# A Competing Risks Duration Model to Study PrEP Discontinuation Among MSM in France: The ERAS 2023 Study

Clément Boutet, Marion Di Ciaccio, Bruno Spire, Annie Velter, Luis Sagaon-Teyssier

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Clément Boutet, Marion Di Ciaccio, Bruno Spire, Annie Velter, Luis Sagaon-Teyssier. A Competing Risks Duration Model to Study PrEP Discontinuation Among MSM in France: The ERAS 2023 Study. AIDS and Behavior, 2025, 29 (9), pp.2711-2727. 10.1007/s10461-025-04729-4 . inserm-05471397

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A competing risks duration model to study PrEP discontinuation among MSM in France: the ERAS 2023 study.

Clément Boutet<fnref n="1" />, Marion Di Ciaccio<fnref n="1" />,<fnref n="2" />, Bruno Spire<fnref n="1" />, Annie Velter<fnref n="1" />,<fnref n="3" />, Luis Sagaon-Teyssier<fnref n="1" />

**Corresponding author:** Clément Boutet, clement.boutet@ird.fr

ORCID :

Clément Boutet : 0009-0000-8091-8345

Marion Di Ciaccio : 0000-0002-6971-0233

Bruno Spire : 0000-0002-3546-8020

Annie Velter : 0000-0003-3188-9108

Luis Sagaon-Teyssier : 0000-0001-7318-6596

<footnote n="1">¹ Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France.</footnote>

<footnote n="2">² Laboratoire de Recherche Communautaire, Coalition PLUS, Pantin, France.</footnote>

<footnote n="3">³ Santé Publique France, Saint Maurice, France.</footnote>
1 Keywords: HIV, PrEP, MSM, duration, Weibull model

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• Abstract - 250 words max - 250

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27 Introduction

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28 The discontinuation rate of HIV pre-exposure prophylaxis (PrEP) six months after initiation is estimated at 41.0%

29 [1]. First recommended by the WHO in 2012, PrEP was used by 1.6 million persons worldwide in 2021, as the number of countries including it in their HIV-infection prevention recommendations continued to increase [2,3].

30 The efficacy of PrEP strongly depends on adherence while at risk of exposure [4]. This has been demonstrated for both daily and event-driven PrEP in various clinical trials (IPREX, PROUD, ANRS-Ipergay) and real-life settings (ANRS-Prévenir) [5–9]. However, studies have shown that risk evaluation among persons who take PrEP is not accurate; accordingly, discontinuation is an important challenge for public health programs [10,11].

31 Discontinuation is defined as the stop or the interruption of PrEP by users who are exposed to HIV, and has been widely studied [1,11–15]. Inadequate risk evaluation can lead to a serious risk of HIV acquisition. A recent study showed that PrEP users tend to overestimate their knowledge about the correct time to start and to discontinue PrEP [16]. The risk of contracting HIV is especially high during the post-discontinuation period in the absence of other protection tools [12,13,17].

35 Younger people and women are the two sub-populations most likely to inappropriately discontinue PrEP [18–22].

40 Social factors such as low income, job instability, financial inability to take out private insurance, a lack of housing, and belonging to a disadvantaged community, are all factors hindering PrEP adherence. This in turn often leads to PrEP discontinuation [14,15,23–26]. Psycho-behavioral and PrEP-related factors such as misperceiving the level of HIV risk, stigmatization (perceived or experienced), the fear of adverse effects, weariness about using a chemical substance over the long term, and the medicalization of HIV prevention, also play an important role in the decision to discontinue its use [15,22–25,27–32]. Eventually, structural factors such as distance from healthcare facilities, long waiting times, and complex healthcare systems also influence a PrEP user’s decision to no longer use this prevention tool [24,26].

49 One pitfall of the studies cited in the previous paragraph is that they analyze PrEP discontinuation in cohort settings, with relatively small samples. Moreover, they assume that discontinuation occurs after a participant is lost to follow-up. However, this is not realistic, as some persons who discontinue might have access to PrEP through channels outside of the cohort study [17,18,33,34]. In addition, PrEP discontinuation is often studied as a unidimensional (i.e., yes/no) phenomenon. However, this choice leads to a loss of detailed information in terms of the potential specific factors (individual, psychosocial, behavioral and structural) associated with the different reasons for discontinuation [10,30,35]. Furthermore, despite some studies suggesting that weariness is associated
56 with PrEP discontinuation, quantitative studies do not consider this factor (although we must point out that is not clear whether this weariness reflects clinical follow-up or taking the medicine itself) [33,36,37]. This context highlights the importance of using suitable methods to study factors associated with different reasons for PrEP discontinuation, while taking into account the time since PrEP initiation as an intrinsic factor of the phenomenon.

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60 In France, where PrEP and associated care are provided free of charge, daily and event-driven PrEP services have been progressively rolled out since 2017. Today, the tool is delivered in hospitals, in primary care settings by general practitioners, and in sexual health centers (called CeGIDD) [38]. The numbers of people initiating PrEP have risen sharply: from 1269 in 2016 to 52802 in 2023 [39]. However, literature about the individual, behavioral, psychosocial, and structural factors related with PrEP discontinuation are scarce in the French setting. The few studies that have been performed highlight that younger persons, women, sex workers, chemsexers, and PrEP users who experience side effects are more likely to discontinue PrEP. However, the main limitation of these studies is that they were implemented in cohort settings (hospitals or CeGIDD). Accordingly, they cannot be considered truly representative of the wider population of PrEP users who discontinue uptake [35,40]. In this context, we used data from the national French cross-sectional survey ERAS 2023 to improve knowledge about PrEP discontinuation in a more heterogeneous population of gay and bisexual men who have sex with men (GBMSM).

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85 websites and dating applications for GBMSM (Facebook, Grindr, Scruff, etc.). Clicking on a link, potential participants were re-directed to the survey website, where information about the aims and contents of the survey, as well as the terms of participation and data privacy, were provided. Participant consent was collected online by Santé Publique France, the national public health agency, before the questionnaire was displayed. In agreement with the French National Data Protection Agency's regulations, no IP address was collected. ERAS 2023 followed the ethical guidelines set out in the 1975 Helsinki Declaration. The online survey protocol was evaluated and approved by the Ethics Evaluation Committee of the French National Institute for Health and Medical Research (Inserm) (IRB00003888 no. 23-989).

93 The self-administered online questionnaire collected data about: 1) socio-demographic characteristics; 2) sexual and social identity; 3) sexual and reproductive health (HIV testing history, PrEP use, sexually transmitted infections (STI), vaccination); 4) Mpox infection; 5) sexual behaviors (number of male and/or female partners, frequentation of social gay venues or dating apps, chemsex); 6) protection used during sex with different partners (stable partner, casual partners) and during the most recent sexual intercourse. The study population for the present analysis included cis, trans, non-binary, or non-gendered participants in ERAS 2023 who were born in France, living in France, who self-identified as gay or bisexual, and who had lifetime PrEP use.

## Outcome

100 The study outcome was PrEP use duration (expressed in months) before discontinuation, corresponding to the time between the declared date when PrEP was first prescribed and the declared date of discontinuation. For participants who were taking PrEP at the time of the survey, the outcome was censored at the date when the questionnaire was completed.

## Covariates

106 The following variables were considered in the analysis as potential covariates:

107 **Socio-demographic characteristics**: age, divided into four groups (18-24 years old / 25-29 / 30-44 / 45 and over) ; place of birth, divided into four groups (metropolitan France / French overseas territories / North America and Western Europe / other) ; professional situation (employed vs. unemployed) ; perceived financial situation (dichotomized as follows: very comfortable and comfortable vs. just getting by, difficult to make ends meet, and impossible to get by without going into debt), health insurance coverage (dichotomized into: 'no' and 'I don't know' vs. 'yes'), self-declared sexual orientation (bisexual vs. gay).
In addition, we constructed a four-category geo-epidemiological variable accounting for participants' region of residence in France and the HIV incidence per 1 000 000 inhabitants in that region (< 42, >42, ≥50 and ≥190) [42]. We also created another variable according to the size of municipality of residence (dichotomized into fewer than 20 000 inhabitants vs. more than 20 000 inhabitants).

**Social behaviors:** attending social gay venues like bars, saunas, and backrooms (yes vs. no), Mpox vaccination since 2022 (used as a proxy indicator for how close a relationship the participant had with the gay community) (yes vs. no).

**Psychosocial:** experiencing homophobic insults (yes vs. no), experiencing homophobic violence (yes vs. no), general anxiety disorder score (<10 vs. ≥10) [43], psychological care divided into three categories (no / yes but not in the previous 12 months / yes in the previous 12 months).

**Health and PrEP prescription:** regular health monitoring by a physician (yes vs. no), place where PrEP was first prescribed (sexual health structure (i.e. CeGIDD, community association, or sexual health center) / general practitioner / hospital before April 2021 / hospital after April 2021), diagnosed STI during the previous year divided into three categories (0 / 1 / 2 or more). The two 'April 2021' modalities reflect the fact that general practitioners have been able to prescribe PrEP in France since that date.

**Sexual behaviors:** number of male sexual partners during the previous six months divided into four categories (no answer, 0, 1 / between 2 and 5 / between 6 and 10 / more than 10), chemsex practices during the previous six months (yes vs. no), protection (condoms or PrEP or Treatment as prevention (TasP)) with casual male partners and during the most recent sexual encounter (yes vs. no), condom use during the most recent sexual encounter without specifying partner type (i.e., steady or casual) (yes vs. no).

## Reasons for PrEP discontinuation

To examine the reasons for discontinuation, participants answered the multiple-choice question "Why did you discontinue PrEP?" with seven possible answers: I no longer have sex / I have less sexual intercourse / I have only one sexual partner / I no longer feel like taking PrEP / I use condoms / I have had side effects / Other reasons (with the possibility of providing additional information in a free text section). These seven choices were classed into three categories: i) changes in sex behaviors (I no longer have sex / I have less sexual intercourse / I have only one sexual partner); ii) desire to discontinue PrEP (I no longer feel like taking PrEP / I use condoms); iii) clinical reasons (I have had side effects). When possible, we classified other reasons (when participants explained the
reason in free text) into these same three categories. In order to ensure that all three categories were mutually exclusive, the following decision rule was applied: clinical reasons predominated over a desire to discontinue PrEP and changes in sexual behaviors (i.e., the individual was classified into the clinical reasons category if he ticked all three reasons in his response). For participants who did not answer clinical reasons as their reason to discontinue, a desire to discontinue PrEP predominated over changes in sexual behaviors (i.e. the individual was classified into the desire to discontinue PrEP category if he ticked both of these reasons).

## Statistical analysis

Descriptive statistics compared GBMSM participants on PrEP at the time of the survey with those who declared discontinuing it. Chi-2 and Wilcoxon-Mann-Whitney tests were used for categorical and continuous variables, respectively. We calculated the median duration on PrEP (i.e., PrEP duration), and its interquartile range (IQR) for all explanatory variables. We used the log-rank test and p-values to assess statistical differences. In addition, Kaplan-Meier survival curves were estimated according to the three different reasons for PrEP discontinuation.

