Low awareness of oral and injectable PrEP among high-risk adolescent girls and young women in Kampala, Uganda

Although various HIV prevention interventions (biomedical, behavioral and structural) have mitigated the spread of HIV [1], the number of new cases among adolescent girls and young women (AGYW) remains unacceptably high [2, 3]. In 2019, an estimated 1.7 million adolescents aged 10–19 years were living with HIV across the globe of whom 10% were newly infected [4]. In sub-saharan Africa, AGYW account for 24% of new HIV infections [5] with an estimated HIV prevalence four times higher than their male peers [4, 5]. Additionally, about 5,000 AGYW aged 15–24 years are newly infected with HIV every week [5, 6]. In Eastern and Southern Africa alone, AGYW accounted for 26% of new infections in 2019 [5]. In Uganda, the prevalence of HIV among adolescent sex workers is 22.5% [7]. Most of these are involved in high-risk sexual behavior including sex work and having multiple partners, which has accelerated the spread of HIV in this age group.

The World Health Organization (WHO) recommends the use of oral pre-exposure prophylaxis (PrEP) to reduce the number of new HIV infections among high-risk populations [8], and many national programs have adopted this biomedical HIV prevention strategy [9]. Recent long-acting injectable PrEP findings have shown that it is safe and highly effective [10]. Additionally there many products in the pipeline that are being evaluated for example the PrEP Implant [11]. It is essential that awareness of these methods are built early at the population level. In 2018, of the 3 million people at substantial risk of HIV [12], only 381,580 people were taking oral PrEP worldwide. Of these, only 27% were from sub-saharan Africa with a majority of these PrEP users being AGYW [13]. By July 2020, an estimated 31,000–32,000 people were using PrEP in Uganda, which was lower than the Ministry of Health target of 90,000 people at risk [14].

PrEP is highly effective when adherence is good [15, 16]. A sub study among partners in East Africa, found that high PrEP adherence (> 80%) was associated with 100% PrEP efficacy [17]. However, there is limited awareness of oral PrEP as an HIV prevention method among populations at high risk for HIV in sub-Saharan Africa despite years of science and nascent programs to provide it [18]. The prevalence of PrEP awareness among AGYW remains unknown within Uganda [19] and poor uptake has been reported [18, 20]. Awareness of novel HIV prevention methods among key populations remains important as it will likely motivate uptake and adherence to future prevention products. We therefore need to improve understanding of awareness of both available and future HIV prevention methods. Literature suggests that most individuals at risk support PrEP usage once provided with details on its use and efficacy [21]. Additionally a study among adolescents in the US reported that many persons at risk do not know how to access oral PrEP even if they are aware that they need it [22]. A recent study among AGYW in South Africa found that only 19% were aware of PrEP, and family support and discussing HIV and sexually transmitted infections with sexual partners were associated factors for PrEP awareness [2]. Also, a recent study among Black and Latinx adolescents in the US residing in higher prevalence areas revealed that only 38% knew about PrEP [23].

In recent clinical trials, injectable PrEP has proven to be 89% more effective than oral PrEP [10] and will likely be available as a prevention tool soon. Raising awareness of oral or injectable PrEP is a first and necessary step to increase their use among at-risk AGYW, yet data is still limited in Uganda. Since 2015, the Determined Resilient Empowered AIDS-free Mentored and Safe women (DREAMS) project was implementing a package of HIV prevention services including PrEP provision to AGYW in selected districts of Uganda [24‐26]. Also, at the time we enrolled the cohort of AGYW, the Ministry of Health in Uganda was conducting trainings for health workers and rolling out oral PrEP to selected key populations and, 3 clinical trial sites in Uganda were enrolling for the HIV Prevention Trials Network (HPTN084) trial to compare efficacy of long acting injectable cabotegravir to daily oral Truvda [10, 27]. The aim of our study was to determine awareness of oral and injectable PrEP, and to assess factors associated with awareness of oral PrEP among high-risk AGYW in Kampala, Uganda.

We found only one in four AGYW participants had heard about oral PrEP, and fewer than one in twenty had ever heard about injectable PrEP, a hypothetical intervention still in clinical trials at the time of this study. Peer interactions contributed more to awareness of oral and injectable PrEP when compared to other sources such as health workers and media.

