"It's hard for us men to go to the clinic. We naturally have a fear of hospitals." Men's risk perceptions, experiences and program preferences for PrEP: A mixed methods study in Eswatini

Barriers and facilitators to uptake and persistence on prep among key populations in Southern Province, Zambia: a thematic analysis

BACKGROUND

Especially in high HIV prevalence contexts, such as Zambia, effective biomedical prevention tools are needed for priority populations (PPs), including key populations (KPs), who are at higher risk. HIV pre-exposure prophylaxis (PrEP) has been scaled up nationally in Zambia, but little is known about barriers to PrEP use among specific PPs to date.

METHODS

To understand barriers and facilitators to PrEP use in Zambia, we conducted a qualitative case study of PrEP services to PPs including sero-discordant couples (SDCs), female sex workers (FSWs), and men who have sex with men (MSM) in Livingstone. The study conducted in 2021 included in-depth interviews (n = 43) guided by the socio-ecological model, and focus group discussions (n = 4) with clinic and community-based providers and PrEP-eligible clients including users and non-users across PP groups. We used thematic analysis to analyze data using codes derived both deductively and inductively.

RESULTS

We found multilevel barriers and facilitators to PrEP use. Cross-cutting barriers shared across PP groups included amplifying effects of PrEP being mistaken for antiretroviral drugs used to treat HIV, including anticipated stigma, and concerns about side-effects based on both misinformation and experience. In addition, stigmatized identities, particularly that of MSM, served as a barrier to PrEP use. The fear of being mislabeled as having HIV was of greatest concern for FSWs. Facilitators to PrEP use primarily included the importance of confidential, KP-sensitive services, and the role of informed, supportive family, friends, and peers. Participants across all PP groups urged expanded education efforts to increase awareness of PrEP within the general population toward mitigating concerns of being mislabeled as living with HIV.

CONCLUSION

To our knowledge, this is the first qualitative study of the PrEP cascade among multiple PPs in Zambia. This study provides important explanation for the low rates of PrEP continuation found in earlier demonstration trials among KPs in Zambia. The study also offers recommendations for programming efforts going forward such as inclusive PrEP awareness campaigns, expanded KP sensitivity training, and related efforts to thwart PrEP stigma while expanding access.

Men's perceptions of HIV self-testing in Eswatini: a qualitative study

Men in Eswatini test for HIV at lower rates compared to women despite the widespread availability of HIV testing services in the country. HIV self-test kits have been proposed as an HIV testing model to reach more men by bypassing the health facility, which is known to be a barrier for men using HIV testing services. In this study, we sought to understand men's perspectives on HIV self-testing in Eswatini. We conducted semi-structured interviews with 22 men, recruited from a rural community and from an urban men's clinic, to assess their awareness of HIV self-testing and their perceptions of it as an alternative HIV testing option. Findings show that men were aware of HIV self-testing but had concerns that left most feeling hesitant about adopting it. Many men expressed doubts about the accuracy of self-testing and their own technical competence to use the kit without supervision. They also expressed fears about testing, and possibly learning they were HIV positive, without adequate pre - and post-HIV test counseling. To allay men's fears and improve uptake of HIV self-testing, practitioners might consider innovative methods such as virtual counseling services and linking HIV self-testing to other community-based HIV care services.

Experiences of oral pre-exposure prophylaxis use among heterosexual men accessing sexual and reproductive health services in South Africa: a qualitative study

INTRODUCTION

South African men face a substantial burden of HIV and are less likely to test for HIV and initiate antiretroviral therapy if tested positive and more likely to die from AIDS-related causes than women. In addition to condoms and circumcision, guidelines provide for the use of daily oral pre-exposure prophylaxis (PrEP) as an HIV prevention intervention for any men who recognize their need and request PrEP. However, heterosexual men have not been a focus of PrEP programmes, and since its introduction, there is limited literature on PrEP use among men in South Africa. This study explores the experiences, motivators and barriers to oral PrEP use among heterosexual men accessing primary healthcare services in South Africa.

METHODS

This study forms part of a mixed-methods implementation science study aimed at generating evidence for oral PrEP introduction and conducted in primary healthcare clinics in South Africa since 2018. Men aged ≥15 years who initiated oral PrEP and enrolled in a parent cohort study were purposefully invited to participate in an in-depth interview (IDI). Between March 2020 and May 2022, 30 men participated in IDIs exploring their motivators for PrEP use, and experiences with accessing health services. Interviews were audio recorded, transcribed and analysed thematically.

