Abstract
The world has been on the path to ending HIV and AIDS as a global threat by 2030; despite these efforts, the rate of new HIV infections among men who have sex with men remains very high. This study sought to explore the perceptions of key stakeholders on the potential barriers and facilitators of pre-exposure prophylaxis use among this key population. An exploratory, descriptive (through interviews) qualitative study was conducted on 10 key informants who were purposively selected and snowballed based on their knowledge and experience toward pre-exposure prophylaxis programming among men who have sex with men. The interviews were recorded, transcribed verbatim, coded, and thematically analyzed on MAXQDA. Stated barriers were stigma, lack of information, wrong messaging around pre-exposure prophylaxis, hearing negative things about the pills, the burden of taking pills daily, negative attitudes from health care providers, non-friendly health care facilities, pre-exposure prophylaxis not being affordable, and lack of flexibility and privacy from public hospitals. Identified facilitators were correct messaging on pre-exposure prophylaxis, long-lasting injectable pre-exposure prophylaxis, improved packaging, de-stigmatization, more friendly facilities, differentiated service approach, community groups, engagement, and partnership. To address these barriers and leverage the facilitators, it is imperative to have accessible, affordable services, non-judgmental health care providers, and peer support networks to empower men who have sex with men to make informed decisions regarding their sexual and reproductive health. Continued efforts to remove barriers and promote facilitators are crucial for maximizing the potential of pre-exposure prophylaxis as an effective HIV prevention tool among this population.
Background
Various strategies have been used over the years in the management of HIV and AIDS, such as combined preventive approach that includes sexual education and economic empowerment to women, human rights programs for key populations (LGBTQI+, sex workers, and disabled people), condom programs, voluntary medical male circumcision (VMMC), and the use of pre-exposure prophylaxis (PrEP; United Nations Programme on HIV/AIDS [UNAIDS], 2016a). Although there has been significant improvement in preventing new HIV infections, HIV transmission among men who have sex with men (MSM) remains a significant challenge (UNAIDS, 2016a, 2016b). Most nations have been looking the other way toward the sexual and gender minority (SGM) groups, particularly MSM, despite their risk of HIV transmission. According to Pérez-Jiménez et al. (2009), heterosexuals have been the primary target of the majority of self-interventions for people living with HIV as they have been prioritized at the expense of other key populations that need those services (Pérez-Jiménez et al., 2009). However, there has been a paradigm shift with many organizations, facilities, and personnel dedicated to providing inclusive services catering to key populations’ unique needs, including MSM (Conserve et al., 2017; World Health Organization [WHO], 2017).
Despite making up a small portion of the world’s population in 2019, the LGBTIQ+ community and their partners accounted for 62% of new infections (UNAIDS, 2019). Zimbabwe is one of many nations with laws that make same-sex sexual activity illegal. According to UNAIDS (2019), MSM in these nations are 5 times more likely to have HIV than people in nations where same-sex sexual behavior is not punishable by law (UNAIDS, 2019). Gay men and MSM had a 26-fold higher chance of contracting HIV in 2019 than the rest of the adult male population (UNAIDS, 2019). According to the UNAIDS 2019 Data Report, Sub-Saharan Africa continues to be the region with the highest prevalence of HIV (17.9% among MSM; UNAIDS, 2019). Zimbabwe has a 31% MSM HIV prevalence rate, according to UNAIDS (2019), although the Ministry of Health and Child Care claims that data on HIV prevalence among important demographics are unclear (UNAIDS, 2019). These statistics are undoubtedly highly concerning, highlighting the necessity for MSM to access sexual and reproductive health services. It would not be feasible to stop the HIV epidemic from being a global threat without reaching out and embracing this population (Gupta & Granich, 2017).
It is important to note that some MSM populations face barriers and challenges to PrEP uptake and acceptability. These can include concerns about side effects, cost, stigma, and access to health care services (Emmanuel et al., 2020; Patrick et al., 2019; Yu et al., 2021). Disparities in PrEP uptake and acceptability have been observed among racial, ethnic, and socioeconomic groups (Kuhns et al., 2017; Pérez-Figueroa et al., 2015). PrEP uptake among MSM has generally been reported to be increasing over time. Multiple studies have identified different facilitators and strategies to improve PrEP uptake among this population, and this includes increased awareness campaigns through PrEP education (Pichon et al., 2022), improved accessibility (Kimani et al., 2022), availability of free or affordable PrEP (Dean et al., 2023), support groups (Zhou et al., 2022), and the existence of MSM-friendly facilities (Yu et al., 2021).