For the multivariate analysis, we implemented a Weibull accelerated failure time (AFT) model; this took into account duration dependence (i.e., parameter indicating the effect of the duration on PrEP on the probability of discontinuing it) [44,45]. The AFT model provided accelerating factors (AF), which are interpreted in a similar way to hazard ratios: An AF less than 1 and greater than 1 indicated, respectively, a longer and shorter duration before PrEP discontinuation. Competing risks, represented by the three different reasons (i.e., categories) for PrEP discontinuation, were accounted for in the Weibull AFT model. Variables with a p-value ≤ 0.2 in the log-rank test were tested in the multivariate model. We then performed a sensitivity analysis to ensure that changing the decision rule did not disrupt the results, by inversing the rule between sexual behavior categories for PrEP discontinuation and the desire to discontinue.

All the statistical analyses were performed with R 4.3.3 software [46].

## Results

### ERAS 2023 and sample selection

Among the 23 502 people who responded to the ERAS 2023 online survey, 18 331 had no lifetime PrEP use and were therefore excluded from the present analysis. The final sample included 4 855 participants corresponding to GBMSM living in France (Figure 1). Of these, 36 were secondarily excluded because their reason for discontinuing
PrEP could not be classified into the three-category variable (see above): changes in sexual behavior, a desire to discontinue PrEP, and clinical reasons. Accordingly, the final study sample comprised 4 819 persons.

<figure><img src="image_2.png" /><figcaption>Figure 1: Study flowchart</figcaption></figure>

## Participants' characteristics

Participants' socio-demographic, geographic, behavioral and clinical characteristics are shown in Table 1. Those who had discontinued PrEP at the time of the survey i) were younger than those taking PrEP (34 years [28-43] vs. 39 years (IQR) [32-48]) (p<0.001); ii) were less likely to live in a region with a higher HIV incidence (i.e., Île-de-France (greater Paris region) and all overseas regions) (36.1% vs. 41.5%) (p=0.029); iii) were more likely to experience social deprivation and difficulties associated with their sexual identities. Specifically, they were more likely to be unemployed (18.4% vs. 10.7%, p=0.032), to face financial difficulties (37.9% vs. 31.2%, p<0.001), to define themselves as bisexual (8.9% vs. 7.2%, p=0.092), to suffer homophobic insults (28.1% vs. 19.8%, p<0.001), and to suffer from anxiety (28.2% vs. 20.2%, p<0.001). Moreover, those who discontinued PrEP were less likely to frequent social gay venues (70.3% vs. 85%, p<0.001), to declare numerous sexual partners during the previous six months (3.0 [1.0-8.0] vs. 10.0 [5.0-25.0], p<0.001), to practice chemsex (18.3% vs. 25.9%, p<0.001), and two times less likely to be vaccinated against Mpox (37.1% vs. 74.4%, p <0.001). All these four indicators highlight a less close relationship with the gay community. In addition, they were less likely to have STI during the previous year (10.7% vs. 18.4%, p<0.001), were less regularly monitored for their general health by a doctor (84.8% vs.
95.4%, p<0.001), and were less likely to have first been prescribed PrEP at a general practitioner's office (16.8% vs 19.2%). In contrast, those on PrEP at the time of the study were less likely to have had their first PrEP prescription in a hospital before April 2021 (21.5% vs 25.2%, p = 0.043).

<table><caption>Table 1: Descriptive analysis of PrEP discontinuation among MSM who self-defined as gay or bisexual with a lifetime history of PrEP use (N=4819)*</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">PrEP discontinuation</th><th rowspan="2">p-value</th></tr><tr><th>No N = 3,949<br>n<br>(%)</th><th>Yes N = 870<br>n<br>(%)</th><th>Overall, N = 4,819<br>n<br>(%)</th></tr></thead><tbody><tr><td>Age (years) (continuous)</td><td>39 [32 - 48]</td><td>34 [28 - 43]</td><td>38 [31 - 47]</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Place of birth</td><td></td><td></td><td></td><td>0.300</td></tr><tr><td>Metropolitan France</td><td>3551 (89.9%)</td><td>769 (88.4%)</td><td>4320 (89.6%)</td><td></td></tr><tr><td>Overseas French region</td><td>85 (2.2%)</td><td>27 (3.1%)</td><td>112 (2.3%)</td><td></td></tr><tr><td>North America and Western Europe</td><td>137 (3.5%)</td><td>31 (3.6%)</td><td>168 (3.5%)</td><td></td></tr><tr><td>Other</td><td>176 (4.5%)</td><td>43 (4.9%)</td><td>219 (4.5%)</td><td></td></tr><tr><td>HIV incidence in French region of residence</td><td></td><td></td><td></td><td><strong>0.029</strong></td></tr><tr><td>&lt; 42 1 000 000 inhabitants</td><td>493 (12.5%)</td><td>113 (13%)</td><td>606 (12.6%)</td><td></td></tr><tr><td>&gt; 42 for 1 000 000 inhabitants</td><td>545 (13.8%)</td><td>129 (14.8%)</td><td>674 (14%)</td><td></td></tr><tr><td>≥ 50 for 1 000 000 inhabitants</td><td>1273 (32.2%)</td><td>314 (36.1%)</td><td>1587 (32.9%)</td><td></td></tr><tr><td>Ile-de-France (Greater Paris) region and all<br>French overseas regions combined</td><td>1638 (41.5%)</td><td>314 (36.1%)</td><td>1952 (40.5%)</td><td></td></tr><tr><td>Size of municipality of residence</td><td></td><td></td><td></td><td><strong>0.110</strong></td></tr><tr><td>Fewer than 20 000 inhabitants</td><td>1009 (25.6%)</td><td>245 (28.2%)</td><td>1254 (26%)</td><td></td></tr><tr><td>More than 20 000 inhabitants</td><td>2940 (74.4%)</td><td>625 (71.8%)</td><td>3565 (74%)</td><td></td></tr><tr><td>Professional situation</td><td></td><td></td><td></td><td><strong>0.032</strong></td></tr><tr><td>Employed</td><td>3339 (71.3%)</td><td>710 (81.6%)</td><td>4049 (84%)</td><td></td></tr><tr><td>Unemployed</td><td>610 (10.7%)</td><td>160 (18.4%)</td><td>770 (16%)</td><td></td></tr><tr><td>Perceived financial situation in two categories</td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>Very comfortable/ Comfortable</td><td>2716 (68.8%)</td><td>540 (62.1%)</td><td>3256 (67.6%)</td><td></td></tr><tr><td>Just getting by/Difficult to make ends<br>meet/Impossible to make ends meet without<br>going into debt</td><td>1233 (31.2%)</td><td>330 (37.9%)</td><td>1563 (32.4%)</td><td></td></tr></tbody></table>
<table><caption>Table 1: Descriptive analysis of PrEP discontinuation among MSM who self-defined as gay or bisexual with a lifetime history of PrEP use (N=4819)*</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">PrEP discontinuation</th><th rowspan="2">p-value</th></tr><tr><th>No N = 3,949<br>n<br>(%)</th><th>Yes N = 870<br>n<br>(%)</th><th>Overall, N = 4,819<br>n<br>(%)</th></tr></thead><tbody><tr><td><strong>Supplementary Health insurance in two categories</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No/I do not know</td><td>113 (2.9%)</td><td>46 (5.3%)</td><td>159 (3.3%)</td><td></td><td></td></tr><tr><td>Yes</td><td>3836 (97.1%)</td><td>824 (94.7%)</td><td>4660 (96.7%)</td><td></td><td></td></tr><tr><td><strong>Self-identified sexual orientation</strong></td><td></td><td></td><td></td><td></td><td><strong>0.092</strong></td></tr><tr><td>Bisexual</td><td>284 (7.2%)</td><td>77 (8.9%)</td><td>361 (7.5%)</td><td></td><td></td></tr><tr><td>Gay</td><td>3665 (92.8%)</td><td>793 (91.1%)</td><td>4458 (92.5%)</td><td></td><td></td></tr><tr><td><strong>Frequented social gay venues (bars, saunas, backrooms)</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>592 (15%)</td><td>258 (29.7%)</td><td>850 (17.6%)</td><td></td><td></td></tr><tr><td>Yes</td><td>3357 (85%)</td><td>612 (70.3%)</td><td>3969 (82.4%)</td><td></td><td></td></tr><tr><td><strong>Experienced homophobic insults</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>3167 (80.2%)</td><td>626 (72%)</td><td>3793 (78.7%)</td><td></td><td></td></tr><tr><td>Yes</td><td>782 (19.8%)</td><td>244 (28.1%)</td><td>1026 (21.3%)</td><td></td><td></td></tr><tr><td><strong>Experienced homophobic attacks in the previous year</strong></td><td></td><td></td><td></td><td></td><td><strong>0.130</strong></td></tr><tr><td>No</td><td>3766 (95.4%)</td><td>819 (94.1%)</td><td>4585 (95.1%)</td><td></td><td></td></tr><tr><td>Yes</td><td>183 (4.6%)</td><td>51 (5.9%)</td><td>234 (4.9%)</td><td></td><td></td></tr><tr><td><strong>General anxiety disorder score GAD-7 &gt;= 10</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>3152 (79.8%)</td><td>625 (71.8%)</td><td>3777 (78.4%)</td><td></td><td></td></tr><tr><td>Yes</td><td>797 (20.2%)</td><td>245 (28.2%)</td><td>1042 (21.6%)</td><td></td><td></td></tr><tr><td><strong>Received lifetime care from a psychiatrist, psychoanalyst, psychotherapist, or psychologist</strong></td><td></td><td></td><td></td><td></td><td><strong>0.084</strong></td></tr><tr><td>No</td><td>1888 (47.8%)</td><td>383 (44%)</td><td>2271 (47.1%)</td><td></td><td></td></tr><tr><td>Yes, but not in the previous 12 months</td><td>1024 (25.9%)</td><td>253 (29.1%)</td><td>1277 (26.5%)</td><td></td><td></td></tr><tr><td>Yes in the previous 12 months</td><td>1037 (26.3%)</td><td>234 (26.9%)</td><td>1271 (26.4%)</td><td></td><td></td></tr></tbody></table>

