“I am still negative”: Female sex workers’ perspectives on uptake and use of daily pre-exposure prophylaxis for HIV prevention in South Africa

Eakle, Robyn; Bothma, Rutendo; Bourne, Adam; Gumede, Sanele; Motsosi, K.S.; Rees, Helen

doi:10.1371/journal.pone.0212271

Cited by 33 publications

(46 citation statements)

References 43 publications

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“…Quantitative analyses among men who have sex with men (MSM) in the United States and Africa and heterosexual women in the United States have found that stigma significantly reduces PrEP interest, uptake and adherence [14,[22][23][24][25][26][27][28]. Stigma may also influence African women's PrEP adherence as shown by qualitative work conducted among AGYW and FSWs that describes women's need to discreetly use HIV prevention products and miss doses because of concerns around stigma [18,19,[27][28][29][30].…”

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confidence: 99%

The influence of HIV‐related stigma on PrEP disclosure and adherence among adolescent girls and young women in HPTN 082: a qualitative study

et al. 2020

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Introduction Stigma and disclosure concerns have been key barriers to oral pre‐exposure prophylaxis (PrEP) adherence for African adolescent girls and young women (AGYW) in efficacy trials. We aimed to understand the impact of these factors among African AGYW in an open‐label PrEP study. Methods HPTN 082 was an open‐label PrEP study among AGYW (ages 16 to 24) in Harare, Zimbabwe, and Cape Town and Johannesburg, South Africa from 2016 to 2018. Women starting PrEP were randomized to standard adherence support (counselling, two‐way SMS, monthly adherence clubs) or standard support plus drug‐level feedback. Serial in‐depth interviews were conducted among 67 AGYW after 13‐week and 26‐week study visits to explore experiences of stigma, disclosure and PrEP adherence. We analysed data by coding transcripts and memo‐writing and diagramming to summarize themes. Results AGYW described stigma related to sexual activity (e.g. “people say I'm a prostitute”) and being perceived to be living with HIV because of taking antiretrovirals (e.g. “my husband's friends say I'm HIV infected”). Participants who anticipated stigma were reluctant to disclose PrEP use and reported adherence challenges. Disclosure also resulted in stigmatizing experiences. Across all sites, negative descriptions of stigma and disclosure challenges were more common in the first interview. In the second interview, participants often described disclosure as an “empowering” way to combat community‐level PrEP stigma; many said that they proactively discussed PrEP in their communities (e.g. became a “community PrEP ambassador”), which improved their ability to take PrEP and encourage others to use PrEP. These empowering disclosure experiences were facilitated by ongoing HPTN 082 study activities (e.g. counselling sessions, adherence clubs) in which they could discuss PrEP‐related stigma, disclosure and PrEP adherence issues. Conclusions Stigma and disclosure challenges were initial concerns for African AGYW newly initiating PrEP but many were empowered to disclose PrEP use over their first six months of PrEP use, which helped them cope with stigma and feel more able to take PrEP regularly. PrEP programmes can foster disclosure through community and clinic‐based discussion, adherence clubs and activities normalizing sexual behaviour and PrEP use, which can reduce stigma and improve PrEP adherence and thus effectiveness.

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confidence: 99%

The influence of HIV‐related stigma on PrEP disclosure and adherence among adolescent girls and young women in HPTN 082: a qualitative study

et al. 2020

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“…The potential for individuals on PrEP to reduce their use of condoms due to negation of HIV risk is a commonly voiced concern . Nonetheless, acceptability studies suggest that FSWs consider PrEP a favourable user‐controlled back‐up option for when condoms fail or cannot be used, rather than an alternative . Based on a recent meta‐analysis, individuals starting PrEP have a high burden of STIs .…”

Section: Discussionmentioning

confidence: 99%

“…Pregnancy and childcare may also lead to women taking unplanned or unwanted breaks from sex work, thus adding to household insecurity . Conversely, for some FSWs, responsibility to care for children may be a motivator to use PrEP in order to stay healthy and maintain their earning potential .…”

