A stepped-wedge randomized trial and qualitative survey of HIV pre-exposure prophylaxis uptake in the Eswatini population

Abstract

Clinical trials have shown that antiretroviral drugs used as pre-exposure prophylaxis (PrEP) are highly effective for preventing HIV acquisition. PrEP efforts, including in sub-Saharan Africa, have almost exclusively focused on certain priority groups, particularly female sex workers, men having sex with men, pregnant women, serodiscordant couples, and young women. As part of a PrEP demonstration project involving the general population at six primary health care facilities in Eswatini (formerly Swaziland), we conducted a randomized trial of a health care facility–based PrEP promotion package designed to increase PrEP uptake. Over the 18-month study duration, 33.6% (517 of 1538) of adults identified by health care workers as being at risk of acquiring HIV took up PrEP, and 30.0% of these individuals attended all scheduled appointments during the first 6 months after initiation of PrEP. The PrEP promotion package was associated with a 55% (95% confidence interval, 15 to 110%; P = 0.036) relative increase in the number of individuals taking up PrEP, with an absolute increase of 2.2 individuals per month per health care facility. When asked how PrEP uptake could be improved in 217 accompanying in-depth qualitative interviews, interviewees recommended an expansion of PrEP promotion activities beyond health care facilities to communities. Although a health care facility–based promotion package improved PrEP uptake, both uptake and retention remained low. Expanding promotion activities to the community is needed to achieve greater PrEP coverage among adults at risk of HIV infection in Eswatini and similar settings.

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

“…Furthermore, PrEP in Uganda is identical to ART for HIV treatment (tenofovir/lamivudine), such that PrEP users are indistinguishable from people living with HIV. Fears of being misidentified as living with HIV have been reported among PrEP users in many other parts of sub-Saharan Africa [ 23 , 44 – 49 ]. Our data illustrate that despite perceived need for PrEP as HIV prevention, anticipated stigma can interfere with PrEP uptake use among target users.…”

The Costs of Creatinine Testing in the Context of a HIV Pre-Exposure Prophylaxis Demonstration Project in Eswatini

“…The costs of blood sample collection in a public primary care clinic and serum creatinine testing in the government referral laboratory of the Hhohho region were assessed during the PrEP demonstration project in the region in 2017–19. During the 18 months demonstration project, PrEP was provided to over 500 PrEP clients in six public primary care clinics which may have served about 20% of the Hhohho population in 2016/17 [ 6 , 9 ]. To monitor serum creatinine levels, blood samples should have been regularly taken from PrEP clients during clinic visits—at PrEP initiation and then 6-monthly for clients continuing PrEP according the demonstration project guidelines [ 12 , 13 ].…”

“…In Eswatini, a 2017–19 demonstration project introduced the provision of PrEP to everyone at a high risk of HIV infection through public primary care clinics [ 5 , 6 ]. PrEP provision through public primary care clinics has been scaled-up nationwide in Eswatini since the demonstration project [ 7 , 8 ].…”

Evidence-based policymaking when evidence is incomplete: The case of HIV programme integration

“…Approaches, such as “A/B testing” [ 33 , 34 ], i.e., experimental designs in which several variants of a new service are randomly offered to people and service uptake and effects are measured in real time, could rapidly result in knowledge on preferences, barriers, and enablers of specific health service design choices. Furthermore, health system innovations could contain built-in trial elements to ensure rapid impact assessment and knowledge generation alongside real-world implementation, for instance, through stepped-wedge randomised trials [ 35 , 39 , 40 ].…”