Women at high risk of HIV-infection in Kampala, Uganda, and their candidacy for PrEP

Abstract

Pre-exposure prophylaxis (PrEP), antiretroviral medication for prevention of HIV-acquisition, is part of biomedical HIV prevention strategies recommended for people at risk of HIV-infection. A decision to take PrEP depends on an assessment of ‘being at risk’ either by an individual, or healthcare provider. In this paper, we draw on the concept of ‘candidacy’ to examine the different ways in which women attending a dedicated clinic in Kampala, Uganda, for women at risk of HIV infection (including sex workers), assessed their suitability for PrEP. We conducted in-depth interviews with 30 HIV negative women up to four different times, to gather information on the motives for taking PrEP, and their life history and daily life. All the women described the relevance of PrEP to mitigate their risk of HIV infection. However, there were challenges to adherence because of alcohol use, irregular working hours and a fear of being seen taking pills that others might assume to be HIV treatment. The ways in which the different women used PrEP and interpreted the place of PrEP in their lives were not solely based on their assessment of protecting themselves during sex work. They also used PrEP to guard against infection from their regular partners, and as a tool to allow them to make more money safely, by having sex without a condom with clients. While eligibility to access PrEP was predicated on the women's being in an ‘at risk’ population group, an incentive to use PrEP was to protect themselves from HIV acquisition from a long-term partner and preserve the ‘trust’ in their intimate relationship by having condom-less sex. Applying a candidacy lens we highlight the complexity in how women experience and present as being ‘at risk’ and query the criteria on which categories of risk and PrEP eligibility are determined.

Assessing acceptability of pre-exposure prophylaxis (PrEP) among participants in an HIV vaccine preparedness study in southwestern Uganda

“…Our study findings show that individuals at high risk of HIV infection who were enrolled in an HIV vaccine preparedness study in Uganda were interested in taking oral PrEP because they understood that it would protect them against acquisition of HIV, a finding corroborated by other recent work in Uganda [11,23,24]. However, among those who had chosen to start PrEP many did not initiate and/or persist with the drug.…”

How gender norms and ‘good girl’ notions prevent adolescent girls and young women from engaging with PrEP: qualitative insights from Zimbabwe

“…A study from Kenya and Uganda found PrEP to be perceived as a means to help young women control their HIV risk in a context where they had limited control of male partners’ risky behavior [ 18 ]. Similar observations have been made in Uganda, where AGYW engaged in transactional sex saw PrEP as a tool to charge clients more for sex without a condom [ 19 ].…”

“I prefer to take pills when I plan to have sex”: Perceptions of on-demand versus daily oral pre-exposure prophylaxis among adolescents in Kampala, Uganda

“…One major challenge to acceptability of PrEP in this study, as has been noted elsewhere ( Kawuma et al, 2021 ; Muhumuza et al, 2021 ), was taking pills which are similar to those taken by people living with HIV. Hence participants preferred on-demand PrEP, largely because it would shelter them from being seen “taking pills daily".…”