We conducted a cross-sectional study with participants recruited from the Greater Kuala Lumpur region between July 2018 and March 2020. Data collection was conducted in a private room at the Centre of Excellence for Research in AIDS (University of Malaya), because of its central location in the Greater Kuala Lumpur region, accessibility by public transport, and ability to provide free parking to participants.

Inclusion criteria were (1) being 18 years or older; (2) identifying as a cisgender male; (3) currently residing in the Greater Kuala Lumpur region; (4) reporting having been engaged in sexual activity with male sexual partners in the previous 6 months; and (5) being able to read and understand English, Chinese, or Bahasa Malaysia.

The questionnaires were created in English and then translated to Chinese and Bahasa Malaysia. We used forward-backward translation and pilot tested the translated questionnaires to ensure translation quality.

Participants were recruited using respondent-driven sampling, which is a network-based sampling method that is often used for hard-to-reach populations and combines peer-driven recruitment and statistical adjustments to reduce bias and approximate random sampling [34]. During our formative work, initial respondent-driven sampling participants, called seed participants, were carefully selected with assistance from community-based organizations for men who have sex with men. We aimed to recruit a seed participant sample (n=27) that reflected the diversity (eg, ethnicity, age) of the community of men who have sex with men in the region.

Each participant who completed the study was given 3 coupons to recruit men from their peer networks, who were, in turn, also given 3 coupons. Each coupon card contained a unique respondent-driven sampling number that allowed us to trace the peer recruitment chain and important study-related information (study site address, contact information for the study team, and inclusion criteria). Coupon management software was used to track distributed and redeemed coupons during the study, and a standard numbering system was used to track the recruiter-recruit relationship. Participants received 30 Malaysian Ringgit (at the time of publication, 1 MYR was approximately equivalent to US $0.23) for study participation and an additional 10 MYR for each peer who was successfully recruited to the study (up to 3 peers).

Individuals could choose whether to come during walk-in hours or set an appointment by phone. The research site was open 7 days a week to offer maximum flexibility and accommodate different work schedules. Individuals who presented with a valid coupon underwent initial eligibility screening. If eligible, they were asked to provide informed consent. Each participant completed the web-based questionnaire (Qualtrics, Qualtrics XM) in a private room, which took approximately 20 minutes, while study staff waited outside the room, to ensure privacy.

The study was approved by the institutional review boards of the University of Malaya (201854) and Yale University (2000023152).

Analyses were performed using SPSS software (version 26; IBM Corp). We calculated descriptive statistics, such as frequencies and percentages for categorical variables and means and standard deviations for continuous variables, and used multivariate linear regression to assess factors associated with the primary outcome—willingness to use mHealth (measured by the mHealth acceptability scale (continuous variable). Candidate covariates were selected based on previous literature on mHealth acceptability and were included in the multivariable model if P<.05 in a bivariate model. Estimates were evaluated for statistical significance based on probability criteria of P<.05.

A total of 376 men (age: mean 27.5 years, SD 6.5 years) participated in the survey. Most participants identified ethnically as Malay (220/376, 58.5%). Over half of the participants were university graduates (216/376, 57.4%) and single (216/376, 56.4%). The mean monthly income was 3602.9 MYR. The majority of participants (222/376, 59.0%) reported symptoms consistent with moderate to severe depression (Table 1).

Although almost all participants had engaged in anal sex in the past 6 months (363/376, 96.5%; receptive role: 285/376, 75.8%), only one-fifth (72/376, 19.1%) reported consistent condom use. Moreover, one-fifth of participants (82/376, 21.8%) reported having ever engaged in sexualized drug use. Overall, 71.0% (267/376) of the participants had been tested for HIV at least once in their lifetime, and 27.4% (103/376) had been previously diagnosed with a sexually transmitted infection other than HIV. Only a small proportion of participants had ever used pre-exposure prophylaxis (26/376, 6.9%) or postexposure prophylaxis (27/376, 7.2%).

Almost all participants (368/376, 97.9%) owned or had access to a smartphone with internet access, and 13.3% (50/376) of participants had access to a basic cell phone without internet access (Table 2). More than two-thirds of participants (270/376, 71.8%) reported having access to a laptop; between one-quarter and one-fifth of participants had access to a personal computer (100/376, 26.6%), a tablet (85/376, 22.6%), and a landline telephone (81/376, 21.6%). The frequency of use of each device was largely consistent with the frequency of ownership and access, with smartphones representing the most frequently used technology (mean 4.9, SD 0.4), followed by laptops (mean 3.8, SD 1.2), personal computers (mean 2.5, SD 1.4), tablets (mean 2.3, SD 1.3), basic cell phones (mean 2.1, SD 1.3), and landline telephones (mean 1.8, SD 0.9).

