Abstract
Sexual minority men (SMM) in Nigeria have been disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) reduces risk for HIV acquisition among SMM by over 90%. The current study investigated the association between demographics, socioeconomic marginalization, sexual health, and willingness to use long-acting injectable (LAI) PrEP and preferences for other PrEP modalities in a sample of HIV-negative SMM in Nigeria. Between March and June 2019, SMM residing in Abuja, Delta, Lagos, and Plateau completed a quantitative survey. To examine willingness to use LAI PrEP and PrEP modality preferences, multivariable binomial and multinomial logistic regression models were fit. We found that 88% were willing to use LAI PrEP, and 44% preferred LAI PrEP to other PrEP modalities. Participants who reported interest in LAI PrEP were more likely to be single, engage in inconsistent condom use, and report having a primary care provider. Compared to participants who preferred daily oral PrEP, participants who preferred other PrEP modalities had higher odds of having some university education/university degree or higher and reporting low financial hardship. It is imperative that SMM in Nigeria are prioritized for access to new HIV prevention interventions, as they bear a disproportionate burden of HIV and are especially vulnerable to HIV infection.
Introduction
Sexual minority men (SMM)—SMM refers to cisgender men who have romantic and sexual attractions to other cisgender men in addition to transgender and gender nonconforming individuals—in Nigeria have been disproportionately affected by the HIV epidemic. HIV prevalence among SMM in Nigeria has increased significantly, from 14% in 2007 to 17% in 2010, and 23% in 2014 [1]. Factors associated with HIV seropositivity among SMM in Nigeria include older age, receptive anal sex, condomless sex, transactional sex, reporting no history of HIV testing, and having a history of other sexually transmitted infections (STIs) [1-4]. Studies have also shown that the criminalization of homosexuality in Nigeria is a major barrier to SMM accessing HIV-related health services [5, 6].
Daily oral pre-exposure prophylaxis (PrEP) significantly reduces HIV acquisition among SMM when taken consistently [7]. In 2015, a demonstration trial found high effectiveness of HIV prevention utilizing three different PrEP delivery models for serodiscordant (one partner is living with HIV and the other is HIV negative) couples in Nigeria [8]. In the National Strategic Framework on HIV and AIDS (2017–2021) instituted by the Nigerian National Agency for the Control of AIDS, there is a goal that 90% of key populations (including SMM) who are eligible for PrEP be using PrEP and that 90% of health facilities be providing PrEP, but no data is available on the progress that has been made towards achieving those targets. While daily oral PrEP has only been available in Nigeria for 4 years, uptake remains low. According to PrEPWatch, there are an estimated 85,000 people currently on daily oral PrEP in Nigeria. While long-acting injectable (LAI-) PrEP is not currently approved for use in Nigeria, it shows a lot of promise. Increasing PrEP uptake and adherence have the potential to significantly reduce HIV incidence among SMM in Nigeria. A multisite study of HIV-negative SMM in Nigeria found that 54% of participants reported being aware of PrEP, 80% were willing to use PrEP, but only 10% had a history of daily oral PrEP use [9]. Factors associated with higher odds of having a history of daily oral PrEP use were increasing numbers of insertive anal sex acts and PrEP awareness [9]. Studies have also demonstrated that access to subsidized healthcare services and costs were significant predictors of PrEP uptake among SMM [10, 11]. PrEP use remains low among SMM in Nigeria, which has implications for HIV prevention efforts and jeopardizes the goal of ending the HIV epidemic.
Recently, substantial scientific progress has been made in the development and testing of new modalities for PrEP including LAI-PrEP. A study by the HIV Prevention Trials Network (HPTN 083) compared long-acting cabotegravir, which was administered intramuscularly every 8 weeks, (CAB LA) to tenofovir disoproxil fumarate and emtricitabine (TDF/FTC)—the FDA-approved formulation for daily oral PrEP—in 4570 SMM and transgender women in the United States, South America, Asia, and Africa [12-14]. They found an HIV incidence of 1.22/100 person-years in participants that received TDF/FTC and 0.41/100 person-years in participants that received CAB LA, and the study concluded that CAB LA was superior to TDF/FTC [12-14]. Other studies have found modalities of PrEP such as LAI and subdermal implants to be acceptable [15, 16], while rectal microbicides and antibody infusions have lower levels of interest and acceptability among SMM [15]. Recently, the U.S. Food and Drug Administration approved Apretude (cabotegravir extended-release injectable suspension) for use in at-risk adults and adolescents for PrEP to reduce the risk of sexually acquired HIV. Consequently, it is important to understand the acceptability of various PrEP modalities among SMM in Nigeria, especially as advancements in science make these innovative PrEP product types reality.
The goal of the current study was to investigate the association between demographics, socioeconomic marginalization, and sexual health (predictors) and willingness to use long-acting injectable (LAI-) PrEP and preferences for other PrEP modalities (outcomes) in a community-recruited sample of SMM who self-reported being HIV-negative or unaware of their serostatus in four diverse regions of Nigeria.
Methods
Participants and Procedures
Between March and June 2019, SMM residing in four regions of Nigeria (Abuja, Delta, Lagos, and Plateau) were recruited and completed a quantitative survey. Inclusion criteria were: (1) being 18 years of age or older; (2) identifying as cisgender male; and (3) reporting any history of sex with another male. Out of the total sample (N = 413), 26% (n = 108) self-identified as HIV-positive and were not asked questions related to PrEP. Thus, the sample for this analysis (n = 305) consisted of SMM who either self-identified as HIV-negative or who were unaware of their HIV status.
