Barriers and facilitators to pre-exposure prophylaxis uptake among male sex workers in Mexico: an application of the RE-AIM framework

Abstract

Background The ImPrEP México demonstration project is the first to distribute free HIV pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM) and transgender women living in Mexico. In Mexico City, MSM who are also male sex workers (MSWs) face a disproportionately high risk of HIV infection. PrEP is highly effective for HIV prevention, yet “real-life” implementation among MSWs is a challenge due to the unique adherence barriers faced by this population. Methods This study uses the RE-AIM implementation science framework to characterize the unique barriers to and facilitators of PrEP uptake among MSWs in Mexico City. We conducted 9 in-depth key informant interviews and 2 focus group discussions with MSWs across 5 clinic and community sites. Qualitative data were analyzed using inductive, open coding approaches from grounded theory. We supplemented findings from the primary qualitative analysis with quantitative indicators derived from ImPrEP program records to describe the current Reach of the ImPrEP program among MSWs in Mexico City and the potential for wider PrEP Adoption among other high-risk populations in Mexico. Results The Reach of the ImPrEP program was 10% of known HIV-negative MSWs in Mexico City. Program Reach was lowest among MSWs who were street-based sex workers, of lower socioeconomic status, migrants from other states and self-identified as heterosexual. Barriers to program Reach included limited PrEP knowledge, HIV-related stigma, and structural barriers; facilitators included in-person program recruitment, patient-centered care, and spread of information through word of mouth among MSWs. Two out of the four eligible institutions had adopted the ImPrEP protocol. Barriers to wider program Adoption included HIV- and sexual identity– related stigma, protocol limitations, and lack of a national policy for PrEP distribution; facilitators of Adoption included existing healthcare infrastructure, sensitized providers, and community support from non-governmental organizations. Conclusions Increasing the ImPrEP program’s Reach among MSWs will depend on improving PrEP education and addressing HIV-related stigma and access barriers. Future Adoption of the ImPrEP program should build on existing clinical infrastructure and community support. Creation of a national policy for PrEP distribution may improve the Reach and Adoption of PrEP among highest-risk populations in Mexico.

Longitudinal patterns of initiation, persistence, and cycling on preexposure prophylaxis among female sex workers and adolescent girls and young women in South Africa

“…Across the study period, 19% of negative tests among FSW and 55% among AGYW resulted in initiation. Some possible explanations, as provided anecdotally by those delivering PrEP, for the lower levels of initiation seen among FSW include: FSW have been using condoms as a trusted prevention method and may not see the need to change or supplement this and FSW experience unstable housing, which may challenge daily pill-taking [25]. Additionally, because women can test multiple times each year (FSW are recommended to test quarterly) and because it includes those who are already on PrEP, the denominator overestimates the number eligible, and the proportion initiating in a given month is likely an underestimate of the proportion who ever initiated PrEP.…”

Safety and efficacy of long-acting injectable cabotegravir as preexposure prophylaxis to prevent HIV acquisition

“…long-acting bimonthly provider-administered injection versus a pill taken daily or during times of risk). Programs implementing oral PrEP have noted challenges with uptake and effective use among oral PrEP users [10][11][12][13][14]. Furthermore, strong preferences for long-acting prevention products among certain populations, such as adolescent girls and young women, have been reported [15,16].…”

Effect of an mHealth intervention on retention in HIV pre-exposure prophylaxis services among female sex workers: Preliminary evidence of the use of the Jichunge app in Dar es Salaam, Tanzania

“…PrEP interventions are complex and their implementation associated with a range of barriers at different levels. 12 – 15 Finding ways of supporting retention in care could potentially strengthen the impact of PrEP.…”