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. Author manuscript; available in PMC: 2020 Oct 1.
Published in final edited form as: AIDS Care. 2019 Apr 30;31(10):1185–1192. doi: 10.1080/09540121.2019.1612023

Awareness and Acceptability of pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men (GBMSM) in Kenya

Adedotun Ogunbajo 1,2, Augustine Kang 1,2, Sylvia Shangani 1, Ryan M Wade 4, Daniel Peter Onyango 5, Wilson W Odero 6, Gary W Harper 3
PMCID: PMC6663573  NIHMSID: NIHMS1528996  PMID: 31039628

Abstract

Kenyan gay, bisexual, and other men who have sex with men (GBMSM) are significantly affected by HIV. Pre-exposure prophylaxis (PrEP) is an effective biomedical approach to HIV prevention. We conducted a cross-sectional survey of 459 HIV negative Kenyan GBMSM to assess individual and interpersonal correlates of PrEP awareness/acceptability using univariate and hierarchical logistic regression models. 64.3% of participants had heard of PrEP and 44.9% were willing to use PrEP. In hierarchical logistic regression models for PrEP awareness, condom use with regular partners, higher condom use self-efficacy, higher perceived ability to use PrEP, history of STI, and membership in LGBT organization were significantly associated with being aware of PrEP (χ2=69.6, p<0.001). In hierarchical logistic regression models for PrEP acceptability, higher self-esteem, higher condom use self-efficacy, depression/anxiety, higher perceived ability to use PrEP, willingness to engage in PrEP follow-up visits, coercion at sexual debut, and family exclusion were significantly associated with being acceptable to PrEP (χ2=231.8, p<0.001). Individual and interpersonal factors were significantly associated with PrEP awareness and acceptability. Our findings underscore the need to promote awareness and understanding of PrEP as an effective HIV prevention tool in combination with other safer-sex methods that are appropriate given an individual’s personal circumstances.

Keywords: Kenya, Pre-Exposure Prophylaxis, Awareness, Acceptability, HIV Prevention

Introduction

Gay, bisexual, and other men who have sex with men (GBMSM) living in Kenya are significantly affected by human immunodeficiency virus (HIV) (Sanders et al., 2007; Sanders et al., 2013; Sanders et al., 2010). Factors associated with HIV seropositivity among Kenyan GBMSM include condomless receptive anal sex (Price et al., 2012; Sanders, et al., 2007; Sanders, et al., 2013), lower educational attainment (Price, et al., 2012), group sex (Sanders, et al., 2013), genital ulcers (Price, et al., 2012), gonorrhea (Sanders, et al., 2013), discrimination (Kunzweiler et al., 2017), violence (Kunzweiler, et al., 2017), and childhood sexual abuse (Kunzweiler, et al., 2017). Due to the high burden of HIV in Kenyan GBMSM, the Kenya National AIDS Strategic Framework identified GBMSM as a priority group for HIV prevention and treatment. Consequently, new approaches to HIV prevention among Kenyan GBMSM are needed (Baral et al., 2013).

Pre-exposure prophylaxis (PrEP) is a biomedical HIV prevention approach that significantly reduces the likelihood of HIV acquisition (Fonner et al., 2016). Currently, PrEP is approved in oral pill form (Truvada), to be taken daily to reduce risk of acquiring HIV (Choopanya et al., 2013; Grant et al., 2010; Thigpen et al., 2012). PrEP has been proven to be most effective at preventing HIV incidence among individuals who are highly adherent to the medication (Donnell et al., 2014; Grant et al., 2014). The ANRS IPERGAY study demonstrated that on-demand PrEP dosing (immediately before and after sex) was effective at protecting against HIV infection among GBMSM (Molina et al., 2015). In 2017, Kenya made PrEP available to those at high risk for HIV. While the Kenyan PrEP guidelines include transactional sex, injection drug use, and inconsistent condom use as criteria for initiating PrEP, it does not include GBMSM or condomless anal sex. There is potential for PrEP to significantly impact the HIV epidemic among Kenyan GBMSM.