Several factors hamper PrEP uptake for HIV prevention in African nations. Different authors have alluded to this low uptake of PrEP among MSMs in different country contexts in Sub-Saharan Africa to be a lack of awareness and knowledge (Matacotta et al., 2020), stigma and discrimination (Isano et al., 2020; Keuroghlian et al., 2021), legal and policy barriers (Embleton et al., 2023; Mbilizi Chimwaza et al., 2022), limited access to health care (Mgodi et al., 2023; Muraguri et al., 2012), cost and affordability of health services (Mgodi et al., 2023), health care provider bias and inadequate training (Keuroghlian et al., 2021), and lack of tailored health services and privacy and confidentiality concerns (Khozah & Nunu, 2023; Munyimani & Nunu, 2022).
African countries such as Zambia, Malawi, Algeria, and Zimbabwe prohibit same-sex sexual relations, which negatively affects the uptake of sexual and reproductive health services (Khozah & Nunu, 2023). Some of the notable barriers to PrEP uptake include lack of knowledge about PrEP, ongoing stigma and discrimination surrounding HIV, challenges in obtaining and affording PrEP medications and services, flaws in the health care system, and cultural and gender norms that restrict access (Adeagbo et al., 2021; Galea et al., 2011; Graham et al., 2022). However, factors that encourage the use of PrEP include supportive laws and regulations, community involvement and the participation of important populations, education and training programs for health care professionals, and efforts to make health care more affordable and accessible (Ahouada et al., 2020; Kimani et al., 2022; Ogunbajo et al., 2020). African nations may increase PrEP uptake and significantly advance HIV prevention efforts by tackling these obstacles and utilizing the facilitators.
Zimbabwe has made significant progress in the management of HIV and AIDS; however, despite these efforts in the prevention, treatment, and care program of HIV and AIDS, MSM has not been properly embraced, as they continue to face discrimination, stigma, and social exclusion (Moyo et al., 2021). The epidemiological data on the progress in PrEP uptake and acceptability among MSM in the region remains scant. This is a huge public health threat because this population has limited knowledge of the barriers and facilitators to PrEP use. Therefore, this study aims to evaluate the potential barriers and facilitators to PrEP use among MSM in Bulawayo using the perspectives of health care providers. The findings from this study could inform policymakers, potentially influence programmatic decisions, ensure they are as inclusive as possible, and consider the different stakeholders’ roles. This could, in turn, improve the quality of PrEP services offered to MSM and thus improve their sexual health outcomes.
Method
Study Area
The study was conducted in the Bulawayo city, Zimbabwe. The study area has an estimated population of 665,940 (ZIMSTAT, 2022). It is regarded as a bustling town with various diverse communities and is the second largest city in Zimbabwe. Bulawayo has 763 MSM, according to the HIV and STI Biobehavioral Survey (2020). The city is served by public and private health institutions, most of which are owned and run by the government. The study area map is presented in Figure 1.
Study Area Map
Study Design
An exploratory, descriptive qualitative study was conducted on 10 key informants. This approach enabled the researchers to explore in-depth perceptions and comprehensively understand the potential barriers and facilitators influencing PrEP utilization among MSM.
Target Population and Sampling
The study population consisted of key informants such as Key Populations Officers, Programs Officers, Policy Specialists, Health Services Providers, Nurses, Pharmacists, and Monitoring and Evaluation Specialists. These individuals were selected based on their knowledge and experience with PrEP programming among MSM. Purposive sampling techniques were used to select key informants stated above. In addition, snowball sampling was used to identify potential key informants through the networks of those who had already been interviewed. The total number of key informants who participated in the study was determined by data saturation. It should also be noted that data collection and analysis in qualitative studies are done concurrently, and the saturation was determined when the respondents gave no new information.
Data Collection Procedure and Tools
The study participants responded to piloted semi-structured interview questions that probed their perceptions of the barriers and facilitators influencing PrEP use among MSM. The interviews were steered using an interview guide, which enabled appropriate data collection. The researchers explained the purpose of the study to the interviewees and obtained written informed consent before proceeding with data collection. The interview duration depended on the interviewees’ varied discussions and took between 10 and 45 min. The researcher ensured only one key informant participant was interviewed at a time. The interviews were conducted in local languages depending on the participant’s preferences (English, Ndebele, and Shona). These interviews probed on the nature of work that the key informant did about the PrEP program, the barriers faced by MSM in accessing these services, and the facilities that could be improved to ensure accessibility of these services.