Participants were recruited through four community-based organizations (CBOs) that provide HIV prevention, care, and other support services to SMM in the respective regions described above. Outreach workers, who were also SMM, provided information about the study to potential participants during community outreach events and provided study contact information to individuals who expressed interest.
Study activities took place in private offices of each CBO. The study was approved by the institutional review boards at Brown University and the Nigerian Institute of Medical Research. Informed verbal consent was obtained from each participant prior to enrollment. Each participant completed an interviewer-administered behavioral survey. Participants were compensated 4000 Naira (10 US dollars) for their participation. More detailed information on the study procedures has been published elsewhere [9, 17-20].
Measures
The primary outcome in the current analysis was willingness to use LAI-PrEP. To assess willingness to use LAI-PrEP, participants were asked: “Would you be willing to take an injection every three months to prevent getting HIV infection?” (willing/not willing/not sure, dichotomized into willing/not willing or not sure). The secondary outcome was PrEP modality preferences. To assess PrEP modality preferences, participants were asked: “If you had a choice to use a daily pill, an implant inside your body, injections every three months, or lubricant to protect you from HIV, which would you choose (select one only)? Responses were categorized as “prefer daily oral pill, prefer LAI-PrEP, prefer other type of PrEP (subdermal implant and rectal microbicides), and like them all equally.”
Demographics and Socioeconomic Marginalization
Participants were asked about their age (in years), relationship status (single, non-single), educational attainment (secondary school or lower, some university or vocational school, university degree or higher), sexual orientation (gay/homosexual, bisexual, heterosexual, other), religious affiliation (Christian, Muslim, other), monthly income (in naira), employment status (employed, unemployed), and financial hardship (low, high).
Sexual Health
Participants provided information on their history of STIs (lifetime and in the previous year), number of sexual acts (receptive and insertive) acts in the previous 30 days, and consistent condom use. Consistent condom use for receptive and insertive sexual acts was defined as reporting always using a condom for sexual acts in the last 3 months. Lastly, we collected data on geosocial networking app usage and exchange sex in the previous 3 months as sexual risk behaviors have been demonstrated to be associated with PrEP acceptability and usage [21, 22].
Healthcare Access
Participants were asked if they had a primary care provider, health insurance (it is important to note that while Nigeria has a national health insurance scheme, only about 3% of the population is covered [23] and private health insurance schemes are becoming increasingly popular), and whether they had been unable to access healthcare due to costs.
PrEP Indicators
To assess PrEP awareness, participants were asked: “Have you heard of pre-exposure prophylaxis (PrEP) for HIV prevention?” (yes/no). To assess the history of oral PrEP use, participants were asked: “Have you ever taken PrEP to prevent HIV?” (yes/no).
Data Analysis
We assessed the distribution (percentages and means) of all variables by willingness to use LAI-PrEP and PrEP modality preferences. To estimate correlates of willingness to use LAI PrEP, we fitted a multivariable logistic regression model to the data, specifying willingness to use LAI PrEP as the dependent variable and demographics, socioeconomic marginalization, and sexual health as the explanatory variables. To estimate correlates of PrEP preferences, we fitted a multinomial logistic regression model to the data, specifying preferences for PrEP modalities as the outcome (with daily oral pill as the baseline comparison) and the same covariates as the model for willingness to use LAI PrEP. Variables that were significant at P < 0.05 in the bivariate logistic regression models were retained in the multivariable models. Data were analyzed using SAS version 9.4 (Cary, NC).
Results
Sample characteristics are presented in Table 1. Participants ranged in age from 18 to 60 years (mean = 29.1 years; standard deviation = 6.1 years). Nearly two-thirds of participants (63%) identified as bisexual, and 61% were single. More than a fourth (29%) reported an STI diagnosis in the previous year. Almost half (43%) had a primary care provider, but only 15% had health insurance. While 45% (n = 135) were aware of PrEP; only 15% (n = 44) had previously used PrEP.
Table 1.