A study examining adherence to PrEP among GBMSM and female sex workers in Kenya found higher adherence rates in daily dosing of PrEP compared to intermittent dosing (Mutua et al., 2012). A qualitative study exploring acceptability of PrEP among Kenyan GBMSM found that 83% were willing to take PrEP daily, and motivators included wanting to stay HIV-negative and protecting sexual partners (Karuga et al., 2016). Another qualitative study of Kenyan GBMSM found high acceptability of PrEP, but potential barriers included medication stigma and side effects (Van der Elst et al., 2013). Studies have shown that individual, interpersonal, and structural level factors are associated with PrEP awareness and acceptability in GBMSM (Bauermeister, Meanley, Pingel, Soler, & Harper, 2013; Eaton, Driffin, Bauermeister, Smith, & Conway-Washington, 2015; Krakower et al., 2012). However, individual and interpersonal level factors associated with awareness and acceptability of PrEP in Kenyan GBMSM remains unknown.

To date, no known quantitative study has investigated awareness/acceptability of PrEP among Kenyan GBMSM. This study explored the individual and interpersonal correlates of awareness/acceptability of PrEP among GBMSM in Kenya.

Methods

Study Population

Participants were drawn from a cross-sectional study conducted among GBMSM in Kenya (Harper et al., 2015). Eligibility criteria were: (1) being between 18–29 years; (2) birth-assigned male sex; (3) identifying as gay, bisexual, or another non-heterosexual identity; (4) oral or anal sex with another man in the last year; and (5) residing in Western Kenya. Participants living with HIV (n=52) were excluded from this analysis due to ineligibility for PrEP.

Recruitment & Procedures

Enrollment occurred between January and September 2014. Participants were recruited utilizing key informant and peer mobilization, distributing study materials at social events, and hosting an official study launch party (Harper, et al., 2015). Eligible participants completed the questionnaire on a computer in either English or Dholuo. Study completion time ranged from 45 minutes to 2.5 hours. Study procedures were approved by the IRB at University of Michigan (HUM00078414) and Maseno University (MUERC000083/14)

Measures

Individual-level Factors

Self-esteem.

Self-esteem was measured using the 10-item Rosenberg Self-Esteem Scale(Gray-Little, Williams, & Hancock, 1997). Each item was measured using a 4-point Likert scale ranging from 1= “strongly disagree” to 4= “strongly agree.” Higher scores indicated higher levels of self-reported self-esteem.

Internalized homonegativity.

Internalized homonegativity (IH) was measured utilizing the 3-item IH subscale of the Lesbian, Gay, and Bisexual Identity Scale (LGBIS) (Mohr and Kendra, 2011). Each item was measured using a 6-point Likert scale ranging from 1= ‘disagree strongly’ to 6= ‘agree strongly.’ Higher scores indicated higher levels of self-reported internalized homonegativity.

Condom Use.

Condom use during anal sex with a regular and non-regular male sex partner in the past 12 months was measured using a 5-point Likert scale ranging from 0= ‘never’ to 4= ‘all of the time.’ Higher scores indicated higher self-reported levels of condom use.

Condom Use Self-Efficacy.

Condom use self-efficacy was measured utilizing a shortened 8-item version of the Condom Use Self-Efficacy Scale (CUSES) (Barkley Jr and Burns, 2000). Each item was measured using a 5-point Likert scale format, ranging from 1= ‘strongly disagree’ to 5= ‘strongly agree.’ Higher scores indicated higher self-reported levels of condom use self-efficacy.

Depression and Anxiety.

Depression/anxiety was measured utilizing the 25-item Hopkins Symptom Checklist (HSCL-25) (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). Each item assessed levels of depression/anxiety-related symptoms in the last week and was measured using a 4-point Likert scale ranging from 1= ‘not at all’ to 4= ‘extremely.’ Higher scores indicated higher self-reported levels of depression and anxiety symptoms.

Substance Use.

Problems with alcohol and drug use were measured using the 11-item CRAFFT screening interview (Knight, Sherritt, Shrier, Harris, & Chang, 2002; Knight et al., 1999). Each item was measured using a dichotomous response option (1=‘yes;’ 0=‘no’). Higher scores indicated higher self-reported substance use dependency.

STI History.

