Understanding PrEP Acceptability Among Priority Populations: Results from a Qualitative Study of Potential Users in Central Uganda

Willingness to Use Long-Acting Injectable Pre-Exposure Prophylaxis among Adolescent Girls and Young Women in Kampala, Uganda

Pre-exposure prophylaxis (PrEP) has proven to be a powerful tool in preventing HIV infection. There is limited information about the factors associated with willingness to use different PrEP modalities among adolescent girls and young women (AGYW) in Africa. We assessed willingness to use long-acting injectable PrEP (LAI-PrEP) among 14-24-year-old AGYW at high risk of HIV in Uganda, and associated factors determined using multivariable complementary log-log regression. Of the 285 participants, 69.8% of participants showed willingness to use LAI-PrEP despite only 3.9% having knowledge about it before enrolment. Report of recent transactional sex was high (92.6%). Participants that were divorced/separated (aOR = 1.74, 95% CI 1.03-2.92) and those with multiple sexual partners (aOR = 2.11, 95% CI 1.46-3.06) compared to those with one partner were more likely to be willing to use LAI-PrEP while those that were screened as heavy episodic drinkers (consuming 6 or more drinks on an occasion as per the AUDIT tool) were less likely to be willing to use LAI-PrEP (aOR = 0.61, 95% CI 0.42-0.87). LAI PrEP has shown efficacy in clinical trials; the product is approved for use by the Government of Uganda (MoH) and should be expedited for use by AGYW engaged in paid sex and those with multiple sexual partnerships. As it becomes available, we recommend PrEP education and counseling to increase awareness of LAI PrEP as an alternative HIV prevention method.

PrEP in the key population community: A qualitative study of perspectives on pre-exposure prophylaxis by gay, bisexual and other men who have sex with men and female sex workers in Kigali, Rwanda

Gay, bisexual and other men who have sex with men (GBMSM) and cisgender female sex workers (FSW) are increasingly and disproportionately impacted by HIV in sub-Saharan Africa, yet current PrEP care models in this region are not optimized for these communities. Limited data exist describing experiences and preferences of GBMSM and FSW with respect to accessing and using PrEP. We conducted qualitative, semi-structured interviews with GBMSM and FSW recruited from three health centers and seven community organizations in Kigali, Rwanda. Data were analyzed using a mixed deductive and inductive approach to describe key themes related to initiating and adhering to PrEP. Participants included 18 GBMSM and 14 FSW; 12 were using PrEP at the time of interview, 9 had previously used PrEP, and 11 had never used it. Participants highlighted the central role of their social networks as key sources of information about and support for PrEP use, and described a strong motivation to use PrEP as a way to protect both themselves and their communities from HIV. While stigma and discrimination were pervasive, these were experienced differently by GBMSM and FSW. Participants suggested community access points that allowed more discreet and less frequent contact with health care workers as important and desired strategies to improve engagement. These findings suggest that leveraging community resources for disseminating information about HIV prevention and delivering PrEP could contribute to successful implementation of PrEP for GBMSM and FSW in Rwanda and other settings in SSA.

Qualitative study exploring reintegration of clinical trial participants with HIV to public health services in Johannesburg, South Africa

OBJECTIVE

People living with HIV (PLHIV) are often recruited from primary healthcare clinics (PHC) into clinical trials. On trial completion, they are transferred back to the facility for continued care and support in managing their condition, potentially leading to better health outcomes. Because transferring PLHIV back to PHCs post-clinical trials may result in decreased access to specialised care or resources that were available during the trial, this study explored insights into challenges faced during reintegration from clinical trial settings into PHCs and antiretroviral therapy (ART) adherence post-clinical trials.

DESIGN

This cross-sectional study was conducted using a qualitative research approach. Participants were recruited using purposive sampling.

SETTING

The study was conducted at the Ezintsha Research Centre in Johannesburg, South Africa, between November 2022 and February 2023.

PARTICIPANTS

The study population consisted of PLHIV who had participated in two clinical trials (DORA and ADVANCE) at the Ezintsha Research Centre in Johannesburg, South Africa.

