An examination of real-world applicability and acceptability of oral pre-exposure prophylaxis (PrEP) for female sex workers in South Africa

As of 2016, women make up the majority of people living with HIV globally, and especially in sub-Saharan Africa where women and girls make up 59% of all people living with HIV. Female sex workers (FSWs) are at even higher risk of acquiring HIV, given vulnerabilities in criminalization of their work and challenges in negotiating safer sex. HIV prevalence among FSWs in South Africa is higher than any other sub-population, with a recent study recording a prevalence of up to 72% in the greater Johannesburg area, and 40% and 54% prevalence in Cape Town and Durban respectively. To date, female-initiated HIV prevention options have been limited, with most interventions focused on male condom use. However, in the last few years, oral pre-exposure prophylaxis (PrEP) has been shown to be highly efficacious in preventing HIV infection among men and women, if taken consistently. To examine whether women, especially those who are considered part of key populations, will take up and use PrEP outside of clinical trials, many demonstration or pilot studies are underway around the world. This thesis explores the real-world applicability and acceptability of oral PrEP in order to inform intervention design, implementation, and product use for female sex workers in South Africa. A range of methods were used to answer this overarching aim including: an adapted meta-ethnography to explore and understand previous research regarding motivations and barriers to uptake and use of female-initiated HIV prevention technologies that could be used by women in sub-Saharan Africa; formative research in South Africa, using a grounded approach to examine the practical and contextual factors that might influence successful delivery of a PrEP intervention with the aim of designing an intervention; focus group discussions with FSWs to examine community-level acceptability of PrEP with potential end users (the final activity in the formative research); demographic and behaviour surveys conducted during the Treatment And Prevention for Sex workers (TAPS) Demonstration Project to identify key characteristics of FSWs who took up and used PrEP within the context of TAPS; and, in the individual perspectives and lived experiences of PrEP users in TAPS are explored through analysis of in-depth face-to-face interviews with FSW. The overall findings of this thesis point to the multi-dimensional aspects of individual needs, community perceptions and beliefs, clinic delivery platform and feasibility, as well as societal norms and environmental context which determine the ability of FSWs to successfully use PrEP. Recommendations for including and acknowledging these dimensions, as well as how to leverage them to develop more effective programmes are included.