Adherence among Female Sex Workers taking oral HIV pre-exposure prophylaxis in Kampala, Uganda

Abstract

Title: Adherence among female sex workers taking oral HIV pre-exposure prophylaxis in Kampala, Uganda. Background: Globally, Sub-Saharan Africa remains most severely affected with highest HIV prevalence rates. Oral PrEP is a novel HIV prevention intervention that offers hope to decrease HIV incidence in key populations. In Kampala Uganda, female sex workers (FSWs) have high HIV prevalence (33%), and inadvertently form the majority of PrEP users at the Most at Risk Population Initiative (MARPI) PrEP clinic in Kampala. However, studies have shown that with poor adherence, oral PrEP has no efficacy, and therefore adherence to PrEP is critical in realizing the benefits of PrEP for maximum HIV prevention. To date, implementation data on adherence to PrEP among FSWs is limited in Africa. This study therefore sought to assess adherence to PrEP among FSWs. Specifically, we sought to 1) determine the level of adherence to PrEP among FSWs, 2) determine factors associated with PrEP adherence as well as 3) explore factors influencing PrEP adherence among FSWs. Methods: This mixed methods cross-sectional study was conducted from August to December 2018; 126 FSWs using PrEP were interviewed using a questionnaire, and 30 women underwent in-depth interviews. Adherence was categorically defined as high adherence if a FSW takes at least six doses of PrEP in the past week and low adherence if a FSW takes less than 6 doses of PrEP in a week. Logistic regression using STATA version 14 and thematic data analysis were conducted for the quantitative and qualitative objectives respectively. viii

Results: The median age of the FSWs was 24.5 years. Forty one percent of the FSWs had attended secondary level education. The median duration of sex work was 3 years. On average, the FSWs had 11 sex partners in the past week. Reported condom use among FSWs was far more consistent with clients (87.9%) compared to 59% among non-paying sexual partners. Self reported proportion with high adherence to PrEP was 71%. Factors associated with high adherence to PrEP at bivariate level were condom use with clients, color of PrEP tablet, and PrEP packaging. In multivariate analysis, not using condoms with clients (OR 0.07, 95% CI: 0.01-0.42) and using long-term contraception methods (OR 0.06, 95% CI: 0.04-0.77) were significantly negatively associated with high PrEP adherence; whereby FSWs who used long-term contraceptive methods (IUD and Implants) were 94% less likely to adhere to PrEP. FSWs adhered to PrEP because they felt at risk; because they experienced condom breaks or because they do not use condoms. Barriers of PrEP adherence include drug side effects, lack of financial resources, food insecurity, stigma, and doubts about PrEP efficacy, travel and health system factors. Conclusion: A high proportion of FSWs had high self-reported adherence to PrEP. FSWs considered PrEP as a reliable method of protection against HIV in cases of condom breaks or sex without a condom. However a number of barriers to PrEP adherence at both personal and systems level need to be addressed for successful PrEP implementation.