Awareness, Willingness and Use of HIV Pre-Exposure Prophylaxis Among Female Sex Workers Living in Dar-es-Salaam, Tanzania

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.

Associations with HIV preexposure prophylaxis use by cisgender female sex workers in two Ugandan cities

BACKGROUND

Sex workers of all genders have a high risk of HIV acquisition and are a priority population for HIV pre-exposure prophylaxis (PrEP). We aimed to assess current oral PrEP use and associated factors among cisgender female sex workers (FSW) in two Ugandan cities.

METHODS

We administered a survey questionnaire to 236 HIV-negative FSW in the cities of Mbale and Mbarara from January to March 2020. The survey was nested in a quasi-experimental study to assess the effect of peer education and text message reminders on the uptake of regular sexually transmitted infection (STI) and HIV testing. Using interviewer-administered questionnaires, we obtained data on current self-reported tenofovir-based oral PrEP use. We used modified Poisson regression with robust standard errors to evaluate the factors associated with current oral PrEP usage.

RESULTS

Nearly 70% of FSWs reported taking an HIV test during the past three months. Among the respondents, 33% (33/100) in Mbale and 67% (91/136) in Mbarara reported having ever heard of PrEP. However, only 9.7% (23/236) self-reported currently taking oral-PrEP. In Mbarara, FSWs were twice as likely to be aware of or use oral PrEP than those in Mbale (adjusted prevalence ratio [aPR] 2.33; 95% confidence interval (CI) 1.19-3.97; p = 0.01). Additionally, current use was positively associated with attainment of secondary (aPR 2.50; 95% CI: 1.14-5.45; p = 0.02) or tertiary education (aPR 3.12; 95% CI: 1.09-8.96; p = 0.03).

CONCLUSION

PrEP use in this cohort of FSWs was low and was associated with location and level of education. To increase PrEP uptake among FSWs, targeted educational campaigns and implementation studies are needed, particularly for those with lower levels of education.

Pre‑exposure Prophylaxis Awareness and Endorsement among Adolescents and Young Adults in Tanzania: Insights from the 2022 Demographic and Health Survey

Background: Pre‑exposure prophylaxis (PrEP) is an effective measure for preventing human immunodeficiency virus (HIV) infection among people at risk, including adolescents and young adults (AYA). Objectives: This study evaluates the prevalence of PrEP awareness and endorsement, as well as the factors associated with these outcomes, using data from the 2022 Tanzania Demographic and Health Survey. Methods: The analysis included participants aged 15-24 years. Participants were asked whether they had ever heard of daily medication to prevent HIV (PrEP) and whether they approved of daily PrEP use. Demographic characteristics and HIV testing information were also collected. Logistic regression models were used to assess factors associated with PrEP awareness and endorsement, and the weighted prevalence of these outcomes was calculated. Findings: A total of 8,268 respondents aged 15-24 years were evaluated, of whom 5,852 (70.9%) were female. Overall, the prevalence of PrEP awareness and endorsement was 6.9% (95% confidence interval [CI] 6.2-7.7) and 5.7% (95% CI 5.1-6.4), respectively. Female respondents (adjusted odds ratio [aOR] = 0.69; 95% CI 0.51-0.91) and rural residents (aOR = 0.78; 95% CI 0.61-1.00) had lower odds of PrEP awareness compared with male respondents and urban residents, respectively. Previously, HIV testing and receiving test results (aOR = 2.00; 95% CI 1.50-2.66) and an age of 20-24 years versus 15-19 years (aOR = 1.54; 95% CI 1.20-1.96) were associated with increased odds of PrEP awareness. The odds of AYA endorsement of PrEP were higher among those aged 20-24 years versus 15-19 years (aOR = 1.39; 95% CI 1.07-1.83) and those who previously tested for HIV and received results (aOR = 1.97; 95% CI 1.43-2.72), but lower among female respondents (aOR = 0.66; 95% CI 0.49-0.88). Conclusion: PrEP awareness and endorsement among AYA in Tanzania were low, with nearly 7 in 100 aware of PrEP and 6 in 100 approving of its use. Targeted interventions focused on adolescents, females, and rural communities are needed to increase PrEP awareness and usage to achieve the Joint United Nations Programme on HIV/Acquired Immune Deficiency Syndrome (AIDS) (UNAIDS) 95-95-95 goals for HIV epidemic control.

