Abstract
Background
Long-acting injectable (LAI)-PrEP provides better protection against HIV compared to oral PrEP, which requires taking a daily pill. Our study aimed to assess knowledge about oral and LAI-PrEP and identify factors associated with willingness to use LAI-PrEP among key populations (KPs) in Uganda.
Methods
We conducted a cross-sectional study at the Most at Risk Populations Initiative (MARPI) clinic between November and December 2021. Participants were recruited through convenience sampling and interviewed using a structured questionnaire by trained interviewers. Participants were categorised into three groups based on their oral PrEP use: those who had not yet initiated PrEP, those who had discontinued oral PrEP, and those currently on oral PrEP. Modified Poisson regression analysis was performed to determine factors associated with the participants’ willingness to use LAI-PrEP. Data was analysed using STATA 14 software.
Results
Of the 234 participants, 135 (57.7%) were female, 82.5% knew about LAI-PrEP, and 65.8% were willing to use it. The mean age was 28.7 years (standard deviation [SD] 5.8). Willingness to use LAI-PrEP was less likely among divorced, widowed, or separated individuals than singles (i.e., people with no prior marital experience and neither in a romantic relationship) (adjusted prevalence ratio [aPR] 0.65, 95% CI: 0.43–0.98). Relative to current oral PrEP users, willingness to use LAI-PrEP was similar among those who discontinued oral PrEP (aPR 1.39, 95% CI: 0.92–2.11) and those who had not yet initiated PrEP but were at risk for HIV (aPR 1.26, 95% CI: 0.83–1.89).
Conclusions
This cross-sectional analysis of diverse members of KPs in Uganda revealed that the willingness to use LAI-PrEP was lower among individuals who were divorced, separated, or widowed compared to those who were single. Future studies should investigate effective methods for promoting the uptake of long-acting PrEP formulations among populations at high risk of HIV acquisition.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12981-025-00747-3.
Keywords: HIV, Long-acting injectable preexposure prophylaxis (LAI-PrEP), Key populations, Female sex workers, People who inject drugs, Men who have sex with men, Truck drivers
Background
Despite significant advancements in antiretroviral therapy and a decrease in mortality rates, HIV remains a significant global health issue after more than four decades. There are currently 37.7 million people living with HIV worldwide (range 30.2–45.1 million), and in 2020, there were 1.5 million new infections globally [1–3]. Most people living with HIV (PLHIV) (71%) reside in sub-Saharan Africa, where over three-quarters of all deaths related to HIV occur, and approximately two-thirds of the estimated 4,000 daily new infections worldwide take place [1, 4]. In Uganda, the adult HIV prevalence was 5.1%, with an estimated 52,000 new infections in 2022 [5]. Most HIV transmissions in Uganda (70%) occur among key populations (KPs), specifically female sex workers (FSW), people who inject drugs (PWID), truck drivers (TD), fisher folk (FF), and men who have sex with men (MSM) [4, 6]. In these populations, the prevalence of HIV is 31.3%, 14.9–35.0%, 16.0%, and 12.7% among FSW, FF, PWID, and MSM, respectively [7, 8].
Pre-exposure prophylaxis (PrEP) for HIV is a highly effective strategy in preventing HIV acquisition. The World Health Organization (WHO) recommends PrEP as an additional preventative measure for individuals at high risk of acquiring HIV in conjunction with other combination HIV prevention approaches [9]. As of January 2025, Uganda had the third-highest number of PrEP initiations in Africa, totalling 743,696. South Africa led with 1,342,154 initiations, followed by Zambia with 895,585. Globally, 8,00,762 individuals have started PrEP [10]. In addition, the government of Uganda, in collaboration with its PEPFAR implementing partners, has facilitated free access to HIV prevention services such as condoms, safe male circumcision, sexually transmitted infection (STI) testing and treatment, and oral PrEP [11–14]. Although there has been a substantial uptake of PrEP in HIV prevention programs, persistence remains a challenge. Two systematic reviews published in 2020 and 2022 reported discontinuation rates of 37.3% and 41%, respectively, within six months of starting PrEP [15, 16]. Research conducted in Kenya, South Africa, and the United States revealed that over half of the individuals who began taking oral PrEP discontinued use within the first six months [17–19]. Other work conducted in Uganda showed low PrEP uptake (30.6%), high discontinuation (67.9%), and poor adherence, where 38.8% of adolescent girls and young women (AGYW) had detectable tenofovir (> 10 µg/L), and only 6.1% had protective tenofovir levels (> 40 µg/L) [20]. Reasons for discontinuing oral PrEP include side effects, transport costs to the clinic, stigma, and the inconvenience of a daily pill.