Almost all participants (373/376, 99.2%) accessed the internet daily, largely through a smartphone (334/376, 88.8%), and spent on average 9.4 hours per week (SD 4.9) on the internet (Table 3). The most common activities that participants used the internet on their smartphones for were social networking (mean 4.5, SD 0.8) and sending or receiving emails (mean 4.0, SD 1.0). Participants also used their smartphones to access geosocial networking apps or websites (mean 3.6, SD 1.1), search for health-related information (mean 3.5, SD 0.9), and use health-related apps (mean 2.9, SD 1.1). The majority (345/376, 91.8%) of participants used geosocial networking apps, with Grindr, Blued, and Hornet being the most popular.

The majority of participants were interested in receiving HIV prevention information (345/376, 91.8%) on a monthly (147/376, 42.6% of those who expressed willingness) or weekly (131/376, 38.0%) basis, and in receiving medication reminders (336/376, 89.4%) mostly on a daily basis (191/376, 56.8%). Additionally, there was interest in using mHealth to screen and monitor sexual activity (306/376, 81.4%) on a weekly (135/376, 44.1%) or monthly (99/376, 32.4%) basis; screen and monitor illicit drug use (281/376, 74.7%) on a weekly (104/376, 37.0%) or monthly (100/376, 35.6%) basis; and monitor drug cravings (280/376, 74.5%) on a weekly (115/376, 41.1%) or monthly (79/376, 28.2%) basis. The preferred modality of mHealth strategies was via apps, regardless of the type of intervention (Table 4).

The mean score for mHealth acceptance was 4.1 (SD 1.5), with α=.875. In the multivariable model, being a university graduate (β=0.456, P=.003), being in a relationship with a partner (β=0.322, P=.04), lifetime engagement in sexualized drug use (β=0.489, P=.01), and recent engagement in receptive anal sex (β=0.498, P=.006) were associated with higher willingness to use mHealth strategies (Table 5).

The rapid growth and use of web-based communication technologies have led to innovations in public health programming and patient care [28], particularly as COVID-19–related restrictions affect health care delivery, with decreased access to in-person health care and prevention interventions, which has had negative consequences on health [43-47]. The utilization of innovative tools in virtual spaces (eHealth or mHealth) can help bridge gaps in service delivery that are needed to improve access to needed health and prevention services, particularly among underserved populations [26]. Until now, there has been a lack of empirical evidence on how communication technologies can improve access to and engagement in care or support for the use of mHealth strategies for HIV prevention needs among men who have sex with men in Malaysia. The findings from this study allow us to assess opportunities to implement mHealth strategies for HIV prevention efforts and inform the specific format and features of a mHealth platform tailored to the needs of men who have sex with men in Malaysia. We found near-universal access to communication technology and internet use and high levels of acceptability of mHealth, particularly smartphone apps, for HIV prevention efforts. Our findings provide preliminary evidence that supports the feasibility of mHealth deployment to deliver HIV prevention and related interventions among men who have sex with men in Malaysia.

We identified a number of interventions that can be incorporated into HIV-prevention mHealth, including tracking and monitoring the sexual and drug use behaviors and assessing symptoms associated with depression. Consistent with information in existing literature [48-50], a considerable proportion of men who have sex with men in our sample had high rates of condomless sex, sexualized drug use, and mental health comorbidities and sexually transmitted infections, highlighting the vulnerabilities in men who have sex with men in an evolving and dynamic HIV epidemic. In addition, it was concerning that a proportion of participants had never been tested for HIV (109/376, 29.0%). HIV testing is the first step in engaging individuals in HIV prevention and treatment cascades; frequent screenings are thus of the utmost importance for individuals most at risk. mHealth can play a uniquely important role in assessing risk and reminding and motivating men who have sex with men to be tested regularly [51-55]. As such, innovations in mHealth can accelerate engagement in HIV testing and facilitate the uptake of HIV prevention services, such as pre-exposure prophylaxis and HIV self-testing, particularly in areas where such services are underutilized or have limited availability [53]. Our findings underscore the urgent need for innovative strategies to reach and deliver HIV prevention services to this key population, particularly in a context where same-sex sexual behavior is deeply stigmatized.

Near-universal access to smartphones, combined with daily internet access among our sample, consistent with previous studies [56] with Malaysian men who have sex with men, support the feasibility of developing mHealth strategies for Malaysian men who have sex with men. Participants reported already using their smartphones to search for health-related information or apps, and most participants used mobile technologies (ie, smartphones) far more frequently than they used other technologies (eg, computers, landline telephone). This likely reflects the digital revolution that is especially explosive in Asia and the fast-paced growth and use of mobile technologies in the community [57-61]. The rapid advances in mobile technologies and the development of apps open new opportunities for integrating mobile health into existing HIV prevention service delivery in the region. Future research, however, is needed to gather additional information on Malaysian men who have sex with men’s interests in health-related content using smartphones, access points (eg, websites, chatbots, apps), which types of information, and where gaps in existing web-based resources exist.

