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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 pill-taking 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.

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Acknowledgements

We gratefully acknowledge the Ministries of Health of Uganda and Kenya, the SEARCH research team, collaborators and advisory boards, and especially all communities and participants involved. We also wish to thank Prof. Janet Seeley of the London School of Hygiene and Tropical Medicine for her helpful review of an earlier version of this manuscript.

Funding

Research reported in this article was supported by the National Institutes of Health, NIAID under award number UM1AI068636, NCT #01864603 (AIDS Clinical Trial Group, Kuritzkes PI; SEARCH Supplement, Havlir PI) and in part by the Bill and Melinda Gates Foundation and Gilead Sciences. CAK was also supported by funding from the National Institute of Mental Health (K23 MH114760) and the Gilead Research Scholars Program in HIV. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, PEPFAR, Bill and Melinda Gates Foundation or Gilead.

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Correspondence to Carol S. Camlin.

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Camlin, C.S., Koss, C.A., Getahun, M. et al. Understanding Demand for PrEP and Early Experiences of PrEP Use Among Young Adults in Rural Kenya and Uganda: A Qualitative Study. AIDS Behav (2020). https://doi.org/10.1007/s10461-020-02780-x

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Keywords

  • HIV prevention
  • Pre-exposure prophylaxis (PrEP)
  • Adolescents
  • Youth
  • Sub-Saharan africa