Long-acting injectable (LAI)-PrEP, formulated for multi-month use, was developed to overcome some of the challenges associated with oral PrEP. It offers numerous benefits, including being discreet and less stigmatising, making it a potential alternative to oral PrEP [21]. LAI-PrEP was safe and preferred to oral PrEP in the HPTN 083 trial, which took place in Argentina, Brazil, Peru, South Africa, Thailand, United States, and Vietnam, as well as in the HPTN 084 trial conducted in Botswana, Eswatini, Kenya, Malawi, South Africa, Uganda, and Zimbabwe. These studies reported reductions of 88% and 66% in HIV acquisitions, respectively, among cisgender women, men who have sex with men, and transgender women [22, 23]. Thus, the introduction of LAI-PrEP has the potential to significantly improve PrEP persistence.
However, even though Uganda’s National Drug Authority approved the use of injectable cabotegravir (CAB-LA) as PrEP in February 2024, access is limited to demonstration projects. The slow global roll-out of CAB-LA has hindered its population-level impact on reducing HIV incidence. Delays in scaling up CAB-LA in resource-limited settings can be attributed to slow regulatory approvals, production challenges, supply chain limitations, and its high cost, ranging from $170-$240 per year, according to estimates by PEPFAR [24, 25].
While LAI-PrEP has various advantages compared to oral PrEP, its acceptability among KPs in Uganda is not well described. We hypothesised that KPs would prefer LAI-PrEP with higher uptake than oral PrEP. This study aimed to assess knowledge about LAI-PrEP and to identify factors related to the willingness to use it among KPs, including those who had discontinued oral PrEP.
Methods
Study design and setting
We conducted a cross-sectional study at the Most at Risk Populations Initiative (MARPI) clinic between November and December 2021. MARPI is a prominent HIV prevention clinic located in Mulago Hospital, Kampala, which provides essential services to the KPs community, including counselling and testing, family planning, condom distribution, STI screening, and other related services. The target populations of MARPI are FSW, TD, MSM, FF, transgender individuals, and bar attendants [26]. We categorised potential LAI-PrEP beneficiaries into three groups: (i) eligible but had not yet initiated PrEP (naïve/not PrEP exposed), (ii) discontinued oral PrEP use, and (iii) currently taking oral PrEP.
Recruitment and sampling
We used data extracted from MARPI PrEP registers to identify and recruit individuals ≥ 18 years old who were invited to visit the MARPI clinic. Through convenience sampling, 234 participants were selected for potential inclusion in the study. Informed consent was obtained before face-to-face interviews were conducted at the MARPI clinic. The desired sample size was 252, but only 234 participants were included due to the unwillingness of 18 selected individuals to be interviewed, who were not replaced.
Data collection
We used an interviewer-administered semi-structured questionnaire to collect data for the study. We captured data about socio-demographic characteristics, willingness to use LAI-PrEP, and its associated factors. Before implementation, the questionnaire was pretested with ten community volunteers who were identified as being at risk for HIV. Trained research assistants contacted and administered the questionnaire to eligible participants. The primary objective of this study was to determine the level of willingness among KPs to use LAI-PrEP, recorded on a binary scale with responses of either “Yes” or “Not sure/No.” Additionally, we documented reasons for declining LAI-PrEP, circumstances in which they would be more inclined to receive it, and their preferred location for obtaining it.
Statistical analysis
The primary outcome was willingness to use LAI-PrEP. Participant characteristics were summarised using descriptive statistics. Modified Poisson regression was used to determine factors associated with willingness to use LAI-PrEP when it became available and to estimate prevalence ratios (PR) and corresponding 95% confidence intervals (CI). Both unadjusted and adjusted modelling were performed, with the adjusted model including only significant factors (p < 0.05) from the unadjusted model. Covariates in the model included age, KPs category, marital status, race, gender, education, occupation, number of sex partners in the previous month, history of unprotected sex in the past 3 months, use of illicit drugs before sex in the last 6 months, previous STI diagnosis, condom use, knowledge of PrEP and HIV risk category. Logistic regression was not performed because the primary outcome’s high prevalence (> 10%) could lead to biased odds ratio estimates. Complete case analysis was used as the primary analytical method because the percentage of missing data was ≤ 5% [27, 28]. Missing data were minimal, with one missing observation for the outcome variable and 1–6 observations missing across six independent variables. Thus, no imputation was performed. Data was analysed using STATA 14.