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<table><caption>Table 1: Descriptive analysis of PrEP discontinuation among MSM who self-defined as gay or bisexual with a lifetime history of PrEP use (N=4819)*</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">PrEP discontinuation</th><th rowspan="2">p-value</th></tr><tr><th>No N = 3,949<br>n<br>(%)</th><th>Yes N = 870<br>n<br>(%)</th><th>Overall, N = 4,819<br>n<br>(%)</th></tr></thead><tbody><tr><td><strong>Regularly monitored for general health by a doctor</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>183 (4.6%)</td><td>132 (15.2%)</td><td>315 (6.5%)</td><td></td><td></td></tr><tr><td>Yes</td><td>3766 (95.4%)</td><td>738 (84.8%)</td><td>4504 (93.5%)</td><td></td><td></td></tr><tr><td><strong>Place where PrEP was first prescribed</strong></td><td></td><td></td><td></td><td></td><td><strong>0.043</strong></td></tr><tr><td>Sexual health structure</td><td>1989 (50.4%)</td><td>439 (50.5%)</td><td>2428 (50.4%)</td><td></td><td></td></tr><tr><td>General practitioner</td><td>759 (19.2%)</td><td>146 (16.8%)</td><td>905 (18.8%)</td><td></td><td></td></tr><tr><td>Hospital before April 2021*</td><td>848 (21.5%)</td><td>219 (25.2%)</td><td>1067 (22.1%)</td><td></td><td></td></tr><tr><td>Hospital after April 2021*</td><td>353 (8.9%)</td><td>66 (7.6%)</td><td>419 (8.7%)</td><td></td><td></td></tr><tr><td><strong>Mpox vaccination since 2022</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>1012 (25.6%)</td><td>547 (62.9%)</td><td>1559 (32.3%)</td><td></td><td></td></tr><tr><td>Yes</td><td>2937 (74.4%)</td><td>323 (37.1%)</td><td>3260 (67.6%)</td><td></td><td></td></tr><tr><td><strong>Sexually Transmitted Infections in the previous 12 months</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>None</td><td>2956 (74.9%)</td><td>752 (86.4%)</td><td>3708 (76.9%)</td><td></td><td></td></tr><tr><td>1</td><td>725 (18.4%)</td><td>93 (10.7%)</td><td>818 (17%)</td><td></td><td></td></tr><tr><td>2 or more</td><td>268 (6.8%)</td><td>25 (2.9%)</td><td>293 (6.1%)</td><td></td><td></td></tr><tr><td><strong>Number of male sexual partners in the previous six months</strong></td><td>10 [5.0 - 25.0]</td><td>3.0 [1.0 - 8.0]</td><td>10 [4.0 - 20.0]</td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td><strong>Chemsex during the previous six months</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>2925 (74.1%)</td><td>711 (81.7%)</td><td>3636 (75.5%)</td><td></td><td></td></tr><tr><td>Yes</td><td>1024 (25.9%)</td><td>159 (18.3%)</td><td>1183 (24.5%)</td><td></td><td></td></tr><tr><td><strong>Used protection with casual male partners and during most recent sexual encounter</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>1185 (30%)</td><td>751 (86.3%)</td><td>1936 (40.2%)</td><td></td><td></td></tr></tbody></table>

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<table><caption>Table 1: Descriptive analysis of PrEP discontinuation among MSM who self-defined as gay or bisexual with a lifetime history of PrEP use (N=4819)*</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">PrEP discontinuation</th><th rowspan="2">p-value</th></tr><tr><th>No N = 3,949<br>n<br>(%)</th><th>Yes N = 870<br>n<br>(%)</th><th>Overall, N = 4,819<br>n<br>(%)</th></tr></thead><tbody><tr><td>Yes</td><td>2764 (70%)</td><td>119 (13.7%)</td><td>2883 (59.8%)</td><td></td></tr><tr><td><strong>Used a condom during most recent sexual encounter</strong></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>3285 (83.2%)</td><td>673 (77.4%)</td><td>3958 (82.1%)</td><td></td></tr><tr><td>Yes</td><td>664 (16.8%)</td><td>197 (22.6%)</td><td>861 (17.9%)</td><td></td></tr><tr><td><strong>Reasons for PrEP discontinuation</strong></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No discontinuation</td><td>3949 (100%)</td><td>/</td><td>3949 (82%)</td><td></td></tr><tr><td>Changes in sexual behaviors</td><td>/</td><td>474 (54.5%)</td><td>474 (9.8%)</td><td></td></tr><tr><td>Desire to discontinue PrEP</td><td>/</td><td>228 (26.2%)</td><td>228 (4.7%)</td><td></td></tr><tr><td>Clinical reasons</td><td>/</td><td>168 (19.3%)</td><td>168 (3.5%)</td><td></td></tr></tbody></table>

* Statement on missing data: missing data were classified as “no” for yes vs. no questions. For the number of sexual partners and STIs, missing data were classified as zero. Missing data on reasons for stopping PrEP were excluded from the analysis as it was the main covariate. No other missing data were reported.

** General practitioners have been able to prescribe PrEP in France since April 2021.

## PrEP duration among participants who discontinued PrEP

Median [IQR] duration on PrEP differed with age: from 11.0 [4.0-24.0] months for persons under 31 years old to 27.0 [10.0-49.0] months for those over 47 (p<0.001). People living in the Île-de-France and French overseas regions were on PrEP longer (23.0 [9.0-45.0] months) than participants in other regions (p<0.001). Participants living in urban areas (20.0 [8.0-44.0] months) (p=0.004), those employed (21.0 [8.0-44.0] months) (p<0.001), and those who had a very comfortable financial situation (21.0 [8.0-43.0] months) (p<0.001) were longer on PrEP than others. MSM who self-identified as gay (20.0 [7.0-43.0] months vs. 13.0 [4.0-29.0] months for bisexual MSM) (p=0.002), and those who frequented social gay venues (21.0 [8.0-44.0] months vs. 13.0 [8.0-44.0] months for bisexual MSM) not frequenting social venues) (p<0.001) were also longer on PrEP.
Participants who experienced homophobic insults (16.0 [6.0-36.0] months vs. 20.0 [8.0-43.0] months) (p<0.001) and those with a high anxiety score (i.e., GAD-7 ≥ 10) (17.0 [6.0-39.75] months vs. 20.0 [7.0-42.0] months) (p<0.001) had a shorter PrEP duration.

Participants regularly monitored by a doctor for general health were longer on PrEP than those not monitored (20.0 [7.0-43.0] months vs. 13.0 [4.0-33.0] months) (p<0.001). Participants who declared more risky sexual behaviors were longer on PrEP. More specifically, median PrEP duration was 19.0 [6.0-42.0] months among participants with no STI in the previous 12 months, and 23.0 [9.0-43.0] months for participants with two or more STI (p<0.001).

Median PrEP also increased with the number of sexual partners in the previous months (from 14.0 [5.0-32.0] months for participants with fewer than four partners to 27.0 [11.0-48.0] months for participants with more than twenty partners) (p<0.001). Participants who used a condom during their most recent sexual encounter had a shorter PrEP duration than those who did not (14.0 [5.0-31.0] months vs. 21.0 [8.0-44.0] months (p<0.001)).

Further details about PrEP duration are provided in Table 2.

<table><caption>Table 2: Median duration on PrEP among participants who discontinued PrEP</caption><thead><tr><th>Variables</th><th>Median duration</th><th>p-value</th></tr></thead><tbody><tr><td><strong>Age (years)*</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>&lt; 31</td><td>11.0 [4.0-24.0]</td><td></td></tr><tr><td>31-38</td><td>19.0 [8.0-41.0]</td><td></td></tr><tr><td>38-46</td><td>23.0 [9.0-46.0]</td><td></td></tr><tr><td>47+</td><td>27.0 [10.0-49.0]</td><td></td></tr><tr><td><strong>Place of birth</strong></td><td></td><td>0.400</td></tr><tr><td>Metropolitan France</td><td>19.0 [7.0-42.0]</td><td></td></tr><tr><td>French overseas region</td><td>19.5 [9.0-41.25]</td><td></td></tr><tr><td>North America and Western Europe</td><td>21.5 [6.75-45.0]</td><td></td></tr><tr><td>Other</td><td>17.0 [5.0-36.0]</td><td></td></tr><tr><td><strong>HIV incidence in region of residence</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>&lt; 42 1 000 000 inhabitants</td><td>15.5 [6.0-36.75]</td><td></td></tr><tr><td>&gt; 42 for 1 000 000 inhabitants</td><td>18.0 [7.0-36.0]</td><td></td></tr><tr><td>≥ 50 for 1 000 000 inhabitants</td><td>18.0 [6.0-40.0]</td><td></td></tr><tr><td>Ile-de-France (Greater Paris) region and all French overseas regions</td><td>23.0 [9.0-45.0]</td><td></td></tr><tr><td><strong>Size of municipality of residence</strong></td><td></td><td><strong>0.004</strong></td></tr><tr><td>Fewer than 20 000 inhabitants</td><td>16.0 [6.0-36.0]</td><td></td></tr><tr><td>More than 20 000 inhabitants</td><td>20.0 [8.0-44.0]</td><td></td></tr><tr><td><strong>Professional situation</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>Employed</td><td>21.0 [8.0-44.0]</td><td></td></tr><tr><td>Unemployed</td><td>16.0 [6.0-38.0]</td><td></td></tr></tbody></table>
<table><caption>Table 2: Median duration on PrEP among participants who discontinued PrEP</caption><thead><tr><th>Variables</th><th>Median duration</th><th>p-value</th></tr></thead><tbody><tr><td><strong>Perceived financial situation in two categories</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>Very comfortable/ Comfortable</td><td>21.0 [8.0-43.0]</td><td></td></tr><tr><td>Just getting by/Difficult to make ends meet/Impossible to make ends meet without going into debt without debt</td><td>16.0 [6.0-38.0]</td><td></td></tr><tr><td><strong>Supplementary health insurance in two categories</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No/I do not know</td><td>20.0 [6.0-36.0]</td><td></td></tr><tr><td>Yes</td><td>19.0 [7.0-42.0]</td><td></td></tr><tr><td><strong>Self-declared sexual orientation</strong></td><td></td><td><strong>0.002</strong></td></tr><tr><td>Bisexual</td><td>13.0 [4.0-29.0]</td><td></td></tr><tr><td>Gay</td><td>20.0 [7.0-43.0]</td><td></td></tr><tr><td><strong>Frequented social gay venues (bars, saunas, backrooms)</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>13.0 [4.0-31.0]</td><td></td></tr><tr><td>Yes</td><td>21.0 [8.0-44.0]</td><td></td></tr><tr><td><strong>Experienced homophobic insults</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>20.0 [8.0-43.0]</td><td></td></tr><tr><td>Yes</td><td>16.0 [6.0-36.0]</td><td></td></tr><tr><td><strong>Experienced homophobic attacks in the previous year</strong></td><td></td><td>0.200</td></tr><tr><td>No</td><td>19.0 [7.0-42.0]</td><td></td></tr><tr><td>Yes</td><td>20.0 [6.0-45.75]</td><td></td></tr><tr><td><strong>General anxiety disorder score GAD-7 &gt;= 10</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>20.0 [7.0-42.0]</td><td></td></tr><tr><td>Yes</td><td>17.0 [6.0-39.75]</td><td></td></tr><tr><td><strong>Received lifetime care from a psychiatrist, psychoanalyst, psychotherapist, psychologist</strong></td><td></td><td>0.300</td></tr><tr><td>No</td><td>18.0 [7.0-40.0]</td><td></td></tr><tr><td>Yes, but not in previous 12 months</td><td>20.0 [7.0-44.0]</td><td></td></tr><tr><td>Yes, in the previous 12 months</td><td>18.0 [7.0-40.0]</td><td></td></tr><tr><td><strong>Regularly monitored for general health by a doctor</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>13.0 [4.0-33.0]</td><td></td></tr><tr><td>Yes</td><td>20.0 [7.0-43.0]</td><td></td></tr><tr><td><strong>Sexually Transmitted Infection in the previous 12 months</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>None</td><td>19.0 [6.0-42.0]</td><td></td></tr><tr><td>1</td><td>21.0 [8.0-43.0]</td><td></td></tr><tr><td>2 or more</td><td>23.0 [9.0-43.0]</td><td></td></tr><tr><td><strong>Place where PrEP was first prescribed</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>Sexual health structure</td><td>19.0 [7.0-41.0]</td><td></td></tr></tbody></table>

