Persistence on oral pre-exposure prophylaxis (PrEP) among female sex workers in eThekwini, South Africa, 2016–2020

Abstract

Background Despite the established efficacy of PrEP to prevent HIV and the advantages of a user-controlled method, PrEP uptake and persistence by women in both trials and demonstration projects has been suboptimal. We utilized real-world data from an HIV service provider to describe persistence on oral PrEP among female sex workers (FSW) in eThekwini, South Africa. Methods We examined time from PrEP initiation to discontinuation among all FSW initiating PrEP at TB HIV Care in eThekwini between 2016–2020. We used a discrete time-to-event data setup and stacked cumulative incidence function plots, displaying the competing risks of 1) not returning for PrEP, 2) client discontinuation, and 3) provider discontinuation. We calculated hazard ratios using complementary log-log regression and sub-hazard ratios using competing risks regression. Results The number of initiations increased each year from 155 (9.3%, n = 155/1659) in 2016 to 1224 (27.5%, n = 1224/4446) in 2020. Persistence 1-month after initiation was 53% (95% CI: 51%-55%). Younger women were more likely to discontinue PrEP by not returning compared with those 25 years and older. Risk of discontinuation through non-return declined for those initiating in later years. Despite the COVID-19 pandemic, a greater number of initiations and sustained persistence were observed in 2020. Conclusions Low levels of PrEP persistence were observed, consistent with data among underserved women elsewhere. Encouragingly, the proportion of women persisting increased over time, even as the number of women newly initiating PrEP and staff workload increased. Further research is needed to understand which implementation strategies the program may have enacted to facilitate these improvements and what further changes may be necessary.

Continued attendance in a PrEP program despite low adherence and non-protective drug levels among adolescent girls and young women in Kenya: Results from a prospective cohort study

“…Data from programmatic settings are important for developing effective implementation strategies for these women but such data very rarely include both program persistence, which focuses on ongoing visit attendance [17][18][19] and objectively measured adherence. To address this, we leveraged data from the PEPFAR-funded DREAMS initiative which offers daily oral PrEP to AGYW within a program that supports HIV prevention activities.…”

Characterizing the Impact of the COVID-19 Pandemic on HIV PrEP care: A Review and Synthesis of the Literature

“…A full description and details of included studies’ characteristics are summarized (see Table 1 ) . These studies were conducted in the United States ( n = 18)[ 21 , 29 – 45 ], United Kingdom ( n = 6)[ 22 , 46 – 50 ], Australia ( n = 4)[ 23 , 51 – 53 ], Brazil ( n = 4)[ 54 – 57 ], Portugal ( n = 3)[ 54 , 56 , 58 ], Kenya ( n = 2)[ 59 , 60 ], Belgium ( n = 2)[ 24 , 26 ], South Africa ( n = 2)[ 25 , 27 ]. The rest of the studies were conducted in Canada[ 61 ], Croatia[ 62 ], Ireland[ 63 ], Zimbabwe[ 64 ], Netherlands[ 65 ], the Philippines[ 66 ], France[ 67 ].…”

“…A majority of studies (n = 27) were comprised of MSM, three of which explicitly focused on young MSM[ 21 , 29 , 30 ]. Four studies included transgender women, two among female sex workers[ 27 , 64 ], one study was conducted among people who inject drugs (opioid-dependent individuals)[ 38 ], and one among pregnant women[ 25 ].…”

“…Matambanadzo et al (2021) discovered that among female sex workers in Zimbabwe, PrEP uptake has increased monthly since May 2020 and peaked at an initiation rate in September 2020[ 64 ]. Lastly, among female sex workers at TB HIV care in eThekwini, South Africa, researchers observed more PrEP initiation, improved PrEP persistence, and lower discontinuation during the pandemic[ 27 ] (see Table 2 ).…”

“…However, these findings were not consistent. In fact, one study in South Africa observed more PrEP initiation, improved persistence, and lower risks of client-initiated stops among female sex workers in 2020, compared to the pre-pandemic period[ 27 ].…”