STI history was assessed using a single item (“In the past year, have you ever been told by a medical provider that you have a sexually transmitted infection) with a dichotomous response option (1 = ‘yes;’ 0= ‘no’).

Coercion at Sexual Debut.

Coercion at sexual debut was assessed using a single item (“When you had this first sexual encounter with a male sexual partner, were you forced or coerced to have sex?”) with three possible response options (1= ‘yes;’ 0= ‘no;’ 3= ‘Refuse to Answer’).

Perceived Ability to Use PrEP.

Perceived ability to use PrEP was assessed using a single item (“How able do you think you would be to take PrEP daily?”) measured using a 4-point Likert scale ranging from 1= ‘very able’ to 4 = ‘not able’ with possible responses ranging from “Very able” to “Not able.” Higher scores indicated higher self-reported perceived ability to use PrEP.

Willingness to Engage in PrEP Follow-up.

Willingness to engage in PrEP follow-up visits was assessed using a single item (“If a PrEP project goes ahead and you join the project, at each monthly visit and then at visits every 3 months after that you will need to give blood. Would you be willing to do so?”) with three response options (1= ‘yes;’ 2= ‘no;’ 3= ‘not sure’).

Membership in LGBT Organization.

Membership in LGBT organization was assessed using a single item (“During the past year, have you been a member of a lesbian, gay, bisexual, and/or transgender (LGBT) organization or group?”) with three response options (1= ‘yes;’ 2= ‘no;’ 3= ‘refuse to answer’).

STI Testing.

Participants perceived ability to access MSM-friendly STI testing was assessed using a single item (“Do you know of a place where you can get tested for a STI by a person who is sensitive to gay/bisexual men and other men who have sex with men?”) with two response options (1= ‘yes;’ 0= ‘no’).

HIV Testing.

Participants perceived ability to access HIV testing was assessed using two items. The first item asked: “If you wanted to get an HIV test, do you know where to go to?” with two response options (1= ‘yes;’ 0= ‘no’). The second item asked: “Do you know of a place where you can receive an HIV test by a person who is sensitive to gay and bisexual men and other men who have sex with men?” with two response options (1= ‘yes;’ 0= ‘no’).

LGBT Clinic Attendance.

LGBT clinic attendance was assessed using a single item (“During the past year, have you visited a clinic that provides health-related services to gay/bisexual men and other men who have sex with men?”) with two response options (1= ‘yes;’ 0= ‘no’).

Interpersonal-level Factors

Perceived Social Support.

Perceived social support was measured using the 12-item Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet, Dahlem, Zimet, & Farley, 1988). The scale consists of three subscales (friends, family, and significant other) and each subscale included 4 items. Each item was measured using a 7-point Likert scale ranging from 1= ‘very strongly disagree’ to 7=‘very strongly agree.’ Higher scores indicated higher self-reported levels of social support.

Loneliness.

Loneliness was measured using the 8-item UCLA loneliness scale (ULS).(Hays and DiMatteo, 1987) Each item was measured using a 4-point Likert scale ranging from 1=‘never’ to 4= ‘often.’ Higher scores indicated higher self-reported levels of loneliness.

Family Exclusion.

Family exclusion was assessed using a single item (“In the past year, how many times have you been excluded or left out by family members?”). Participants were given a free-response option.

Exchange Sex.

Exchange sex was assessed using a single item (“Have you ever exchanged sex for food, goods, clothing, or a place to stay with a male sexual partner?”) with dichotomous response options (1= ‘yes;’ 0= ‘no’).

HIV-Positive Partners.

Number of HIV positive sexual was assessed using a single item (“Of all of your male sexual partners in the past year, how many were HIV positive?”). Participants were given a free-response option. Answers categorized (1= ‘yes (1 or more);’ 2= ‘no;’ 3= ‘don’t know’)

Outcome Variables

PrEP Awareness.

PrEP awareness was assessed using a single item (“Have you heard of PrEP, where HIV medications are taken before doing something risky in order to avoid getting HIV infection?”) with three response options (1= ‘yes;’ 0= ‘no;’ 7= ‘don’t know’). For this analysis, “no” and “don’t know” were combined.

PrEP Acceptability.