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<table><caption>Table 2 : Median duration on PrEP among participants who discontinued PrEP</caption><thead><tr><th>Variables</th><th>Median duration</th><th>p-value</th></tr></thead><tbody><tr><td>General practitioner</td><td>9.0 [4.0-17.0]</td><td></td></tr><tr><td>Hospital before April 2021**</td><td>30.0 [44.0-59.0]</td><td></td></tr><tr><td>Hospital after April 2021**</td><td>10.0 [4.0-16.0]</td><td></td></tr><tr><td><strong>Mpox vaccination since 2022</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>13.0 [4.0-32.0]</td><td></td></tr><tr><td>Yes</td><td>22.0 [9.0-45.0]</td><td></td></tr><tr><td><strong>Number of male sexual partners in previous six months *</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>&lt; 4</td><td>14.0 [5.0-32.0]</td><td></td></tr><tr><td>4 to 9</td><td>17.0 [6.0-36.0]</td><td></td></tr><tr><td>10 to 19</td><td>18.0 [6.0-42.0]</td><td></td></tr><tr><td>20+ partners</td><td>27.0 [11.0-48.0]</td><td></td></tr><tr><td><strong>Chemsex during previous 6 months</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>17.0 [6.0-38.0]</td><td></td></tr><tr><td>Yes</td><td>26.0 [10.0-48.5]</td><td></td></tr><tr><td><strong>Used protection with casual male partners and during most recent sexual encounter</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>13.0 [4.0-33.0]</td><td></td></tr><tr><td>Yes</td><td>23.0 [10.0-46.0]</td><td></td></tr><tr><td><strong>Used a condom during most recent sexual encounter</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>21.0 [8.0-44.0]</td><td></td></tr><tr><td>Yes</td><td>14.0 [5.0-31.0]</td><td></td></tr><tr><td><strong>Reason for PrEP discontinuation</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No discontinuation</td><td>/</td><td></td></tr><tr><td>Changes in sexual behaviors</td><td>12.0 [4.0-24.0]</td><td></td></tr><tr><td>Desire to discontinue PrEP</td><td>7.0 [2.0-17.0]</td><td></td></tr><tr><td>Clinical reasons</td><td>6.0 [1.0-15.0]</td><td></td></tr></tbody></table>

* Categories created using quartiles as thresholds, for descriptive purposes.

** General practitioners have been able to prescribe PrEP in France since April 2021.

With regard to the reasons for discontinuing PrEP, Table 2 shows that participants who replied 'changes in sexual behaviors' stayed longer on PrEP (12 [4.0-24.0] months) than those who replied 'desire to discontinue PrEP' (7 [2.0-17.0] months) and those who discontinued for clinical reasons (6 [1.0-15.0] months), p<0.001. This is also reflected in the Kaplan-Meier duration curves (Figure 2).

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<figure><img src="image_3.png" /><figcaption>Figure 2: Kaplan-Meier estimation of PrEP duration, depending on the reasons for PrEP discontinuation (N=870)</figcaption></figure>

Multivariate accelerated failure-time model for PrEP duration until discontinuation: reasons for discontinuing as competing risks

Discontinuing PrEP because of changes in sexual behaviors was less likely among older participants (AF=0.950, 95% CI [0.937-0.964]), participants who were first prescribed PrEP in a sexual health structure (AF=0.604 [0.424-0.858]) or in a hospital before April 2021 (AF=0.513 [0.345-0.762]), participants who used a condom during their most recent sexual encounter (AF=0.427 [0.937-0.964]), persons who frequented social venues like bars, saunas and backrooms (AF = 0.531 [0.400-0.705]), participants vaccinated against Mpox (AF = 0.159 [0.116-0.220]), and participants with multiple sexual partners during the previous six months (AF = 0.857 [0.831-0.881]) (Table 3).

Discontinuing PrEP out of a desire to no longer use it was less likely among participants vaccinated against Mpox (AF = 0.111 [0.062-0.200]) and those with multiple sexual partners during the previous six months (AF = 0.978 [0.963-0.993]). Conversely, it was more than twice as likely to occur among participants living in a region with one of the lowest HIV incidences in France (AF = 2.320 [1.054-5.107]). A U-shaped relationship was
239 observed for discontinuing PrEP and age (age: AF = 0.780 [0.663-0.919], age²: AF = 1.252 [1.028-1.525]),
240 indicating that the youngest and the oldest participants were the most likely to discontinue PrEP.

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241 **Discontinuing PrEP because of clinical reasons** was less likely among older participants (AF = 0.961 [0.932-0.991]) and those who had a close relationship with the gay community. Conversely, it was more among unemployed participants (AF = 3.513 [1.615-7.645]), those living in a municipality under 20 000 inhabitants (AF = 2.312 [1.099-4.868]), participants who were first prescribed PrEP in a hospital after April 2021 (AF = 4.322 [1.209-15.443]), and those who used a condom during their most recent sexual encounter (AF = 5.223 [2.478-11.005]).

247 **PrEP duration dependence (Weibull parameter)** was negative for all three different reasons for discontinuing PrEP. This implies that, *ceteris paribus*, the longer the duration on PrEP, the lower the probability of discontinuing it (Table 3). The lowest duration dependence score was found for participants who discontinued PrEP due to changes in sexual behaviors (AF = 0.495 [0.469-0.524], vs. AF=0.590 [0.469-0.524] for desire to discontinue, and AF=0.630 [0.590-0.672] for clinical reasons).
<table><caption>Table 3 : Weibull regression of the main factors predicting PrEP duration : reasons for PrEP discontinuation effects</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">Changes in sexual behaviors</th><th colspan="2">Desire to discontinue PrEP</th><th colspan="2">Clinical reasons</th></tr><tr><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th></tr></thead><tbody><tr><td>Age (continuous)</td><td>0.950**</td><td>0.937 to 0.964</td><td>0.780**</td><td>0.663 to 0.919</td><td>0.961*</td><td>0.932 to 0.991</td></tr><tr><td>Age<sup>2</sup> (continuous) a</td><td>/</td><td>/</td><td>1.252*</td><td>1.028 to 1.525</td><td>/</td><td>/</td></tr><tr><td>Professional situation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Employed</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Unemployed</td><td>0.728</td><td>0.504 to 1.051</td><td>0.770</td><td>0.371 to 1.597</td><td>3.513**</td><td>1.615 to 7.645</td></tr><tr><td>HIV incidence per 1 000 000 inhabitants in French region of residence</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Île-de-France region and French overseas regions combined (≥190)</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Region ≥50</td><td>0.819</td><td>0.599 to 1.122</td><td>1.461</td><td>0.785 to 2.718</td><td>1.733</td><td>0.787 to 3.816</td></tr><tr><td>Region >42</td><td>0.865</td><td>0.574 to 1.303</td><td>1.746</td><td>0.816 to 3.738</td><td>0.695</td><td>0.231 to 2.092</td></tr><tr><td>Region <42</td><td>1.066</td><td>0.696 to 1.632</td><td>2.320*</td><td>1.054 to 5.107</td><td>0.472</td><td>0.137 to 1.625</td></tr><tr><td>Size of municipality of residence</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>More than 20000 inhabitants</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Fewer than 20000 inhabitants</td><td>0.887</td><td>0.652 to 1.205</td><td>0.858</td><td>0.479 to 1.537</td><td>2.312*</td><td>1.099 to 4.868</td></tr><tr><td>Sexual orientation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Gay</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Bisexual</td><td>0.784</td><td>0.468 to 1.313</td><td>1.892</td><td>0.860 to 4.162</td><td>1.765</td><td>0.615 to 5.067</td></tr><tr><td>Frequented social gay venues (bars, saunas, backrooms)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Yes</td><td>0.531**</td><td>0.400 to 0.705</td><td>0.633</td><td>0.350 to 1.144</td><td>0.436*</td><td>0.202 to 0.941</td></tr><tr><td>Place where PrEP was first prescribed</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>General practitioner</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Sexual health structure</td><td>0.604**</td><td>0.424 to 0.858</td><td>1.055</td><td>0.504 to 2.207</td><td>0.930</td><td>0.352 to 2.453</td></tr><tr><td>Hospital before 2021 b</td><td>0.513**</td><td>0.345 to 0.762</td><td>1.189</td><td>0.521 to 2.717</td><td>0.608</td><td>0.195 to 1.899</td></tr><tr><td>Hospital after 2021 b</td><td>0.762</td><td>0.421 to 1.380</td><td>1.039</td><td>0.326 to 3.313</td><td>4.322*</td><td>1.209 to 15.443</td></tr></tbody></table>
<table><caption>Table 3 : Weibull regression of the main factors predicting PrEP duration : reasons for PrEP discontinuation effects</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">Changes in sexual behaviors</th><th colspan="2">Desire to discontinue PrEP</th><th colspan="2">Clinical reasons</th></tr><tr><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th></tr></thead><tbody><tr><td><strong>Mpox vaccination since 2022</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Yes</td><td>0.159**</td><td>0.116 to 0.220</td><td>0.111**</td><td>0.062 to 0.200</td><td>0.362**</td><td>0.179 to 0.732</td></tr><tr><td><strong>Condom use during most recent sexual encounter</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Yes</td><td>0.427**</td><td>0.279 to 0.654</td><td>/</td><td>/</td><td>5.223**</td><td>2.478 to 11.005</td></tr><tr><td><strong>Sexual partners during the previous six months (continuous)</strong></td><td>0.857**</td><td>0.833 to 0.881</td><td>0.978**</td><td>0.963 to 0.993</td><td>0.975*</td><td>0.955 to 0.996</td></tr><tr><td>Weibull parameter : duration dependence</td><td>0.495**</td><td>0.469 to 0.524</td><td>0.590**</td><td>0.554 to 0.628</td><td>0.630**</td><td>0.590 to 0.672</td></tr></tbody></table>

* Significant at 5%

** Significant at 1%

a Together with «Age» the variable «Age²» reflects the changes of the effect of age (i.e., accounting for non-linear relationship with the probability of PrEP discontinuation).

b General practitioners have been able to prescribe PrEP in France since April 2021.

/ variable not included for this reason of PrEP discontinuation
252 Discussion

The present study demonstrates that in our study population of GBMSM living in France who self-identified as gay or bisexual, the longer an individual used PrEP, the less likely he was to discontinue it, independently of any other individual or structural factor. This result shows the pertinence of using tailored methods, such as the Weibull parametric model used in this analysis, when studying PrEP discontinuation, as it takes into account the effect of PrEP duration on the risk of discontinuing it (i.e., duration dependence). The negative duration dependence score we found using real-life data suggests that GBMSM with longer PrEP duration were less likely to be weary taking PrEP. This result builds on previous findings highlighting early participant drop out from PrEP programs [33,36] conducted in very specific settings, with small sample sizes and/or which only accounted for individual and structural factors. To the best of our knowledge, no study to date has taken into account PrEP duration as a determinant of PrEP discontinuation. This is the primary contribution of our analysis.

Existing studies highlight the importance of the conditions (i.e., psychological, geographical, financial, sociocultural, etc.) in which individuals initiate PrEP, indicating that they are determinants of discontinuation (whether early or not), although no further insight about this relationship is provided [1,35]. The present study contextualizes users' first experience of PrEP among a large sample of GBMSM and demonstrates that accounting for the different reasons (i.e., motivated by changes in sexual behaviors, a desire to discontinue, or due to clinical reasons) that may lead an individual to discontinue PrEP (i.e. competing risks) offers more precise and nuanced information. Factors associated with each reason differed; this demonstrates that discontinuing PrEP is a differentiated process driven not only by multiple individual and structural factors, but also PrEP duration itself.

