Distance to clinic is a barrier to PrEP uptake and visit attendance in a community in rural Uganda

Abstract

Introduction Geographic and transportation barriers are associated with poorer HIV ‐related health outcomes in sub‐Saharan Africa, but data on the impact of these barriers on prevention interventions are limited. We estimated the association between distance to clinic and other transportation‐related barriers on pre‐exposure prophylaxis (Pr EP ) uptake and initial clinic visit attendance in a rural community in southwestern Uganda enrolled in the ongoing SEARCH study ( NCT 01864603). Methods Community‐wide HIV testing was conducted and offered to adult (≥15 years) participants in Ruhoko. Participants were eligible for Pr EP based on an empiric risk score, having an HIV ‐discordant partner, or self‐referral at either the community health campaign or during home‐based testing from March to April 2017. We collected data from Pr EP ‐eligible households on GPS ‐measured distance to clinic, walking time to clinic and road difficulty. A sample of participants was also asked to identify their primary barriers to Pr EP use with a semi‐quantitative questionnaire. We used multivariable logistic regression to evaluate the association between transportation barriers and (1) Pr EP uptake among Pr EP ‐eligible individuals and (2) four‐week clinic visit attendance among Pr EP initiators. Results Of the 701 Pr EP ‐eligible participants, 272 (39%) started Pr EP within four weeks; of these, 45 (17%) were retained at four weeks. Participants with a distance to clinic of ≥2 km were less likely to start Pr EP ( aOR 0.34; 95% CI 0.15 to 0.79, p = 0.012) and less likely to be retained on Pr EP once initiated ( aOR 0.29; 95% CI 0.10 to 0.84; p = 0.024). Participants who were deemed eligible during home‐based testing and did not have the option of same‐day Pr EP start were also substantially less likely to initiate Pr EP ( aOR 0.16, 95% CI 0.07 to 0.37, p < 0.001). Of participants asked to name barriers to Pr EP use (N = 98), the most frequently cited were “needing to take Pr EP every day” (N = 18) and “low/no risk of getting HIV ” (N = 18). Transportation‐related barriers, including “clinic is too far away” (N = 6) and “t...

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