Introduction
Female and male sex workers experience heightened vulnerability to
HIV
and other health harms that are compounded by substance use, physical and sexual violence, and limited access to health services. In Kisumu, Kenya, where sex work is widespread and substance use is a growing public health concern, offering pre‐exposure prophylaxis (Pr
EP
) for
HIV
prevention could help curtail the
HIV
epidemic. Our study examines “syndemics,” or mutually reinforcing epidemics of substance use, violence and
HIV
, in relation to Pr
EP
acceptability and feasibility among female and male sex workers in Kenya, one of the first African countries to approve Pr
EP
for
HIV
prevention.
Methods
From 2016 to 2017, sex workers in Kisumu reporting recent alcohol or drug use and experiences of violence participated in qualitative interviews on
HIV
risk and perspectives on health service needs, including Pr
EP
programming. Content analysis identified themes relating to Pr
EP
knowledge, acceptability, access challenges and delivery preferences.
Results
Among 45 female and 28 male sex workers, median age was 28 and 25 respectively. All participants reported past‐month alcohol use and 91% of women and 82% of men reported past‐month drug use. Violence was pervasive, with most women and men reporting past‐year physical (96% women, 86% men) and sexual (93% women, 79% men) violence. Concerning Pr
EP
, interviews revealed: (1) low Pr
EP
knowledge, especially among women; (2) high Pr
EP
acceptability and perceived need, particularly within syndemic contexts of substance use and violence; and (3) preferences for accessible, non‐stigmatizing Pr
EP
delivery initiatives designed with input from sex workers.
Conclusions
Through a syndemic lens, substance use and violence interact to increase
HIV
vulnerability and perceived need for Pr
EP
among female and male sex workers in Kisumu. Although interest in Pr
EP
was high, most sex workers in our sample, particularly women, were not benefiting from it. Syndemic substance use and violence experienced by sex workers posed important barriers to Pr
EP
access for sex workers. Increasing Pr
EP
access for sex workers will require addressing substance use and violence through integrated programming.