Median PrEP duration in the present study was 19 months; this is much longer than the median of 9 months found in most studies in the literature (ranging from 3 to 13 months) [22,47,48]. This might be explained by the fact that i) people in France can access PrEP for free through several different structures (hospitals, CeGIDD, and since April 2021, through general practitioners' prescription), and ii) people can freely choose between daily and event-driven regimens. Indeed, our results confirm the role of diversification of providers and of regimens as facilitators of PrEP continuation [1,32,49,50], and the importance of free-of-charge PrEP as a key factor in preventing PrEP discontinuation [10,15,22,30,34,51,52].

With regard to individual factors impacting PrEP discontinuation, the literature shows that age and a close relationship with the gay community are two factors associated with a lower probability of discontinuing PrEP [10,19,32,53,54]. We found similar results for PrEP users who discontinued because of changes in their sexual behaviors and because of clinical reasons. However, among those who declared they discontinued because they
desired to do so, the youngest and oldest participants were the most likely to discontinue. This highlights that all strategies promoting PrEP use and retention in PrEP must take into account the diverse reasons for PrEP discontinuation; in other words, target profiles are not the same. Moreover, participants who discontinued PrEP out of a desire to do so, were more likely to live in a region with low HIV incidence; this suggests they perceived their risk of exposure as low, which reflects findings in the literature [13,32]. However, for participants that discontinued PrEP because of clinical reasons, a different 'geographical' mechanism was observed. More specifically, for this group, persons living in municipalities with fewer than 20 000 inhabitants were much more likely to discontinue. In addition, persons first prescribed PrEP in hospitals after April 2021 were four times more likely to discontinue for clinical reasons than first prescribed PrEP by a general practitioner. This result may be interpreted in several ways; first, it may reflect greater difficulty in accessing PrEP health services in rural areas [55-57]; second, it could mean that some of our participants preferred the care environment provided by general practitioners to that in hospitals, and therefore chose to request PrEP in private offices. Whatever the interpretation, the question remains as to whether the clinical reasons provided for discontinuing PrEP were genuine, or simply reflected social desirability by participants and/or prescribers (i.e. as perceived by participants) to justify the decision of discontinuing PrEP [58-60]. In contrast, participants who declared they discontinued PrEP because of changes in sexual behaviors, and those who were first prescribed PrEP in a hospital before 2021 or in a sexual health structure's premises, were less likely to discontinue PrEP. One aspect common to both structure types (i.e., hospitals and sexual health structures) which might explain this result, is that community-based counselling is offered in both (especially during the large cohort studies conducted in hospitals before 2021) [8,9,52,61]. Longer PrEP duration for participants who declared they discontinued because of changes in sexual behaviors who were first prescribed PrEP in a sexual health structure or in a hospital before 2021, may reflect that these persons had a more accurate perception of HIV risk, leading to better self-management of prevention tools [61]. Indeed, among this sub-population, using a condom during the most recent sexual encounter was also a factor associated with longer PrEP duration. This reflects findings in the ANRS-Ipergay trial where 29% of participants used a combination of PrEP and condoms [62]. It is important to point out that in our study, condoms were the main alternative prevention tool for participants who discontinued PrEP for clinical reasons, suggesting that i) healthcare providers provided advice to them on which harm reduction strategies to use [10], and ii) PrEP users were aware of the importance of staying protected. Indeed, among participants who discontinued for clinical reasons, those who had used a condom in their most recent sexual encounter were five times more likely to discontinue PrEP compared to those who had not used a condom. Irrespective of the reason, the probability of discontinuing PrEP
341 our cross-sectional data did not collect data on possible previous PrEP discontinuation in participants who were taking PrEP at the time of the study. Alternating episodes of PrEP interruption and resumption constitute a public health issue, as they reflect PrEP users' perception of their risk at any one time. Often, the perceived level of risk is inaccurate [13,34,76]. However, relatively few studies have investigated PrEP resumption after discontinuation (only eight among 59 studies included in a recent meta-analysis) [1]. Moreover, as our study was cross-sectional in nature we were not able to take into account the type of PrEP regimen as a covariate. This two missing elements (i.e., PrEP interruption and type of regimen) in our data highlight the need for longitudinal studies implemented in real-life settings, in order to provide in-depth evidence about the processes of PrEP discontinuation, including interruptions and the type of PrEP regimen. Fourth, ERAS 2023 did not collect data on clinical follow-up (declared or objective) or detailed data on HIV risk perception/management. Although clinical follow-up is implicitly accounted for in our analysis, as it is compulsory for PrEP prescription renewal in France, the absence of detailed information about clinical visits associated with PrEP use meant that we could not disentangle individual and structural factors from clinical follow-up-related factors that could contribute to PrEP weariness [36]. As the 'medicalisation' of HIV prevention has been raised as a key element of PrEP discontinuation in the literature [31,33], it needs to be accounted for in any study examining potential weariness taking PrEP. Fifth, the need to create mutually exclusive reasons for PrEP discontinuation obliged us to create a hierarchical rule where clinical reasons predominated over the desire to discontinue and the desire to discontinue predominated over changes in sexual behaviors. HIV seroconversion and PrEP-related side effects, both classified as clinical reasons in this study, have been cited in multiple studies as primary causes of PrEP discontinuation [34,48,76,77]. Some side effects, particularly those affecting bone density, may necessitate mandatory PrEP discontinuation, as they can pose serious health risks to affected users. Additionally, individuals who seroconvert to HIV-positive must discontinue PrEP and initiate antiretroviral therapy (ART) to control their viral load and prevent drug resistance. Furthermore, when PrEP discontinuation results from a medical decision, it indicates that the individual has undergone a consultation and that the decision has been medically validated. For these reasons, clinical factors were classified predominant over personal willingness to discontinue or changes in sexual behavior. For the decision rule between desire to discontinue and changes in sexual behaviors, our sensitivity analysis where changes in sexual behaviors reasons were set as being predominant over the desire to discontinue did not modify our results (Appendices 1 and 2).
371 Conclusions

1 372 Improving knowledge about PrEP weariness is necessary to construct public health policies to tackle
2 373 discontinuation. Among participants in the present study, PrEP duration was longer than that reported in other
3 374 countries, confirming the importance of offering flexible access in terms of structures and type of regimens. PrEP
4 375 discontinuation seems to be more related with individual and structural factors than the duration of use, suggesting
5 376 no weariness. Further research using ‘real-life’ detailed data on clinical follow-up and risk perception is needed to
6 377 improve counseling and support for PrEP users. In a context where the range of HIV PrEP tools is expanding (e.g.,
7 378 novel long-acting molecules), it would appear essential to have an in-depth understanding of the diversity of
8 379 reasons and the potential role of weariness in the process of PrEP discontinuation among GBMSM.
9 380
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12 381 Acknowledgments
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381 Acknowledgments

21 Our thanks to Jude Sweeney (Milan, Italy) for the English revision and editing of the manuscript.

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24 383 Authorship confirmation/contribution statement (CRediT format is preferred)

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388 Author(s') disclosure (Conflict of Interest) statement(s), even when not applicable

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The authors report no conflict of interest.

390 Funding statement, even when not applicable

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391 This study was supported by Santé Publique France (the French public health agency) and the French National
392 Research Agency on AIDS and Viral Hepatitis (ANRS). Clément Boutet is the recipient of a doctoral fellowship
393 from the French National Research Agency on AIDS and Viral Hepatitis (ANRS 0512b).
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Appendix 1: Kaplan-Meier estimation of PrEP duration, depending on the different reasons for PrEP discontinuation (N=870)

<figure><img src="image_4.png" /></figure>
<table><caption>Appendix 2: Weibull regression of main factors predicting PrEP duration : reasons for PrEP discontinuation effects</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">Sexual behavior</th><th colspan="2">Willingness to discontinue PrEP</th><th colspan="2">Clinical reasons</th></tr><tr><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th></tr></thead><tbody><tr><td>Age (years) (continuous)</td><td>0.949**</td><td>0.936 to 0.961</td><td>0.712**</td><td>0.554 to 0.915</td><td>0.961*</td><td>0.932 to 0.991</td></tr><tr><td>Age<sup>2</sup> (years)(continuous) a</td><td>/</td><td>/</td><td>1.402*</td><td>1.039 to 1.892</td><td>/</td><td>/</td></tr><tr><td>Professional situation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Employed</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Unemployed</td><td>0.747</td><td>0.536 to 1.042</td><td>0.866</td><td>0.276 to 2.717</td><td>3.512**</td><td>1.614 to 7.641</td></tr><tr><td>HIV incidence in French region of residence</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Île-de-France (Greater Paris) region and all French overseas regions combined (≥190)</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Region ≥50</td><td>0.825</td><td>0.619 to 1.099</td><td>2.838*</td><td>1.015 to 7.939</td><td>1.733</td><td>0.787 to 3.816</td></tr><tr><td>Region >42</td><td>0.896</td><td>0.619 to 1.295</td><td>2.796</td><td>0.787 to 9.930</td><td>0.696</td><td>0.231 to 2.094</td></tr><tr><td>Region <42</td><td>1.022</td><td>0.693 to 1.507</td><td>2.320**</td><td>1.649 to 20.784</td><td>0.472</td><td>0.137 to 1.627</td></tr><tr><td>Size of municipality of residence</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>More than 20000 inhabitants</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Fewer than 20000 inhabitants</td><td>0.927</td><td>0.702 to 1.225</td><td>0.642</td><td>0.250 to 1.650</td><td>2.314*</td><td>1.099 to 4.872</td></tr><tr><td>Sexual orientation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Gay</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Bisexual</td><td>0.879</td><td>0.561 to 1.377</td><td>2.179</td><td>0.628 to 7.554</td><td>1.767</td><td>0.616 to 5.072</td></tr><tr><td>Frequenting social gay venues (bars, saunas, backrooms)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>59</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>60</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>61</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>62</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>63</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>64</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>65</td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<table><caption>Appendix 2: Weibull regression of main factors predicting PrEP duration : reasons for PrEP discontinuation effects</caption><thead><tr><th rowspan="2">Variable</th><th rowspan="2"></th><th colspan="2">Sexual behavior</th><th colspan="2">Willingness to discontinue PrEP</th><th colspan="2">Clinical reasons</th></tr><tr><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th></tr></thead><tbody><tr><td>26</td><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>27</td><td>Yes</td><td>0.533**</td><td>0.411 to 0.691</td><td>0.945</td><td>0.343 to 2.601</td><td>0.436*</td><td>0.202 to 0.941</td></tr><tr><td colspan="9">Place where PrEP was first prescribed</td></tr><tr><td>31</td><td>General practitioner</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>32</td><td>Sexual health structure</td><td>0.611**</td><td>0.443 to 0.843</td><td>1.894</td><td>0.524 to 6.846</td><td>0.930</td><td>0.352 to 2.454</td></tr><tr><td>33</td><td>Hospital before April 2021 <i>b</i></td><td>0.548**</td><td>0.381 to 0.788</td><td>2.499</td><td>0.604 to 10.341</td><td>0.608</td><td>0.195 to 1.898</td></tr><tr><td>34</td><td>Hospital after April 2021 <i>b</i></td><td>0.813</td><td>0.477 to 1.386</td><td>1.005</td><td>0.131 to 7.689</td><td>4.322*</td><td>1.209 to 15.446</td></tr><tr><td colspan="9">Mpox vaccination</td></tr><tr><td>41</td><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>42</td><td>Yes</td><td>0.175**</td><td>0.131 to 0.233</td><td>0.051**</td><td>0.019 to 0.135</td><td>0.362**</td><td>0.179 to 0.732</td></tr><tr><td colspan="9">Condom use during most recent sexual encounter</td></tr><tr><td>46</td><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>47</td><td>Yes</td><td>0.871</td><td>0.633 to 1.199</td><td>/</td><td>/</td><td>5.221**</td><td>2.477 to 11.002</td></tr><tr><td colspan="9">Having sexual partners during previous six months (continuous)</td></tr><tr><td>51</td><td></td><td>0.874**</td><td>0.854 to 0.894</td><td>0.995</td><td>0.981 to 1.010</td><td>0.975*</td><td>0.955 to 0.996</td></tr><tr><td>52</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>53</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>54</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>57</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>58</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>59</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>60</td><td></td><td>Coeff</td><td>95% CI</td><td></td><td></td><td></td><td></td></tr><tr><td>61</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>62</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>63</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>64</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>65</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<table><caption>Appendix 2: Weibull regression of main factors predicting PrEP duration : reasons for PrEP discontinuation effects</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">Sexual behavior</th><th colspan="2">Willingness to discontinue PrEP</th><th colspan="2">Clinical reasons</th></tr><tr><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th></tr></thead><tbody><tr><td>Weibull parameter : duration dependence</td><td>0.497**</td><td>0.473 to 0.523</td><td>0.643**</td><td>0.598 to 0.691</td><td>0.630**</td><td>0.590 to 0.672</td></tr></tbody></table>