METHODS

Using a semistructured guide, 12 in-depth interviews were conducted with PLHIV until data saturation was reached. Data were then transcribed verbatim and analysed thematically with MAXQDA software.

RESULTS

The majority (n=8, 67%) of participants were female, and the average age of all participants was 40 (SD 7.2) years. Two main themes emerged: reintegration from clinical trials to public healthcare and barriers to ART adherence. These themes were further separated into seven subthemes, namely, negative attitude of healthcare workers, poor healthcare service delivery, poor communication to patients, waiting time at healthcare facilities, lack of privacy and confidentiality, mistakes in ART dispensing and bad reception at facilities post-clinical trials.

CONCLUSION

Clinical trial sites should cultivate better stakeholder engagement with PHCs to facilitate a smoother transition of research participants, especially PLHIV, back into public healthcare for continued care.

PrEP in the key population community: a qualitative study of perspectives on pre-exposure prophylaxis by men who have sex with men and female sex workers in Kigali, Rwanda

Background

Men who have sex with men (MSM) and female sex workers (FSW) are increasingly and disproportionately impacted by HIV in sub-Saharan Africa, yet current PrEP care models in this region are not optimized for these communities. Limited data exist describing experiences and preferences of MSM and FSW with respect to accessing and using PrEP.

Methods

We conducted qualitative, semi-structured interviews with MSM and FSW recruited from three health centers and seven community organizations in Kigali, Rwanda. Data were analyzed using a mixed deductive and inductive approach to describe key themes related to initiating and adhering to PrEP.

Results

Participants included 18 MSM and 14 FSW; 12 were using PrEP at the time of interview, 9 had previously used PrEP, and 11 had never used it. Participants highlighted the central role of their social networks as key sources of information about and support for PrEP use, and described a strong motivation to use PrEP as a way to protect both themselves and their communities from HIV. While stigma and discrimination were pervasive, these were experienced differently by MSM and FSW. Participants suggested community access points that allowed more discreet and less frequent contact with health care workers as important and desired strategies to improve engagement.

Conclusions

These findings suggest that leveraging community resources for disseminating information about HIV prevention and delivering PrEP could contribute to successful implementation of PrEP for MSM and FSW in Rwanda and other settings in SSA.

HIV Pre-Exposure Prophylaxis Uptake Among High-Risk Population in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Globally, 38.4 million people are affected by the human immunodeficiency virus (HIV) pandemic, and more than 2.5 million new HIV infections occur yearly. HIV pre-exposure prophylaxis (PrEP) has been widely recognized as a potential way to prevent new infections among risk population. There is a paucity of abridged evidence on the level and barriers to PrEP service uptake in sub-Saharan Africa (SSA). Therefore, we conducted a systematic review to synthesize existing evidence on PrEP uptake in SSA. Relevant studies were searched from major databases (PubMed and PsychInfo) and direct Google Scholar. Data were extracted and recorded using a pilot-tested template. Methodological rigor, heterogeneity and publication bias of studies were assessed to minimize the inclusion of erroneous findings. A random effect model was used for the meta-analysis followed by narrative metasynthesis. The protocol of this systematic review has been by registered PROSPERO (ID: CRD42022308855). A total of 1830 studies were retrieved, and 30 studies met inclusion criteria of the systematic review. People who heard about PrEP ranged from 23% to 98%. The pooled prevalence of willingness to use PrEP was 64.2% (95% confidence interval: 55.5-72.0). Fear of side effect, stigma, nonreceptive attitude, cost of pills, low awareness about PrEP, perceived reason about the effectiveness of PrEP, and lack of friendly services were the common barriers to PrEP uptake in Africa. In conclusion, comprehensive knowledge and willingness to use PrEP were low in SSA. The barriers to low PrEP service uptake are avoidable through comprehensive awareness creation and availing essential services to key population in Africa. Expanding educational messages to key population using friendly approaches and more accessible platforms, engaging stakeholders, and integrating PrEP service with routine health care are important to foster HIV prevention and control in the future.