Demographic characteristics (N=305)
| Demographics | |
|---|---|
| Site | |
| Abuja | 59 (19.5) |
| Delta | 88 (29.1) |
| Lagos | 83 (27.5) |
| Plateau | 72 (23.8) |
| Age | |
| 18-24 years | 70 (23.4) |
| 25–29 years | 87 (29.1) |
| 30+ years | 142 (47.5) |
| Relationship status | |
| Single | 186 (61.0) |
| Not single | 119 (39.0) |
| Educational attainment | |
| Senior secondary school or lower | 142 (46.6) |
| Some University or Vocational School | 65 (21.3) |
| University degree or higher | 80 (26.2) |
| Other | 18 (5.9) |
| Sexual orientation | |
| Gay/homosexual | 113 (37.3) |
| Bisexual | 190 (62.7) |
| Religious affiliation | |
| Christian | 190 (62.5) |
| Muslim | 93 (30.6) |
| Other | 21 (6.9) |
| Social marginalization | |
| Monthly income (in Naira) | |
| 0–10,000 | 82 (27.3) |
| 10,000–30,000 | 84 (28.0) |
| 30,000–50,000 | 62 (20.7) |
| 50,000–100,000 | 35 (11.7) |
| 100,000+ | 37 (12.3) |
| Employment status | |
| Employed | 241 (79.0) |
| Unemployed | 64 (21.0) |
| Financial hardship | |
| High | 180 (59.6) |
| Low | 122 (40.4) |
| Sexual health | |
| Any history of STIs | |
| Yes | 121 (39.8) |
| No | 183 (60.2) |
| STIs in the past year | |
| Yes | 86 (28.5) |
| No | 216 (71.5) |
| # of Receptive anal sex acts in last 30 days | |
| 0 | 146 (48.0) |
| 1 | 43 (14.1) |
| 2–3 | 65 (21.4) |
| 4–5 | 35 (21.4) |
| 6+ | 15 (4.9) |
| # of Insertive anal sex acts in last 30 days | |
| 0 | 104 (34.4) |
| 1 | 40 (13.3) |
| 2–3 | 76 (25.2) |
| 4–5 | 41 (13.6) |
| 6+ | 41 (13.6) |
| Consistent condom use for receptive sex acts in the last 3 months | |
| Yes | 211 (69.6) |
| No | 92 (30.4) |
| Consistent condom use for insertive sex acts in the last 3 months | |
| Yes | 198 (65.8) |
| No | 103 (34.2) |
| Geosocial Networking app usage in previous 3 months | |
| Yes | 148 (48.5) |
| No | 157 (51.5) |
| Exchange sex in previous 3 months | |
| Yes | 112 (36.7) |
| No | 193 (63.3) |
| Healthcare access | |
| Primary care provider | |
| Yes | 130 (42.6) |
| No | 175 (57.4) |
| Health insurance | |
| Yes | 45 (14.9) |
| No | 258 (85.1) |
| Unable to access medical care due to cost in last year | |
| Yes | 130 (42.6) |
| No | 175 (57.4) |
| PrEP indicators | |
| Awareness of PrEP | |
| Yes | 135 (44.9) |
| No | 166 (55.1) |
| History of oral PrEP use | |
| Yes | 44 (14.5) |
| No | 260 (85.5) |
The denominator utilized to calculate percentage are from each individual variable not the total sample size and therefore change by variable depending on participant nonresponse
Acceptability of LAI-PrEP
A vast majority of respondents (88%) were willing to use LAI-PrEP. While almost half preferred LAI-PrEP (44%), 21% preferred daily oral PrEP, 17% preferred a lubricant, 10% liked them all equally, and only 6% preferred an implant. In bivariate analyses (Table 2), respondents who were interested in LAI-PrEP were more likely to be: single [odds ratio (OR) 2.15; 95% confidence interval (CI) 1.06–4.33], report inconsistent condom use for insertive sex acts in the previous 3 months (OR 3.64; 95% CI 1.37–9.67), and report having a primary care provider (OR 2.45; 95% CI 1.11–5.41).
Table 2:
Factors associated with willingness to use long-acting injectable (LAI-) PrEP among Nigerian sexual minority men SMM, bivariate and multivariable (N=305)
| Total Sample (N=305) |
Willingness to Use LAI PrEP |
P-Value | Logistic Regression Modeling | |||
|---|---|---|---|---|---|---|
| Willing (n=269, 88.2%) |
Not Willing/ Not Sure (n=36, 11.8%) |
Unadjusted Odds Ratio (95% Confidence Interval) |
Adjusted Odds Ratio (95% Confidence Interval) |
|||
| Demographics | ||||||
| Site | 0.99 | |||||
| Abuja | 59 (19.5) | 52 (88.1) | 7 (11.9) | Ref | ||
| Delta | 88 (29.1) | 78 (88.6) | 10 (11.4) | 1.05 (0.38-2.93) | ||
| Lagos | 83 (27.5) | 73 (88.0) | 10 (12.0) | 0.98 (0.35-2.75) | ||
| Plateau | 72 (23.8) | 63 (87.5) | 9 (12.5) | 0.94 (0.33-2.70) | ||
| Age | 0.36 | |||||
| 18-24 years | 70 (23.4) | 59 (84.3) | 11 (15.7) | Ref | ||
| 25-29 years | 87 (29.1) | 76 (87.4) | 11 (12.6) | 1.29 (0.52-3.18) | ||
| 30+ years | 142 (47.5) | 129 (90.9) | 13 (9.1) | 1.85 (0.78-4.37) | ||
| Relationship Status | 0.03 | |||||
| Single | 186 (61.0) | 170 (91.4) | 16 (8.6) | 2.15 (1.06-4.33) * | 2.14 (1.04-4.39) * | |
| Not Single | 119 (39.0) | 99 (83.2) | 20 (16.8) | Ref | Ref | |
| Educational Attainment | 0.92 | |||||
| Senior Secondary School or lower | 142 (46.6) | 125 (88.0) | 17 (12.0) | Ref | ||
| Some University or Vocational School | 65 (21.3) | 58 (89.2) | 7 (10.8) | 1.13 (0.44-2.87) | ||
