“It’s hard for us men to go to the clinic. We naturally have a fear of hospitals.” Men’s risk perceptions, experiences and program preferences for PrEP: A mixed methods study in Eswatini

Abstract

Few studies on HIV Pre-Exposure Prophylaxis (PrEP) have focused on men who have sex with women. We present findings from a mixed-methods study in Eswatini, the country with the highest HIV prevalence in the world (27%). Our findings are based on risk assessments, in-depth interviews and focus-group discussions which describe men's motivations for taking up or declining PrEP. Quantitatively, men self-reported starting PrEP because they had multiple or sero-discordant partners or did not know the partner's HIV-status. Men's self-perception of risk was echoed in the qualitative data, which revealed that the hope of facilitated sexual performance or relations, a preference for pills over condoms and the desire to protect themselves and others also played a role for men to initiate PrEP. Trust and mistrust and being able or unable to speak about PrEP with partner(s) were further considerations for initiating or declining PrEP. Once on PrEP, men's sexual behavior varied in terms of number of partners and condom use. Men viewed daily pill-taking as an obstacle to starting PrEP. Side-effects were a major reason for men to discontinue PrEP. Men also worried that taking anti-retroviral drugs daily might leave them mistaken for a person living with HIV, and viewed clinic-based PrEP education and initiation processes as a further obstacle. Given that men comprise only 29% of all PrEP users in Eswatini, barriers to men's uptake of PrEP will need to be addressed, in terms of more malefriendly services as well as trialing community-based PrEP education and service delivery.

Feasibility of a community‐based delivery model for HIV pre‐exposure prophylaxis among bar patrons in rural South Africa

“…Men's acceptance of PrEP has primarily been evaluated among men who have sex with men [28]. Men who have sex with women acknowledge that multiple sexual partners are risky but culturally acceptable, and that they would consider PrEP as an acceptable risk‐mitigation strategy, though anticipate barriers with clinic‐based care [18, 19].…”

“…The greatest gap in the PrEP cascade is uptake, particularly for young and mobile individuals [14]. Community‐based PrEP delivery has the potential to address this gap but few models exist, particularly in rural areas [3,8,14–19]. Furthermore, little data exist on PrEP use in the context of alcohol consumption.…”

Cultural Repertoires and Situated Selections as an Alternative Framework to Hegemonic Masculinities: Findings From Eswatini

“…Historically, HIV policies and interventions hardly mentioned MSW ( Higgins et al, 2010 ; Mills et al, 2012 ). While MSW’s role in preventing HIV in women was highlighted ( Amaro, 1995 ), MSW’s own susceptibility to HIV remained largely unacknowledged ( Dworkin, 2015 ), see also ( Berner-Rodoreda et al., 2020 , 2021 ). MSW were “relegated to the margins of a health care and service field that was developed historically within a context which privileges the priorities of gay men and heterosexual women” ( Antoniou et al, 2012 , p. 8), thus positioning MSW at the bottom of a gender hierarchy with regard to accessing health services.…”

“…MSW’s PrEP experiences are a new and under-researched area of interest ( Koechlin et al, 2017 ), as PrEP is only gradually being offered to the general population in high-prevalence countries. Even studies with adolescent or adult MSW published in the 2020s mainly portray MSW’s views rather than their actual experience of PrEP ( Hannaford et al, 2020 ; Muhumuza et al, 2021 ; Yoshioka et al, 2020 ), see also ( Berner-Rodoreda et al, 2020 ). Qualitative PrEP studies that included MSW primarily focused on serodiscordance as part of PrEP trials ( Carroll et al, 2016 ; Nakku-Joloba et al, 2019 ; Patel et al., 2016 ; Toledo et al, 2015 ; Ware et al, 2012 ), see also ( Berner-Rodoreda et al, 2020 ).…”

HIV PrEP is more than ART‐lite: Longitudinal study of real‐world PrEP services data identifies missing measures meaningful to HIV prevention programming

“…Published modelling studies suggest diminishing impact and cost effectiveness as use duration decreases [ 5 , 6 ], leading to speculations about whether clients’ ability and willingness to use PrEP “long enough” may prove too difficult to make it a feasible and strategic HIV prevention intervention in low‐ and middle‐income country settings [ 7 , 8 ]. However, PrEP users have reported risk‐use alignment, which refers to non‐continuous dosing corresponding to episodic risk that often spans days or weeks rather than consecutive, continuous months [ 9 , 10 , 11 , 12 , 13 , 14 , 15 ]. There is early evidence of reduced HIV incidence even in the context of clients’ early and frequent PrEP discontinuation [ 16 , 17 , 18 ], which points to a need for appropriate use metrics to more fully describe use patterns, especially non‐continuous dosing, to ensure PrEP use remains as effective as possible [ 19 , 20 ].…”