Barriers to Oral PrEP: A Qualitative Study of Female Sex Workers, PrEP Prescribers, Policymakers, and Community Advocates in Morocco

In 2017, Morocco became the first Arab country to incorporate pre-exposure prophylaxis (PrEP) in its HIV-prevention program. Yet no research has been published on PrEP from Morocco. Although female sex workers are one of the target populations of PrEP in Morocco, their enrollment in PrEP is lower than men who have sex with men. In this study, we conducted 38 semi-structured interviews with female sex workers, physicians who prescribe PrEP, policymakers, and community advocates to identify problems associated with access to and use of PrEP. We also investigated preferences for daily oral, vaginal ring, and long-acting injectable PrEP. A reflexive thematic analysis revealed seven themes: PrEP stigma; stigmatization and criminalization of sex work; one size doesn't fit all; knowledge and misconceptions about PrEP; economic burden; inconvenience of PrEP pills; and preferred PrEP modalities. This paper discusses the implications of the findings for increasing access and use of PrEP in Morocco.

Recommendations for Improving Oral Pre-exposure Prophylaxis Implementation and Social Marketing in Ugandan Fisherfolk Communities: A Qualitative Exploration

Background: HIV is hyperendemic among fisherfolk in Sub-Saharan Africa, especially around Lake Victoria, Uganda. Purpose/Research Design: We conducted cross-sectional semi-structured interviews about oral pre-exposure prophylaxis (PrEP) implementation with 35 Ugandan fisherfolk (15 women, 20 men) and 10 key stakeholders (healthcare providers, policymakers, community leaders). We used a directed content analysis approach based on implementation science and social marketing frameworks. Results: Participants showed high acceptability for PrEP. Anticipated barriers among fisherfolk included stigma (due to similar medications/packaging as HIV treatment); misconceptions; mobility, competing needs, poverty, and partner conflict. Anticipated provider barriers included insufficient staffing and travel support. Recommendations included: change PrEP packaging; integrate PrEP with other services; decrease PrEP refill frequency; give transportation resources to providers; train more healthcare workers to provide PrEP to fisherfolk; and use positively framed messages to promote PrEP. Conclusions: Results can inform policymakers and healthcare organizations on how to overcome barriers to PrEP scale-up in most at-risk populations with poor healthcare access.

Sexual pleasure and HIV-related worry in female sex workers on oral pre-exposure prophylaxis in south-western Uganda

BACKGROUND

Female sex workers (FSWs) contribute disproportionately to HIV transmission in Uganda, and pre-exposure prophylaxis (PrEP) is effective in preventing HIV among cisgender women. Psychological factors are important for PrEP uptake, but few studies have examined psychosocial changes due to PrEP use in Uganda.

METHODS

In 2021, we recruited 524 FSWs in three Trans-African Highway towns and four fishing communities in south-western Uganda. We conducted structured interviews among women who were attending routine PrEP follow-up visits in six health units. Bivariable and multivariable modified regression using a robust covariance matrix estimator were used to identify factors associated with experiencing increased sexual pleasure and less worry about HIV because of PrEP.

RESULTS

Overall, 80.9% participants reported that sex was more pleasurable because of taking PrEP. There were statistical trends for sex being more pleasurable when taking PrEP or when having condomless sex with casual paying partners (aPR=1.19, 95% CI=1.07-1.32, P =0.001). Almost three-quarters of the participants (76.3%) were less worried about getting HIV because of PrEP. Condomless sex with casual paying partners (aPR=1.17, 95% CI=1.05-1.31, P =0.032, P =0.003) and being On PrEP for the past 1-2years (aPR=1.18, 95% CI=1.00-1.38, P =0.032) was significantly associated with HIV-related worry (aPR=1.17, 95% CI=1.05-1.31, P =0.032, P =0.003) Conclusions : We found a positive impact of PrEP in Ugandan FSWs on two key psychosocial dimensions: (1) more pleasurable sex; and (2) less worry about acquiring HIV. Interventions aiming to increase PrEP uptake may find it useful to focus on psychosocial dimensions.