RESULTS

The final analysis included 28 heterosexual men (18-56 years old). Motivations to initiate PrEP included fear of acquiring HIV, self-perceived vulnerability to HIV and mistrust in relationships; health systems factors which motivated PrEP use included the influence of healthcare providers, educational materials and mobile services. Perceived reduction in HIV vulnerability and changing proximity to partners were reasons for PrEP discontinuation. Side effects, daily-pill burden and stigma were noted as challenges to PrEP use. Health system barriers to PrEP use included limited PrEP availability, school and work demands, and inconsistent mobile clinic schedules.

CONCLUSIONS

Our study reports on the experiences of heterosexual men accessing oral PrEP in real-world settings and contributes to the limited literature among this population. We highlight multiple levels which could be strengthened to improve men's PrEP use, including individual support, education among partners and communities, and addressing health system barriers to access.

Comparing PrEP initiation rates by service delivery models among high risk adolescent boys and young men in KwaZulu-Natal, South Africa: findings from a population-based prospective study

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is an HIV prevention strategy that can reduce the risk of HIV acquisition by more than 90% if taken consistently. Although South Africa has been implementing PrEP since 2016, initially for selected population groups before expanding access to more people, there is a dearth of research focused on PrEP among adolescent boys and young men (ABYM), despite them experiencing high rates of HIV infection. To address this gap, we compared PrEP initiation rates by service delivery points (SDPs) among ABYM in KwaZulu-Natal, South Africa.

METHODS

We conducted a population-based prospective study in 22 SDPs from July 2021 to July 2022 in KwaZulu-Natal, South Africa. Sexually active ABYM aged 15-35 years who tested HIV negative were recruited at purposively selected PrEP SDPs (i.e., healthcare facilities, secondary schools and Technical Vocational Education and Training (TVET) colleges, and community-based youth zones). We collected baseline quantitative data from each participant using self-administered electronic questionnaires built into REDCap, including demographic information such as age, sex, employment status and level of education, as well as PrEP initiation outcomes. We extracted data from REDCap and exported it to Stata version 17.0 for analysis, and then eliminated discrepancies and removed duplicates. We described baseline characteristics using summary and descriptive statistics (median, interquartile range [IQR] and proportions) and reported PrEP initiation proportions overall and by SDPs.

RESULTS

The study included 1104 ABYM, with a median age of 24 years (interquartile range (IQR): 21-28)). Almost all participants were black African (n = 1090, 99%), with more than half aged 15-24 years (n = 603, 55%) and 45% (n = 501) aged 25-35 years. The majority (n = 963; 87%) had attained a secondary level of education. Overall PREP initiation rate among adolescent boys and young men was low: among 1078 participants who were eligible for PrEP, 13% (n = 141) were started on PrEP. Among the participants who were initiated on PrEP, over three quarters (78%, n = 58) were initiated from high schools, compared with community-based youth zones (40%, n = 37), TVET colleges (26%, n = 16) and healthcare facilities (4%, n = 30).

CONCLUSIONS

This study provided evidence suggesting that expanding PrEP services to non-traditional settings, such as high schools, TVET colleges, and community-based organizations, may have a potential to increase PrEP access among ABYM in South Africa.

PrEPare_Morocco a successful community-based PrEP delivery demonstration program for men who have sex with men and female sex workers in Morocco

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool, recommended for persons at substantial risk for HIV, such as female sex workers (FSW) and men who have sex with men (MSM). We present Morocco's and the Middle East/North Africa's first PrEP demonstration project. Our pilot aimed to assess the feasibility and acceptability of a community-based PrEP program for FSW and MSM in Morocco's highest HIV prevalence cities: Agadir, Marrakech, and Casablanca. From May to December 2017, 373 eligible participants engaged in a 5-9 month program with daily oral TDF/FTC and clinic visits. Of these, 320 initiated PrEP, with 119 retained until the study's end. We report an 86% PrEP uptake, 37% overall retention, and 78% retention after 3 months. No seroconversions occurred during follow-up. These results underscore PrEP's need and acceptability among MSM and FSW and demonstrate the effectiveness of a community-based PrEP program in Morocco. These findings informed Morocco's current PrEP program and hold potential for the wider region with similar challenges.

