Adherence levels and associated factors to Pre-exposure prophylaxis among high risk individuals enrolled at public health facilities in Mbale district

Abstract

Introduction: HIV, a major disease of public health importance, is responsible for over 35 million deaths worldwide (WHO 2018). HIV prevention strategies have been made available to people at risk of HIV sexual transmission but inspite of all the strategies in place, transmission remains high. Oral pre-exposure prophylaxis (PrEP) is an effective strategy to reduce the risk of HIV acquisition in high-risk individuals. However, the effectiveness of oral pre-exposure prophylaxis is highly dependent on user adherence. Currently PrEP is being made available to populations at high risk for HIV infection. However adherence and retention are developing into a major challenge, with individuals initiating or expressing interest in PrEP choosing not to continue. A number of factors limit the scale-up of PrEP in areas of high HIV burden. In order to maximize the impact of PrEP, it is important to understand the factors that influence uptake of and adherence to PrEP and draw a definitive conclusion about the HIV prevention benefit of PrEP for people at HIV risk. This study aimed at assessing the adherence level and factors influencing adherence to PrEP among these HIV high-risk populations in Mbale District, Eastern Uganda.

Methods: This was a cross-sectional study that employed qualitative and quantitative methods and used one-to-one structured interviews for data collection. The study was carried out in 3 public health facilities in Mbale District that offer PrEP. The demographics of the participants were collected from client files and PrEP registrars, and then quantitative and qualitative interviews were conducted with the participants who were enrolled on PrEP from April 2018 to March 2019. The measure used for adherence assessment was 30 day pill count. A total of 6 key informant interviews were conducted with the health facility service providers and 16 in-depth interviews were also conducted with the high-risk populations.

Results: A total of 252 respondents were enrolled. The mean (SD) age was 30 years (8.22) while the median (IQR) was 30 years (25, 33.5). Majority of the respondents (78.17%) were aged 16-34 years. and males constituted 60.3%. The categorization of high-risk included female sex workers (33.73%); mobile populations (25.79%)-including long distance truck drivers, boda boda riders and migrant workers; people who use drugs (22.22%); sero-discordant couples (9.13%); adolescents and young adults (5.16%); and men who have sex with men (3.97%). The adherence level among the HIV high-risk populations who reported to have a good adherence was found to be at 62%. Factors significantly associated with poor adherence were younger age (16-34years ) , mobile population category , primary level of education or no education attained, those who reported to have experienced side effects to PrEP, and the use of other HIV prevention tools were significantly associated with poor adherence to PrEP. Older participants were found to be more adherent to PrEP as compared to younger participants; Mobile population category was found to be the category with the least adherence to PrEP as compared to sero-discordants; those who experienced side effects to PrEP were found to have a poor adherence to PrEP as compared to those who did not; the participants who had received primary or no education had a poor adherence to PrEP as compared to those who had attained tertiary level of education.

Conclusion: Overall, good adherence among the HIV high-risk population was 62%. Barriers to adherence in this population include side effects to PrEP medication, younger age, no education or only primary level of education attained, being a mobile population and use of other HIV prevention tools.

Recommendation: Strategies are needed to address these barriers to adherence. These could include community-based delivery mechanisms that could help to facilitate adherence to PrEP, the Health facilities should develop a plan for managing side effects (e.g. over the counter medications that can mitigate symptoms) should help patients feel more in control and prevent them from stopping their medication. Adequate adherence counselling and care especially among the younger populations should be done to improve adherence among the younger age group. Centralised Health information systems could be put in place to enable the mobile population be able to access healthcare from anywhere in the country and proper monitoring of their drug usage. Use of drugs that are safe for use and have less side effects such as TAF (Tenofovir alafenamide Fumarate) as compared to TDF/3TC that is currently provided for use in Uganda, may improve adherence.