Simon Mwima
All Authors:Simon Mwima, MPH1, Jennifer Evans, MSW2, Ramirez Xavy, MSW2, David Muheni, BA3, Saldana Joel, BA4, Bosco Mukubba, MS5 and Sophie Kukunda, MA6, (1)Doctoral Student, University of Illinois at Urbana-Champaign, Urbana, IL, (2)Graduate Research Assistant, University of Illinois at Urbana-Champaign, Champaign, IL, (3)Medical Social Worker, Budaka District Local Government, budaka, Uganda, (4)Research Assistant, University of Illinois at Urbana-Champaign, Champaign, IL, (5)M & E, Alliance of Women Advocating for Change, budaka, Uganda, (6)Social Worker, Kiruhura District Local Government, budaka, Uganda
Background
People who engage in sex work and inject drugs have an elevated risk for HIV infection. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy. We contribute to the limited knowledge about women who engage in sex work and use drugs in Uganda by using socio-ecological analyses to explore their perceived barriers and facilitators of PrEP uptake.
Methods
The study was conducted through qualitative methods and used semi-structured interviews and focus group discussions involving 28 women who engaged in sex work and used drugs, ages 15 and 25, recruited through urban HIV clinics and counseling facilities in Kampala between April 2018 and May 2019. The interviews were recorded in English, transcribed verbatim, and analyzed and coded thematically using deductive and inductive thematic analysis techniques.
Results
We used the framework approach to generate themes and key concepts for analysis following the social-ecological model. Women expressed their willingness to use PrEP and identified potential barriers and facilitators of PrEP uptake. Barriers included factors at the individual (PrEP side effects, and adherence-related concerns such as pill burden, hard-to-remember daily pill/forgetting, fear of testing for HIV, and lack of basic HIV and PrEP knowledge and misinformation), interpersonal (shared use of injection drug, gender-based violence due to PrEP use, sexual and drug-using networks, fear of losing clients), community (cultural norms, inadequate community sensitization, stigma, and discrimination - due to association with drug use, HIV, sex work and, internalized stigma), institutional (prejudice and discriminatory attitudes from health workers, punitive laws related to drug use and sex work), and structural (accessibility concerns, unstable housing, lack of secure medication storage options, limited availability of health care providers, long distance to health facilities, transport costs, scarce financial resources, income, and employment opportunities) levels. Facilitators included factors at individual (experience managing co-morbidities such as HCV, high HIV risk perception and preventing HIV/desire to remain HIV negative, and high perceived risk of clients), interpersonal (peer influence, social support and care for PrEP uptake), institutional (provision of appropriate and sufficiently resourced services), and structural (availability of free PrEP services, availability of other health services) levels. Risk reduction programs such as needle exchange program utilization and social support systems from peers were identified as sources of support.
Conclusion
Our findings demonstrated how intersectional stigma and social exclusion impacts PrEP uptake. PrEP was an acceptable yet not universally accessed HIV prevention method for women who use drugs. PrEP uptake is linked to personal and environmental factors that need to be considered for successful PrEP implementation. Integrating multi-level PrEP interventions with other healthcare services in a person-centered manner will increase PrEP uptake among drug-using women. Within their own networks, they can find help.
*As presented at the 31st Annual Society for Prevention Research (SPR) Conference during the 2023 NIDA International Program Poster Session at SPR.