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Qualitative Assessment of Barriers and Facilitators of PrEP Use Before and After Rollout of a PrEP Program for Priority Populations in South-central Uganda

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Abstract

Uganda piloted HIV pre-exposure prophylaxis (PrEP) for priority populations (sex workers, fishermen, truck drivers, discordant couples) in 2017. To assess facilitators and barriers to PrEP uptake and adherence, we explored perceptions of PrEP before and experiences after rollout among community members and providers in south-central Uganda. We conducted 75 in-depth interviews and 12 focus group discussions. We analyzed transcripts using a team-based thematic framework approach. Partners, family, peers, and experienced PrEP users provided adherence support. Occupational factors hindered adherence for sex workers and fishermen, particularly related to mobility. Pre-rollout concerns about unskilled/untrained volunteers distributing PrEP and price-gouging were mitigated. After rollout, awareness of high community HIV risk and trust in PrEP effectiveness facilitated uptake. PrEP stigma and unexpected migration persisted as barriers. Community-initiated, tailored communication with successful PrEP users may optimize future engagement by addressing fears and rumors, while flexible delivery and refill models may facilitate PrEP continuation and adherence.

Resumen

En 2017, Uganda introdujo profilaxis pre-exposición (PrEP), dirigida a las populaciones con alto riesgo de contraer al VIH (trabajadoras sexuales, pescadores, camioneros, parejas sero-discordantes). Para investigar facilitadores y barreras para la adopción y la adherencia a la PrEP, exploramos percepciones de PrEP antes y después de su introducción en Uganda. Realizamos 75 entrevistas y 12 grupos focales con miembros de la comunidad y trabajadores de salud. Analizamos las transcripciones temáticamente usando un marco de referencia. Parejas, familias, compañeros, y clientes usando PrEP apoyaron a los demás mantener adherencia. Movilidad fue una barrera para la adherencia a la PrEP para trabajadoras sexuales y pescadores. Preocupaciones sobre el entrenamiento de los distribuidores de PrEP y la especulación de precios no fueron realizadas. Percepciones del riesgo del VIH y confianza en la eficacia de PrEP facilitaron su adopción. Estigma y migración inesperada persistieron como barreras para la adopción de PrEP. Comunicaciones manejadas por clientes usando PrEP pueden motivar interés en PrEP y abordar rumores. Sistemas flexibles del entrego y la recarga de medicinas pueden permitir continuación de, y adherencia a, la PrEP.

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Acknowledgements

We would like to thank our RHSP Social and Behavioral Science team who collected this qualitative data: Charles Ssekyawa, Dauda Isabirye, Aminah Nambuusi, Rosette Nakubulwa, and Ann Linda Namuddu. We appreciate Grace Mongo Bua who contributed to qualitative coding of several transcripts during data analysis. We also thank all study participants who graciously shared their time, thoughts, and experiences. We acknowledge research grant funding support from the US National Institute of Mental Health, the US National Institute of Allergy and Infectious Diseases, the US National Institutes of Health Fogarty International Center, the JHU Center for AIDS Research, The Swedish Physicians Against AIDS Research Foundation, and the Division of Intramural Research at the US National Institute of Allergy and Infectious Diseases. We also acknowledge the United States President’s Emergency Program for AIDS Relief (PEPFAR) through Centers for Disease Control and Prevention (CDC) which supports the provision of pre-exposure prophylaxis to Ugandans in the study region.

Funding

This research was supported by the US National Institute of Mental Health (R01MH090173, R01MH107275), the US National Institute of Allergy and Infectious Diseases (R01AI143333), the US National Institutes of Health Fogarty International Center (D43TW010557), the JHU Center for AIDS Research (P30AI094189), the Swedish Physicians Against AIDS Research Foundation, and in part by the Division of Intramural Research at the US National Institute of Allergy and Infectious Diseases. The funders played no role in data collection, interpretation, or reporting.

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  1. William Ddaaki, Susanne Strömdahl and Ping Teresa Yeh are co-first authors, and Anna Mia Ekström and Caitlin E. Kennedy are co-senior authors.

Authors and Affiliations

  1. Rakai Health Sciences Program, Kalisizo, Uganda

    William Ddaaki, Neema Nakyanjo, Joseph Kagaayi, Godfrey Kigozi, Gertrude Nakigozi, Steven J. Reynolds & Fred Nalugoda

  2. Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden

    Susanne Strömdahl & Anna Mia Ekström

  3. Section of Infectious Diseases, Department of Medical Sciences, Uppsala University, Uppsala, Sweden

    Susanne Strömdahl

  4. Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., E5547, Baltimore, MD, 21205, USA

    Ping Teresa Yeh, Joseph G. Rosen, Larry W. Chang & Caitlin E. Kennedy

  5. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Jade Jackson, Larry W. Chang & Steven J. Reynolds

  6. Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Jade Jackson & M. Kathryn Grabowski

  7. Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA

    Steven J. Reynolds

  8. Department of Infectious Disease, Division of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Larry W. Chang & Steven J. Reynolds

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  1. William Ddaaki
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Contributions

All authors contributed to the study conception and design. Field guide preparation was led by CEK, PTY, JGR, SS, and AME, with feedback from all authors. Data collection was led by WD and NN. Data analysis was performed by WD, SS, PTY, JGR, JJ, NN, AME, and CEK. Data synthesis was led by WD, PTY, and CEK, with help from co-authors. The first draft of the manuscript was written by WD, SS, and PTY. All authors reviewed and commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Caitlin E. Kennedy.

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The authors declare that they have no conflicts of interest.

Ethical Approval

Approval was obtained from the Research and Ethics Committee of the Uganda Virus Research Institute, the Uganda National Council of Science and Technology), the Johns Hopkins School of Medicine eIRB, and the Western IRB.

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Informed consent was obtained from all participants.

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Ddaaki, W., Strömdahl, S., Yeh, P.T. et al. Qualitative Assessment of Barriers and Facilitators of PrEP Use Before and After Rollout of a PrEP Program for Priority Populations in South-central Uganda. AIDS Behav 25, 3547–3562 (2021). https://doi.org/10.1007/s10461-021-03360-3

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