Let’s talk about pre-exposure prophylaxis: a participatory HIV prevention intervention with and for female sex workers in Durban, South Africa.

Abstract

Introduction: Since the discovery of HIV/AIDS in the early 1980s, scientists have been in search of a cure. Significant scientific efforts have so far led to the discovery of antiretroviral treatment that suppresses the replication of HIV that leads to AIDS. Recently, Tenofovir or Tenofovir-emtricitabine as antiretroviral treatment for HIV-positive persons can now be used as prevention in the form of oral pre-exposure prophylaxis (PrEP). This HIV prevention therapy is currently being administered to people considered at high risk of HIV, such as men who have sex with men, intravenous drug users and serodiscordant couples. In 2015, the WHO expanded its oral PrEP guidelines to include female sex workers (FSWs) who are a high-risk group for HIV worldwide. In response to these WHO guidelines, the South African government approved oral PrEP distribution among FSWs in 2016, as part of combination prevention with the expectation that FSWs would take up PrEP and this will reduce the rate of new HIV infections. However, the response to PrEP was underwhelming. Identifying the reasons for the low uptake of PrEP among FSWs is the primary objective of this study. This was followed with engaging FSW peer educators in a participatory intervention mapping process to design an intervention plan to address these challenges to uptake and potentially inform PrEP programming in Durban in the KwaZulu-Natal province which is a high HIV prevalence area in South Africa. Methods: This study was a participatory action intervention research that was conducted in two phases. The first phase was a qualitative needs analysis conducted from May to November 2018 to identify the challenges associated with PrEP uptake and retention, as well as to ascertain the motivating factors for PrEP use among FSWs. Interviews were conducted with 39 participants, 30 individual participants, and nine focus group participants. Eleven participants were FSW peer educators including one health worker and one researcher from sex work and PrEP distributing organisations (13 in total); the rest of the participants were FSWs (n=26). Consent was obtained from all participants. Data were analysed thematically. The second phase of this study was an intervention mapping phase during which a PrEP intervention plan was developed with eight FSW peer educators who were at the forefront of PrEP promotion among FSWs. This intervention plan was informed by data obtained from the needs analysis. A total of six meetings took place in which the individual, interpersonal and environmental determinants that have an impact on PrEP uptake, adherence, and retention were discussed. This resulted in the performance and change objectives, including a theory of change logic framework that systematically depicted the process of change. Furthermore, theory-based methods and activities were established which culminated into a PrEP intervention workshop programme. Additionally, the implementation and evaluation plans were also formulated. Results: The needs analysis showed that the majority of the participants could not distinguish between PrEP and antiretrovirals. This inability contributed to the stigma against PrEP. Another challenge was that distribution was fragmented with the research organisations distributing PrEP to FSWs through peer education and yet, PrEP was not well understood or promoted by health care providers from public health facilities. This resulted in the mistrust of PrEP efficacy among FSWs and delayed uptake and lessened retention. The FSWs taking PrEP were met with hostility from their friends who failed to understand that PrEP as an antiretroviral can be taken to prevent HIV. This resulted in HIV positive FSWs on antiretrovirals accusing PrEP users of deception, and HIV denialism. They also experienced similar reactions from intimate partners. These accusations were believed to arise because of lack of knowledge and competition for clients, given the preferred market for HIV-negative FSWs. PrEP users reported feeling stigmatised and thrust into interpersonal conflicts with their peers, which caused broken relationships, this led some FSWs to discontinue PrEP, while others took it secretly. The FSWs who remained on PrEP mentioned various motivating factors for adherence, such as PrEP being an empowering tool that gives them agency to prevent HIV and bodily autonomy as well as a sense of hope for the future, because HIV was no longer a consequence of sex work. The PrEP intervention mapping process which resulted in a workshop programme showed how FSWs can engage in reflexive dialogues that help promote agency, power, self-efficacy, hope and responsibility to the self and others, to encourage effective engagement in HIV prevention. Conclusion: This study recommends for a wider promotion and dissemination of PrEP through public health care facilities. This will encourage the normalisation of PrEP and curb the stigma associated with PrEP being for high-risk groups. Biomedical interventions should be coupled with behavioural strategies that engage users on the personal, interpersonal, and environmental challenges that have an impact on behavioural change. FSWs should be involved in the design and implementation of their own interventions to ensure effective approaches and to create a sense of responsibility, power and ownership. It is important for future interventions to realise that simply promoting a prevention method because it is medically effective will not warrant uptake and adherence on the part of end users; therefore, interventions need to engage with the complexity of human behaviour. This makes it imperative for practitioners to invest in understanding the patient’s deeper motivations that encourage or discourage behavioural change.