| University degree or higher | 80 (26.2) | 71 (88.8) | 9 (11.2) | 1.07 (0.46-2.53) | ||
| Other | 18 (5.9) | 15 (83.3) | 3 (16.7) | 0.68 (0.18-2.60) | ||
| Sexual Orientation | 0.56 | |||||
| Gay/Homosexual | 113 (37.3) | 98 (86.7) | 15 (13.3) | Ref | ||
| Bisexual | 190 (62.7) | 169 (89.0) | 21 (11.0) | 0.81 (0.40-1.65) | ||
| Religious Affiliation | 0.94 | |||||
| Christian | 190 (62.5) | 168 (88.4) | 22 (11.6) | Ref | ||
| Muslim | 93 (30.6) | 82 (88.2) | 11 (11.8) | 0.98 (0.45-2.11) | ||
| Other | 21 (6.9) | 18 (85.7) | 3 (14.3) | 0.79 (0.21-2.88) | ||
| Social Marginalization | ||||||
| Monthly income (in Naira) | 0.28 | |||||
| 0-10,000 | 82 (27.3) | 74 (90.2) | 8 (9.8) | Ref | ||
| 10,000-30,000 | 84 (28.0) | 72 (85.7) | 12 (14.3) | 0.65 (0.25-1.68) | ||
| 30,000-50,000 | 62 (20.7) | 53 (85.5) | 9 (14.5) | 0.64 (0.23-1.76) | ||
| 50,000-100,000 | 35 (11.7) | 29 (82.9) | 6 (17.1) | 0.52 (0.17-1.64) | ||
| 100,000+ | 37 (12.3) | 36 (97.3) | 1 (2.7) | 3.89 (0.47-32.3) | ||
| Employment Status | 0.29 | |||||
| Employed | 241 (79.0) | 215 (89.2) | 26 (10.8) | 1.53 (0.70-3.37) | ||
| Unemployed | 64 (21.0) | 54 (84.4) | 10 (15.6) | Ref | ||
| Financial Hardship | 0.36 | |||||
| High | 180 (59.6) | 156 (86.7) | 24 (13.3) | 0.71 (0.34-1.48) | ||
| Low | 122 (40.4) | 110 (90.2) | 12 (9.8) | Ref | ||
| Sexual Health | ||||||
| Any history of STIs | 0.12 | |||||
| Yes | 121 (39.8) | 111 (91.7) | 10 (8.3) | 1.84 (0.85-3.97) | ||
| No | 183 (60.2) | 157 (85.8) | 26 (14.2) | Ref | ||
| STIs in the past year | ||||||
| Yes | 86 (28.5) | 79 (91.9) | 7 (8.1) | 1.75 (0.74-4.16) | ||
| No | 216 (71.5) | 187 (86.6) | 29 (13.4) | Ref | ||
| # of Receptive Anal sex acts in last 30 days | 0.95 | |||||
| 0 | 146 (48.0) | 128 (87.7) | 18 (12.3) | Ref | ||
| 1 | 43 (14.1) | 37 (86.1) | 6 (13.9) | 0.87 (0.32-2.34) | ||
| 2-3 | 65 (21.4) | 58 (89.2) | 7 (10.8) | 1.17 (0.46-2.94) | ||
| 4-5 | 35 (21.4) | 32 (91.4) | 3 (8.6) | 1.50 (0.42-5.41) | ||
| 6+ | 15 (4.9) | 13 (86.7) | 2 (13.3) | 0.91 (0.19-4.39) | ||
| # of Insertive Anal sex acts in last 30 days | 0.71 | |||||
| 0 | 104 (34.4) | 92 (88.5) | 12 (11.5) | Ref | ||
| 1 | 40 (13.3) | 34 (85.0) | 6 (15.0) | 0.74 (0.26-2.13) | ||
| 2-3 | 76 (25.2) | 69 (90.8) | 7 (9.2) | 1.29 (0.48-3.44) | ||
| 4-5 | 41 (13.6) | 37 (90.2) | 4 (9.8) | 1.21 (0.37-3.98) | ||
| 6+ | 41 (13.6) | 34 (82.9) | 7 (17.1) | 0.63 (0.23-1.74) | ||
| Consistent condom use for receptive sex acts in the last 3 months | 0.16 | |||||
| Yes | 211 (69.6) | 183 (86.7) | 28 (13.3) | Ref | ||
| No | 92 (30.4) | 85 (92.4) | 7 (7.6) | 1.86 (0.78-4.42) | ||
| Consistent condom use for insertive sex acts in the last 3 months | 0.006 | |||||
| Yes | 198 (65.8) | 167 (84.3) | 31 (15.7) | Ref | ||
| No | 103 (34.2) | 98 (95.2) | 5 (4.9) | 3.64 (1.37-9.67) * | 3.94 (1.47-10.59) * | |
| Geosocial Networking app usage in previous 3 months | 0.38 | |||||
| Yes | 148 (48.5) | 133 (89.9) | 15 (10.1) | 1.37 (0.68-2.78) | ||
| No | 157 (51.5) | 136 (86.6) | 21 (13.4) | Ref | ||
| Exchange sex in previous 3 months | 0.51 | |||||
| Yes | 112 (36.7) | 97 (86.6) | 15 (13.4) | 0.79 (0.39-1.60) | ||
| No | 193 (63.3) | 172 (89.1) | 21 (10.9) | Ref | ||
| Healthcare Access | ||||||
| Primary care Provider | 0.02 | |||||
| Yes | 130 (42.6) | 121 (93.1) | 9 (6.9) | 2.45 (1.11-5.41) * | 2.68 (1.20-6.00) * | |
| No | 175 (57.4) | 148 (84.6) | 27 (15.4) | Ref | Ref | |
| Health Insurance | 0.50 | |||||
| Yes | 45 (14.9) | 41 (91.1) | 4 (8.9) | 1.45 (0.49-4.32) | ||
| No | 258 (85.1) | 226 (87.6) | 32 (12.4) | Ref | ||
| Unable to assess medical care due to cost in last year | 0.23 | |||||
| Yes | 130 (42.6) | 118 (90.8) | 12 (9.2) | 1.56 (0.75-3.25) | ||
| No | 175 (57.4) | 151 (86.3) | 24 (13.7) | Ref | ||
| PrEP Indicators | ||||||
| Awareness of PrEP | 0.65 | |||||
| Yes | 135 (44.9) | 121 (89.6) | 14 (10.4) | 1.18 (0.57-2.44) | ||
| No | 166 (55.1) | 146 (88.0) | 20 (12.0) | Ref | ||
| History of oral PrEP Use | 0.27 | |||||
| Yes | 44 (14.5) | 41 (93.2) | 3 (6.8) | 1.99 (0.58-6.8) | ||
| No | 260 (85.5) | 227 (87.3) | 33 (12.7) | Ref | ||
p<0.05
p<0.01
In the multivariable model (Table 2), participants who reported interest in LAI-PrEP had higher odds of: being single [adjusted odds ratio (aOR) 2.14; 95% CI 1.04–4.39], report inconsistent condom use for insertive sex acts in the previous 3 months (aOR 3.94; 95% CI: 1.47–10.59), and report having a primary care provider (aOR 2.68; 95% CI 1.20–6.00).