Understanding Oral PrEP Interest, Uptake, Persistence, and Experience of Use Among Heterosexual Men in Johannesburg, South Africa: An Exploratory Pilot Study

South Africa's PrEP programming has primarily focused on men who have sex with men and other key populations through dedicated clinical and outreach services. However, data shows that the pool of men vulnerable to contracting HIV extends beyond this group, including men who have sex only with women and who do not identify as gay. The aim of this pilot study was to assess acceptability of PrEP among this subset of men who are at risk of HIV acquisition in South Africa and to describe the demographic and behavioral characteristics of male PrEP users as well as their experience of PrEP use. We employed a mixed-methods study design consisting of in-depth interviews and quantitative analysis of routine clinic data collected between September 2021 and February 2022 from 10 private health facilities. Men who enrolled in the study and initiated PrEP had low consistent condom use and nearly three quarters reported more than one sexual partner in the past three months. Despite minimal follow-up support, PrEP persistence was relatively high and similar to other populations. 57% of men returned for their 1-month visit, 40% returned for their 4-month visit, and 16% returned for their 7-month visit. The greatest barriers to ongoing use were the need to take a daily pill and low perceived HIV risk. To improve uptake and continuation, programs should increase awareness of PrEP, leverage trusted sources to build credibility, make access more convenient, and accommodate flexible use through event-driven PrEP.

A community-based dynamic choice model for HIV prevention improves PrEP and PEP coverage in rural Uganda and Kenya: a cluster randomized trial

INTRODUCTION

Optimizing HIV prevention may require structured approaches for providing client-centred choices as well as community-based entry points and delivery. We evaluated the effect of a dynamic choice model for HIV prevention, delivered by community health workers (CHWs) with clinician support, on the use of biomedical prevention among persons at risk of HIV in rural East Africa.

METHODS

We conducted a cluster randomized trial among persons (≥15 years) with current or anticipated HIV risk in 16 villages in Uganda and Kenya (SEARCH; NCT04810650). The intervention was a client-centred HIV prevention model, including (1) structured client choice of product (pre-exposure prophylaxis [PrEP] or post-exposure prophylaxis [PEP]), service location (clinic or out-of-clinic) and HIV testing modality (self-test or rapid test), with the ability to switch over time; (2) a structured assessment of patient barriers and development of a personalized support plan; and (3) phone access to a clinician 24/7. The intervention was delivered by CHWs and supported by clinicians who oversaw PrEP and PEP initiation and monitoring. Participants in control villages were referred to local health facilities for HIV prevention services, delivered by Ministry of Health staff. The primary outcome was biomedical prevention coverage: a proportion of 48-week follow-up with self-reported PrEP or PEP use.

RESULTS

From May to July 2021, we enrolled 429 people (212 intervention; 217 control): 57% women and 35% aged 15-24 years. Among intervention participants, 58% chose PrEP and 58% chose PEP at least once over follow-up; self-testing increased from 52% (baseline) to 71% (week 48); ≥98% chose out-of-facility service delivery. Among 413 (96%) participants with the primary outcome ascertained, average biomedical prevention coverage was 28.0% in the intervention versus 0.5% in the control: a difference of 27.5% (95% CI: 23.0-31.9%, p<0.001). Impact was larger during periods of self-reported HIV risk: 36.6% coverage in intervention versus 0.9% in control, a difference of 35.7% (95% CI: 27.5-43.9, p<0.001). Intervention effects were seen across subgroups defined by sex, age group and alcohol use.

CONCLUSIONS

A client-centred dynamic choice HIV prevention intervention, including the option to switch between products and CHW-based delivery in the community, increased biomedical prevention coverage by 27.5%. However, substantial person-time at risk of HIV remained uncovered.

'We Should Not Be Quiet but We Should Talk': Qualitative Accounts of Community-Based Communication of HIV Pre-Exposure Prophylaxis

Community leaders play an important role in the acceptance of public health services, but little is known about their willingness to facilitate HIV pre-exposure prophylaxis (PrEP) roll-out in Eswatini. We conducted in-depth interviews (n = 25) with purposefully selected male and female community leaders in Eswatini. We analysed our data inductively using a thematic analysis approach. Community leaders feel they are important communicators of culturally appropriate PrEP messaging. Our participants described a complex social space within their communities influenced by religion, tradition, values, and HIV stigma. Community leaders use their position to provide leverage for unique, effective, and easily accessible messages and platforms to reach the community in a manner that ensures trust, relatability, familiarity, and shared faith. Community leaders feel that they are trusted and see trust manifesting in the conversations they are able to engage in, and have a reach that extends beyond formal health services. Existing PrEP programming should embed community leader participation in PrEP programming and engage the trust, knowledge, and potential of community leaders to support PrEP uptake and acceptance.