* Significant at 5%

** Significant at 1%

a Together with «Age» the variable «Age²» reflects the changes of the effect of age (i.e., accounting for non-linear relationship with the probability of PrEP discontinuation).

b General practitioners have been able to prescribe PrEP in France since April 2021.

c Variable not included for this reason of PrEP discontinuation

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<figure><img src="image_5.png" /><figcaption>Figure 1 : Study Flowchart</figcaption></figure>
<figure><img src="image_6.png" /><figcaption>Figure 2: Kaplan-Meier estimation of PrEP duration, depending on the reasons for PrEP stop (N=870)</figcaption></figure>
<figure><img src="image_7.png" /><figcaption>Appendix 1: Kaplan-Meier estimation of PrEP duration, depending on the reasons for PrEP stop (N=870)</figcaption></figure>
<table><caption>Table 1: Descriptive analysis of PrEP discontinuation among MSM who self-defined as gay or bisexual with a lifetime history of PrEP use (N=4819)*</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">PrEP discontinuation</th><th rowspan="2">p-value</th></tr><tr><th>No N = 3,949<br>n<br>(%)</th><th>Yes N = 870<br>n<br>(%)</th><th>Overall, N = 4,819<br>n<br>(%)</th></tr></thead><tbody><tr><td>Age (years) (continuous)</td><td>39 [32 - 48]</td><td>34 [28 - 43]</td><td>38 [31 - 47]</td><td><strong>&lt;0.001</strong></td></tr><tr><td>Place of birth</td><td></td><td></td><td></td><td>0.300</td></tr><tr><td>Metropolitan France</td><td>3551 (89.9%)</td><td>769 (88.4%)</td><td>4320 (89.6%)</td><td></td></tr><tr><td>Overseas French region</td><td>85 (2.2%)</td><td>27 (3.1%)</td><td>112 (2.3%)</td><td></td></tr><tr><td>North America and Western Europe</td><td>137 (3.5%)</td><td>31 (3.6%)</td><td>168 (3.5%)</td><td></td></tr><tr><td>Other</td><td>176 (4.5%)</td><td>43 (4.9%)</td><td>219 (4.5%)</td><td></td></tr><tr><td>HIV incidence in French region of residence</td><td></td><td></td><td></td><td><strong>0.029</strong></td></tr><tr><td>&lt; 42 for 1 000 000 inhabitants</td><td>493 (12.5%)</td><td>113 (13%)</td><td>606 (12.6%)</td><td></td></tr><tr><td>&gt; 42 for 1 000 000 inhabitants</td><td>545 (13.8%)</td><td>129 (14.8%)</td><td>674 (14%)</td><td></td></tr><tr><td>≥ 50 for 1 000 000 inhabitants</td><td>1273 (32.2%)</td><td>314 (36.1%)</td><td>1587 (32.9%)</td><td></td></tr><tr><td>Ile-de-France (Greater Paris) region and all French overseas regions combined</td><td>1638 (41.5%)</td><td>314 (36.1%)</td><td>1952 (40.5%)</td><td></td></tr><tr><td>Size of municipality of residence</td><td></td><td></td><td></td><td><strong>0.110</strong></td></tr><tr><td>Fewer than 20 000 inhabitants</td><td>1009 (25.6%)</td><td>245 (28.2%)</td><td>1254 (26%)</td><td></td></tr><tr><td>More than 20 000 inhabitants</td><td>2940 (74.4%)</td><td>625 (71.8%)</td><td>3565 (74%)</td><td></td></tr></tbody></table>
<table><caption>Table 1: Descriptive analysis of PrEP discontinuation among MSM who self-defined as gay or bisexual with a lifetime history of PrEP use (N=4819)*</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">PrEP discontinuation</th><th rowspan="2">p-value</th></tr><tr><th>No N = 3,949<br>n<br>(%)</th><th>Yes N = 870<br>n<br>(%)</th><th>Overall, N = 4,819<br>n<br>(%)</th></tr></thead><tbody><tr><td><strong>Professional situation</strong></td><td></td><td></td><td></td><td></td><td><strong>0.032</strong></td></tr><tr><td>Employed</td><td>3339 (71.3%)</td><td>710 (81.6%)</td><td>4049 (84%)</td><td></td><td></td></tr><tr><td>Unemployed</td><td>610 (10.7%)</td><td>160 (18.4%)</td><td>770 (16%)</td><td></td><td></td></tr><tr><td><strong>Perceived financial situation in two categories</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>Very comfortable/ Comfortable</td><td>2716 (68.8%)</td><td>540 (62.1%)</td><td>3256 (67.6%)</td><td></td><td></td></tr><tr><td>Just getting by/Difficult to make ends meet/Impossible to make ends meet without going into debt</td><td>1233 (31.2%)</td><td>330 (37.9%)</td><td>1563 (32.4%)</td><td></td><td></td></tr><tr><td><strong>Supplementary Health insurance in two categories</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No/I do not know</td><td>113 (2.9%)</td><td>46 (5.3%)</td><td>159 (3.3%)</td><td></td><td></td></tr><tr><td>Yes</td><td>3836 (97.1%)</td><td>824 (94.7%)</td><td>4660 (96.7%)</td><td></td><td></td></tr><tr><td><strong>Self-identified sexual orientation</strong></td><td></td><td></td><td></td><td></td><td><strong>0.092</strong></td></tr><tr><td>Bisexual</td><td>284 (7.2%)</td><td>77 (8.9%)</td><td>361 (7.5%)</td><td></td><td></td></tr><tr><td>Gay</td><td>3665 (92.8%)</td><td>793 (91.1%)</td><td>4458 (92.5%)</td><td></td><td></td></tr></tbody></table>
<table><caption>Table 1: Descriptive analysis of PrEP discontinuation among MSM who self-defined as gay or bisexual with a lifetime history of PrEP use (N=4819)*</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">PrEP discontinuation</th><th rowspan="2">p-value</th></tr><tr><th>No N = 3,949<br>n<br>(%)</th><th>Yes N = 870<br>n<br>(%)</th><th>Overall, N = 4,819<br>n<br>(%)</th></tr></thead><tbody><tr><td><strong>Frequented social gay venues (bars, saunas, backrooms)</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>592 (15%)</td><td>258 (29.7%)</td><td>850 (17.6%)</td><td></td><td></td></tr><tr><td>Yes</td><td>3357 (85%)</td><td>612 (70.3%)</td><td>3969 (82.4%)</td><td></td><td></td></tr><tr><td><strong>Experienced homophobic insults</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>3167 (80.2%)</td><td>626 (72%)</td><td>3793 (78.7%)</td><td></td><td></td></tr><tr><td>Yes</td><td>782 (19.8%)</td><td>244 (28.1%)</td><td>1026 (21.3%)</td><td></td><td></td></tr><tr><td><strong>Experienced homophobic attacks in the previous year</strong></td><td></td><td></td><td></td><td></td><td><strong>0.130</strong></td></tr><tr><td>No</td><td>3766 (95.4%)</td><td>819 (94.1%)</td><td>4585 (95.1%)</td><td></td><td></td></tr><tr><td>Yes</td><td>183 (4.6%)</td><td>51 (5.9%)</td><td>234 (4.9%)</td><td></td><td></td></tr><tr><td><strong>General anxiety disorder score GAD-7 &gt;= 10</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>3152 (79.8%)</td><td>625 (71.8%)</td><td>3777 (78.4%)</td><td></td><td></td></tr><tr><td>Yes</td><td>797 (20.2%)</td><td>245 (28.2%)</td><td>1042 (21.6%)</td><td></td><td></td></tr><tr><td><strong>Received lifetime care from a psychiatrist, psychoanalyst, psychotherapist, or psychologist</strong></td><td></td><td></td><td></td><td></td><td><strong>0.084</strong></td></tr></tbody></table>
<table><caption>Table 1: Descriptive analysis of PrEP discontinuation among MSM who self-defined as gay or bisexual with a lifetime history of PrEP use (N=4819)*</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">PrEP discontinuation</th><th rowspan="2">p-value</th></tr><tr><th>No N = 3,949<br>n<br>(%)</th><th>Yes N = 870<br>n<br>(%)</th><th>Overall, N = 4,819<br>n<br>(%)</th></tr></thead><tbody><tr><td>No</td><td>1888 (47.8%)</td><td>383 (44%)</td><td>2271 (47.1%)</td><td></td></tr><tr><td>Yes, but not in the previous 12 months</td><td>1024 (25.9%)</td><td>253 (29.1%)</td><td>1277 (26.5%)</td><td></td></tr><tr><td>Yes in the previous 12 months</td><td>1037 (26.3%)</td><td>234 (26.9%)</td><td>1271 (26.4%)</td><td></td></tr><tr><td><strong>Regularly monitored for general health by a doctor</strong></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>183 (4.6%)</td><td>132 (15.2%)</td><td>315 (6.5%)</td><td></td></tr><tr><td>Yes</td><td>3766 (95.4%)</td><td>738 (84.8%)</td><td>4504 (93.5%)</td><td></td></tr><tr><td><strong>Place where PrEP was first prescribed</strong></td><td></td><td></td><td></td><td><strong>0.043</strong></td></tr><tr><td>Sexual health structure</td><td>1989 (50.4%)</td><td>439 (50.5%)</td><td>2428 (50.4%)</td><td></td></tr><tr><td>General practitioner</td><td>759 (19.2%)</td><td>146 (16.8%)</td><td>905 (18.8%)</td><td></td></tr><tr><td>Hospital before April 2021*</td><td>848 (21.5%)</td><td>219 (25.2%)</td><td>1067 (22.1%)</td><td></td></tr><tr><td>Hospital after April 2021*</td><td>353 (8.9%)</td><td>66 (7.6%)</td><td>419 (8.7%)</td><td></td></tr><tr><td><strong>Mpox vaccination since 2022</strong></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>1012 (25.6%)</td><td>547 (62.9%)</td><td>1559 (32.3%)</td><td></td></tr><tr><td>Yes</td><td>2937 (74.4%)</td><td>323 (37.1%)</td><td>3260 (67.6%)</td><td></td></tr></tbody></table>
<table><caption>Table 1: Descriptive analysis of PrEP discontinuation among MSM who self-defined as gay or bisexual with a lifetime history of PrEP use (N=4819)*</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">PrEP discontinuation</th><th rowspan="2">p-value</th></tr><tr><th>No N = 3,949<br>n<br>(%)</th><th>Yes N = 870<br>n<br>(%)</th><th>Overall, N = 4,819<br>n<br>(%)</th></tr></thead><tbody><tr><td><strong>Sexually Transmitted Infections in the previous 12 months</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>None</td><td>2956 (74.9%)</td><td>752 (86.4%)</td><td>3708 (76.9%)</td><td></td><td></td></tr><tr><td>1</td><td>725 (18.4%)</td><td>93 (10.7%)</td><td>818 (17%)</td><td></td><td></td></tr><tr><td>2 or more</td><td>268 (6.8%)</td><td>25 (2.9%)</td><td>293 (6.1%)</td><td></td><td></td></tr><tr><td><strong>Number of male sexual partners in the previous six months</strong></td><td>10 [5.0 - 25.0]</td><td>3.0 [1.0 - 8.0]</td><td>10 [4.0 - 20.0]</td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td><strong>Chemsex during the previous six months</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>2925 (74.1%)</td><td>711 (81.7%)</td><td>3636 (75.5%)</td><td></td><td></td></tr><tr><td>Yes</td><td>1024 (25.9%)</td><td>159 (18.3%)</td><td>1183 (24.5%)</td><td></td><td></td></tr><tr><td><strong>Used protection with casual male partners and during most recent sexual encounter</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>1185 (30%)</td><td>751 (86.3%)</td><td>1936 (40.2%)</td><td></td><td></td></tr><tr><td>Yes</td><td>2764 (70%)</td><td>119 (13.7%)</td><td>2883 (59.8%)</td><td></td><td></td></tr></tbody></table>
<table><caption>Table 1: Descriptive analysis of PrEP discontinuation among MSM who self-defined as gay or bisexual with a lifetime history of PrEP use (N=4819)*</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">PrEP discontinuation</th><th rowspan="2">p-value</th></tr><tr><th>No N = 3,949<br>n<br>(%)</th><th>Yes N = 870<br>n<br>(%)</th><th>Overall, N = 4,819<br>n<br>(%)</th></tr></thead><tbody><tr><td><strong>Used a condom during most recent sexual encounter</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>3285 (83.2%)</td><td>673 (77.4%)</td><td>3958 (82.1%)</td><td></td><td></td></tr><tr><td>Yes</td><td>664 (16.8%)</td><td>197 (22.6%)</td><td>861 (17.9%)</td><td></td><td></td></tr><tr><td><strong>Reasons for PrEP discontinuation</strong></td><td></td><td></td><td></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No discontinuation</td><td>3949 (100%)</td><td>/</td><td>3949 (82%)</td><td></td><td></td></tr><tr><td>Changes in sexual behaviors</td><td>/</td><td>474 (54.5%)</td><td>474 (9.8%)</td><td></td><td></td></tr><tr><td>Desire to discontinue PrEP</td><td>/</td><td>228 (26.2%)</td><td>228 (4.7%)</td><td></td><td></td></tr><tr><td>Clinical reasons</td><td>/</td><td>168 (19.3%)</td><td>168 (3.5%)</td><td></td><td></td></tr></tbody></table>

