Understanding Demand for PrEP and Early Experiences of PrEP Use Among Young Adults in Rural Kenya and Uganda: A Qualitative Study

Abstract

Few studies have sought to understand factors influencing uptake and continuation of pre-exposure prophylaxis (PrEP) among young adults in sub-Saharan Africa in the context of population-based delivery of open-label PrEP. To address this gap, this qualitative study was implemented within the SEARCH study (NCT#01864603) in Kenya and Uganda, which achieved near-universal HIV testing, and offered PrEP in 16 intervention communities beginning in 2016-2017. Focus group discussions (8 groups, n = 88 participants) and in-depth interviews (n = 23) with young adults who initiated or declined PrEP were conducted in five communities, to explore PrEP-related beliefs and attitudes, HIV risk perceptions, motivations for uptake and continuation, and experiences. Grounded theoretical methods were used to analyze data. Young people felt personally vulnerable to HIV, but perceived the severity of HIV to be low, due to the success of antiretroviral therapy (ART): daily pilltaking was more threatening than the disease itself. Motivations for PrEP were highly gendered: young men viewed PrEP as a vehicle for safely pursuing multiple partners, while young women saw PrEP as a means to control risks in the context of engagement in transactional sex and limited agency to negotiate condom use and partner testing. Rumors, HIV/ART-related stigma, and desire for "proof" of efficacy militated against uptake, and many women required partners' permission to take PrEP. Uptake was motivated by high perceived HIV risk, and beliefs that PrEP use supported life goals. PrEP was often discontinued due to dissolution of partnerships/changing risk, unsupportive partners/peers, or early side effects/pill burden. Despite high perceived risks and interest, PrEP was received with moral ambivalence because of its associations with HIV/ ART and stigmatized behaviors. Delivery models that promote youth access, frame messaging on wellness and goals, and foster partner and peer support, may facilitate uptake among young people.

Achievements and gaps to provide pre-exposure prophylaxis (PrEP) for women across the European Region – Results from a European survey study

“…23 Having a history of partner violence, being recently diagnosed with a STI, and living in a high prevalence area, have also been cited in the literature as characteristics associated with PrEP eligibility among women. 22 , 24 Perceptions of HIV risk have been reported to be highly gendered and one challenge may be that many women do not consider themselves at risk of HIV acquisition 25 , 26 , particularly if they consider themselves to be in a monogamous relationship. A holistic discourse about HIV risk and risk perception that includes partner, structural and community influences may thus be particularly important for women’s uptake of PrEP.…”

Antiretroviral Therapy Based Hiv Prevention Targeting Young Female-Sex Workers: A Mixed Method Approach to Understand the Implementation of Prep in a Rural Area of Kwazulu-Natal, South Africa

“…Healthcare providers and key stakeholders acknowledge the effectiveness and importance of PrEP, but worry about young people not taking responsibility of their sexuality (36,37). Such attitudes will potentially fuel the internalised and enacted stigma towards PrEP (30,36,37), much as they have around HIV testing in rural settings (36).…”

“…Healthcare providers and key stakeholders acknowledge the effectiveness and importance of PrEP, but worry about young people not taking responsibility of their sexuality (36,37). Such attitudes will potentially fuel the internalised and enacted stigma towards PrEP (30,36,37), much as they have around HIV testing in rural settings (36). To minimize such risks, PrEP could be integrated within wider strategies to improve adolescent and youth sexual health, rather than leaving it as a vertical HIV prevention intervention, and be offered as an option within a wider choice of HIV prevention modalties, as is done with contraception methods (32).…”

HIV Prevention at Drug Shops: Awareness and Attitudes Among Shop Dispensers and Young Women About Oral Pre-Exposure Prophylaxis and The Dapivirine Ring in Shinyanga, Tanzania

“…Adolescent girls and young women (AGYW, ages 15-24) comprise 25% of new adult HIV infections in sub-Saharan Africa (1). In many countries where pre-exposure prophylaxis (PrEP) is available, AGYW are prioritized for PrEP outreach (2), yet early evidence demonstrates suboptimal PrEP uptake and coverage among AGYW (3,4). The gap in implementation may be partially explained by the unique barriers AGYW face when accessing sexual and reproductive health (SRH) services in healthcare facilities, such as stigma and provider bias (5)(6)(7)(8)(9).…”