What motivated men to start PrEP? A cross-section of men starting PrEP in Buffalo city municipality, South Africa

BACKGROUND

Compared to women, South African men are less likely to know their HIV status (78% vs. 89%), have suppressed viral loads (82% vs. 90%), or access HIV prevention services. To achieve epidemic control where heterosexual sexual behavior drives transmission, interventions to improve the uptake of HIV testing services (HTS) and prevention services must also target cis-gendered, heterosexual men. There is limited understanding of these men's needs and wants with regards to accessing pre-exposure prophylaxis (PrEP).

METHODS

Adult men (≥ 18 years) from a peri-urban community in Buffalo City Municipality were offered community-based HTS. Those who received a negative HIV test result were offered community-based, same-day oral PrEP initiation. Men initiating PrEP were invited to participate in a study exploring men's HIV prevention needs and reasons for initiating PrEP. An in-depth interview guide, developed using the Network-Individual-Resources model (NIRM), explored men's perceived HIV acquisition risk, prevention needs, and preferences for PrEP initiation. Interviews were conducted by a trained interviewer in isiXhosa or English, audio-recorded and transcribed. Thematic analysis was used, guided by the NIRM to generate findings.

RESULTS

Twenty-two men (age range 18-57 years) initiated PrEP and consented to study participation. Men reported elevated HIV acquisition risk associated with alcohol use and condom-less sex with multiple partners as facilitators driving PrEP initiation. They anticipated social support from family members, their main sexual partner and close friends for their PrEP use, and discussed other men as important sources of support for PrEP initiation. Nearly all men expressed positive views of people using PrEP. Participants believed HIV testing would be a barrier for men interested in accessing PrEP. Men recommended that access to PrEP be convenient, rapid, and community-based (i.e., not clinic-based).

DISCUSSION

Self-perceived risk for HIV acquisition was a major facilitator for men's PrEP initiation. Although men expressed positive perceptions of PrEP users, they noted that HIV testing may be a barrier to PrEP initiation. Finally, men recommended convenient access points to facilitate PrEP initiation and sustained use. Gender-responsive interventions tailored to men's needs, wants, and voices will facilitate their uptake of HIV prevention services, and help to end the HIV epidemic.

Cultural Repertoires and Situated Selections as an Alternative Framework to Hegemonic Masculinities: Findings From Eswatini

Since the 1980s studies on men have frequently utilized Connell's framework of hegemonic masculinities. We critically appraise this framework in the context of a population-based HIV pre-exposure prophylaxis study in Eswatini. Our findings highlight that men confidently show variation in their behavior and choices, which manifest across different men and within the same men acting in particular situations and over the life course. This led us to interrogate the hegemonic masculinities framework on the following grounds: Men's choices and behavior do not seem to fit the model of aspiring to a hegemonic ideal; the delineation of masculine traits as hegemonic or subordinate remain vague in terms of "responsibility," "fidelity," and "consideration for others"; the binary gender concept underpinning hegemonic masculinities seems outdated. Building on the work of Hirsch and Kachtan, we propose cultural repertoires as an alternative framework which also bridges the gender divide.

Factors influencing adolescent girls and young women's uptake of community-based PrEP services following home-based HIV testing in Eastern Cape, South Africa: a qualitative study

Home-based service delivery has been used to improve access to HIV testing and antiretroviral initiation across sub-Saharan Africa, but it has yet to be leveraged to improve pre-exposure prophylaxis (PrEP) uptake. We interviewed 37 adolescent girls and young women (AGYW) in Eastern Cape, South Africa to explore why they chose to initiate PrEP or not following home-based HIV testing and referral for PrEP, and what influenced time to PrEP initiation. Participants reported that home visits provided a source of trusted information and a way to involve family members in their PrEP initiation decisions, motivating some to start PrEP. AGYW who initiated PrEP were more likely to qualitatively perceive themselves to be at high risk for HIV compared with those who never initiated PrEP. Integrating home-based HIV testing with PrEP education and referral may be a valuable way to reduce familial barriers and boost PrEP uptake among AGYW in South Africa. Trial registration: NCT03977181. Retrospectively registered on June 6, 2019.