Exploring Barriers and Facilitators That Influence Uptake of Oral Pre-Exposure Prophylaxis Among Men Who Have Sex With Men in Bulawayo, Zimbabwe: Key Stakeholder's Perspectives

The world has been on the path to ending HIV and AIDS as a global threat by 2030; despite these efforts, the rate of new HIV infections among men who have sex with men remains very high. This study sought to explore the perceptions of key stakeholders on the potential barriers and facilitators of pre-exposure prophylaxis use among this key population. An exploratory, descriptive (through interviews) qualitative study was conducted on 10 key informants who were purposively selected and snowballed based on their knowledge and experience toward pre-exposure prophylaxis programming among men who have sex with men. The interviews were recorded, transcribed verbatim, coded, and thematically analyzed on MAXQDA. Stated barriers were stigma, lack of information, wrong messaging around pre-exposure prophylaxis, hearing negative things about the pills, the burden of taking pills daily, negative attitudes from health care providers, non-friendly health care facilities, pre-exposure prophylaxis not being affordable, and lack of flexibility and privacy from public hospitals. Identified facilitators were correct messaging on pre-exposure prophylaxis, long-lasting injectable pre-exposure prophylaxis, improved packaging, de-stigmatization, more friendly facilities, differentiated service approach, community groups, engagement, and partnership. To address these barriers and leverage the facilitators, it is imperative to have accessible, affordable services, non-judgmental health care providers, and peer support networks to empower men who have sex with men to make informed decisions regarding their sexual and reproductive health. Continued efforts to remove barriers and promote facilitators are crucial for maximizing the potential of pre-exposure prophylaxis as an effective HIV prevention tool among this population.

An implementation strategy package (video education, HIV self-testing, and co-location) improves PrEP implementation for pregnant women in antenatal care clinics in western Kenya

Background

Pre-exposure prophylaxis (PrEP) is recommended by the World Health Organization and the Kenyan Ministry of Health for HIV prevention in pregnancy and postpartum for women at risk for HIV. Integration of PrEP into antenatal care is promising, but delivery gaps exist in the face of healthcare provider shortages in resource-limited settings.

Methods

Between May and November 2021, we conducted a difference-in-differences study (3 months pre-intervention data collection and 3 months post-intervention data collection) analyzing four intervention facilities, where the strategies were implemented, and four comparison facilities, where no strategies were implemented. We tested a combination of three implementation strategies-video-based PrEP information in the waiting bay, HIV self-testing, and dispensing of PrEP in the antenatal care rooms-to improve PrEP delivery. We compared absolute changes in the proportion of antenatal attendees screened for PrEP (PrEP penetration), the proportion receiving all PrEP-specific steps in a visit (HIV testing, risk screening, and PrEP counseling) (PrEP fidelity), and client PrEP knowledge, client satisfaction, and waiting time and service time (a priori outcomes); post hoc, we compared the proportion offered PrEP (PrEP offer) and completing HIV testing. We measured provider perceptions of the acceptability and appropriateness of the implementation strategies.

Results

We observed significant improvements in PrEP penetration, PrEP offer, satisfaction, and knowledge (p < 0.05) and improvements in fidelity that trended towards significance (p = 0.057). PrEP penetration increased 5 percentage points (p = 0.008), PrEP fidelity increased 8 percentage points (p = 0.057), and PrEP offer increased 4 percentage points (p = 0.003) in intervention vs. comparison facilities. Client PrEP knowledge increased by 1.7 out of 6 total points (p < 0.001) and client satisfaction increased by 0.7 out of 24 total points (p = 0.003) in intervention vs. comparison facilities. We observed no changes in service time (0.09-min decrease; p = 0.435) and a small increase in waiting time (0.33-min increase; p = 0.005). HIV testing among those eligible did not change (1.5 percentage point decrease, p = 0.800). Providers felt the implementation strategies were acceptable and appropriate (median acceptability: 20/20; median appropriateness: 19.5/20). However, absolute levels of each step of the PrEP cascade remained suboptimal.

Conclusions

An implementation strategy package with video information, HIV self-testing, and co-location of medication dispensing enhanced PrEP delivery across several implementation outcomes and client satisfaction, while not substantially increasing wait time or decreasing provider-client contact time.

Clinical trial registration

ClinicalTrials.gov , identifier, NCT04712994.