Results
Socio-demographic characteristics
Of the 234 participants, 135 (57.7%) were female, and 115 (49.2%) were FSW. The mean age was 28.7 years (standard deviation [SD] 5.8). Most participants, 189 (80.8%), engaged in unprotected sexual activity within the last 3 months, 117 (75.6%) reported having more than two sexual partners in the previous month, and 158 (67.8%) expressed fear of acquiring HIV (Table 1). Nearly half, 114 (48.9%), had been previously (since sex debut) diagnosed with STIs. Seventy-nine (33.9%) frequently used illicit drugs before sex in the past 6 months, and only 76 (32.5%) consistently used condoms. Most participants, 193 (82.5%), were aware of LAI-PrEP, with the highest level of knowledge observed among FSW (88.7%). A total of 102 (43.7%) were currently taking oral PrEP, 75 (32.1%) were at risk but PrEP naïve, and 57 (24.4%) had discontinued oral PrEP. All participants knew about oral PrEP; 173 (73.9%) had heard about oral PrEP from health workers, 21 (15.7%) from a friend, and 15 (11.2%) from social media.
Table 1.
Socio-demographic characteristics
| Social demographics |
General (n = 234) N (%) |
Taking oral PrEP(n = 102) N (%) |
Eligible but PrEP naïve (n = 75) N (%) |
Discontinued oral PrEP (n = 57) N (%) |
| Age (years) | ||||
| 18–30 | 146 (62.4) | 67 (65.7) | 42 (56.0) | 37 (64.9) |
| 31–40 | 74 (31.6) | 24 (23.5) | 33 (44.0) | 17 (29.8) |
| 41–45 | 14 (6.0) | 11 (10.8) | 0 | 3(5.3) |
| Gender | ||||
| Female | 135 (57.7) | 52 (51.0) | 48 (64.0) | 35 (61.4) |
| Male | 99 (42.3) | 50 (49.0) | 27 (36.0) | 22 (38.6) |
| Key population | ||||
| FSW | 115 (49.2) | 34 (33.3) | 48 (64.0) | 33 (57.9) |
| Truckers | 40 (17.1) | 24 (23.5) | 12 (16.0) | 4 (7.0) |
| PWID | 33 (14.1) | 24 (23.5) | 3 (4.0) | 6 (10.5) |
| MSM | 28 (12.0) | 9 (8.8) | 9 (12.0) | 10 (17.5) |
| Transgender | 4 (1.7) | 0 | 0 | 4 (7.0) |
| Other (fisher folk, bar attendants) | 4 (1.7) | 1 (1.0) | 3 (4.0) | 0 |
| None | 10 (4.3) | 10 (9.8) | 0 | 0 |
| Education* | ||||
| Primary | 92 (39.5) | 34 (33.3) | 33 (44.0) | 25 (44.6) |
| Secondary | 81 (34.7) | 23 (22.6) | 36 (48.0) | 22 (39.3) |
| University/post-university | 43 (18.5) | 43 (42.2) | 0 | 0 |
| None | 17 (7.3) | 2 (2.0) | 6 (8.0) | 9 (16.1) |
| Marital Status | ||||
| Divorced/separated | 86 (36.8) | 23 (22.6) | 42 (56.0) | 21 (36.8) |
| Single | 61 (26.1) | 16 (15.7) | 21 (28.0) | 24 (42.1) |
| Cohabiting | 36 (15.4) | 27 (26.5) | 2 (2.7) | 7 (12.3) |
| Married (Polygamous) | 44 (18.8) | 31 (30.4) | 10 (13.3) | 3 (5.3) |
| Widowed | 7 (3.0) | 5 (4.9) | 0 | 2 (3.5) |
| Occupation** | ||||
| Labourer (Semi skilled) | 61 (26.4) | 25 (25.3) | 26 (34.7) | 10 (17.5) |
| Farming | 23 (10.0) | 23 (23.2) | 0 | 0 |
| Traders/sales | 18 (7.8) | 18 (18.2) | 0 | 0 |