Our findings indicate that there is considerable interest in specific mHealth strategies, such as receiving information related to HIV (345/376, 91.8%), receiving medication reminders (336/376, 89.4%), screening and monitoring sex activity (306/376, 81.4%) and illicit drug use (281/376, 74.7%), and monitoring drug cravings (280/376, 74.5%). In the absence of public dialogue about these issues in Malaysia, it is not surprising that Malaysian men who have sex with men, similar to men who have sex with men in other settings [62-67], and specifically, for HIV prevention, in China [68], Vietnam [69], and Indonesia [66], expressed interest. In our sample, men expressed interest in the use of mHealth apps to receive daily reminders to take medications; however, weekly and monthly reminders were preferred for other activities, with smartphone apps being the preferred platform. An mHealth-based app may serve as an additional tool that can help support men who have sex with men with HIV prevention or care needs between clinical visits, guide them to needed services, enhance clinical care and support through screening and recommendations, and provide different modes of accessing information, services, and prevention commodities. Men who have sex with men at higher risk for HIV due to sexual practices, such as recent engagement in receptive anal sex and lifetime engagement in sexualized drug use, were more willing to use mHealth-based strategies, which suggests that mHealth approaches are particularly promising to address the needs of the subset of men who have sex with men who would most benefit.

While this study focused on HIV prevention behavior, knowledge, and access to services among HIV-negative Malaysian men who have sex with men, mHealth-based health intervention strategies can potentially also play an important role among HIV-positive men who have sex with men, for instance, by encouraging adherence to antiretroviral therapy and increasing retention in the HIV-care cascade [70]. High rates of mHealth acceptability have been reported in HIV-positive men who have sex with men and transgender women in Malaysia, for receiving HIV-related and sexual health information, assessing sexual and health behaviors, and receiving reminders to take HIV medications [71].

Despite the many new findings, this study is not without limitations. First, we used self-reported measures for HIV and sexually transmitted infection diagnoses, sexual behavior, and drug use, which may have introduced some social desirability bias and underreporting of stigmatized behaviors. We reduced the potential for social desirability bias by designing the questionnaire to be self-administered and anonymous and by allowing participants to complete the questionnaire alone (without the presence of research staff). Second, though participants were recruited using respondent-driven sampling, some data suggest that a representative sample of all men who have sex with men in Malaysia may not have been achieved. For example, over half of our participants were university graduates, compared with only one-sixth among the general adult population in Malaysia [72]. Men who have sex with men in Malaysia’s capital, however, are typically more educated, which perhaps makes the sample more representative of urban men who have sex with men in Malaysia; our findings on participants’ educational status are consistent with previous studies conducted among men who have sex with men in the region [49,71]. The educational level of our sample may explain the high level of interest in mHealth and the acceptability of mHealth interventions, as a higher level of education likely facilitates greater technology literacy. This is supported by the multivariable analysis of associations between mHealth acceptance and participant characteristics, which showed that university graduates were more willing to use mHealth strategies. Finally, although men in this study showed a strong willingness to use mHealth for various needs, it should be noted that willingness or interest may not fully reflect actual use; therefore, studies of mHealth interventions in practice are needed to assess use.

To the best of our knowledge, this is the first study to assess the acceptability of mHealth to address HIV prevention needs among men who have sex with men in Malaysia. Our findings show that mHealth use, particularly app-based platforms, appears to be highly acceptable to this population. This finding is particularly meaningful in Malaysia, where there are limited physical venues that are culturally acceptable for men who have sex with men to seek health care since same-sex sexual behavior is illegal, and men who have sex with men are highly stigmatized and are frequent targets of discrimination [9].

Our findings support the development of mHealth-based strategies, especially smartphone apps, to jumpstart the HIV prevention cascade by promoting HIV testing and, depending on the results, linking individuals to the appropriate prevention or treatment services. mHealth strategies, such as culturally tailored apps, are uniquely positioned to deliver multicomponent interventions, and thus, can bridge systematic gaps needed to address syndemic and complex interrelated health needs and more effective utilization of health services in this underserved population [53,55,73-76]

In recent years, several apps for HIV prevention and treatment efforts have been evaluated in pilot studies or randomized trials that incorporate components such as HIV testing, condom use, pre-exposure prophylaxis, treatment as prevention, and other support services (eg, mental health, drug use) [53,55,73-76]. Some of these apps offer the opportunity to assess, with ecological momentary assessment, or intervene, via ecological momentary interventions, individuals in their natural environment, thereby enabling a better understanding of the factors triggering problems and addressing the problems when and where they arise [77-79].

Most, if not all, of the available apps, however, are primarily developed for use in high-income countries [53,55,73-76]. Additional research to assess the design, functionality, and content preferences of Malaysian men who have sex with men is now needed to facilitate the design of a customized mHealth app in the Malaysian context (specifically, addressing the multiethnic population of Malaysia, as well as men who have sex with men in nonurban settings, will be important). Further research is also needed to understand the perspective of those tasked with providing care and support services via the mHealth platforms (eg, physicians, pharmacists, counselors, outreach workers). Such research will inform and facilitate the integration of mHealth platforms within existing health care services.