We also found that most of the AGYW reported being willing to use either oral or injectable PrEP after being educated about these methods, including details on the mode of administration, frequency of use, and the fact that the drugs have been found effective in preventing HIV infection. Alcohol consumption risk, number of sexual partners and condom use were associated with Oral PrEP awareness. Our findings are consistent with other studies in sub-Saharan Africa, which have reported low oral PrEP awareness among high-risk populations [2, 18, 20, 31, 32]. This finding could explain the observed low uptake of oral PrEP in the early oral PrEP implementation phase in several communities [33]. Also within these diverse communities, there have been few awareness campaigns, which could also explain the low uptake [2, 34]. On the other hand, low awareness of oral and injectable PrEP may be attributed to the fact that these prevention methods are new and have not been fully appreciated within these communities [35]. Future HIV prevention interventions should leverage on peer to peer networks to not only increase awareness about oral PrEP and other new HIV prevention methods but to also influence uptake and adherence.

Participants with multiple sexual partners had a higher prevalence of oral PrEP awareness. Previous studies have reported similar findings [36, 37]. Since exposure to multiple partners places individuals at higher risk of acquiring different diseases including HIV, individuals involved in such practice may be more likely to search for methods to protect themselves and this could explain the higher PrEP awareness we observe within this group in the current study. Also, it is likely that those with multiple sexual partners may have deeper social and peer-based networks, perhaps increasing their access to sources of information for health including PrEP [38].

The prevalence of oral PrEP awareness was higher among non-condom users. This is similar to results reported from a study in Kenya that assessed PrEP awareness among AGYW [39]. One reason for this would be misconceptions about condom use that drives the search for alternative methods of protection other than condoms within this group of individuals [40, 41]. Furthermore, it is likely that non-condom users just do not like condoms or cannot use condoms because sexual partners may control condom use in a relationship [42, 43]. Non condom users may therefore be driven by the need to protect themselves from HIV to search for and learn about alternative novel methods such as oral PrEP. Oral PrEP has been identified as a more user friendly and user-controlled method for AGYW and likely a suitable alternative for those who may not have skills to negotiate condom use with sexual partners [44]. Also, those who do not use condoms are likely to be more aware of PrEP in this population with a high prevalence of transactional sex. In our study setting, female sex workers are often offered higher fees by their clients in return for condomless sex [45]. This might explain why some participants prefer not to use condoms. In such circumstances, the need to protect themselves could lead them to search for or learn about more discrete methods that are not partner controlled e.g. oral PrEP [46, 47].

While our study suggests higher PrEP awareness among AGYW with alcohol dependence, other studies have reported PrEP awareness to be lower among persons with alcohol dependence compared to low risk alcohol consumers [36]. The majority of volunteers (> 90%) in our study engaged in transactional sex; alcohol consumption in this context occurs within sex work venues such as bars and nightclubs often as a way of coping with sex work [48]. It is possible that during the national oral PrEP roll out, the Ministry of Health and other stakeholders prioritized oral PrEP educational interventions in locations where key populations congregated, e.g., bars and nightclubs [49].

Peer influence was a key contextual factor contributing to awareness of oral PrEP. Peers with whom AGYW interacted were also potential sources of information about oral PrEP. Future HIV prevention interventions should leverage on peer to peer networks to not only increase awareness about oral PrEP but to influence uptake and adherence.

Alcohol dependent individuals tended to spend a long time away from their homes, which exposes them to meeting new people who may become sexual partners [50]. This is consistent with results reported by several studies that have indicated a correlation between alcohol dependency and high-risk sexual behavior among young people [51, 52] and older populations at risk [53, 54]. If aware of such risk, persons dependent upon alcohol may be more aware of the available methods that may protect them from contracting HIV.

Our study has three main limitations. First, this study focused on AGYW at risk within peri-urban areas and results may not be generalizable to at-risk AGYW found in rural areas and other regions of sub-Saharan Africa. Second, it was a cross-sectional study and so we were only able to assess the association between factors and PrEP awareness but could not establish causal directions. Last, the questionnaire assessed the source of PrEP awareness but did not collect information on whether the participant sought this knowledge for themselves or received it passively hence speculating on the reasons for the noted associations. Despite these limitations, our study was the first in Uganda to show that oral PrEP awareness remains low among this AGYW at high risk of HIV infection.

Promoting awareness for new effective HIV prevention tools among high risk AGYW is critical and should be conducted in a timely manner. In addition, this needs to be scaled up to potentially impact demand, uptake and adherence.