Feasibility of a community-based delivery model for HIV pre-exposure prophylaxis among bar patrons in rural South Africa

Introduction

South Africa, home to the world's largest HIV epidemic, has made great strides in improving access to HIV services, but specific groups, particularly young men, remain difficult to engage in the HIV care cascade. Alcohol use disorder, prevalent in South Africa, further complicates engagement. Congregate settings where alcohol is served, known as shebeens, are an ideal place to engage young people for HIV testing, treatment and prevention, including pre‐exposure prophylaxis (PrEP). Here, we characterize the uptake of PrEP in shebeen patrons and explore the effect of alcohol consumption on PrEP uptake by piloting a community‐based delivery model.

Methods

In the rural Kwazulu‐Natal province (KZN) of South Africa, a field team made up of all men offered screenings outside of shebeens at 27 events over 6 months in 2020. Screenings included rapid HIV testing and Alcohol Use Disorder Identification Test (AUDIT). Participants who tested negative for HIV were offered PrEP as once daily oral tenofovir disoproxil fumarate/emtricitabine. Short‐term retention was determined. Logistic regression was performed to identify predictors of PrEP uptake, including unadjusted and adjusted odds ratios (OR) with 95% confidence interval.

Results

One hundred and sixty‐two shebeen patrons were screened, and 136 (84%) were eligible for PrEP. Among those eligible, 37 (27%) completed clinical evaluation and initiated PrEP. Among PrEP initiators, 91.9% were men, median age was 26.0 years (interquartile range 21–31), 32.4% were employed, 18.9% had running water and 70.3% had AUDIT scores indicating hazardous drinking. Among 37 initiators, 25 (68%) were retained at 1 month, and 19 (51%) were retained at 4 months. Independent predictors of PrEP uptake among all bar patrons, and only men (108 screened and 34 initiators), included younger age (OR 0.92 [0.88–0.97]) and lifetime number of sexual partners (OR 1.07 [1.02–1.13]).

Conclusions

Community‐based PrEP delivery after engagement at shebeens in rural South Africa is a feasible and novel approach to reach a traditionally difficult‐to‐engage population, particularly young men. In this small sample, sexual risk behaviours predicted PrEP uptake. Hazardous drinking was not a barrier to PrEP initiation.

HIV PrEP is more than ART-lite: Longitudinal study of real-world PrEP services data identifies missing measures meaningful to HIV prevention programming

INTRODUCTION

Evidence indicates HIV oral pre-exposure prophylaxis (PrEP) is highly efficacious and effective. Substantial early discontinuation rates are reported by many programs, which may be misconstrued as program failure. However, PrEP use may be non-continuous and still effective, since HIV risk fluctuates. Real-world PrEP use phenomena, like restarting and cyclical use, and the temporal characteristics of these use patterns are not well described. The objective of our study was to characterize and identify predictors of use patterns observed in large PrEP scale-up programs in Africa.

METHODS

We analysed demographic and clinical data routinely collected during client visits between 2017 and 2019 in three Jhpiego-supported programs in Kenya, Lesotho and Tanzania. We characterized duration on/off PrEP and, using ordinal regression, modelled the likelihood of spending additional time off and identified factors associated with increasing cycle number. The Andersen-Gill model was used to identify predictors of time to PrEP discontinuation. To analyse factors associated with a client's first return following initiation, we used a two-step Heckman probit.

RESULTS

Among 47,532 clients initiating PrEP, approximately half returned for follow-up. With each increase in cycle number, time off PrEP between use cycles decreased. The Heckman first-step model showed an increased probability of returning versus not by older age groups and among key and vulnerable population groups versus the general population; in the second-step model older age groups and key and vulnerable populations were less likely in Kenya, but more likely in Lesotho, to return on-time (refill) versus delayed (restarting).

CONCLUSIONS

PrEP users frequently cycle on and off PrEP. Early discontinuation and delays in obtaining additional prescriptions were common, with broad predictive variability noted. Time off PrEP decreased with cycle number in all countries, suggesting normalization of use with experience. More nuanced measures of use are needed than exist for HIV treatment if effective use of PrEP is to be meaningfully measured. Providers should be equipped with measures and counselling messages that recognize non-continuous and cyclical use patterns so that clients are supported to align fluctuating risk and use, and can readily restart PrEP after stopping, in effect empowering them further to make their own prevention choices.