Effectiveness of community-based PrEP delivery for men who have sex with men: a global systematic review and meta-analysis.

UNLABELLED: Pre-exposure prophylaxis (PrEP) is a critical HIV prevention tool for men who have sex with men (MSM), used throughout as an inclusive umbrella term encompassing gay, bisexual, and other men who have sex with men (GBMSM). Yet, the global effectiveness of community-based delivery models across the prevention cascade remains unclear. This systematic review and meta-analysis (Prospero registered: CRD420261382434) provides a comprehensive global synthesis of community-based PrEP delivery for MSM. Following PRISMA guidelines, six databases were searched (2015-2023), and random-effects models were used to pool Odds Ratios from 21 studies. Community-based models significantly increased PrEP willingness (OR = 5.12, 95% CI: 4.30-6.10) and positive risk behavior changes (OR = 1.61, 95% CI: 1.33-1.96); however, pooled effects for uptake and adherence were non-significant with extreme heterogeneity (i 2 > 88%). Critically, subgroup analyses revealed that effectiveness is not monolithic but context-dependent: telehealth models were exceptionally effective for uptake (OR = 25.20), and outcomes varied significantly by region and study design. Policy should support differentiated, hybrid models that combine community-based engagement with streamlined telehealth or pharmacy-led pathways, tailored to the local context. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261382434, Identifier CRD420261382434.