Prior to asking about PrEP acceptability, participants were provided with the following prompt: “Pre-exposure prophylaxis refers to taking a pill every day to prevent HIV infection through sex. We know that PrEP can protect people from HIV infection if they take it every day.” PrEP acceptability was assessed using a single item (“Would you be willing to take a pill every day to prevent getting HIV infection?”) with three response options (1= ‘willing;’ 2= ‘not sure;’ 3= ‘not willing’) For this analysis, ‘not sure’ and ‘not willing’ were combined.

Statistical Analyses

We used descriptive statistics to examine sample characteristics and proportions of PrEP awareness/acceptability. Univariate analysis using logistic regression and chi-square analysis (Tables 1 and 2) were conducted with PrEP awareness/acceptability as outcome variables. Variables with significant univariate associations were included in the hierarchical logistic regression model.

Table 1.

Univariate Logistic Regression Results

Aware
(M±SD)		 Unaware (M±SD) B SE Odds p-value Acceptable (M±SD) Not Acceptable (M±SD) B SE Odds p-value
Individual Level
Self-Esteem 2.14±.37 2.16±.33 −.075 .286 .927 .793 2.21±.33 2.11±.38 .864 .285 2.373 .002*
Internalized Homonegativity 2.73±1.18 2.90±1.14 −.119 .086 .888 .167 2.97±1.28 2.65±1.09 .229 .083 1.257 .006*
Condom Use with Regular Sex Partner1 (n = 378/380) 2.78±1.25 3.10±1.17 −.216 .082 .806 .019* 2.69±1.38 3.03±1.16 −.220 .083 .803 .008*
Condom Use with Non-regular Sex Partner1 (n = 149/154)) 2.51 ±1.52 2.48±1.41 .017 .120 1.017 .890 1.58±.18 1.38±.16 −.289 .111 1.749 .009*
Condom Use Self-eficacy 1.65 ± .56 1.82 ± .68 −.481 .169 .618 .004* 1.83±.59 1.65±.66 .449 .160 1.567 .005*
Depression and Anxiety 1.53±.62 1.44±.72 .213 .162 1.238 .189 1.62±.67 1.41±.64 .486 .153 1.625 .001*
Substance Use .26±.34 .17±.30 .872 .334 2.392 .009* .25±.35 .21±.31 .344 .295 1.410 .245
Perceived ability to use PrEP 3.08±1.12 2.54±1.08 .414 .091 1.512 <.001* 3.67±.59 2.22±1.07 1.812 .178 6.121 <.001*
Interpersonal Level
Social Support (Friends) 4.86±1.13 4.98±1.17 −.090 .091 .914 .211 4.74±1.25 5.05±1.04 −.234 .087 .792 .007*
Social Support (Family) 5.13±1.33 4.94±1.27 .103 .077 1.109 .179 5.13±1.51 5.01±1.11 .074 .075 1.077 .325
Social Support (Significant Other) 5.33±1.15 5.12±1.12 .158 .088 1.171 .072 5.33±1.25 5.01±1.11 .092 .086 1.096 .286
Loneliness 1.69±.55 1.76±.57 −.225 .182 .798 .217 1.69±.65 1.72±.49 -.093 .173 .911 .590
Family Exclusion .54±1.52 .25±.85 .201 .100 1.223 .044* .72±1.68 .19±.86 .390 .106 1.477 <.001*
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1

Note. n = 420 and n = 428 for awareness and acceptability respectively unless otherwise stated.

Table 2.