The interviews were audio recorded and transcribed verbatim to ensure authenticity and a clear audit trail. Measures were taken to ensure trustworthiness and rigor. This was achieved through developing and pretesting and ensuring consistency to aid credibility. At the same time, interview guides were developed by other key studies conducted in different settings on access to PrEP by gender and sexual minorities. This ensured that the findings of this study could be transferred to other similar settings. Furthermore, the methods used in collecting, cleaning, and analyzing data were standard methods that other researchers could replicate. The methods used were described in detail to ensure that they could be replicated, thus ensuring the dependability of this study and its findings. Finally, the authors analyzed the data independently. They generated themes that an independent coder further confirmed to minimize the effect of positionality by the researchers, thus ensuring conformability through reducing researcher bias. Verbatim extracts from the interviews were used to enhance authenticity. Records would be kept for 5 years in case any issues arise and need to be verified through the raw data, after which they will be destroyed and deleted from the electronic databases where they are stored. These databases are password protected, and only authorized personnel have access, that is, the primary authors of this article.
Data Analysis
Data collected from key informant interviews were transcribed and thematically coded and analyzed on MAXQDA Version 20 Pro using Braun and Clarke’s six-step method: becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining themes, and writing up. Interviews were organized into themes based on the topic areas of the interview guide, which were deductively identified from the literature and related to the facilitators and barriers likely to affect the uptake of PrEP. Data were then coded (by the two authors and later confirmed by an independent coder) within these themes and identified additional inductive themes that emerged from the data. After identifying text related to each theme, an analytical framework was applied to the data, creating a framework matrix in Microsoft Excel. Coding was checked against codes assigned to interview extracts. Codes were then compared within and across participants to identify patterns and associations. The two authors discussed and agreed upon any coding discrepancies through dialogue.
Findings
Description of Key Informants
The key informants were varied, though directly or indirectly, and they influenced the PrEP services being accessed by MSM. Ten participants were interviewed in this study, six of whom were males and four were female. Generally, there are limited influential stakeholders experienced in PrEP and MSM-related issues in Bulawayo; thus, the sample was very small as a few individuals met the inclusion criteria for this study. The brief demographic characteristics of the key informants are presented in Table 1.
Sociodemographic Characteristics of Respondents
Barriers to PrEP Use Among MSM
Four main themes and 16 subordinate themes arose from the key informant interviews. The reported barriers to using PrEP by MSM were the lack of/inadequate information about PrEP, which reduced demand for the services. Furthermore, it is reported that stigma (associating PrEP usage with promiscuous behaviors and stigma around being known to be an MSM) contributed to reduced demand and uptake of PrEP services. Participants also cited that taking the pill daily was a challenge and a burden, leading to some individuals defaulting or opting out of this service. Furthermore, it was reported that the negative attitudes exhibited by some health care providers, lack of privacy, and lack of MSM-friendly facilities in some areas were among the barriers that hindered access to PrEP by MSM. These themes are described in depth in Table 2 and the cementing quotes from the participants.
Themes of Barriers and Quotations
Note. PrEP = pre-exposure prophylaxis; MSM = men who have sex with men; ART = antiretroviral therapy.
Facilitators of PrEP Use Among MSM
Five main themes and 11 subordinate themes were obtained from the data after the interviews on the facilitators of PrEP use among MSM. Participants cited a need for accurate and comprehensive information dissemination methods that demystify myths and reduce stigma around PrEP services. They further advocated for long-lasting injections compared to taking the pill daily, which they said was cumbersome. Participants further cited that there should be an improvement in packaging that ensures that PrEP packaging differs from antiretrovirals (ARVs). They felt these changes could improve the demand for PrEP services by MSM. These themes and others are described in detail in Table 3.
Themes of Facilitators to PrEP Use and Quotations
Note. PrEP = pre-exposure prophylaxis; MSM = men who have sex with men; ART = antiretroviral therapy.