| Student | 22 (9.5) | 14 (14.1) | 3 (4.0) | 5 (8.7) |
| Professional | 9 (3.9) | 9 (9.1) | 0 | 0 |
| Housewife | 3 (1.3) | 3 (3.0) | 0 | 0 |
| Other | 82 (35.5) | 7 (7.1) | 46 (61.3) | 29 (59.9) |
| Unemployed | 13 (5.6) | 0 | 0 | 13 (22.8) |
| Sexual behaviour |
General (n = 234) N (%) |
Taking oral PrEP (n = 102) N (%) |
Eligible but PrEP naïve (n = 75) N (%) |
Discontinued oral PrEP (n = 57) N (%) |
| Sex Partners (previous month) | ||||
| More than two | 177 (75.6) | 47 (46.1) | 75 (100) | 55 (96.5) |
| Two | 31 (13.3) | 29 (28.4) | 0 | 2 (3.5) |
| One | 23 (9.8) | 23 (22.6) | 0 | 0 |
| None | 3 (1.3) | 3 (2.9) | 0 | 0 |
| Had unprotected sex in the last 3 months | ||||
| Yes | 189 (80.8) | 61 (59.8) | 75 (100) | 53 (93.0) |
| No | 26 (11.1) | 22 (21.6) | 0 | 4 (7.0) |
| Not sure | 19 (8.1) | 19 (18.6) | 0 | 0 |
| Used illicit drug before sex in previous 6 months* | ||||
| All the time/very frequently | 79 (33.9) | 41 (40.2) | 15 (20.3) | 23 (40.4) |
| Sometimes | 34 (14.6) | 0 | 0 | 34 (59.7) |
| No | 81 (34.8) | 49 (48.0) | 32 (43.2) | 0 |
| Not sure | 39 (16.7) | 12 (11.8) | 27 (36.5) | 0 |
| Previous STI diagnosis* | ||||
| Yes | 114 (48.9) | 37 (36.3) | 64 (85.3) | 13 (23.2) |
| No | 101 (43.4) | 52 (51.0) | 11 (14.7) | 38 (67.9) |
| Not sure | 18 (7.7) | 13 (12.7) | 0 | 5 (8.9) |
| Use condoms | ||||
| All the time/very frequently | 142 (60.7) | 38 (37.3) | 53(70.0) | 51 (89.5) |
| Sometimes | 73 (31.2) | 51 (50.0) | 22 (29.3) | 0 |
| No | 19 (8.1) | 13 (12.8) | 0 | 6 (10.5) |
*1 missing, **2 missing observations
Willingness to use LAI-PrEP
Two-thirds, 154 (65.8%), were willing to use LAI-PrEP. Most participants, 44/57 (77.2%), who had discontinued oral PrEP were willing to use LAI-PrEP, while 45/75 (60.0%) who were at risk but PrEP naïve and 65/102 (63.7%) who were using oral PrEP were willing to use LAI-PrEP. Most participants reported that they would be more interested in LAI-PrEP for the following reasons: 209 (89.3%) if they could get access to free sexual health care/monitoring while receiving LAI-PrEP, 167 (71.4%) if they could get free HIV testing, 148 (63.2%) if they did not have to go to their regular doctor to get LAI-PrEP, 122 (52.1%) if they could talk to someone and get support or counselling about their sex life, 117 (50.0%) if they could have access to one-on-one counselling and support around LAI-PrEP use, 85 (36.3%) if they could get text-based support for injectable PrEP use, and 92 (39.3%) if they could have group-based adherence support for injectable PrEP use. Reasons for not being willing to use LAI-PrEP included myths and misconceptions like “If I become HIV positive, the medicines may not work because I was on LAI-PrEP”, 26 (44.8%), and LAI-PrEP putting themselves at increased risk of HIV, 14 (24.1%) (Table 2).
Table 2.