<footnote>* Statement on missing data: missing data were classified as “no” for yes vs. no questions. For the number of sexual partners and STIs, missing data were classified as zero. Missing data on reasons for stopping PrEP were excluded from the analysis as it was the main covariate. No other missing data were reported.</footnote>

<footnote>** General practitioners have been able to prescribe PrEP in France since April 2021.</footnote>
<table><caption>Table 2: Median survival time on PrEP among participants who stopped PrEP</caption><thead><tr><th>Variables</th><th>Mean survival time</th><th>p-value</th></tr></thead><tbody><tr><td><strong>Age *</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>&lt; 31 years</td><td>11.0 [4.0-24.0]</td><td></td></tr><tr><td>31-38 years</td><td>19.0 [8.0-41.0]</td><td></td></tr><tr><td>38-46 years</td><td>23.0 [9.0-46.0]</td><td></td></tr><tr><td>47+ years</td><td>27.0 [10.0-49.0]</td><td></td></tr><tr><td><strong>Place of birth</strong></td><td></td><td>0.400</td></tr><tr><td>France</td><td>19.0 [7.0-42.0]</td><td></td></tr><tr><td>French overseas departments and territories</td><td>19.5 [9.0-41.25]</td><td></td></tr><tr><td>North America and Western Europe</td><td>21.5 [6.75-45.0]</td><td></td></tr><tr><td>Others</td><td>17.0 [5.0-36.0]</td><td></td></tr><tr><td><strong>French region of residence regarding discovery of seropositivity</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>&lt; 42 1 000 000 inhabitants</td><td>15.5 [6.0-36.75]</td><td></td></tr><tr><td>&gt; 42 for 1 000 000 inhabitants</td><td>18.0 [7.0-36.0]</td><td></td></tr><tr><td>≥ 50 for 1 000 000 inhabitants</td><td>18.0 [6.0-40.0]</td><td></td></tr><tr><td>Ile-de-France and French overseas departments and territories</td><td>23.0 [9.0-45.0]</td><td></td></tr><tr><td><strong>Size of municipality of residence</strong></td><td></td><td><strong>0.004</strong></td></tr><tr><td>Less than 20 000 inhabitants</td><td>16.0 [6.0-36.0]</td><td></td></tr><tr><td>More than 20 000 inhabitants</td><td>20.0 [8.0-44.0]</td><td></td></tr><tr><td><strong>Professional situation</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>In employment</td><td>21.0 [8.0-44.0]</td><td></td></tr><tr><td>Unemployed</td><td>16.0 [6.0-38.0]</td><td></td></tr><tr><td><strong>Perceived financial situation in two categories</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>Comfortable/ Ok</td><td>21.0 [8.0-43.0]</td><td></td></tr></tbody></table>
<table><caption>Table 2: Median survival time on PrEP among participants who stopped PrEP</caption><thead><tr><th>Variables</th><th>Mean survival time</th><th>p-value</th></tr></thead><tbody><tr><td>Just/Difficult/Impossible without debt</td><td>16.0 [6.0-38.0]</td><td></td></tr><tr><td><strong>Supplementary Health insurance in two categories</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No/I do not know</td><td>20.0 [6.0-36.0]</td><td></td></tr><tr><td>Yes with the different insurances gathered</td><td>19.0 [7.0-42.0]</td><td></td></tr><tr><td><strong>Sexual orientation</strong></td><td></td><td><strong>0.002</strong></td></tr><tr><td>Bisexual</td><td>13.0 [4.0-29.0]</td><td></td></tr><tr><td>Gay</td><td>20.0 [7.0-43.0]</td><td></td></tr><tr><td><strong>Frequentation of social gay venues (bars saunas backrooms)</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>13.0 [4.0-31.0]</td><td></td></tr><tr><td>Yes</td><td>21.0 [8.0-44.0]</td><td></td></tr><tr><td><strong>Homophobic insults</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>20.0 [8.0-43.0]</td><td></td></tr><tr><td>Yes</td><td>16.0 [6.0-36.0]</td><td></td></tr><tr><td><strong>Homophobic attacks in the last year</strong></td><td></td><td>0.200</td></tr><tr><td>No</td><td>19.0 [7.0-42.0]</td><td></td></tr><tr><td>Yes</td><td>20.0 [6.0-45.75]</td><td></td></tr><tr><td><strong>General anxiety disorder score GAD-7 &gt;= 10</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>20.0 [7.0-42.0]</td><td></td></tr><tr><td>Yes</td><td>17.0 [6.0-39.75]</td><td></td></tr><tr><td><strong>Follow-up by a psychiatrist psychoanalyst psychotherapist or psychologist</strong></td><td></td><td>0.300</td></tr><tr><td>No</td><td>18.0 [7.0-40.0]</td><td></td></tr></tbody></table>
<table><caption>Table 2: Median survival time on PrEP among participants who stopped PrEP</caption><thead><tr><th>Variables</th><th>Mean survival time</th><th>p-value</th></tr></thead><tbody><tr><td>Yes but not in the last 12 months</td><td>20.0 [7.0-44.0]</td><td></td></tr><tr><td>Yes in the last 12 months</td><td>18.0 [7.0-40.0]</td><td></td></tr><tr><td><strong>Be regularly monitored by a doctor</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>13.0 [4.0-33.0]</td><td></td></tr><tr><td>Yes</td><td>20.0 [7.0-43.0]</td><td></td></tr><tr><td><strong>Sexually Transmitted Infection (STI) in the last 12 months</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>None</td><td>19.0 [6.0-42.0]</td><td></td></tr><tr><td>1</td><td>21.0 [8.0-43.0]</td><td></td></tr><tr><td>2 or more</td><td>23.0 [9.0-43.0]</td><td></td></tr><tr><td><strong>Place of the first PrEP prescription</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>Association</td><td>19.0 [7.0-41.0]</td><td></td></tr><tr><td>General practitioner</td><td>9.0 [4.0-17.0]</td><td></td></tr><tr><td>Hospital before April 2021</td><td>30.0 [44.0-59.0]</td><td></td></tr><tr><td>Hospital after April 2021</td><td>10.0 [4.0-16.0]</td><td></td></tr><tr><td><strong>Mpox vaccination since 2022</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>13.0 [4.0-32.0]</td><td></td></tr><tr><td>Yes</td><td>22.0 [9.0-45.0]</td><td></td></tr><tr><td><strong>Number of male sexual partners in the last 6 months *</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>&lt; 4 partners</td><td>14.0 [5.0-32.0]</td><td></td></tr><tr><td>4 to 9 partners</td><td>17.0 [6.0-36.0]</td><td></td></tr><tr><td>10 to 19 partners</td><td>18.0 [6.0-42.0]</td><td></td></tr><tr><td>20+ partners</td><td>27.0 [11.0-48.0]</td><td></td></tr></tbody></table>
<table><caption>Table 2: Median survival time on PrEP among participants who stopped PrEP</caption><thead><tr><th>Variables</th><th>Mean survival time</th><th>p-value</th></tr></thead><tbody><tr><td><strong>Chemsex during the last 6 months</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>17.0 [6.0-38.0]</td><td></td></tr><tr><td>Yes</td><td>26.0 [10.0-48.5]</td><td></td></tr><tr><td><strong>Protection with casual male partners and during the last sexual intercourse</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>13.0 [4.0-33.0]</td><td></td></tr><tr><td>Yes</td><td>23.0 [10.0-46.0]</td><td></td></tr><tr><td><strong>Condom during the last sexual intercourse</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No</td><td>21.0 [8.0-44.0]</td><td></td></tr><tr><td>Yes</td><td>14.0 [5.0-31.0]</td><td></td></tr><tr><td><strong>Reasons for PrEP stop</strong></td><td></td><td><strong>&lt;0.001</strong></td></tr><tr><td>No stop</td><td>/</td><td></td></tr><tr><td>Sexual behaviour</td><td>12.0 [4.0-24.0]</td><td></td></tr><tr><td>Willingness to stop PrEP</td><td>7.0 [2.0-17.0]</td><td></td></tr><tr><td>Clinical reasons</td><td>6.0 [1.0-15.0]</td><td></td></tr></tbody></table>
<table><caption>Table 3 : Weibull regression of main factors predicting PrEP duration : reasons for PrEP stop effects</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">Sexual behaviour</th><th colspan="2">Willingness to stop PrEP</th><th colspan="2">Clinical reasons</th></tr><tr><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th></tr></thead><tbody><tr><td>Age (continuous)</td><td>0.950**</td><td>0.937 to 0.964</td><td>0.780**</td><td>0.663 to 0.919</td><td>0.961*</td><td>0.932 to 0.991</td></tr><tr><td>Age<sup>2</sup> (continuous) <sup>a</sup></td><td>/</td><td>/</td><td>1.252*</td><td>1.028 to 1.525</td><td>/</td><td>/</td></tr><tr><td>Professional situation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>In employment</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Non employed</td><td>0.728</td><td>0.504 to 1.051</td><td>0.770</td><td>0.371 to 1.597</td><td>3.513**</td><td>1.615 to 7.645</td></tr><tr><td>French region of residence regarding discovery of seropositivity</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Île-de-France and french overseas departments and territories (≥190)</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Region ≥50</td><td>0.819</td><td>0.599 to 1.122</td><td>1.461</td><td>0.785 to 2.718</td><td>1.733</td><td>0.787 to 3.816</td></tr><tr><td>Region >42</td><td>0.865</td><td>0.574 to 1.303</td><td>1.746</td><td>0.816 to 3.738</td><td>0.695</td><td>0.231 to 2.092</td></tr><tr><td>Region <42</td><td>1.066</td><td>0.696 to 1.632</td><td>2.320*</td><td>1.054 to 5.107</td><td>0.472</td><td>0.137 to 1.625</td></tr><tr><td>Size of municipality of residence</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>More than 20000 inhabitants</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Less than 20000 inhabitants</td><td>0.887</td><td>0.652 to 1.205</td><td>0.858</td><td>0.479 to 1.537</td><td>2.312*</td><td>1.099 to 4.868</td></tr><tr><td>Sexual orientation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Gay</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Bisexuel</td><td>0.784</td><td>0.468 to 1.313</td><td>1.892</td><td>0.860 to 4.162</td><td>1.765</td><td>0.615 to 5.067</td></tr><tr><td>Frequentation of social gay venues (bars, saunas, backrooms)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Yes</td><td>0.531**</td><td>0.400 to 0.705</td><td>0.633</td><td>0.350 to 1.144</td><td>0.436*</td><td>0.202 to 0.941</td></tr><tr><td>Place of the first PrEP prescription</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>General practitioner</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Associations</td><td>0.604**</td><td>0.424 to 0.858</td><td>1.055</td><td>0.504 to 2.207</td><td>0.930</td><td>0.352 to 2.453</td></tr><tr><td>Hospital before 2021 <sup>b</sup></td><td>0.513**</td><td>0.345 to 0.762</td><td>1.189</td><td>0.521 to 2.717</td><td>0.608</td><td>0.195 to 1.899</td></tr><tr><td>Hospital after 2021 <sup>b</sup></td><td>0.762</td><td>0.421 to 1.380</td><td>1.039</td><td>0.326 to 3.313</td><td>4.322*</td><td>1.209 to 15.443</td></tr></tbody></table>
<table><caption>Table 3 : Weibull regression of main factors predicting PrEP duration : reasons for PrEP stop effects</caption><thead><tr><th rowspan="2">Variable</th><th rowspan="2"></th><th colspan="2">Sexual behaviour</th><th colspan="2">Willingness to stop PrEP</th><th colspan="2">Clinical reasons</th></tr><tr><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th></tr></thead><tbody><tr><td rowspan="2">Mpox vaccination</td><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Yes</td><td>0.159**</td><td>0.116 to 0.220</td><td>0.111**</td><td>0.062 to 0.200</td><td>0.362**</td><td>0.179 to 0.732</td></tr><tr><td rowspan="2">Condom use during the last sexual intercourse</td><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Yes</td><td>0.427**</td><td>0.279 to 0.654</td><td>/</td><td>/</td><td>5.223**</td><td>2.478 to 11.005</td></tr><tr><td>Sexual partners during the last 6 months (continuous)</td><td></td><td>0.857**</td><td>0.833 to 0.881</td><td>0.978**</td><td>0.963 to 0.993</td><td>0.975*</td><td>0.955 to 0.996</td></tr><tr><td colspan="2"></td><td>Coeff</td><td>95% CI</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="2">Weibull parameter : duration dependence</td><td>0.495**</td><td>0.469 to 0.524</td><td>0.590**</td><td>0.554 to 0.628</td><td>0.630**</td><td>0.590 to 0.672</td></tr></tbody></table>