Discussion
Like earlier studies looking at the factors influencing MSM’s use of PrEP, stigma was the most common barrier that emerged from different key informants. Stigma was categorized into different forms: stigma on PrEP users being promiscuous or sex workers, stigma about PrEP users being HIV positive, and stigma about their sexuality (nature of sex they engage into). All these forms of stigma negatively affect the utilization and accessibility of PrEP in public health care facilities where services rendered are not differentiated to accommodate the needs of MSM. This further reduces the demand and utilization of these services as most MSM shun away from the health facilities to avoid stigmatization. Our findings are supported by many studies that have also identified stigma as a significant barrier that negatively influences PrEP utilization among this population. It is reported in the literature that there is usually a stigma around PrEP users and labeling them promiscuous or sex workers (Graham et al., 2022; Klein & Washington, 2020; Patrick et al., 2019; Pichon et al., 2022; Yu et al., 2021). There is also misconception and stigma where PrEP users are being labeled to be HIV positive, and some individuals confuse the taking of PrEP with the taking of ARVs meant to reduce the viral load (Ahouada et al., 2020; Diabaté et al., 2021; Emmanuel et al., 2020; Graham et al., 2022; Grant et al., 2014; Harawa et al., 2016; Patrick et al., 2019; Pichon et al., 2022; Santos et al., 2022; Sundararajan et al., 2022). It is also reported by different scholars that there is stigma that is usually associated with sexual orientation as a significant number of communities in different countries have not fully embraced the key populations and acknowledged their existence and their rights (Adeagbo et al., 2021; Grant et al., 2014; Harawa et al., 2016; Pelletier et al., 2019; Philbin et al., 2016; Santos et al., 2022; Voglino et al., 2021). Certain writers have demanded that providers of sexual health services guarantee a decrease in stigmatization and that their services are free from discrimination (Mgodi et al., 2023). It is envisaged that this call for accessible discrimination-free services would encourage MSMs to access PrEP and thus reduce the risk of being infected with HIV.
Information-related factors were among the reported barriers that influence PrEP use among MSM. Inadequate information on PrEP, incorrect messaging on PrEP, hearing negative about PrEP, and outdated policies were noted to affect uptake levels of PrEP. This significantly reduces access and demand for PrEP by MSM as they lack critical information to make sound decisions. These findings concur with what other scholars reported at different geographic locations. Graham et al. (2022) reported that hearing negative things about PrEP caused low uptake and adherence to PrEP. As reported by many scholars, lack of information has a negative bearing on the uptake and adherence of PrEP (Cox et al., 2021; Graham et al., 2022; Klein & Washington, 2020; Mansergh et al., 2012). Access to information is key in ensuring that MSM make informed decisions about their sexual health, hence improving their sexual health outcomes. Programmers could leverage these findings to develop contextual, sound information dissemination programs that would demystify some of the myths associated with the lack of information and thus increase the demand for PrEP.
Health care workers in public hospitals reported health services rendered as not private, undifferentiated, and not flexible, affecting a significant number of MSM accessing these services. Negative attitudes from health care workers were reported to emanate from these public hospitals. This is generally a barrier reported in several studies and thus needed attention in reorientating health services that would make them friendly to MSMs, thus ensuring demand for these services. These findings are not peculiar to our study, as they have been similar in literature. Many studies reported MSM preferring to access their PrEP from MSM-friendly facilities due to barriers they face in non-MSM facilities, such as negative attitudes from health care workers (Adeagbo et al., 2021; Graham et al., 2022; Holloway et al., 2017; Patrick et al., 2019), lack of confidentiality by health care providers (Graham et al., 2022), and PrEP being unaffordable (Dean et al., 2023; Graham et al., 2022; Kota et al., 2021; Voglino et al., 2021). In Sub-Saharan African countries where same-sex sexual interaction is criminalized, health service providers also exhibit negative attitudes toward MSM, thus reducing their ability to access services they need, such as accessing PrEP (Khozah & Nunu, 2023; Munyimani & Nunu, 2022). Despite Zimbabwe criminalizing same-sex sexual interaction, health care providers must be educated and trained to render good quality services to MSM without any form of discrimination because transmission of HIV and AIDS remains unacceptably high among this population.
Concerns about taking pills every day were noted to be a barrier to PrEP use; although event-driven PrEP is a solution, it was reported that event-driven pills were not as readily available as daily oral PrEP; hence, MSM had no choice but to opt for daily oral PrEP. These concerns negatively affect PrEP use among this population due to fear of unknown side effects associated with taking these pills every day. These findings are similar to what other scholars reported in their studies that daily pill taking was a barrier to PrEP utilization among MSM (Galea et al., 2011; Graham et al., 2022; Grant et al., 2014; Holloway et al., 2017; Klein & Washington, 2020; Pelletier et al., 2019; Pingel et al., 2017). This study also reported that the packaging of PrEP as ART was reported as a barrier due to fear by MSM of being mistaken as someone who is HIV positive. Such issues reduce the uptake of PrEP by MSM and, thus, increase their chances of contracting and transmitting HIV. These findings have also been reported by Graham et al. (2022), who indicated that the packaging of PrEP, which is similar to that of ARVs, significantly reduces its uptake by the target population that is denting the effectiveness of this intervention program in the reduction of risk of HIV infection in MSM. It is important to ensure that event-driven PrEP is accessible at all times in health care facilities to reduce the fear of taking pills every day as a barrier. It is highly recommended that pharmaceutical companies differentiate the packaging of PrEP from that of ARVs to improve the uptake of PrEP by MSM without fear of being mistaken as a person with HIV.