HIV prevention and treatment cascades among female sex workers in Ghana: gaps and priorities that should be addressed by the national programme

BACKGROUND

There is currently limited knowledge about HIV prevention and treatment cascades among female sex workers (FSW) in Ghana. This study sought to use the 2020 bio-behavioural survey (BBS) among FSWs to identify gaps and priorities in HIV treatment and prevention cascades to help achieve the 95-95-95 fast track targets.

METHOD

The study used a cross-sectional design with Time Location Sampling (TLS) technique in all regions of Ghana. All eligible FSW at the selected venues and stipulated time frame were interviewed and tested for HIV onsite using the national testing algorithm. For condom use and HIV testing cascades, each step of the cascade was calculated as a percentage of all FSW. Analysis of treatment cascade was restricted to HIV positive participants and was presented using both conditional (% eligible PLHIV) and unconditional (% all PLHIV) approaches. Viral suppression level was defined as < 1000 copies/ml.

RESULTS

A total of 6,773 participants took part in the behavioral interviews while 6,217 took part in the biological component which involves HIV testing. In all, 33% and 80% of all FSW do not consistently use condoms with their paying clients and non-paying partners respectively. The findings further show that 26.6% of FSW have never tested for HIV, and contrary to the HIV testing policy of every six months for FSW, 70.0% did not test for HIV 6 months preceding the survey and 40.7% of all FSW did not test for HIV 12 months preceding the survey. The conditional treatment cascade was 32%-71%-57% while the unconditional cascade was 32%-23%-49%. The study further shows 68% of the HIV positive FSW were not aware of their HIV positive status, 77% were not on treatment, while nearly 51% were not virally suppressed regardless of treatment status.

CONCLUSION

The results show that both the prevention and treatment cascades are suboptimal. Key gaps identified include low: HIV testing, viral load suppression, condom use with both paying clients and non-paying partners. There is therefore the need to scale prevention and treatment interventions particularly HIV testing, treatment initiation, consistent condoms use with both paying clients and non-paying partners to help achieve the 95-95-95 fast track targets.

Trial of an mHealth intervention to improve HIV prophylaxis for female sex workers, United Republic of Tanzania

Objective

To evaluate the effect of a mobile health (mHealth) intervention on early retention of female sex workers in human immunodeficiency virus (HIV) pre-exposure prophylaxis services in the United Republic of Tanzania.

Methods

The study involved 783 female sex workers: 470 from Dar es Salaam who were given the Jichunge mHealth application (app) in addition to standard HIV pre-exposure prophylaxis (intervention arm), and 313 from Tanga who received pre-exposure prophylaxis alone (control arm). Participants were recruited using respondent-driven sampling and followed up for 12 months. Early retention was defined as attending a pre-exposure prophylaxis follow-up clinic within 28 days of an appointment scheduled for 1 month after starting treatment. To assess if the Jichunge app led to higher retention, we conducted intention-to-treat and per-protocol analyses using a regression model adjusted by inverse probability weighting.

Findings

Early retention in HIV pre-exposure prophylaxis care was observed in 27.6% (130/470) of participants in the intervention arm and 20.1% (63/313) in the control arm. In the adjusted, intention-to-treat analysis, early retention was observed in 29.4% in the intervention arm and 17.7% in the control arm (risk difference: 11.8 percentage points; 95% confidence interval: 5.3-18.3).

Conclusion

Early retention in HIV pre-exposure prophylaxis care was significantly greater among female sex workers in the United Republic of Tanzania who used the Jichunge app than in those who did not. Nevertheless, more than two thirds of sex workers using the application did not attend follow-up services after 1 month, suggesting that additional interventions are needed.

High retention among key populations initiated on HIV pre-exposure prophylaxis in Kigali City, Rwanda

INTRODUCTION

Key populations (KPs) including female sex workers (FSWs) and men who have sex with men (MSM) in sub-Saharan Africa are disproportionately impacted by HIV. Despite the increasing availability of pre-exposure prophylaxis (PrEP), data on retention remain limited. This study assessed PrEP retention at 1 and 12 months among Rwandan FSWs and MSM.

METHODS

We analysed routine clinical data on adult FSWs and MSM receiving PrEP care from 11 health facilities in Kigali, Rwanda between 2019 and 2022. Retention was defined as attendance at regularly scheduled appointments for a PrEP refill. We used logistic regression to assess associations between demographic and clinical characteristics and retention at 1 and 12 months.

