Discontinuation of pre-exposure prophylaxis and associated factors among sex workers attending the most at Risk Population Clinic, Mulago Hospital

Abstract

Background Pre-exposure prophylaxis (PrEP) uptake and retention rates in clinical trials have been well characterized. However, little is known about PrEP discontinuation in routine public health settings in developing countries. It is important to retain clients who initiate PrEP forasmuch they are still at risk. We therefore, determined PrEP discontinuation and reason for discontinuation among commercial sex workers attending most at-risk population clinic (MARPI) in Uganda. Methods We conducted an explanatory sequency mixed-methods study in 2020 among female commercial sex workers attending MARPI clinic in Mulago hospital, Uganda. We obtained quantitative data from a systematic random sample of 484 medical files of clients enrolled in care from January 2018 to December 2019. Those who had missed at least two refill-visits were categorized to have discontinued PrEP. We then conducted In-depth interviews, to explore reasons for discontinuation, among a purposive sample(n=30) who had discontinued PrEP. We performed univariate analysis and multivariable-modified Poison regressions to assess PrEP discontinuation. We used content analysis to identify emergent themes. Results Overall, 360 (74.3%) of 484 clients discontinued PrEP. PrEP discontinuation was higher among clients aged 30-34 years (adjusted prevalence ratios (adj.PR)=1.21;95%CI:1.23,1.56) and those who had taken PrEP for >6months(adj.PR=7.82;95%CI:5.05,12.11). Clients with secondary level education were less likely to discontinue PrEP(adj.PR=0.92;95% CI:0.86,0.99). From the interviews, participants discontinued PrEP due to experienced side-effects including nausea, fatigue and loss of appetite. Other reasons for discontinuation were: dislike of uninterrupted swallowing of a pill daily; fear of stigma attached to HIV-patients due to the PrEP drugs resembling ARVs; and perceived change in sexual behavior by getting one partner. Conclusion PrEP discontinuation was high among sex-workers. Strategies to reduce PrEP discontinuation including health education and sensitization support programs should address concerns about drug side effects, pill burden, and stigma particularly, among those aged 30-34 years and those who take PrEP for more than six months.