It is reported in the study that MSM encounter various barriers at different levels, and these barriers have a major impact on their decision to utilize and access PrEP. The findings are in sync with what other authors report in general, that there is a need to examine and consider these barriers if meaningful progress is to be made (Moyo & Nunu, 2023b). The study findings highlighted that correct messaging around PrEP reduces stigma around PrEP users, which is important in improving PrEP uptake among MSM. These findings are confirmed by other authors who reported that PrEP education and correction information as vital facilitators in PrEP uptake. A study done in Kenya highlighted that accessible and good information on PrEP improves uptake and adherence among gay, bisexual, and other MSM (Graham et al., 2022). Harawa et al. (2016) indicated that MSM suggested PrEP education, marketing, and message framing as vital in using PrEP (Harawa et al., 2016). The use of social media to spread information on PrEP was identified by Pichon et al. (2022) as strategies to improve PrEP uptake (Pichon et al., 2022).
The study findings identified the availability of MSM-friendly facilities and services as an important facilitator to improve PrEP acceptance and uptake among this population. It was clear that participants preferred to access PrEP from these MSM-friendly facilities as these have been tailor-made to provide services that meet their unique needs. Furthermore, health service providers in these facilities are trained to provide affirming sexual health services to gender and minority populations, thus ensuring a safe and friendly environment. These findings align with other authors who reported that having MSM-friendly facilities is important in the uptake and adherence of PrEP and having relatable health care providers is vital in ensuring improved PrEP uptake among this population (Graham et al., 2022; Moyo & Nunu, 2023a; Pichon et al., 2022).
The study findings identified making PrEP always available, partner support on PrEP use, and increasing the number of PrEP facilities and support groups as vital facilities to PrEP use among MSM. Making PrEP available at all times means MSM can access it any time and cannot run out of pills, hence reducing the transmission of HIV and AIDS. Having many MSM-friendly facilities means more MSM are going to access PrEP in a non-judgmental environment, offering differentiated and support services, hence improving PrEP use. The study findings concur with other literature sources that reported increasing the number of health care facilities and offering PrEP services as important facilitators (Harawa et al., 2016; Moyo & Nunu, 2023a). Other scholars reported support organizations or clubs for PrEP users as vital facilitators in improving PrEP utilization (Graham et al., 2022; Harawa et al., 2016). It was reported that having one social support increased the likelihood of PrEP acceptability by about 5% (Zhou et al., 2022). The study reported that the accessibility of long-lasting injectable PrEP was also an important facilitator of PrEP uptake. In 2022, Zimbabwe became the first African country to approve long-lasting injectable PrEP (WHO, 2022). This study proves that more MSM will take up this service, hence eliminating the barrier of taking daily oral PrEP. The findings are in sync with other scholars that long-lasting injectable PrEP improves the acceptability of PrEP among MSM, as reported in India (Chakrapani et al., 2015).
Limitations
The study typically involves a small sample size, recruited on non-random methods such as purposive and snowball sampling. As a result, findings may not represent the broader population of key stakeholders or apply to different contexts or cultural settings. The study may not have captured the full spectrum of barriers and facilitators. Some factors influencing PrEP uptake might be missed or underrepresented due to the study’s focus or the participants’ perspectives.
Conclusion
In conclusion, addressing the barriers and leveraging the facilitators identified above can increase PrEP uptake among MSM. Combining comprehensive education, accessible and affordable services, non-judgmental health care providers, and peer support networks can empower MSM to make informed decisions regarding their sexual health and reduce the transmission of HIV. Continued efforts to remove barriers and promote facilitators are crucial for maximizing the potential of PrEP as an effective HIV prevention tool among this population.
Footnotes
Author Contributions
P.L.M. conceptualized the research idea and drafted the manuscript, W.N.N. coordinated the manuscript writing process, guided the manuscript writing process, and revised the draft manuscript. Both authors read and approved the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Approval and Consent to Participate
An application for ethical approval was lodged with the Institutional Review Board at the National University of Science and Technology in Bulawayo, Zimbabwe. This ethics committee (after two rounds of review) granted ethics clearance (Ethics Clearance Number: NUST/IRB/2023/52).
Ethics Clearance
The Institutional Review Board received an application for ethical approval, and it was approved, and an ethics clearance number was granted. Participants were given access to an information and consent sheet, which they reviewed and had the chance to ask questions about any aspects of the study they did not fully understand. They then granted written consent before taking part in the study. It should be underlined that everyone who participated did so voluntarily; nobody was coerced.
