Background: Sex workers (SW) and men who have sex with men (MSM) in South Africa are at substantial risk of HIV. Hence oral pre-exposure prophylaxis (PrEP) was launched for SW in 2016 and MSM in 2017. Programmatic data shows variability in initiation and continuation between these populations. This study examines factors related to PrEP initiation, continuation, and discontinuation during the national PrEP rollout.
Methods: A cross-sectional survey was administered September 2017-January 2018 among clients (ages 18-62) and providers at 9 facilities implementing oral PrEP in South Africa. The client survey captured PrEP initiation, continuation and discontinuation. The provider survey captured knowledge, attitudes and practiced behaviors towards PrEP. Descriptive analyses were performed on survey data. Continuation and discontinuation questions allowed for multiple responses.
Results: 288 clients (152 SW, 68 MSM, 68 other) and 30 providers (3 clinicians, 13 nurses, 6 counselors, 8 peer-educators) participated. Of 152 SW, 57 (37.5%) self-identified as current PrEP users and 46 (30.2%) as past users. Of 68 MSM, 25 (36.8%) self-identified as current PrEP users and 34 (50%) as past users. Primary reasons current and past users initiated PrEP included: being sexually active (SW 33%; MSM 18.6%), having multiple sexual partners (SW 26.2%; MSM 8.5%), and perceiving HIV risk (SW 22.3%; MSM 8.5%). Reasons current users continued PrEP were similar to initiation reasons: being sexually active (SW 50.9%; MSM 76.0%), having multiple sexual partners (SW 35.1%; MSM 24%), and perceiving HIV risk (SW 40.4%; MSM 40%). The primary reason for past users discontinuing PrEP was that side effects were too great (SW 71.7%; MSM 79.4%). The majority of providers (n=29; 96.7%) said that participants experienced minimal side effects on PrEP and only 8 (26.7%) identified side effects as a barrier.
Conclusions: SW and MSM in South Africa identify their sexual behavior and perception of HIV risk as reasons to initiate oral PrEP. However, side effects appear to be a challenge among users for oral PrEP continuation, and appear underestimated by providers. This highlights the need to better sensitize providers on user perceptions about side effects in order to inform their counseling messages and side effect management.