Section: Discussionmentioning

confidence: 99%

“…Pre‐exposure prophylaxis (PrEP) is a relatively new intervention being offered to FSWs and other populations with high risk of HIV acquisition. Although the potential benefits and acceptability of PrEP among FSWs have been previously established , specific consideration of the implications of PrEP for family planning in this population is lacking.…”

Section: Introductionmentioning

confidence: 99%

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HIV pre‐exposure prophylaxis for female sex workers: ensuring women’s family planning needs are not left behind

et al. 2020

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Introduction Female sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre‐exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs. Discussion FSWs have high unmet need for effective contraception and unintended pregnancy is common in low‐ and middle‐income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk‐taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single‐focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real‐life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two‐fold increase in condomless sex among FSWs on PrEP, which, given low use of non‐barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW‐focused community‐based HIV services is likely to be the most effective model for improving access to non‐barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed. Conclusions As PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women’s rights.

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“…PrEP demonstration before its roll out could be critcical for the success of the program. The first demonstration study in South Africa reported that not having faith in efficacy of PrEP affected retention and adherence (32). Several side effects which were the symptoms of Reproductive Tract Infections (RTIs) were openly associated with any medical product being used by them.…”

Section: 2) Preserving Beauty / Female Physical Attributes: Concernmentioning

confidence: 99%

Oral PrEP: Is it only a pill to be swallowed: a qualitative study among female sex workers in India

Sahay

Verma

Shewale

et al. 2020

Preprint

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Background Empowering female sex workers (FSWs) through women controlled HIV prevention option has been in focus globally. The success of targeted interventions among FSWs indicates that this population could become an important and feasible target for oral PrEP (Pre Exposure Prophylaxis). A qualitative study was conducted to study FSWs’ willingness to use oral PrEP in India.Methods In-depth interviews (n=39) and two focus group discussions (n=14) were conducted at 3 high HIV prevalence urban and rural sites in India among FSWs. Key informant interviews (n=34) were conducted with a bisexual man, 6 brothel keepers and 27 Health Care Providers (HCPs). The study explored issues around willingness to use oral PrEP. The study was approved by the respective institutional ethics committee of the study sites. Thematic analysis using the grounded theory approach was used to analyze the data in N-VIVO version 8.0. Results FSWs were willing to use daily oral PrEP and hoped to use it as an alternative to the male condom. One of the emerging themes showed that the situations of condom-less sex over which FSWs had no control. This made them desire oral PrEP which was easy to use and geared to provide independence, financial gains, and privacy. HCP initiated oral PrEP was not acceptable. However, HCPs pointed out safety monitoring needs. For FSWs, safety concerns pertained to their own physical/ aesthetic attributes and reproductive system in a major way. Adherence emerged as a challenge because of: 1) FSWs’ prevalent habit and need of alcohol use; 2) their notion of daily dosing being too mundane; 3) Stigma because Oral PrEP is ARV based. Alcohol use and dread of repetitive dose bring forth the need for long-acting oral PrEP. Conclusion Oral PrEP is acceptable among FSWs; it should be rolled out alongside strong messages on STI protection given the perceptions of FSWs that oral PrEP might replace condoms. Education about ARV-based oral PrEP needs to be spelled to prevent stigma. Adherence counseling should take cognizance of FSWs’ lifestyle, specifically making oral PrEP less of a mundane task.

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“I am still negative”: Female sex workers’ perspectives on uptake and use of daily pre-exposure prophylaxis for HIV prevention in South Africa

Cited by 33 publications

References 43 publications

The influence of HIV‐related stigma on PrEP disclosure and adherence among adolescent girls and young women in HPTN 082: a qualitative study

The influence of HIV‐related stigma on PrEP disclosure and adherence among adolescent girls and young women in HPTN 082: a qualitative study

HIV pre‐exposure prophylaxis for female sex workers: ensuring women’s family planning needs are not left behind

Oral PrEP: Is it only a pill to be swallowed: a qualitative study among female sex workers in India

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