“We know this will be hard at the beginning, but better in the long term”: understanding PrEP uptake in the general population in Eswatini

ABSTRACT

Information regarding HIV pre-exposure prophylaxis (PrEP) for the general population is largely lacking, because the majority of PrEP demonstration projects have focused on key populations. This qualitative study examines barriers and facilitators to PrEP uptake and adherence among the general population in Eswatini, where PrEP is offered through public-sector primary-care clinics. We analysed 106 semi-structured in-depth interviews with healthcare workers (n = 26), stakeholders (n = 30), and clients who initiated, continued, declined or discontinued PrEP (n = 50). Some healthcare workers and stakeholders feared that PrEP would reduce condom use and cause drug resistance, while some clients feared possible side effects and the reaction of family members when learning of PrEP use. At the same time, respondents across all groups valued that PrEP could be taken without partner knowledge or consent, and that PrEP was available via public sector clinics. Clients felt that PrEP relieved the fear of HIV infection and thus bolstered enjoyment during sex. Overall, respondents described the general population approach to PrEP delivery as enabling and life-improving, despite the above concerns. Respondents recommended to create community PrEP promotion and delivery, gain community leaders' approval and understanding of PrEP, shorten the PrEP initiation process, and target men and adolescent girls.

KEYWORDS:

• Pre-exposure prophylaxis (PrEP)
• HIV
• qualitative
• Eswatini
• general population

Acknowledgements

We thank all our participants for their time and insights. We thank our Research Assistants for their dedication: Phiwayinkhosi Dlamini, Mxolisi Mavuso, Nelisiwe Masilela, David Fakudze and Phetsile Kunene. We thank Sam Beckham for guiding us in terms of PrEP literature. The authors would also like to thank the Eswatini Ministry of Health for their leadership and Mylan Pharmaceuticals for donation of TDF/3TC for the duration of the study.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethical approval

The study received ethical approval from the Eswatini Ministry of Health National Health Research Review Board (MH/599C/IRB 0009688/NHRRB538/17), Chesapeake Institutional Review Board, USA (Pro00021864). This study was exempted from additional ethical review from the Ethics Committee of the Medical School of Heidelberg University.

ORCID

Kate Bärnighausen http://orcid.org/0000-0002-4466-8921

Additional information

Funding

Funding for this research was received from the Bob L. Herd Foundation and the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor Award to Till Bärnighausen, which is funded by the Federal Ministry of Education and Research. The Olympia-Morata-Programm supports co-author Shannon A. McMahon in her position as an Assistant Professor at Heidelberg University. The funders had no role in the decision to publish, or preparation of the manuscript. The content is the responsibility of the authors and does not necessarily represent the views of any funder. Finally, we acknowledge financial support by the Deutsche Forschungsgemeinschaft within the funding programme Open Access Publishing, by the Baden-Württemberg Ministry of Science, Research and the Arts and by Heidelberg University.