PrEP Knowledge, Attitudes and Use Among Vulnerable Women Engaged in Sex Work in Uganda: Implications for HIV Prevention

Background and Purpose: Women engaged in sex work (WESW) are disproportionately affected by HIV in low and middle income countries. In Uganda HIV prevalence among WESW is 37% compared to the national prevalence of 5.7%. Such marginalized women experience poverty, gender-based violence, and other issues that reduce power and limit ability to negotiate condom use. Female-controlled strategies, including pre-exposure prophylaxis (PrEP), may afford women more protection, but many barriers to access and use persist. This study examined baseline use and attitudes towards PrEP among economically-vulnerable WESW in Uganda who recently enrolled in a randomized clinical trial to test the impact of a combination HIV risk reduction and economic empowerment intervention on risk reduction outcomes (clinicaltrials.gov, NCT03583541).

Methods: 542 WESW were enrolled in the Kyaterekera Project across 19 high HIV-prevalent geographical areas in fishing regions of Lake Victoria from June 2019 to March 2020. Women were eligible to participate if they met the following criteria: 1) age 18 or over; 2) reported engagement in unsafe transactional sex (defined as a sex act in exchange for pay) in the past 30 days; and 3) reported engagement in one or more episodes of unprotected sex in the past 30 days. Women were tested for HIV and other sexually transmitted infections at study enrollment and connected with Antiretroviral therapy or PrEP, based on need and interest. Women completed baseline assessment at enrollment. Descriptive statistics examined screening, enrollment and baseline assessment data related to women’s use of and attitudes towards PrEP.

Results: While 63% (n=350) of women reported that they were HIV negative (or unaware of status) at study enrollment actual biological blood sample testing determined that 59% of women (n=322) were HIV negative. Among women testing negative, 11% (n=36) were already enrolled on PrEP. Of the WESW not already on PrEP, half of them agreed to initiate PrEP (n=158; 49%), while the remaining women declined PrEP (n=128, 39%), citing inability to adhere to daily medication, and concerns that PrEP packaging resembles HIV medication, fearing stigma associated with HIV-positive status. Despite declinations for actual PrEP initiation, women overwhelmingly endorsed willingness to use PrEP (n=317; 91%). Barriers expressed by those less inclined included drug side effects and fear of discrimination by others. Most women prefer to receive information from physicians (n=314; 90%) and to obtain PrEP through venues that are convenient, offer higher quality of care and greater privacy protection.

Conclusions: Preliminary findings indicate that while most women endorse PrEP use, many remain reluctant to use PrEP. This discordance between women’s endorsement conceptually and yet unwillingness to use PrEP highlights a challenge at the heart of HIV prevention for many women. Findings reinforce existing literature and indicate the need for creating easy, confidential access to PrEP with ongoing medical support in conjunction with structural level efforts to destigmatize PrEP use, integrating positive messaging into health promotion campaigns for women and their families. Qualitative research to more closely examine how best to reduce barriers are also needed.