Bridging Gaps in HIV Prevention: A Machine Learning-Enhanced Mixed-Methods Study on PrEP Awareness and Willingness Among Refugee Male Sex Workers from Sub-Saharan Africa in Italy

Background: Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy that significantly reduces transmission risks among at-risk populations. However, PrEP awareness and uptake remain low among marginalized groups, including African refugee male sex workers (MSWs), who face intersecting vulnerabilities that heighten their risk of HIV infection in Europe. This study investigates PrEP awareness, usage patterns, and factors influencing PrEP adoption among African refugee MSWs in Italy. Methods: Employing a mixed-methods approach, this study combined quantitative surveys with qualitative interviews and focus group discussions (FGDs) to explore PrEP knowledge, willingness, and barriers to adoption. Logistic regression models and random forest analysis were used to identify significant predictors of PrEP awareness and willingness to adopt PrEP. Results: PrEP awareness was reported by only 36% of participants, and among them, only 28% had used it. Barriers to adoption included limited knowledge, stigma, and cost. Notably, individuals without children and those engaging in consistent condom use and other health behaviors were more likely to be aware of PrEP. Willingness to use PrEP was significantly associated with awareness of HIV self-testing. In predictive modeling, K-fold cross-validation using logistic regression demonstrated that variables selected through Random Forest feature selection achieved higher predictive accuracy (77%) than those chosen using the chi-square test. Conclusion: These findings highlight significant gaps in PrEP awareness and uptake among African refugee MSWs in Italy. Culturally tailored educational campaigns, stigma reduction strategies, and expanded access to affordable PrEP services are essential to increasing uptake. Future interventions should focus on integrating PrEP into broader sexual health programs to improve engagement and reduce HIV transmission within this vulnerable population.