Pre-Exposure Prophylaxis Initiation and Adherence in Female Sex Workers, New Africa House Clinic in Harare, 2020-2021

Abstract

Prevention is key in keeping female sex workers (FSW) protected from Human Immunodeficiency Virus (HIV). Pre-Exposure Prophylaxis (PrEP) offers additional safety for populations who are at substantial risk of acquiring HIV. Recent studies have shown that FSW are among the key and vulnerable populations at most risk of contracting HIV infection. The purpose of this secondary data analysis was to determine factors associated with the female sex workers decision to initiate and adhere to PrEP medication up to the end of the cycle. Between June 2020 and December 2021, New Africa House Clinic recruited 5323 individuals and of these 1285 were FSW in the electronic medical records system-BAHMNI. Logistic Regression analysis was used to determine the predictor variables associated with the FSW' decision to initiate and adhere to PrEP. After adjusting for all other independent variables, the probability that FSW in the age group 20-24 were adherent to PrEP medication was 1.7 times higher compared to age category 18-19 (95% CI: 0.7-4.2) though not statistically significant. The Wald test showed statistically significant association with adherence to PrEP only in the 40-44 years age groups (p=0.022). Married FSW were 6.7% less likely to adhere to PrEP medication compared to single FSW (95%CI: 0.4–2.5). For FSW who were divorced, the probability was 15.6% less than the single FSW (95%CI: 0.5–1.3) and for widowed, the probability was 6.7 times more than the single FSW (95%CI: 1.0–46.4). The Wald test also showed statistically significant association with adhering to PrEP only in the two marital statuses, cohabiting (p=0.028) and separated (p=0.032). Participants referred from an index patient (p<0.001) and other partner organizations (p=0.034) had a negative association with adherence to PrEP medication. FSW not in a sero-discordant relationship were 9.6 times more likely to adhere to PrEP compared to those in a sero-discordant relationship (95% CI: 1.6-56.1). Those without a history of sexual abuse or gender-based violence were 4.5 times more likely to adhere to PrEP compared to those with the history of sexual abuse or gender-based violence (95% CI: 1.1 - 19.2). Decision to PrEP initiation in FSW was due to the knowledge of risk - being sexually active, inconsistent condom use and having multiple sexual partners. The study showed that older female sex workers are less likely to adhere to PrEP medication as well as those in sero- discordant relationship where not adherent to PrEP. Steps of the PrEP care continuum may be improved through targeted support where FSW are operating in the community including peer-based interventions and safe space groups where they can meet regularly. Learning from the decision-making process, and PrEP adherence and continuation experiences of these FSW can help inform programme adaptations and improvements to support wider uptake among highly vulnerable populations, both in PSH clinics and other contexts.