PrEP Modality Preferences
In bivariate analyses, there were no significant differences among participants who preferred LAI-PrEP compared to participants who preferred daily oral PrEP (Table 3). Compared to participants who preferred daily oral PrEP, participants who preferred other modalities of PrEP (subdermal implant and rectal microbicides) had higher odds of: having some university/university degree or higher, compared to senior secondary or lower (OR 3.04; 95% CI 1.46–6.35) and reporting low financial hardship (OR 2.13; 95% CI 1.03–4.39). Participants who were Muslim compared to Christians had lower odds of preferring other PrEP modalities compared to daily oral PrEP (OR 0.35; 95% CI 0.15–0.82). Compared to participants who preferred daily oral PrEP, participants who liked them all equally had higher odds of: having some university/university degree or higher, compared to senior secondary or lower (OR 2.53; 95% CI 1.01–6.38), reporting a monthly income of 50,000–100,000 Naira compared to 0–10,000 Naira (OR 7.00; 95% CI 1.56–31.52), and reporting low financial hardship (OR 4.56; 95% CI 1.83–11.4).
Table 3:
Factors associated with preference for different PrEP modalities, bivariate and multivariable
| Frequency of PrEP preferences | Multinomial Logistic Regression for PrEP preferencesa |
|||||||
|---|---|---|---|---|---|---|---|---|
| Prefer daily Oral pill (n=62,21.0%) |
Prefer LAI- PrEP (n=131, 44.4%) |
Prefer other type of PrEP (subdermal implant, and rectal microbicides ) (n=70, 23.7%) |
Like them all equally (n=32, 10.9%) |
P-value | Prefer LAI- PrEP |
Prefer other type of PrEP (subdermal implant, and rectal microbicides |
Like them all equally |
|
| Demographics | ||||||||
| Site | 0.06 | |||||||
| Abuja | 12 (21.4) | 19 (33.9) | 17 (30.4) | 8 (14.3) | 0.58 (0.23-1.51) | 1.65 (0.57-4.81) | 3.11 (0.67-14.43) | |
| Delta | 16 (18.4) | 31 (35.6) | 26 (29.9) | 14 (16.1) | 0.71 (0.30-1.69) | 1.90 (0.70-5.11) | 4.08 (0.97-17.2) | |
| Lagos | 18 (22.0) | 42 (51.2) | 15 (18.3) | 7 (8.5) | 0.86 (0.38-1.96) | 0.97 (0.35-2.73) | 1.81 (0.40-8.31) | |
| Plateau | 14 (20.9) | 38 (56.7) | 12 (17.9) | 3 (4.5) | Ref | |||
| Age | 0.12 | |||||||
| 18-24 years | 17 (25.8) | 27 (40.9) | 18 (27.3) | 4 (6.1) | 0.69 (0.33-1.45) | 1.22 (0.52-2.85) | 0.54 (0.15-1.93) | |
| 25-29 years | 14 (16.5) | 32 (37.7) | 26 (30.6) | 13 (15.3) | 0.99 (0.47-2.13) | 2.14 (0.93-4.94) | 2.14 (0.79-5.81) | |
| 30+ years | 30 (21.7) | 69 (50.0) | 26 (18.8) | 13 (9.4) | Ref | |||
| Relationship Status | 0.92 | |||||||
| Single | 40 (21.9) | 80 (43.7) | 42 (22.9) | 21 (11.5) | 0.86 (0.46-1.62) | 0.83 (0.41-1.67) | 1.05 (0.43-2.57) | |
| Not Single | 22 (19.6) | 51 (45.5) | 28 (25.0) | 11 (9.8) | Ref | |||
| Educational Attainment | 0.04 | |||||||
| Senior Secondary School or lower | 38 (27.3) | 64 (46.0) | 25 (18.0) | 12 (8.6) | Ref | |||
| Some University/ University degree/higher | 20 (14.5) | 62 (44.9) | 40 (29.0) | 16 (11.6) | 1.83 (0.97-3.51) | 3.04 (1.46-6.4) * | 2.53 (1.01-6.38) * | |
| Other | 4 (22.2) | 5 (27.8) | 5 (27.8) | 4 (22.2) | 0.74 (0.19-2.94) | 1.90 (0.47-7.77) | 3.17 (0.69-14.6) | |
| Sexual Orientation | 0.25 | |||||||
| Gay/Homosexual | 26 (23.6) | 50 (45.5) | 27 (24.6) | 7 (6.4) | 0.84 (0.45-1.56) | 0.85 (0.42-1.70) | 0.38 (0.14-1.00) | |
