Background: Pre-exposure Prophylaxis (PrEP) is an effective HIV prevention method recommended by WHO since 2011 for key populations at high risk, such as men who have sex with men (MSM), people who inject drugs, and sex workers. In Guinea, national 2023-2027 AIDS strategies aim to reduce incidence within this group. However, data on PrEP access and willingness to use it remain scarce. This study assessed PrEP access and factors influencing its uptake among MSM to address this critical gap in Conakry city. Methods: This cross-sectional analytical study was conducted from April 15 to June 15, 2024, among MSM in Conakry, Guinea. Eligible participants self-identified as MSM, reported being HIV-negative, and consented to participate. Data were collected via structured questionnaires on Kobocollect by trained interviewers. Recruitment occurred at two MSM care centers and through network referrals, with interviews conducted in confidential locations. Descriptive analysis summarized numeric and categorical variables. Multivariate logistic regression identified factors associated with unwillingness to use PrEP, coding willingness as “1” and unwillingness as “0”. Adjusted odds ratios (AOR) with p-values ≤ 0.05 indicated statistically significant associations. Results: This study surveyed 460 MSM in Conakry, with a mean age of 27 ± 7 years. While 76.85% had heard of PrEP. After detailed explanations, 78.64% expressed willingness to adopt PrEP, but only 8.21% had used it at moment of data collection. The barriers of unwillingness to adopt PrEP included low perceived HIV risk (33.13%), stigma (18.16%), medication adherence challenges (10.12%), and overconfidence in protective practices (7.22%). Multivariate analysis revealed that being single (adjusted OR: 1.45), lower education levels (no formal: 1.68; primary: 1.54), regular sexual partners (1.68), and specific sexual practices (penetrative: 1.66; oral: 1.54) significantly reduced PrEP acceptance. Findings highlight the need for targeted interventions. Conclusion: This study reveals that, although most men who have sex with men (MSM) are willing to use PrEP as a means of reducing the risk of HIV transmission, their access to this treatment remains limited. This highlights the need to strengthen the integration of PrEP services into key population care centers while supporting community initiatives from MSM associations. To better understand the variability in willingness to use PrEP and to assess access among MSM, we recommend conducting a nationwide
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