Pre‐exposure prophylaxis implementation gaps among people vulnerable to HIV acquisition: a cross‐sectional analysis in two communities in western Kenya, 2021–2023

Abstract

IntroductionDespite the increasing availability of prevention tools like pre‐exposure prophylaxis (PrEP), HIV incidence remains disproportionately high in sub‐Saharan Africa. We examined PrEP awareness, uptake and persistence among participants enrolling into an HIV incidence cohort in Kenya.MethodsWe used cross‐sectional enrolment data from the Multinational Observational Cohort of HIV and other Infections (MOCHI) in Homa Bay and Kericho, Kenya. The cohort recruited individuals aged 14–55 years with a recent history of sexually transmitted infection, transactional sex, condomless sex and/or injection drug use. Participants completed questionnaires on PrEP, demographics and sexual behaviours. We used multivariable robust Poisson regression to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for associations with never hearing of PrEP, never taking PrEP and ever stopping PrEP.ResultsBetween 12/2021 and 5/2023, 399 participants attempted the PrEP questionnaire, of whom 316 (79.2%) were female and median age was 22 years (interquartile range 19–24); 316 of 390 participants (81.0%) engaged in sex work or transactional sex. Of 396 participants who responded to the question, 120 (30.3%) had never heard of PrEP. Of 275 participants who had heard of PrEP, 206 (74.9%) had never taken it. Of 69 participants who had ever taken PrEP, 50 (72.5%) stopped it at some time prior to enrolment. Participants aged 15–19 years more often reported never taking PrEP compared with those 25–36 years (aPR 1.31, 95% CI: 1.06–1.61). Participants who knew someone who took PrEP less often reported never hearing about PrEP (aPR 0.10, 95% CI: 0.04–0.23) and never taking PrEP (aPR: 0.69, 95% CI: 0.60–0.80). Stopping PrEP was more common among participants with a weekly household income ≤1000 versus >1000 Kenyan shillings (aPR 1.40, 95% CI: 1.02–1.93) and those using alcohol/drugs before sex (aPR 1.53, 95% CI: 1.03–2.26). Stopping PrEP was less common among those engaging in sex work or transactional sex (aPR 0.6, 95% CI: 0.40–0.92).ConclusionsWe identified substantial gaps in PrEP awareness, uptake and persistence, which were associated with potential system‐ and individual‐level risk factors. Our analyses also highlight the importance of increasing PrEP engagement among individuals who do not know others taking PrEP.