HIV Pre-Exposure Prophylaxis in the Real World: A Qualitative Exploration of Uptake and Adherence Among Women Who Engage in Sex Work in Gauteng, South Africa

Abstract

Nearly 66% of new HIV infections in 2015 occurred in sub-Saharan Africa (1). This demonstrates the urgent need for the effective deployment of prevention modalities in the region. In recent years, an increasing allocation of resources has been diverted towards research aimed at HIV chemoprophylaxis in non-infected individuals. In outreach sites where oral PrEP is provided through mobile clinics, we conducted 24 in-depth interviews with women engaged in sex work identified through systematic random sampling and 9 in-depth interviews with healthcare providers identified through purposive sampling. Through an iterative process, data were analysed for recurring patterns or themes using a grounded theory approach. Results: Women’s narratives indicated that uptake and adherence to oral PrEP is strongly influenced by forces outside of the women’s control. Among factors identified in women’s narratives include extreme economic adversity, uncooperative gatekeepers intimate partner violence, restricted focus of PrEP programs and fractured trust. Conclusions: This qualitative study indicates that there are complex and interconnected structural forces that actively shape women’s engagement and retention in PrEP that are not currently being addressed in the conceptualization and roll-out of PrEP programs. To address uptake and adherence to PrEP we propose a rethink of the current PrEP HIV care model that provides a corrective lens for the current biomedical tunnel vision by integrating interventions that will address the confluent forces influencing uptake and adherence such as intimate partner violence, alcohol and drug addiction, abuse by police and the presence of extreme economic deprivation.