“We’ve Got Our Own Beliefs, Attitudes, Myths”: A Mixed Methods Assessment of Rural South African Health Care Workers' Knowledge of and Attitudes Towards PrEP Implementation

Abstract

South Africa maintains the world’s largest HIV prevalence, accounting for 20.4% of people living with HIV internationally. HIV Pre-exposure prophylaxis (PrEP) has demonstrated efficacy; however, there is limited data on PrEP implementation in South Africa, particularly in rural areas. Using grounded theory analysis of semi-structured interviews and exploratory factor analyses of structured surveys, this mixed methods study examines healthcare workers’ (HCWs)’ beliefs about their patients and the likelihood of PrEP uptake in their communities. The disproportionate burden of HIV among Black South Africans is linked to the legacy of apartheid and resulting disparities in wealth and employment. HCWs in our study emphasized the importance of addressing these structural barriers, including increased travel burden among men in the community looking for work, poor transportation infrastructure, and limited numbers of highly skilled clinical staff in their rural community. HCWs also espoused a vision of PrEP that prioritizes women due to perceived constraints on their sexual agency, and that minimizes the impact of HIV-related stigma on PrEP implementation. However, HCWs' additional concerns for risk compensation may reflect dominant social mores around sexual behavior. In recognition of HCWs’ role as both informants and community members, implementation scientists should invite local HCWs to partner as early as the priority-setting stage for PrEP interventions. Inviting leadership from local HCWs may increase the likelihood of delivery plans that account for unique local context and structural barriers researchers may otherwise struggle to uncover.

Appendices

Appendix

Appendix 1: PrEP Attitudes, Knowledge, and Engagement (PAKE) Survey

*Assessment of Preexisting Knowledge and Attitudes Concerning PrEP

1. Have you ever heard of pre-exposure prophylaxis (PrEP)?

Y

N

U

2. How much would you say you know about HIV PrEP?

Nothing

A little

Some

A lot

A great deal

3. How often do you talk to your patients about HIV?

Every visit

More than half the time

Less than half the time

Never

Declined to Answer

Ask: “Do you agree with any of these statements?”

4	PrEP reduces someone’s risk of getting HIV	Y	N	U
5	PrEP is a medicine that needs to be taken everyday	Y	N	U
6	If someone takes PrEP, they will not get sick with HIV	Y	N	U
7	If someone takes PrEP, their partner do(es) not need to use a condom	Y	N	U
8	PrEP can decrease HIV infection in my communityǂ	Y	N	U
9	PrEP could harm current efforts to prevent/address HIVǂ	Y	N	U
10	I am interested in learning about new methods to prevent HIV	Y	N	U
11	I have the proper knowledge/training to advocate for my community to use PrEP	Y	N	U

Part Two

Following a brief presentation on PrEP

The next questions ask how you feel about patients taking medicine to prevent HIV.

*PrEP stigma: Ask: Do you agree with the following statements?

12	If a patient was taking PrEP, others would think less of that patient	Y	N	U
13	If a patient was taking PrEP, others would avoid that patient	Y	N	U
14	If a patient was taking PrEP, that patient would feel comfortable telling a close friend	Y	N	U
15	If a patient was taking PrEP, the patient would think less of oneself	Y	N	U
16	If a patient was taking PrEP, others will think that patient has HIV	Y	N	U
17	My patients would feel comfortable telling others that they are taking PrEP	Y	N	U

*Attitudes towards PrEP: Read the following, tick Y, N, or U. ²

18	I am concerned that PrEP would not protect patients 100%	Y	N	U
19	I am concerned about the potential side effects of PrEP for my patients	Y	N	U
20	I think patients will be interested in PrEP	Y	N	U
21	I think patients would take the PrEP medication every day	Y	N	U
22	I think patients would come to the clinic monthly to get PrEP	Y	N	U
23	I am concerned that patients will not use condoms if they take PrEP	Y	N	U
24	I am concerned that patients will have more sexual partners if they take PrEP	Y	N	U
25	I am concerned that patients using PrEP will no longer get tested for HIV	Y	N	U
26	I am concerned that taking PrEP continuously would be too expensive for patients	Y	N	U
27	I am concerned that using PrEP would cause HIV drug resistance	Y	N	U

Interest in working with PrEP: Read the following, tick Y, N, or U ².

28	I would not recommend PrEP if it is not 100% effective*	Y	N	U
29	I have time to counsel patients about ways to decrease HIV risk	Y	N	U
30	I have time to counsel patients about PrEP	Y	N	U
31	I have the training I need to counsel patients about ways to decrease HIV risk	Y	N	U
32	I have the training I need to counsel patients about PrEP	Y	N	U
33	I believe HIV testing and treating HIV patients are more important than PrEPǂ	Y	N	U
34	I believe promoting safe sex practices will work better than PrEP to decrease risk of HIV infectionsǂ	Y	N	U
35	If available, I would recommend PrEP to my patients right nowǂ	Y	N	U
36	Should professional nurses prescribe and monitor patients on PrEP?	Y	N	U
37	Should PrEP be available to patients at primary care clinics?	Y	N	U

1. *Item 28 was excluded from the analysis because it was unclear to survey respondents
2. ǂIndicates items that were used as outcomes in regression analyses

Appendix 2

See Table 5.

Table 5 Factor Loadings