Univariate Chi-Square Analysis Results – Awareness

Awareness of PrEP n (%) χ2 p-value Acceptability of PrEP n (%) χ2 p-value
Individual Level Yes No Yes No
STI History 6.175 .013* .001 .974
Yes 74 (27.4) 25(16.7) 45 (23.4) 55 (23.3)
No 196 (72.6) 125 (83.3) 147 (76.6) 181 (76.7)
Coercion at sexual debut 4.061 .044* 13.041 <.001*
Yes 208 (78.8) 56 (56.0) 31 (16.6) 73 (32.0)
No 56 (21.2) 44 (44.0) 156 (83.4) 155 (68.0)
PrEP Follow-up 20.417 <.001 165.53 <.001*
Yes 180 (66.7) 66 (44.0) 177 (92.2) 72 (30.5)
No 90 (33.3) 84 (56.0) 15 (7.8) 164 (69.5)
Membership in LGBT Organization1 (n = 409/412) 46.629 <.001* 69.302 <.001*
Yes 196 (74.2) 58 (40.0) 157 (84.0) 99 (44.0)
No 68 (25.8) 87 (60.0) 30 (16.0) 126 (56.0)
Know where to go for STI testing sensitive to MSM (n = 420) 27.099 <.001* 11.978 .001*
Yes 232 (85.9) 96 (64.0) 163 (84.9) 167 (70.8)
No 38 (14.1) 54 (36.0) 29 (15.1) 69 (29.2)
Know where to go for HIV testing (n = 420) 16.069 <.001* 15.845 <.001*
Yes 249 (92.2) 118 (78.7) 180 (93.8) 190 (80.5)
No 21 (7.8) 32 (21.3) 12 (6.3) 46 (19.5)
Know where to go for HIV testing sensitive to MSM (n = 420) 30.344 <.001* 11.332 .001*
Yes 231 (85.6) 93 (62.0) 161 (83.9) 165 (69.9)
No 39 (14.4) 57 (38.0) 31 (16.1) 71 (30.1)
LGBT Clinic Attendance (n = 420) 40.726 <.001* 58.195 <.001*
Yes 203 (75.2) 66 (44.0) 159 (82.8) 111 (47.0)
No 67 (24.8) 84 (56.0) 33 (17.2) 125 (53.0)
Interpersonal Level
Exchange Sex 7.491 .006* 12.109 .001*
Yes 73 (27.0) 23 (15.3) 58 (30.2) 38 (16.1)
No 197 (73.0) 127 (84.7) 134 (69.8) 198 (83.9)
HIV-Positive male partners 12.193 .002* 30.854 <.001*
No 92 (34.1) 67 (44.7) 54 (28.1) 106 (44.9)
Yes (1 or more) 41 (15.2) 7 (4.7) 38 (19.8) 10 (4.2)
Don’t Know 137 (50.7) 76 (50.7) 100 (52.1) 120 (50.8)
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1

Note. n = 420 and n = 428 for awareness and acceptability respectively unless otherwise stated.

Hierarchical logistic regression models were constructed to investigate association with PrEP awareness/acceptability (Tables 3 and 4). Individual-level factors were entered in the first step, and interpersonal-level factors were entered in the second step. At Step 2, the cluster of variables were entered to test if they were associated with PrEP awareness/acceptability above and beyond Step 1. Interpretation of effect sizes of parameter estimates were based on recommendations by Cohen(Cohen, 1988). Statistical significance level is set at .05 for all procedures. All the procedures were performed using the Statistical Package for Social Sciences (SPSS) version 24.0 (IBM, 2016).

Table 3.

Hierarchical Logistic Regression - Awareness

Variable B SE(B) β (Odds) χ2 p R2 R2Δ
Step 1: Individual 69.116 <.001* .246 .246
Condom Use with Regular Sex Partner .215 .114 .807 .059ϕ
Condom Use Self-efficacy .639 .243 .528 .008*
Substance Use .329 .405 1.389 .417
Perceived ability to use PrEP .252 .168 1.287 .021*
PrEP Follow-up −.503 .407 .605 .217
STI History .614 .323 1.847 .057ϕ
Coercion at sexual debut −.340 .300 .712 .257
Membership in LGBT Organization 1.147 .359 3.149 .001*
Know where to go for STI testing sensitive to MSM .229 .505 1.257 .650
Know where to go for HIV testing −.454 .557 .635 .415
Know where to go for HIV testing sensitive to MSM .739 .475 2.093 .120
LGBT Clinic Attendance .141 .360 1.151 .696
Step 2: Interpersonal 69.577 <.001* .247 .001
Exchange Sex −.008 .347 .992 .982
HIV positive male partners .078 .136 1.082 .566
Family Exclusion .043 .115 1.044 .706
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Note. Final Sample in the model is n = 351.

*

Statistically significant.