RESULTS

Among 2043 PrEP initiators, 1343 (66%) were FSWs and 700 (34%) were MSM. FSWs reported a median number of eight sexual partners in the prior 7 days, 70% reported condomless sex and 94% considered themselves at high HIV risk. About 1239 (92%) and 1032 (77%) were retained at 1 and 12 months, respectively. One-month retention was lower among FSWs living with others (OR 0.59, 95% CI: 0.35-0.99; ref: living alone) or with low HIV risk perception (OR 0.12, 95% CI: 0.04-0.29). At 12 months, low HIV risk perception remained statistically significant (aOR 0.20, 95% CI: 0.12-0.32). At PrEP initiation, MSM reported a median of four sexual partners in the prior 12 months, 88% reported condomless sex and 72% considered themselves at high HIV risk. Retention rates were 96% at 1 month and 82% at 12 months. At 1 month, retention was higher among MSM with some education (OR 12.74, 95% CI: 2.74-70.93; ref: no education). At 12 months, retention was lower among MSM with part-time employment (aOR 0.29, 95% CI: 0.11, 0.76), students (aOR 0.12, 95% CI: 0.04, 0.37) and unemployed (aOR 0.12, 95% CI: 0.05, 0.28); ref: full-employed) and those unaware of PrEP at baseline (aOR 0.15, 95% CI: 0.10, 0.23).

CONCLUSIONS

We observed very high rates of PrEP retention among Rwandan FSWs and MSM. Predictors of retention included living situation, employment status, HIV risk perception and low PrEP awareness, but differed between FSWs and MSM. These findings suggest that targeted awareness campaigns tailored to different KPs could improve PrEP retention in care.

What can PrEP do for female sex workers? Unpacking the "effectosphere" of biomedical HIV prevention in Dar es Salaam

Pre-exposure prophylaxis (PrEP) is a drug with the power to prevent HIV transmission. This study delved into the broader implications of PrEP use among female sex workers in Dar es Salaam, Tanzania, a group disproportionately affected by HIV and socio-structural challenges. Through 46 in-depth interviews with 40 women who were either former or current PrEP users or intended to start PrEP between January 2021 and February 2022, we sought to explore the nuanced effects of PrEP. Inspired by Whyte et al. and "Social Life of Medicines", we asked what PrEP could do in the lives of female sex workers and analyzed the data using reflexive thematic analysis and an interpretative phenomenological approach. We found that PrEP had multiple and diverse effects in many domains of women's lives and refer to these collectively as the "effectosphere" of PrEP. The study identifies four key themes that jointly describe this effectosphere: (1) PrEP could promote human flourishing and empowerment by facilitating a feeling of freedom and confidence which could promote health, social relations, and economic and work opportunities, (2) PrEP could inflict harm (and fears of such harms), partially reflecting medical mistrust rooted in an understanding that sex workers were undesired in society, (3) PrEP could expose sensitive information about its users that could lead to stigma, arguments and needs for elaborate explanations, and (4) PrEP could medicalize daily life, evidenced through daily pill taking, clinical appointments, side-effects, becoming reliant on the medication, and the challenges of integrating PrEP use with other life priorities. We argue that investigating the full effectosphere of any medicine in particular geographic and sociocultural contexts can lead to a better understanding of its use and non-use, highlighting that engaging with medication extends beyond just "taking a pill."

Willingness to Use Long-acting Injectable Pre-exposure Prophylaxis Among Key Populations at a Large Hiv Prevention Clinic in Kampala, Uganda: a Cross-sectional Study

Background

Long-acting injectable (LAI)-PrEP provides better protection against HIV compared to oral PrEP, which requires taking a daily pill. Our study aimed to assess knowledge about oral and LAI-PrEP and identify factors associated with willingness to use LAI-PrEP among key populations (KP) in Uganda.

Methods

We conducted a cross-sectional study at the Most at Risk Populations Initiative (MARPI) clinic between November and December 2021. Participants were recruited through convenience sampling and interviewed using a structured questionnaire by trained interviewers. Participants were categorised into three groups based on their oral PrEP use: those who had not yet initiated PrEP, those who had discontinued oral PrEP, and those currently on oral PrEP. Modified Poisson regression analysis was performed to determine factors associated with the participant's willingness to use LAI-PrEP. Data was analysed using STATA 14 software.