| Bisexual | 35 (19.1) | 80 (43.7) | 43 (23.5) | 25 (13.7) | Ref | |||
| Religious Affiliation | 0.006 | |||||||
| Christian | 37 (19.7) | 80 (42.6) | 50 (26.6) | 21 (11.2) | Ref | |||
| Muslim | 23 (26.7) | 46 (53.5) | 11 (12.8) | 6 (7.0) | 0.93 (0.49-1.74) | 0.35 (0.15-0.82) ** | 0.46 (0.16-1.31) | |
| Other | 2 (10.0) | 5 (25.0) | 8 (40.0) | 5 (25.0) | 1.16 (0.21-6.24) | 2.96 (0.59-14.8) | 4.41 (0.79-24.7) | |
| Social Marginalization | 0.21 | |||||||
| Monthly income (in Naira) | ||||||||
| 0-10,000 | 21 (26.6) | 36 (45.6) | 16 (20.3) | 6 (7.6) | Ref | |||
| 10,000-30,000 | 14 (17.5) | 35 (43.8) | 21 (26.3) | 10 (12.5) | 1.46 (0.64-3.31) | 1.97 (0.77-5.03) | 2.50 (0.74-8.45) | |
| 30,000-50,000 | 18 (30.0) | 24 (40.0) | 14 (23.3) | 4 (6.7) | 0.78 (0.35-1.76) | 1.02 (0.39-2.65) | 0.78 (0.19-3.20) | |
| 50,000-100,000 | 5 (14.7) | 15 (44.1) | 11 (32.4) | 3 (8.8) | 2.77 (0.83-9.25) | 1.97 (0.48-8.17) | 7.00 (1.56-31.5) * | |
| 100,000+ | 4 (10.8) | 19 (51.4) | 6 (16.2) | 8 (21.6) | 1.75 (0.56-5.51) | 2.89 (0.84-9.99) | 2.10 (0.39-11.43) | |
| Employment Status | 0.33 | |||||||
| Employed | 51 (21.8) | 104 (44.4) | 51 (21.8) | 28 (12.0) | 0.83 (0.38-1.81) | 0.56 (0.25-1.34) | 1.51 (0.44-5.19) | |
| Unemployed | 11 (18.0) | 27 (44.3) | 19 (31.2) | 4 (6.6) | Ref | |||
| Financial Hardship | 0.004 | |||||||
| High | 43 (25.0) | 81 (47.1) | 37 (21.5) | 11 (6.4) | Ref | |||
| Low | 18 (15.0) | 48 (40.0) | 33 (27.5) | 21 (17.5) | 1.42 (0.74-2.73) | 2.13 (1.03-4.4) * | 4.56 (1.83-11.4) * | |
| Sexual Health | ||||||||
| Any history of STIs | 0.43 | |||||||
| Yes | 22 (18.5) | 52 (43.7) | 28 (23.5) | 17 (14.3) | 1.21 (0.65-2.27) | 1.21 (0.60-2.46) | 2.06 (0.87-4.91) | |
| No | 40 (22.9) | 78 (44.6) | 42 (24.0) | 15 (8.6) | Ref | |||
| STIs in the past year | 0.19 | |||||||
| Yes | 15 (17.7) | 39 (45.9) | 17 (20.0) | 14 (16.5) | 1.36 (0.68-2.71) | 1.02 (0.46-2.28) | 2.44 (0.98-6.05) | |
| No | 47 (22.7) | 90 (43.5) | 52 (25.1) | 18 (8.7) | Ref | |||
| # of Receptive Anal sex acts in last 30 days | 0.99 | |||||||
| 0 | 29 (20.9) | 63 (45.3) | 30 (21.6) | 17 (12.2) | Ref | |||
| 1 | 8 (19.1) | 19 (45.2) | 11 (26.2) | 4 (9.5) | 1.09 (0.43-2.79) | 1.33 (0.47-3.78) | 0.85 (0.22-3.26) | |
| 2-3 | 13 (20.3) | 29 (45.3) | 17 (26.6) | 5 (7.8) | 1.03 (0.47-2.26) | 1.26 (0.52-3.06) | 0.66 (0.20-2.16) | |
| 4+ | 12 (24.5) | 20 (40.8) | 12 (24.5) | 5 (10.2) | 0.77 (0.33-1.78) | 0.97 (0.37-2.50) | 0.71 (0.21-2.37) | |
| # of Insertive Anal sex acts in last 30 days | 0.68 | |||||||
| 0 | 22 (21.6) | 45 (44.1) | 22 (21.6) | 13 (12.8) | Ref | |||
| 1 | 6 (15.8) | 16 (42.1) | 12 (31.6) | 4 (10.5) | 1.30 (0.45-3.79) | 2.00 (0.64-6.28) | 1.13 (0.27-4.76) | |
| 2-3 | 12 (16.7) | 36 (50.0) | 19 (26.4) | 5 (6.9) | 1.47 (0.64-3.36) | 1.58 (0.62-4.03) | 0.71 (0.20-2.46) | |
| 4+ | 22 (27.5) | 32 (40.0) | 17 (21.3) | 9 (11.3) | 0.71 (0.34-1.50) | 0.77 (0.33-1.84) | 0.69 (0.25-1.95) | |
| Consistent condom use for receptive sex acts in the last 3 months | 0.67 | |||||||
| Yes | 42 (20.9) | 86 (42.8) | 49 (24.4) | 24 (11.9) | 0.91 (0.48-1.73) | 1.23 (0.58-2.60) | 1.43 (0.55-3.74) | |
| No | 20 (21.7) | 45 (48.9) | 19 (20.7) | 8 (8.7) | Ref | |||