Willingness to use long-acting injectable PrEP
| General (n = 234) N (%) |
Taking oral PrEP (n = 102) N (%) |
Eligible but PrEP naïve (n = 75) N (%) |
Discontinued oral PrEP (n = 57) N (%) |
|
|---|---|---|---|---|
| Willingness to use long-acting injectable PrEP* | ||||
| Yes (willing) | 154 (65.8) | 65 (63.7) | 45 (60.0) | 44 (77.2) |
| No (not willing) | 58 (24.8) | 34 (33.3) | 11 (14.7) | 13 (22.8) |
| Not sure/Maybe | 16 (6.8) | 3 (2.9) | 13 (17.3) | 0 |
| If not, why? n = 58 | n = 34 | n = 11 | n = 13 | |
| If I become HIV positive, the medicines may not work because I was on LAI-PrEP | 26 (44.8) | 26 (76.5) | ||
| Prefer taking tablets | 24 (41.4) | 11 (100) | 13 (100) | |
| Tablets will remind me of taking my other medicines | 24 (41.4) | 11 (100) | 13 (100) | |
| People will think I am HIV positive | 23 (39.7) | 23 (67.6) | ||
| Don’t want to talk to the doctor about my sex life | 18 (31.0) | 18 (52.9) | ||
| Because I will be putting myself at risk of HIV | 14 (24.1) | 14 (41.2) | ||
| May affect my other medicines | 8 (13.8) | 8 (23.5) | ||
| May not work | 7 (12.1) | 7 (20.6) | ||
| May have side effects | 6 (10.3) | 6 (17.6) | ||
| I fear Injections | 3 (5.2) | 3 (8.8) | ||
| Because I am not exposed to HIV | ||||
| My partner will see me. | ||||
| I would be more interested in Injectable PrEP if I could get free HIV testing | ||||
| Agree | 167 (71.4) | 39 (38.2) | 72 (96.0) | 56 (98.2) |
| Indifferent | 59 (25.2) | 56 (54.9) | 2 (2.7) | 1 (1.8) |
| Disagree | 7 (3.0) | 7 (6.9) | ||
| Would be more interested in Injectable PrEP if I could get access to free sexual health care/monitoring while receiving Injectable PrEP | ||||
| Agree | 209 (89.3) | 84 (82.4) | 69 (92.0) | 56 (98.2) |
| Indifferent | 19 (8.1) | 13 (12.7) | 5 (6.7) | 1(1.8) |
| Disagree | 4 (1.7) | 4 (3.9) | ||
| I would be more interested in Injectable PrEP if I could have access to one-on-one counselling and support around Injectable PrEP use | ||||
| Agree | 117 (50.0) | 34 (33.3) | 40 (53.3) | 43 (75.4) |
| Indifferent | 103 (44.0) | 65 (63.7) | 26 (34.7) | 12 (21.1) |
| Disagree | 13 (5.5) | 3 (2.9) | 8 (10.7) | 2 (3.5) |
| I would be more interested in Injectable PrEP if I could get text-based support for Injectable PrEP use | ||||
| Agree | 85 (36.3) | 61 (59.8) | 20 (26.7) | 4 (7.0) |
| Indifferent | 85 (36.3) | 28 (27.5) | 28 (37.3) | 29 (50.9) |
| Disagree | 63 (26.9) | 13 (12.7) | 26 (34.7) | 24 (42.1) |
| I would be more interested in Injectable PrEP if I could talk to someone and get support or counselling about my sex life | ||||
| Agree | 122 (52.1) | 49 (48.0) | 70 (93.3) | 3 (5.3) |
| Indifferent | 66 (28.2) | 38 (37.3) | 28 (49.1) | |
| Disagree | 43 (18.4) | 15 (14.7) | 2 (2.7) | 26 (45.6) |
| I would be more interested in Injectable PrEP if I could have group-based adherence support for Injectable PrEP use | ||||
| Agree | 92 (39.3) | 33 (32.4) | 51 (68.0) | 8 (14.0) |
| Disagree | 62 (26.5) | 25 (24.5) | 37 (64.9) | |
| Indifferent | 76 (32.5) | 43 (42.2) | 21 (28.0) | 12 (21.1) |
| If you were to use PrEP (oral/injectable) where would you prefer to get this from? ** | ||||
| PrEP Clinic | 145 (61.9) | 80 (78.4) | 42 (56.0) | 23 (40.4) |
| Home | 58 (24.8) | 8 (7.8) | 20 (26.7) | 30 (52.6) |
| Community Pharmacy | 18 (7.1) | 8 (7.8) | 10 (13.3) | |
| Office | 3 (1.3) | 1 (0.9) | 2 (2.7) | |
| Other | 9 (3.8) | 5 (4.9) | 4 (7.0) | |
| Willingness to use LAI-PrEP by key population category* | ||||
| Key population | Total | Not willing n = 58 | Not sure/maybe n = 16 | Willing n = 154 |
| Female sex worker | 115 (49.2) | 31 (26.9) | 11 (9.6) | 69 (60.0) |
| Truck driver | 40 (17.1) | 12 (30.0) | 4 (10.0) | 24 (60.0) |
| People who inject drugs (PWID) | 33 (14.1) | 5 (15.2) | 1 (3.0) | 27 (81.8) |
| MSMs | 28 (12.0) | 8 (28.6) | 0 | 18 (64.3) |
| Transgender | 4 (1.7) | 0 | 0 | 4 (100) |
| Others | 4 (1.7) | 2 (50.0) | 0 | 2 (50.0) |
| None | 10 (4.3) | 0 | 0 | 10 (100) |
*6 missing values, ** 1 missing value
Factors associated with willingness to use LAI-PrEP
In the multivariate analysis, participants who were not currently in a relationship (i.e., divorced, widowed, or separated) were less likely to be interested in LAI-PrEP than those who were single (adjusted prevalence ratio [APR] 0.65; 95% CI: 0.43–0.98; p = 0.04). Compared with current PrEP users, there was no significant difference in willingness to use LAI-PrEP between those who discontinued oral PrEP (APR 1.39; 95% CI: 0.92–2.11; p = 0.12) or those who had never used PrEP (APR 1.26; 95% CI: 0.83–1.89; p = 0.28). Participants older than 40 years demonstrated higher willingness (78.6%) to receive LAI-PrEP. Participants with primary education showed a willingness of 59.8%, compared to those with university (79.1%), secondary (70.4%), or no formal education (68.7%). Transgender participants exhibited 100% willingness to receive LAI-PrEP. Willingness varied by the number of sex partners in the past month: 100% for those with no partners, 56.5% for one partner, 71.0% for two partners, and 67.8% for more than two partners. Participants who very frequently or sometimes used illicit drugs before sex showed higher willingness (80.3% and 76.5%, respectively) compared to those who did not use drugs (62.5%) (Table 3). In sensitivity analyses that included age and gender in the multivariate model and stratified by gender, the direction, magnitude, and statistical significance of our primary findings remained essentially unchanged, highlighting the robustness of our results.