Results

Of the 234 participants, 135 (56.7%) were female, 82.5% knew about LAI-PrEP, and 67.5% were willing to use it. The mean age was 28.7 years (standard deviation [SD] 5.8). Willingness to use LAI-PrEP was less likely among divorced, widowed, or separated individuals than those in relationships (adjusted prevalence ratio [aPR] 0.65, 95% CI: 0.43-0.98). Relative to current oral PrEP users, willingness to use LAI-PrEP was similar among those who discontinued oral PrEP (aPR 1.39, 95% CI: 0.92-2.11) and those who had not yet initiated PrEP but were at risk for HIV (aPR 1.26, 95% CI: 0.83-1.89).

Conclusions

In this cross-sectional analysis of diverse members of key populations in Uganda, previous or non-use of oral PrEP was not associated with willingness to use LAI-PrEP relative to current users. Future studies should investigate effective methods for promoting the uptake of long-acting PrEP formulations among populations at high risk of HIV acquisition.

Preference for novel biomedical HIV pre-exposure prophylaxis methods among adolescent girls and young women in Kampala, Uganda: a mixed methods study

Background

Novel HIV pre-exposure prophylaxis (PrEP) methods including a potential future HIV vaccine, will increase prevention options for adolescent girls and young women (AGYW) at high risk of HIV infection in Eastern and Southern Africa, yet data on AGYW's preferences for various PrEP methods is limited. We investigated preferences for five biomedical PrEP methods (oral, injectable, vaginal ring, implant, HIV vaccine) among 14-24-years-old AGYW in Kampala, Uganda.

Methods

From January to December 2019, we conducted a mixed methods study including 265 high-risk AGYW. After receiving two education sessions on the five PrEP methods, participants were asked about their "most preferred PrEP method." Multinomial logistic regression (oral PrEP as reference category) was used to determine participant characteristics associated with method preference. Results are presented as adjusted relative risk ratios (aRRR) with 95% confidence intervals (CI). In-depth interviews were conducted with 20 selected participants to examine reasons influencing PrEP preferences and suggestions for method improvements. Transcripts were analyzed thematically.

Results

Participants preferred methods were: HIV vaccine (34.7%), oral PrEP (25.7%), injectable PrEP (24.9%), PrEP implant (13.6%), and vaginal ring (1.1%). Preference for injectable PrEP increased with every year of age (aRRR 1.22; 95% CI 1.04-1.44) and among participants with chlamydia or gonorrhoea (aRRR 2.53; 95% CI 1.08-5.90), while it was lower among participants having sexual partner(s) living with HIV or of unknown HIV status (aRRR 0.30; 95% CI 0.10-0.91). Preference for PrEP implants also increased with age (aRRR 1.42; 95% CI 1.14-1.77) and was strong among participants having ≥10 sexual partners in the past 3 months (aRRR 3.14; 95% CI 1.16-8.55), while it was lower among those with sexual partner(s) living with HIV or of unknown HIV status (aRRR 0.25; 95% CI 0.07-0.92). PrEP method preference was influenced by product attributes and prior experiences with similar product forms commonly used in health care.

Conclusion

AGYW have varied preferences for biomedical PrEP method and those with higher sexual behavioral risk prefer long-acting methods. As we anticipate more available PrEP options, oral PrEP use should be supported among AGYW, especially for those with sexual partners living with HIV or of unknown HIV status.

Early disengagement from HIV pre-exposure prophylaxis services and associated factors among female sex workers in Dar es Salaam, Tanzania: a socioecological approach

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool when taken as prescribed. However, suboptimal use may challenge its real-life impact. To support female sex workers in their efforts to prevent themselves from HIV, it is essential to identify factors that contribute to early disengagement from PrEP care. In this study, we aimed to estimate the risk of early disengagement from PrEP services among female sex workers in Tanzania and associated factors using a socioecological model as a guiding framework.

METHODS

The study was conducted as part of a pragmatic mHealth trial for PrEP roll-out in Dar es Salaam in 2021. We estimated the risk of early disengagement, defined as not presenting for the first follow-up visit (within 56 days of enrolment), and its associations with individual, social, behavioural and structural factors (age, self-perceived HIV risk, mental distress, harmful alcohol use, condom use, number of sex work clients, female sex worker stigma and mobility) using multivariable logistic regression models, with marginal standardisation to obtain adjusted relative risks (aRR).