| Consistent condom use for insertive sex acts in the last 3 months | 0.62 | |||||||
| Yes | 39 (20.7) | 79 (42.0) | 49 (26.1) | 21 (11.2) | 0.95 (0.51-1.78) | 1.45 (0.70-3.00) | 1.13 (0.46-2.75) | |
| No | 23 (22.3) | 49 (47.6) | 20 (19.4) | 11 (10.7) | Ref | |||
| Geosocial Networking app usage in previous 3 months | 0.40 | |||||||
| Yes | 31 (21.1) | 65 (44.2) | 31 (21.1) | 20 (13.6) | 0.99 (0.54-1.80) | 0.80 (0.40-1.58) | 1.67 (0.70-4.00) | |
| No | 31 (21.0) | 66 (44.6) | 39 (26.4) | 12 (8.1) | Ref | |||
| Exchange sex in previous 3 months | 0.71 | |||||||
| Yes | 25 (22.9) | 49 (44.9) | 26 (23.9) | 9 (8.3) | 0.88 (0.48-1.64) | 0.88 (0.43-1.76) | 0.58 (0.23-1.46) | |
| No | 37 (19.9) | 82 (44.1) | 44 (23.7) | 23 (12.4) | Ref | |||
| Healthcare Access | ||||||||
| Primary care Provider | 0.04 | |||||||
| Yes | 23 (18.1) | 65 (51.2) | 22 (17.3) | 17 (13.4) | 1.67 (0.90-3.10) | 0.78 (0.38-1.60) | 1.92 (0.81-4.56) | |
| No | 39 (23.2) | 66 (39.3) | 48 (28.6) | 15 (8.9) | Ref | |||
| Health Insurance | 0.71 | |||||||
| Yes | 9 (20.0) | 23 (51.1) | 8 (17.8) | 5 (11.1) | 1.24 (0.54-2.87) | 0.75 (0.27-2.07) | 1.07 (0.33-3.51) | |
| No | 52 (21.0) | 107 (43.2) | 62 (25.0) | 27 (10.9) | Ref | |||
| Unable to assess medical care due to cost in last year | 0.57 | |||||||
| Yes | 22 (17.3) | 58 (45.7) | 33 (26.0) | 14 (11.0) | 1.44 (0.77-2.70) | 1.62 (0.81-3.27) | 1.41 (0.59-3.38) | |
| No | 40 (23.8) | 73 (43.5) | 37 (22.0) | 18 (10.7) | Ref | |||
| PrEP Indicators | ||||||||
| Awareness of PrEP | 0.53 | |||||||
| Yes | 24 (17.9) | 63 (47.0) | 34 (25.4) | 13 (9.7) | 1.45 (0.78-2.69) | 1.54 (0.77-3.10) | 1.06 (0.44-2.52) | |
| No | 37 (23.6) | 67 (42.7) | 34 (21.7) | 19 (12.1) | Ref | |||
| History of oral PrEP Use | 0.59 | |||||||
| Yes | 12 (27.3) | 20 (45.5) | 9 (20.5) | 3 (6.8) | 0.75 (0.34-1.65) | 0.63 (0.24-1.60) | 0.43 (0.11-1.66) | |
| No | 50 (20.0) | 111 (44.4) | 60 (24.0) | 29 (11.6) | Ref | |||
Multinomial regression, dependent variable = preferring LAI-PrEP, other type of PrEP (subdermal implant, and rectal microbicides), or liking them all equally, compared to preferring a daily oral pill
p<0.05
p<0.01
In the multivariable, multinomial logistic model (Table 3), compared to participants who preferred daily oral PrEP, participants who preferred other modalities of PrEP (subdermal implant and rectal microbicides) had higher odds of: having some university/university degree or higher, compared to senior secondary or lower (aOR 2.70; 95% CI 1.28–5.70). Compared to participants who preferred daily oral PrEP, participants who liked them all equally had higher odds of reporting low financial hardship (aOR 4.12; 95% CI 1.63–10.42).
Discussion
This is the first known quantitative study to explore willingness to use LAI-PrEP and preference for different PrEP modalities among SMM in West Africa. A majority of participants (88%) were willing to use LAI-PrEP. Furthermore, 44% of participants preferred LAI-PrEP, followed by 24% preferring other PrEP products (subdermal implant and rectal microbicides), daily oral PrEP was preferred by 21%, and 11% liked them all equally. These findings provide evidence for high interest in LAI-PrEP and other PrEP modalities among SMM in Nigeria.