Table 3.
Factors associated with willingness to use long-acting injectable PrEP
| Willing (n = 154) N (%) |
Not willing or not sure (n = 74) N (%) |
cPR (95%CI) | p-value | |
|---|---|---|---|---|
| Study group | ||||
| Currently on oral PrEP | 65 (63.7) | 37 (36.3) | (ref) | |
| Previously on oral PrEP but discontinued use | 44 (77.2) | 13 (22.8) | 1.21 (0.83–1.77) | 0.326 |
| At risk but are naïve about PrEP | 45 (65.2) | 24 (34.8) | 1.02 (0.70–1.50) | 0.905 |
| Age in years | ||||
| 18–30 | 97 (66.9) | 48 (33.1) | (ref) | |
| 31–40 | 46 (66.7) | 23 (33.3) | 0.99 (0.70–1.42) | 0.985 |
| 41–45 | 11 (78.6) | 3 (21.4) | 1.17 (0.63–2.19) | 0.613 |
| Gender | ||||
| Female | 85 (64.9) | 46 (35.1) | (ref) | |
| Male | 69 (71.1) | 28 (28.9) | 1.09 (0.80–1.51) | 0.57 |
| Key population | ||||
| FSW | 69 (62.2) | 42 (37.8) | (ref) | |
| Transgender | 4 (100) | 0 | 1.61 (0.58–4.41) | 0.355 |
| PWID | 27 (81.8) | 6 (18.2) | 1.32 (0.84–2.05) | 0.226 |
| MSMs | 18 (69.2) | 8 (30.8) | 1.11 (0.66–1.87) | 0.684 |
| Truckers | 24 (60.0) | 16 (40.0) | 0.96 (0.61–1.53) | 0.881 |
| None | 10 (100) | 0 | 1.61 (0.83–3.12) | 0.16 |
| Others (fisher folk, bar attendants) | 2 (50.0) | 2 (50.0) | 0.8 (0.19–3.28) | 0.761 |
| Education | ||||
| None | 11 (68.7) | 5 (31.3) | (ref) | |
| University/graduate | 34 (79.1) | 9 (20.9) | 1.15 (0.58–2.27) | 0.687 |
| Secondary | 57 (70.4) | 24 (29.6) | 1.02 (0.54–1.95) | 0.944 |
| Primary | 52 (59.8) | 35 (40.2) | 0.86 (0.45–1.66) | 0.673 |
| Marital Status | ||||
| Single | 46 (76.7) | 14 (23.3) | (ref) | |
| Married/Cohabiting | 65 (82.3) | 14 (17.7) | 1.07 (0.74–1.56) | 0.714 |
| Divorced, widowed or separated | 43 (48.3) | 46 (51.7) | 0.63 (0.42–0.95) | 0.029 |
| Occupation | ||||
| Professional | 2 (22.2) | 7 (77.8) | (ref) | |
| Student/ Unemployed/ Housewife | 28 (73.7) | 10 (26.3) | 3.32 (0.79–13.9) | 0.101 |
| Traders/sales | 13 (72.2) | 5 (27.8) | 3.25 (0.73–14.4) | 0.121 |
| Farming /Labourer (Semi skilled) | 59 (71.9) | 23 (28.1) | 3.24 (0.79–13.3) | 0.102 |
| Others | 49 (62.8) | 29 (37.2) | 2.83 (0.68–11.6) | 0.15 |
| Number of sex partners previous month | ||||
| None | 3 (100) | 0 | (ref) | |
| One | 13 (56.5) | 10 (43.5) | 0.56 (0.16–1.98) | 0.373 |
| Two | 22 (71.0) | 9 (29.0) | 0.71 (0.21–2.37) | 0.577 |
| More than two | 116 (67.8) | 55 (32.2) | 0.68 (0.22–2.13) | 0.507 |
| Had unprotected sex in the last 3 months | ||||
| No | 16 (61.5) | 10 (38.5) | (ref) | |
| Yes | 124 (67.8) | 59 (32.2) | 1.1 (0.65–1.85) | 0.717 |
| Not sure | 14 (73.7) | 5 (26.3) | 1.19 (0.58–2.45) | 0.623 |
| Used illicit drug before sex in the previous 6 months | ||||
| Yes/ Very frequently | 61 (80.3) | 15 (19.7) | (ref) | |
| Sometimes | 26 (76.5) | 8 (23.5) | 0.95 (0.60–1.51) | 0.836 |
| No | 50 (62.5) | 30 (37.5) | 0.78 (0.53–1.13) | 0.19 |
| Not sure | 16 (43.2) | 21 (56.8) | 0.54 (0.31–0.93) | 0.028 |
| Previously diagnosed with STI | ||||
| Yes | 69 (63.9) | 39 (36.1) | (ref) | |
| No | 73 (72.3) | 28 (27.7) | 1.13 (0.81–1.57) | 0.463 |
| Not sure | 11 (61.1) | 7 (38.9) | 0.96 (0.51–1.81) | 0.891 |
| Use condoms | ||||
| All the time/ Very frequently | 97 (70.3) | 41 (29.7) | (ref) | |