"Protected Means Armed": Perspectives on Pre-Exposure Prophylaxis (PrEP) Among Women Who Engage in Sex Work and Use Drugs in Kazakhstan

Pre-exposure prophylaxis (PrEP) for HIV prevention has recently become available in Kazakhstan, but women engaged in sex work who use drugs (WESW-UD) could benefit from tailored approaches to support uptake and adherence. To better understand how best to support WESW-UD at each stage of the PrEP continuum (awareness, acceptability, uptake, and adherence), we analyzed data from 30 in-depth interviews and four focus groups with 48 WESW-UD from two cities in Kazakhstan. We conducted thematic analysis to characterize perceptions, barriers, and motivators within each step of the PrEP continuum. Participants reported low awareness, but high interest in PrEP. Motivating factors included optimizing health and increased confidence. Participants expressed many preferences and concerns regarding PrEP modality and delivery. Participants also described how organizational mistrust and social support can prevent or facilitate PrEP uptake or adherence. Kazakhstan's scale-up of PrEP should consider the needs and preferences of WESW-UD to ensure equitable access.

Oral Pre-exposure Prophylaxis Uptake and Acceptability Among Men Who Have Sex With Men: A Scoping Review of the Literature

Despite the global effort to end the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) epidemic as a global threat by 2030, the rate of new HIV infections worldwide remains unacceptably high among men who have sex with men, hence the need to use pre-exposure prophylaxis (PrEP) to reduce the risk of HIV infection. This population has an increased risk of getting HIV; thus, it is imperative to assess the uptake and acceptability of PrEP. This study investigated the willingness, availability, accessibility, and knowledge and identified barriers and facilitators to using PrEP among this population. A scoping literature review search was conducted on research papers published in English and focused on men who have sex with men and their use of PrEP. These were independently screened and coded. Of about 1,202 literature sources, 55 were included in the study. Findings reported that the uptake and acceptability of PrEP were influenced by knowledge and perception of being high-risk. Generally, PrEP uptake and understanding were high in North America, Latin America, and Europe and low in Asia and Africa. Low uptake and acceptability have been largely attributed to fear of side effects, societal stigma, cost, and perception of not being at risk. Noted facilitators to PrEP use include education, availability of free pills, support groups, and friendly health care facilities. Health intervention programs to increase the use of PrEP must be backed by appropriate legal and regulatory frameworks.

Adaptation and psychometric evaluation of a scale to measure oral pre-exposure prophylaxis-related stigma among key and vulnerable populations in Kenya

INTRODUCTION

As oral pre-exposure prophylaxis (PrEP) services scale up throughout sub-Saharan Africa (SSA), clients continue to face challenges with sustained PrEP use. PrEP-related stigma has been shown to influence engagement throughout the HIV PrEP care continuum throughout SSA. Validated quantitative measures of PrEP-related stigma in SSA are of critical importance to better understand its impacts at each stage of the HIV PrEP care continuum. This study aimed to psychometrically evaluate a PrEP-related stigma scale for use among key and vulnerable populations in the context of a Kenya national PrEP programme.

METHODS

As part of a larger prospective cohort study nested within Kenya's Jilinde programme, this study used baseline data collected from 1135 participants between September 2018 and April 2020. We used exploratory factor analysis to evaluate the factor structure of a PrEP-related stigma scale. We also assessed convergent construct validity of the PrEP-Related Stigma Scale by testing for expected correlations with depression and uptake of HIV services. Finally, we examined the relationship between PrEP-related stigma and key demographic, psychosocial and behavioural characteristics.

RESULTS

We identified four dimensions of PrEP-related stigma: (1) interpersonal stigma, (2) PrEP norms, (3) negative self-image and (4) disclosure concerns. The scale demonstrated strong internal consistency (α = 0.84), was positively correlated with depressive symptoms and negatively correlated with uptake of HIV services. Multivariable regression analysis demonstrated associations between PrEP-related stigma and sex worker identity.

CONCLUSIONS

The adapted and validated PrEP-Related Stigma Scale can enable programmes to quantify how PrEP-related stigma and its dimensions may differentially impact outcomes on the HIV PrEP care continuum, evaluate stigma interventions and tailor programmes accordingly. Opportunities exist to validate the scale in other populations and explore further dimensions of PrEP-related stigma.