RESULTS

Of the 470 female sex workers enrolled in the study, 340 (74.6%) did not attend the first follow-up visit (disengaged). Mental distress (aRR=1.14; 95% CI 1.01 to 1.27) was associated with increased risk of disengagement. Participants who reported a higher number of clients per month (10-29 partners: aRR=0.87; 95% CI 0.76 to 0.98 and ≥30 partners: aRR=0.80; 95% CI 0.68 to 0.91) and older participants (≥35 years) (RR=0.75; 95% CI 0.56 to 0.95) had a lower risk of disengagement.

CONCLUSIONS AND RECOMMENDATIONS

Early disengagement with the PrEP programme was high. Mental distress, younger age and having fewer clients were risk factors for disengagement. We argue that PrEP programmes could benefit from including mental health screening and treatment, as well as directing attention to younger sex workers and those reporting fewer clients.

Uptake of Oral HIV Pre-Exposure Prophylaxis (PrEP) and Associated Factors among Female Sex Workers in Tanga, Tanzania

Pre-exposure prophylaxis (PrEP) prevents HIV infection among female sex workers (FSW). WHO recommends the use of Tenofovir disoproxil fumarate for use in oral PrEP regimens (TDF). Emtricitabine (FTC) 200 mg/Tenofovir Disoproxil Fumarate (TDF) 300 mg (Truvada) daily is the approved PrEP regimen in Tanzania. Evidence is limited on oral PrEP uptake and its associated factors in countries with a high burden of HIV, such as Tanzania. This study aimed to examine the uptake of oral PrEP and its associated factors among FSW in the Tanga region of Tanzania. This community-based cross-sectional study was conducted among 428 FSW. Data were collected through face-to-face interviews and analysed using STATA version 17 and RDSAT. Logistic regression was used to examine the associations of independent factors and PrEP uptake among study participants. About 55% of the recruited FSW used oral PrEP. FSW with three or more children were 2.41 times more likely to take oral PrEP (AOR 2.41, 95% CI: 1.08-4.25, p < 0.05). Moreover, those with a positive attitude were more likely to use oral PrEP (AOR 2.8, 95% CI: 1.88-4.17, p < 0.05). Poor belief was a barrier to PrEP use, and side effects of the drugs were a reason for the discontinuation of PrEP services. Most of the participants preferred PrEP services to be provided in the community. Oral PrEP uptake was 55%. Efforts to scale up PrEP for FSW should address misconceptions regarding PrEP, PrEP sensitization, and improving access through community-based intervention.

Pre-exposure prophylaxis use among female sex workers in Gulu city, Uganda: a community-based cross-sectional study

Background

Pre-exposure prophylaxis (PrEP) is an important intervention for reducing the risk of HIV transmission among high-risk populations such as female sex workers in Africa, where HIV prevalence remains high. We aimed to assess the use of PrEP among female sex workers in Gulu, Uganda.

Methods

In this community-based cross-sectional study, we included HIV-negative female sex workers purposely selected from hotspots within Gulu city, Uganda between February and March 2023. A semi-structured questionnaire was administered to collect data on sociodemographic characteristics, reproductive data, sexual practices, and self-reported PrEP use in the past 3 months. Symptoms of depression were screened using Patient Health Questionnaire-2 tool. Predictors of PrEP use was determined using modified Poisson regression analysis model. p < 0.05 was considered statistically significant.

Results

We enrolled 273 female sex workers with a median age of 27 (interquartile range: 24-32) years. Overall, 181 (66.3%) participants used PrEP. PrEP use was associated with; regular source of income beside sex work [adjusted prevalence ratio (aPR): 3.7, 95% confidence interval (CI): 2.11-6.35, p < 0.001], being in a polygamous marriage (aPR: 6.9, 95% CI: 1.32-35.77, p = 0.022), practicing sex work in both rural and urban areas (aPR: 2.5, 95% CI: 1.49-4.35, p < 0.001), having symptoms of depression (aPR: 3.3, 95% CI: 1.43-7.74, p = 0.005), and use of postexposure prophylaxis (PEP) in the past 12 months (aPR: 0.31, 95% CI: 0.17-0.59, p < 0.001).

Conclusion

Almost two in three of the female sex workers in Gulu city were currently using PrEP. Previous use of PEP was associated with lower use of PrEP. These findings suggest the need for targeted interventions to increase PrEP uptake and decrease HIV acquisition in this high-risk population among female sex workers, especially those with low income and limited access to healthcare.