, time of PrEP use, and experiences of treatment failure. The median age of the interviewees was 34 (IQR 30-36.5) years; 10/19 were <35 years and 9/19 were ≥35 years. The majority had completed higher education (15/19, 79%). The thematic saturation criterion was used, and the thematic analysis was conducted by 2 independent researchers with periodic consensus. Results: Participants perceived oral PrEP as highly effective in reducing HIV-related anxiety. On-demand PrEP was valued for its lower pill burden and a perceived lower risk of adverse effects. However, participants reported that adherence to this regimen demands considerable discipline and organization, posing a significant barrier. In this context, a support app was not met with mere acceptance but was conceptualized as a "cognitive offloading" tool, capable of transforming the burden of managing the 2+1+1 schedule into a positive and manageable task. Suggested functionalities included pill reminders, appointment scheduling, and geolocation of postexposure prophylaxis services. Nevertheless, significant concerns about data security and privacy were raised, with participants proposing that the state should manage the app to ensure confidentiality. Conclusions: Findings highlight clear generational differences in how cisgender men perceive daily and on-demand PrEP. Older participants draw on memories of the early AIDS crisis, whereas younger men situate PrEP within app-mediated sexual cultures. Importantly, they agree that the on-demand regimen requires not only greater discipline but also a learning process to incorporate and normalize its episodic dosing into everyday life. The positive reception toward a digital adherence support tool demonstrates potential public health value in such technologies, provided privacy and data security concerns are effectively addressed. Efforts to improve adherence and expand access to on-demand PrEP could significantly benefit from incorporating user-driven insights into digital tool development.