Background: Barriers to the uptake of open-label pre-exposure prophylaxis (PrEP) offered in a population-based context in high HIV prevalence settings have yet to be studied and could include additional barriers to those identified in prior studies in targeted populations.
Methods: SEARCH (NCT01864603) is a combination prevention study in 32 communities of ~10,000 persons each in rural Kenya and Uganda. The study is offering targeted PrEP to individuals age ≥15 years at risk for HIV based on an empirically-derived risk score for HIV seroconversion or self-identified risk for HIV, including serodiscordant partnership. We studied barriers to PrEP uptake via 1) surveys of clients who expressed interest in PrEP but did not start, 2) surveys of community members, and 3) discussions with PrEP counselors and providers in SEARCH. Surveys consisted of open-ended questions about reasons for declining PrEP and perceptions about PrEP.
Results: In 6 communities, we surveyed 63 community members (40% men, 35% women, 25% youth) and 42 clients who did not start PrEP (38% women, median age 28 years [range 16-53], 45% at risk for HIV by empiric score, 43% self-identified at risk). Barriers to PrEP uptake were identified at multiple levels (Figure 1), including individual (pill attributes, side effects, specimen collection, low perceived risk of HIV acquisition, misconceptions about PrEP use), partner/household (need to consult with and receive approval from a spouse or parent prior to starting PrEP), structural (work or school attendance, distance to clinic, transport costs, mobility), and community (stigma, community beliefs). Many individuals expressed a preference for non-daily medication taken pericoitally or during holidays.

Figure 1: Multi-level barriers to PrEP Uptake
[Figure 1: Multi-level barriers to PrEP Uptake]

Conclusions: In communities offered targeted PrEP in this population-based study, multi-level barriers to PrEP uptake, including structural/organizational, were identified. Strategies are needed to address these barriers, such as community sensitization, expanded provision of information on PrEP, and community-based delivery mechanisms to facilitate access to PrEP.

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