| Sometimes | 42 (59.2) | 29 (40.9) | 0.84 (0.58–1.21) | 0.35 |
| No | 15 (78.9) | 4 (21.1) | 1.12 (0.65–1.93) | 0.675 |
| Heard about LAI-PrEP | ||||
| Yes | 125 (66.8) | 62 (33.2) | (ref) | |
| No | 20 (71.4) | 8 (28.6) | 1.02 (0.66–1.71) | 0.783 |
| Not sure | 3 (50.0) | 3 (50.0) | 0.75 (0.24–2.35) | 0.619 |
cPR: Crude Prevalence Ratio
Discussion
In this cross-sectional study, we explored the willingness to use LAI-PrEP among KPs in Kampala when categorised into different PrEP use groups (i.e., those taking oral PrEP, those eligible but PrEP naïve, and those who discontinued oral PrEP). Of the 234 members of KPs in Uganda, two-thirds were willing to use LAI-PrEP. Those who were sexually active showed a greater interest in injectable PrEP compared to those not currently in a relationship. There was no significant difference in willingness to use LAI-PrEP between former oral PrEP users and individuals who were PrEP naive.
Our research revealed that individuals who were divorced, widowed, or separated had a decreased likelihood of being willing to use LAI-PrEP compared to those who were single. In Uganda, years of emphasising abstinence and fidelity in HIV prevention programs have increased the moral stigma surrounding extramarital sex [29]. This may have resulted in divorced, separated, or widowed individuals becoming more discreet, downplaying the risk of sexual HIV transmission, and reporting decreased willingness to use PrEP, as this might suggest involvement in sexual activity. It contrasts with a cohort study among FSWs in Tanzania, which found that being married/cohabiting or separated/divorced/widowed was independently associated with the use of oral PrEP [30]. While willingness to use LAI-PrEP was higher among participants who discontinued oral PrEP than those who were PrEP naive or current oral PrEP users, this did not reach statistical significance [31]. Our research revealed that among those who were not willing to take LAI-PrEP, reasons included myths/misconceptions and potentially stigma-driven reasons. These will need to be addressed to effectively roll out a LAI-PrEP programme. Others include preferences for taking tablets because this served as a reminder to take their other medications. However, other studies have shown that participants’ main concern regarding LAI-PrEP is its potential long-term side effects [31].
Our findings are consistent with previous research conducted in Nigeria and Thailand, which found a high willingness among KPs to use LAI-PrEP. The Nigerian study focusing on MSM reported an 88% willingness to use LAI-PrEP, while the study in Bangkok with PWID reported a 73.5% willingness [31, 32]. Further, a scoping review article among KPs also found a strong interest in using LAI-PrEP among adolescents, transgender women, and FSW [33]. However, our study found a lower level of willingness to use LAI-PrEP among MSM compared to a similar study conducted in the United States (80%), which may be attributed to the limited awareness of LAI-PrEP in Uganda [34]. Additionally, a study among women in Zimbabwe, South Africa, and the United States showed that the majority (> 75%) rated injectable PrEP as acceptable [35].
