Abstract
Pre-exposure prophylaxis (PrEP), antiretroviral medication for prevention of HIV-acquisition, is part of biomedical HIV prevention strategies recommended for people at risk of HIV-infection. A decision to take PrEP depends on an assessment of ‘being at risk’ either by an individual, or healthcare provider. In this paper, we draw on the concept of ‘candidacy’ to examine the different ways in which women attending a dedicated clinic in Kampala, Uganda, for women at risk of HIV infection (including sex workers), assessed their suitability for PrEP. We conducted in-depth interviews with 30 HIV negative women up to four different times, to gather information on the motives for taking PrEP, and their life history and daily life. All the women described the relevance of PrEP to mitigate their risk of HIV infection. However, there were challenges to adherence because of alcohol use, irregular working hours and a fear of being seen taking pills that others might assume to be HIV treatment. The ways in which the different women used PrEP and interpreted the place of PrEP in their lives were not solely based on their assessment of protecting themselves during sex work. They also used PrEP to guard against infection from their regular partners, and as a tool to allow them to make more money safely, by having sex without a condom with clients. While eligibility to access PrEP was predicated on the women's being in an ‘at risk’ population group, an incentive to use PrEP was to protect themselves from HIV acquisition from a long-term partner and preserve the ‘trust’ in their intimate relationship by having condom-less sex. Applying a candidacy lens we highlight the complexity in how women experience and present as being ‘at risk’ and query the criteria on which categories of risk and PrEP eligibility are determined.
Highlights
Pre-exposure prophylaxis (PrEP), antiretroviral medication for the prevention of HIV acquisition among HIV negative individuals, is part of the comprehensive biomedical HIV prevention strategies recommended by the World Health Organisation (WHO) for people at risk of HIV infection (World Health Organization, 2015, 2016, 2019)
There is a note in these guidelines which stresses the suitability for certain groups of people: ‘eligibility [for PrEP] is likely to be more prevalent in populations such as discordant couples, sex workers, fisher folk, long-distance truck drivers, men who have sex with men (MSM), uniformed forces, and adolescents and young women engaged in transactional sex’
In this paper we draw on data from a sub-set of the women enrolled in Good Health for Women Project (GHWP) who took part in the PRe-Exposure Prophylaxis Priming of Immune Effectors (PREPPIE) study, an observational open label study where women were provided with a monthly supply of Tenofovir Dis oproxil Fumarate and Emtricitabine (TDF/FTC, “Truvada®“, Gilead) to be taken daily for HIV pre-exposure prophylaxis (PrEP) for one year
Summary
Pre-exposure prophylaxis (PrEP), antiretroviral medication for the prevention of HIV acquisition among HIV negative individuals, is part of the comprehensive biomedical HIV prevention strategies recommended by the World Health Organisation (WHO) for people at risk of HIV infection (World Health Organization, 2015, 2016, 2019). Being recognised as being at risk of HIV infection is an indicator for being eligible for PrEP uptake (Fearon et al, 2019; Hill et al, 2020; Kagaayi et al, 2020; Muhumuza et al, 2021; Nakku-Joloba et al, 2019), a message endorsed by the language of the guidelines. Other factors, including a low perceived severity of HIV infection (because of the availability of antiretroviral therapy [ART]), attachment to a sexual partner, current knowledge of partner status and a partner’s use of condoms, for example, influenced percep tions of a person’s own risk (Hill et al, 2020). The epidemiological classification of being ‘at risk’ is endowed with political power, as it determines the allocation of rationed resources
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