<footnote>* Significant at 5%</footnote>

<footnote>** Significant at 1%</footnote>

<footnote>a Together with «Age» the variable «Age²» reflects the changes of the effect of age (i.e., accounting for non-linear relationship with the probability of PrEP discontinuation).</footnote>

<footnote>b General practitioners have been able to prescribe PrEP in France since April 2021.</footnote>

<footnote>/ variable not included for this reason of PrEP stop</footnote>
<table><caption>Appendix 2: Weibull regression of main factors predicting PrEP duration : reasons for PrEP discontinuation effects</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">Sexual behavior</th><th colspan="2">Willingness to discontinue PrEP</th><th colspan="2">Clinical reasons</th></tr><tr><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th></tr></thead><tbody><tr><td>Age (years) (continuous)</td><td>0.949**</td><td>0.936 to 0.961</td><td>0.712**</td><td>0.554 to 0.915</td><td>0.961*</td><td>0.932 to 0.991</td></tr><tr><td>Age<sup>2</sup> (years)(continuous) a</td><td>/</td><td>/</td><td>1.402*</td><td>1.039 to 1.892</td><td>/</td><td>/</td></tr><tr><td>Professional situation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Employed</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Unemployed</td><td>0.747</td><td>0.536 to 1.042</td><td>0.866</td><td>0.276 to 2.717</td><td>3.512**</td><td>1.614 to 7.641</td></tr><tr><td>HIV incidence in French region of residence</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Île-de-France (Greater Paris) region and all French overseas regions combined (≥190)</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Region ≥50</td><td>0.825</td><td>0.619 to 1.099</td><td>2.838*</td><td>1.015 to 7.939</td><td>1.733</td><td>0.787 to 3.816</td></tr><tr><td>Region >42</td><td>0.896</td><td>0.619 to 1.295</td><td>2.796</td><td>0.787 to 9.930</td><td>0.696</td><td>0.231 to 2.094</td></tr><tr><td>Region <42</td><td>1.022</td><td>0.693 to 1.507</td><td>2.320**</td><td>1.649 to 20.784</td><td>0.472</td><td>0.137 to 1.627</td></tr><tr><td>Size of municipality of residence</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>More than 20000 inhabitants</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Fewer than 20000 inhabitants</td><td>0.927</td><td>0.702 to 1.225</td><td>0.642</td><td>0.250 to 1.650</td><td>2.314*</td><td>1.099 to 4.872</td></tr><tr><td>Sexual orientation</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Gay</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Bisexual</td><td>0.879</td><td>0.561 to 1.377</td><td>2.179</td><td>0.628 to 7.554</td><td>1.767</td><td>0.616 to 5.072</td></tr><tr><td>Frequenting social gay venues (bars, saunas, backrooms)</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr></tbody></table>
<table><caption>Appendix 2: Weibull regression of main factors predicting PrEP duration : reasons for PrEP discontinuation effects</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">Sexual behavior</th><th colspan="2">Willingness to discontinue PrEP</th><th colspan="2">Clinical reasons</th></tr><tr><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th></tr></thead><tbody><tr><td>Yes</td><td>0.533**</td><td>0.411 to 0.691</td><td>0.945</td><td>0.343 to 2.601</td><td>0.436*</td><td>0.202 to 0.941</td></tr><tr><td>Place where PrEP was first prescribed</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>General practitioner</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Sexual health structure</td><td>0.611**</td><td>0.443 to 0.843</td><td>1.894</td><td>0.524 to 6.846</td><td>0.930</td><td>0.352 to 2.454</td></tr><tr><td>Hospital before April 2021 <i>b</i></td><td>0.548**</td><td>0.381 to 0.788</td><td>2.499</td><td>0.604 to 10.341</td><td>0.608</td><td>0.195 to 1.898</td></tr><tr><td>Hospital after April 2021 <i>b</i></td><td>0.813</td><td>0.477 to 1.386</td><td>1.005</td><td>0.131 to 7.689</td><td>4.322*</td><td>1.209 to 15.446</td></tr><tr><td>Mpox vaccination</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Yes</td><td>0.175**</td><td>0.131 to 0.233</td><td>0.051**</td><td>0.019 to 0.135</td><td>0.362**</td><td>0.179 to 0.732</td></tr><tr><td>Condom use during most recent sexual encounter</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1</td><td></td><td>1</td><td></td><td>1</td><td></td></tr><tr><td>Yes</td><td>0.871</td><td>0.633 to 1.199</td><td>/</td><td>/</td><td>5.221**</td><td>2.477 to 11.002</td></tr><tr><td>Having sexual partners during previous six months (continuous)</td><td>0.874**</td><td>0.854 to 0.894</td><td>0.995</td><td>0.981 to 1.010</td><td>0.975*</td><td>0.955 to 0.996</td></tr><tr><td></td><td>Coeff</td><td>95% CI</td><td></td><td></td><td></td><td></td></tr><tr><td>Weibull parameter : duration dependence</td><td>0.497**</td><td>0.473 to 0.523</td><td>0.643**</td><td>0.598 to 0.691</td><td>0.630**</td><td>0.590 to 0.672</td></tr></tbody></table>
<table><caption>Appendix 2: Weibull regression of main factors predicting PrEP duration : reasons for PrEP discontinuation effects</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">Sexual behavior</th><th colspan="2">Willingness to discontinue PrEP</th><th colspan="2">Clinical reasons</th></tr><tr><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th><th>AF</th><th>95% CI</th></tr></thead></table>

* Significant at 5%

** Significant at 1%

a Together with «Age» the variable «Age²» reflects the changes of the effect of age (i.e., accounting for non-linear relationship with the probability of PrEP discontinuation).

b General practitioners have been able to prescribe PrEP in France since April 2021.

/ variable not included for this reason of PrEP discontinuation.