Willingness to use LAI-PrEP varied across the study groups, with the highest reported among individuals who had previously discontinued oral PrEP and the lowest observed among those currently taking oral PrEP. These findings are consistent with the ÉCLAIR study, which also found a high level of willingness (79%) among participants to continue utilising LAI-PrEP, with an even higher percentage (87%) indicating they would recommend it to others [36]. In comparison, a greater proportion of individuals who had discontinued oral PrEP expressed a willingness to switch to LAI-PrEP versus those currently taking oral PrEP or individuals within the eligible PrEP-naïve KPs. This difference is likely due to challenges in accessing necessary healthcare services or other difficulties with adherence to oral formulations despite the need for PrEP [37]. Among specific KP groups, willingness to switch to LAI-PrEP varied from ~ 60-100%, higher than the 30.8-66.7% reported in US-based studies of gay and bisexual men taking oral PrEP [36, 37]. Moreover, a study conducted in South Africa among heterosexual men found that 48% of participants favoured LAI-PrEP, while 33% and 20% opted for oral PrEP and condoms, respectively [34]. Variations in knowledge levels may explain this disparity, as our study revealed high levels of knowledge regarding LAI-PrEP.
Our study contributes to the literature by demonstrating high awareness and willingness to use LAI-PrEP among KPs in Uganda. This finding underscores the potential for widespread LAI-PrEP adoption if barriers such as access, stigma, and misconceptions are addressed, providing valuable insights for targeted HIV prevention strategies.
Study limitations and strengths
The limitations of our study include its cross-sectional design, lack of access to LAI-PrEP in Uganda during the study period, and the potential for recall and social desirability bias. Furthermore, the restrictions imposed by the COVID-19 lockdown hindered KPs from accessing healthcare services, potentially affecting their ability to participate in the study and leading to selection bias. Additionally, our sample was limited to an urban population and may not fully represent all KPs in the country. However, despite these limitations, our study on KP’s willingness to use LAI-PrEP can provide valuable insights for future planning and implementation when it becomes available in Uganda.
Conclusions
In conclusion, our study showed that most KP members in our sample were aware of LAI-PrEP, and approximately two-thirds were willing to use it. However, those who were divorced, widowed, or separated were less likely to be willing to use LAI-PrEP than their single counterparts. Considering the potential adherence benefits of LAI-PrEP, further research is needed to assess effective demand-creation strategies for KPs to enhance their acceptability and willingness to use this effective HIV prevention method.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
We acknowledge the Infectious Diseases Institute (IDI) and the entire study team for designing the protocol and questionnaire and managing the data, as well as the MARPI team and the study participants. Eva Agnes Laker Odongpiny is supported by the Northern Pacific Global Health Fellows Program (grant D43TW009345).
Author contributions
Conceived, developed and designed the study: JDL, MB, AK, TRM, and EALO. Study registration, documentation and clearance: JDL, MB, AK, and TRM. Study operations and discussions: JDL, MB, AK, TRM, and EALO. Data collection: JDL, MB, AK, TRM, EALO, and WN. Data cleaning and analysis: EKB. Analysed and interpreted the data, and wrote the first draft of the manuscript: EKB, JDL and AM. Supervised participant recruitments, research assistants and data collection: JDL, MB, AK, and WN. Contributed substantially to analysis and interpretation of data: EKB and AM. Critically reviewed the paper for important intellectual content: EKB, AM, TRM, and EALO. All authors read and approved the manuscript.
Funding
No institutional funds or grants were awarded to this study, which was self-funded by the authors.
Data availability
The de-identified patient data has been attached as a supplementary file (supplementary file 1).
Declarations
Ethics approval and consent to participate
Ethical approval and permission to conduct this study were obtained from the School of Health Sciences Institutional Research Board (Protocol number– MAKSHSREC-2021-180). Written informed consent was obtained from study participants before the commencement of the study activities after explaining the purpose of the study and possible benefits. Before the investigation, approval to conduct research at the MARPI clinic was obtained. Respondents’ Participation was voluntary, and the identity of the respondents was not disclosed. All information given as a contribution to the study was handled with confidentiality, kept under lock and key, and with password protection.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The de-identified patient data has been attached as a supplementary file (supplementary file 1).