ϕ

Approaching significance.

Table 4.

Hierarchical Logistic Regression - Acceptability

Variable B SE(B) β (Odds) χ2 p R2 R2Δ
Step 1: Individual 223.32 <.001* .631 .631
Self-Esteem 1.482 .486 4.402 .002*
Internalized Homonegativity −.121 151 .886 .424
Condom Use with Regular Sex Partner −.094 .140 .911 .503
Condom Use Self-efficacy 1.227 .322 3.410 <.001*
Depression and Anxiety −.663 .251 .515 .008*
Perceived ability to use PrEP 1.200 .244 3.320 <.001*
Prep Follow-up 1.984 .471 7.268 <.001*
Coercion at sexual debut −.927 .398 .396 .023*
Membership in LGBT Organization .422 .454 1.524 .353
Know where to go for STI testing sensitive to MSM .228 .629 1.256 .717
Know where to go for HIV testing 1.338 .805 3.812 .096
Know where to go for HIV testing sensitive to MSM 0.892 .633 .410 .158
LGBT Clinic Attendance .537 .461 1.711 .244
Step 2: Interpersonal 231.75 <.001* .648 .017
Social Support (Friends) .045 .158 1.046 .776
Exchange Sex .574 .400 1.775 .151
HIV-Positive male partners .016 .184 1.016 .932
Family Exclusion .272 .133 1.313 .040*
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Note. Final Sample in the model is n = 352.

*

Statistically significant.

ϕ

Approaching significance.

Results

Participants’ (N=459) ages ranged between 18–29 years of age (M=22.5, SD=3.2). Almost half of the sample identified as gay/homosexual (47.5%) and a majority had completed secondary education or higher (81.7%).

Univariate Logistic Regression

For individual-level variables in the PrEP awareness model, increasing condom use with regular sex partners (p=.019) and condom use efficacy (p=.004) was associated with a 19.4% and 38.2% less likelihood of being PrEP-aware (p=.019) respectively. Substance use (OR=2.39; p=.009) and increasing scores on PrEP self-efficacy (OR=1.51; p<.001) were associated with higher odds of being PrEP-aware respectively.

For interpersonal level variables in the PrEP awareness model, an increase in family exclusion was associated with 1.22 times higher odds of being PrEP-aware (p=.044).

For individual-level variables in the PrEP acceptability model, increasing scores on self-esteem (OR=2.37; p=.002) and internalized homonegativity (OR=1.26; p=.006) was associated with higher odds of PrEP acceptability. Increasing condom use with regular sex partners was associated with 25.1% less likelihood of PrEP acceptability (p=0.008), but increasing condom use with non-regular sex partners was associated with 1.75 times higher odds of PrEP acceptability (p=.009). Increasing scores on condom use self-efficacy (OR=1.57; p=.005), depression/anxiety symptoms (OR=1.63; p=.001), and PrEP self-efficacy (OR=6.12; p<.001) were all associated higher odds of PrEP acceptability.

For interpersonal level variables in the PrEP acceptability model, an increase in reported social support from friends was associated with 20.8% less likelihood of PrEP acceptability (p=.007). An increase in reported scores of being excluded by family members was associated with 1.48 times higher odds of PrEP acceptability (p<.001) [Table 1 near here].

Chi-Square Analysis

PrEP awareness was significantly associated with STI history (p = .013), sexual orientation (p<.001), history of forced sex (p=.044), willingness to engage in PrEP follow-up (p<.001), history of exchange sex (p =.006), history of HIV positive male partners (p=.002), membership in LGBT organizations (p<.001), knowing where to go for STI testing with providers sensitive to MSM (p<.001), knowing where to go for HIV testing (p<.001), knowing where to go for HIV testing with providers sensitive to MSM (p<.001), and LGBT clinic attendance (p<.001).

PrEP acceptability was significantly associated with coercion at sexual debut (p<.001), willingness to engage in PrEP follow-up (p<.001), history of exchange sex (p=.001), history of HIV positive male partners (p<.001), membership in LGBT organizations (p<.001), knowing where to go for STI testing with providers sensitive to MSM (p<.001), knowing where to go for HIV testing (p<.001), knowing where to go for HIV testing with providers sensitive to MSM (p<.001), and LGBT clinic attendance (p<.001). [Table 2 near here].

