Readiness for Use of HIV Preexposure Prophylaxis Among Men Who Have Sex With Men in Malawi: Qualitative Focus Group and Interview Study

Abstract

Background Men who have sex with men (MSM) are a key group for HIV interventions in Malawi considering their high HIV prevalence (17.5% compared to 8.4% among men in the general population). The use of oral preexposure prophylaxis (PrEP) presents a new opportunity for MSM to be protected. We present the findings from a qualitative assessment designed to assess awareness of and willingness and barriers to using PrEP among MSM in Malawi. Objective The 3 main objectives of this assessment were to determine: (1) awareness of PrEP, (2) factors that influence willingness to use PrEP, and (3) potential barriers to PrEP use and adherence among MSM in order to guide the design and implementation of a PrEP program in Malawi. Methods Ahead of the introduction of PrEP in Malawi, a qualitative study using in-depth interviews (IDIs) and focus group discussions (FGDs) was conducted in October 2018 in Blantyre, Lilongwe, and rural districts of Mzimba North and Mangochi. With support of members of the population, study participants were purposively recruited from 4 MSM-friendly drop-in centers where MSM receive a range of health services to ensure representativeness across sites and age. Participants were asked what they had heard about PrEP, their willingness to use PrEP, their barriers to PrEP use, and their preferences for service delivery. The data were analyzed using a thematic content analysis framework that was predetermined in line with objectives. Results A total of 109 MSM were interviewed—13 through IDIs and 96 through FGDs. Most participants were aware of PrEP as a new HIV intervention but had limited knowledge related to its use. However, the majority were willing to use it and were looking forward to having access to it. IDI participants indicated that they will be more willing to take PrEP if the dosing frequency were appropriate and MSM were involved in information giving and distribution of the drug. FGD participants emphasized that places of distribution and characteristics of the service provider are the key factors that will affect use. Knowing the benefits of PrEP emerged as a key theme in both the IDIs and FGDs. Participants highlighted barriers that would hinder them from taking PrEP such as side effects which were cited in IDIs and FGDs. Key factors from FGDs include cost, fear of being outed, drug stockouts, fear of being known as MSMs by wives, and lack of relevant information. FGDs cited stigma from health care workers, forgetfulness, and community associated factors. Conclusions Despite having inadequate knowledge about PrEP, study participants were largely willing to use PrEP if available. Programs should include an effective information, education, and communication component around their preferences and provide PrEP in MSM-friendly sites.

Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa

“…Fourteen articles13 68–80 were partially intersectional stigma studies incorporating an intersectional approach to some elements of the analysis or presentation of their findings. We also identified 10 articles81–90 that studied multiple stigmas in a non-intersectional manner and 142 articles4 13 16–18 21 51 52 91–224 that studied one stigma in one population of SGM or studied one stigma in each of multiple populations (eg, SSSAB stigma only among MSM and transgender stigma only among TGW). A summary of each intersectional stigma study (n=21) appears in online supplemental file 2 and a summary of each non-intersectional stigma study (n=152) appears in online supplemental file 3.…”

Multifaceted Barriers to Rapid Roll-out of HIV Pre-exposure Prophylaxis in China: A Qualitative Study Among Men Who Have Sex with Men

“…This paper offers several implications for future research and public health practitioners to promote PrEP in China. First, approaches are urgently needed to normalize PrEP messaging outside of HIV/STI-related locations like hospitals and clinics (e.g., adding PrEP into sex education curricula) and expand PrEP messaging within and beyond MSM-affiliated spaces [ 42 ]. Second, in addition to scaling-up PrEP delivery in traditional clinical settings, a multi-pronged strategy could invest in developing supplemental pathways for PrEP provision, such as through CBOs and legitimate online pharmacies [ 14 , 43 ], to overcome MSM’s anticipated and experienced multi-level barriers to initiation and maintenance.…”

Understanding PrEP decision making among pregnant women in Lilongwe, Malawi: A mixed‐methods study

“…For some, this anticipated stigma was related to their own confusion about the difference between PrEP and ART. In contexts like Malawi where the adult HIV prevalence approaches 9% [ 38 ], familiarity with ART is likely high, while familiarity with novel interventions like PrEP is likely low [ 39 , 40 , 41 ]. While communicating that TDF/FTC has been used safely as ART may provide safety assurances, it may also lead to confusion about women's true HIV status and raise anticipated stigma [ 42 , 43 , 44 ].…”