We found that participants who reported interest in LAI-PrEP were more likely to be engaged in inconsistent condom use and report having a primary care provider. Our findings are consistent with previous studies that showed SMM with an increased risk for HIV infection (i.e., engagement in condomless anal sex [16, 24], a higher number of sexual partners [25], and high self-perception of future HIV infection [26]) were more willing to use LAI-PrEP. This finding provides evidence that SMM who are at the highest risk for HIV infection, due to sexual behavior, might be more willing to use LAI-PrEP. This is important since LAI-PrEP may help reduce the adherence barriers associated with daily oral PrEP. It is important that interventions designed to increase PrEP uptake and adherence among SMM in Nigeria assess HIV risk for potential PrEP adopters and recommend PrEP to individuals who are at high risk for HIV infection. Consequently, CBOs and healthcare providers that work with SMM in Nigeria should routinely screen their HIV-negative clients for PrEP eligibility and recommend PrEP to eligible candidates. It is also important that healthcare providers stress the need to use condoms in combination with PrEP, as PrEP only protects against HIV infection.
Consistent with our findings, prior studies have shown that individuals with health insurance [24] were more willing to take LAI-PrEP, although a major concern related to LAI-PrEP was the difficulty of navigating constant medical appointments [27]. It is important to consider how SMM without access to health services may be unable to access oral daily PrEP as well as other future PrEP modalities. CBOs—which often serve as the medical home of SMM in countries like Nigeria—play a major role in the dissemination of health information about PrEP and building their capacity to provide PrEP-related healthcare services, including laboratory testing and pharmacy services. Additionally, these PrEP-related health services must be provided at low cost or free of charge to eligible clients, as research has demonstrated cost to be a major barrier to PrEP uptake and adherence among SMM [28-30].
Participants who preferred other PrEP modalities—specifically subdermal implant and rectal microbicides—were more likely to be highly educated and reported lower levels of financial hardship, compared to participants who preferred daily oral PrEP. Other studies exploring PrEP modality preference among SMM found that participants with higher educational attainment preferred other PrEP modalities to daily oral PrEP [31, 32]. This suggests that individuals of higher socioeconomic status may find other forms of PrEP more acceptable, which might be explained by their ability to afford more sophisticated and expensive healthcare products and services. This hypothesis is supported by another study of SMM in China that found willingness to pay for PrEP was associated with higher monthly income [33]. Additionally, higher-income individuals may have higher health literacy, which might make them more comfortable with new and innovative approaches to HIV prevention. This finding supports the need to make oral daily PrEP and all future PrEP modalities affordable to achieve equitable uptake and adherence among SMM, especially in the Nigerian context. However, it is important to note that the availability and affordability of various PrEP modalities will not automatically translate to increased acceptability, uptake, and adherence. Consequently, it is important to increase awareness and knowledge about PrEP through both traditional (e.g., radio and billboards) and digital (e.g., television and social networking) media campaigns that prominently feature Nigerian SMM.
We found no statistically significant difference between awareness and history of daily oral PrEP and the acceptability of LAI-PrEP. A published analysis of the same sample found high willingness to use PrEP (80%) but low history of PrEP use (30%) [9]. This finding suggests that factors associated with low uptake of daily oral PrEP might persist when LAI-PrEP becomes available in Nigeria. Consequently, it is important that the preferences of SMM be carefully considered when implementing PrEP health programs to ensure that a similar gap in daily oral PrEP acceptability and uptake does not occur with new PrEP modalities. Specifically, a comprehensive assessment of a client’s sexual health and daily life experiences should be conducted to identify the best modality of PrEP (e.g., daily oral, LAI, intermittent, etc.) that fits their unique lived experiences, to maximize the chances of optimal adherence. Lastly, given that some individuals might adopt PrEP temporarily, it is important that healthcare providers periodically reassess the fit of their clients’ PrEP regimen to their lifestyle and readjust based on patient preferences and possible changes in sexual behaviors and partnerships.
This study has several limitations. The measures relied on participant recall/self-report, which may have contributed to social desirability bias. Also, we asked hypothetical questions about PrEP modality preferences, without providing details about possible side effects, costs, medical follow-up obligations, possible risks, etc. Further information about each PrEP modality has the ability to drastically change participant responses. Additionally, individuals who chose daily oral PrEP versus the other hypothetical PrEP modalities that aren’t currently available may have done so due to the proven efficacy of daily oral PrEP to prevent HIV acquisition.
Conclusions
We found that a majority of the SMM (88%) were willing to use LAI-PrEP. Furthermore, almost half (44%) preferred LAI-PrEP, 24% preferring other PrEP products (subdermal implant and rectal microbicides), 21% preferred daily oral PrEP, and 11% liked them all equally. Consequently, as more data is released on the efficacy and effectiveness of LAI-PrEP and other PrEP products, it is imperative that SMM, especially in vulnerable settings such as Nigeria, are prioritized for uptake, as they bear a disproportionate burden of HIV and are especially vulnerable to HIV infection.
Acknowledgements
This work was supported by grant R36 DA047216 from the National Institute on Drug Abuse (PI: Adedotun Ogunbajo), and the Robert Wood Johnson Health Policy Research Scholars Program. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. We would like to thank all the participants of the study for their time and efforts. We would also like to thank the staff at the Centre for Right to Health (Abuja) Equality Triangle Initiative (Delta), Improved Sexual Health and Rights Advocacy Initiative (ISHRAI, Lagos), and Hope Alive Health Awareness Initiative (Plateau).
Footnotes
Declarations
Conflict of interest ACT reports receiving a financial stipend from Elsevier, Inc. for his work as Co-Editor in Chief of the journal SSM- Mental Health.
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