| Sumario: | Background: The Western region of the US has received comparatively less attention in HIV research despite housing several Ending the HIV Epidemic priority areas. Understanding HIV risk and prevention behaviors among men who have sex with men (MSM) in this region is critical. This study examines differences in HIV risk and prevention behaviors among MSM in the Pacific (CA, WA) and Mountain (AZ, NV) sub-regions. Methods: We conducted a serial cross-sectional analysis using 2017–2021 data from the American Men's Internet Survey. The sample included MSM with HIV-negative or unknown status. Key outcomes included condomless anal intercourse, substance use, STI diagnoses, HIV/STI testing, and PrEP awareness, willingness and use. Poisson regression models with robust standard errors estimated prevalence ratios and 95% confidence intervals, adjusting for sociodemographics. Results: Among 7423 MSM, 81.3% resided in the Pacific sub-region, 53.0% were aged <30 years and 50.8% were white. Condomless anal intercourse rates were similar across sub-regions, but STI diagnoses (13.0% vs 10.1%, P < 0.05) and substance use were higher in the Pacific compared with the Mountain sub-region. HIV testing (55.5% vs 59.8%, P < 0.05) and STI testing (39.2% vs 45.7%, P < 0.001) were lower in the Mountain sub-region compared with the Pacific sub-region. PrEP awareness was similar, but usage was lower (17.2% vs 23.1%, P < 0.001) despite higher willingness (51.8% vs 44.5%, P < 0.001) in the Mountain compared with the Pacific sub-region. Conclusions: HIV risk was similar across sub-regions, but disparities in prevention engagement highlight regional barriers. Expanding PrEP access and HIV/STI testing in the Mountain sub-region is critical to achieving Ending the HIV Epidemic goals. HIV infections in the United States have declined overall, but important regional differences remain, especially in the West, which has received far less attention than the South. Analyzing survey data from more than 7400 men who have sex with men in four Western states, we found that sexual risk behaviors were similar across regions, yet men in Arizona and Nevada were less likely to be tested for sexually transmitted infections and less likely to use preventive medication, despite being more willing to try it. These findings suggest that gaps in healthcare access, rather than differences in behavior, are driving prevention shortfalls and point to where targeted investments could help end the HIV epidemic in the West.
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