Multivariate Hierarchical Logistic Regression

Step 1 of the awareness model achieve (χ2 = 69.12, p<.001) and accounted for 24.6% of the model variance. PrEP awareness was significantly associated with condom use self-efficacy (β=.64, p=.008), perceived ability to use PrEP (β=.25, p=.021), and membership in LGBT organization (β=1.15, p=.001). No significant association between the remaining individual-level variables and PrEP awareness were found. The awareness model remained significant at Step 2 (χ2=69.58, p<.001) and accounted for 24.7% of the variance. No associations between the interpersonal-level variables and PrEP awareness were found. [Table 3 near here]

Step 1 of the acceptability model achieved significance (χ2 = 223.32, p <.001) and accounted for 63.1% of the model variance. PrEP acceptability was significantly associated with self-esteem (β =1.48, p=.002), condom use self-efficacy (β=1.23, p< .001), perceived ability to use PrEP (β =1.20, p<.001) and willingness to engage in PrEP follow-up (β=1.98, p< .001), where higher scores were associated with more PrEP acceptability. PrEP acceptability was also significantly associated with depression/anxiety (β=−.66, p =.008) and coercion at sexual debut (β=−.93, p=.023), where higher scores were associated with less PrEP acceptability. No associations between the remaining individual variables and PrEP awareness were found. The acceptability model remained significant at Step 2 (χ2=231.75, p<.001) and accounted for 64.8% of the model variance. PrEP acceptability was significantly associated with family exclusion, where higher scores was associated with more PrEP acceptability being associated with PrEP acceptability (β=.27, p=.040). No associations between the remaining interpersonal-level variables and PrEP acceptability were found [Table 4 near here].

Discussion

This is among the first known quantitative studies to explore PrEP awareness/acceptability among GBMSM in East Africa. We found that while PrEP awareness among Kenyan GBMSM was high (64.3%), willingness to use PrEP was relatively lower (44.9%). Our findings align with previous studies that have shown that individuals with high awareness of PrEP reported lower acceptability for PrEP (George Ayala et al., 2013; Jackson et al., 2012), these findings are inconsistent with recent studies conducted in low-and middle-income countries (George Ayala, et al., 2013; Karuga, et al., 2016; Van der Elst, et al., 2013; Yi et al., 2017). A recent study showed awareness of PrEP among MSM in low-and middle-income countries is generally low (29.3%) across all studies (Yi, et al., 2017). The same review found that willingness to use PrEP was generally high (64%), suggesting that once MSM become aware of PrEP, the majority are willing to use it (Yi, et al., 2017). The review findings are supported by two qualitative studies conducted in Nairobi and the coastal region of Kenya (Karuga, et al., 2016; Van der Elst, et al., 2013).

Consistent with prior studies, individual and interpersonal factors were significantly associated with PrEP awareness (G Ayala, Makofane, Santos, Arreola, & Hebert, 2014; Jackson, et al., 2012; Yi, et al., 2017). Condom use with regular partner, condom use self-efficacy, substance use, perceived ability to use PrEP, STI history, coercion at sexual debut, willingness to engage in PrEP follow-up, membership in LGBT organization, access to STI testing, and LGBT clinic attendance was significantly associated with PrEP awareness. It is likely that belonging to a LGBT group and access to LGBT-friendly health services may foster an environment that provides opportunities for accessing HIV prevention/treatment information, particularly in environments where same-sex attractions are highly stigmatized. Consequently, LGBT service organizations and LGBT-affirming healthcare settings should be utilized as primary delivery hubs for information about PrEP and PrEP services to Kenyan GBMSM. Perceived ability to use PrEP and willingness to engage in PrEP follow-up visits were the strongest independent predictors of PrEP awareness/acceptability, underscoring the importance of providing adequate health information about PrEP and ensuring barriers to engaging in follow-up medical visits, such as financial and time constraints, are preemptively addressed. We recommend that PrEP be offered at little to no cost to optimize uptake and adherence.

There are important limitations in this study. First, this was a cross-sectional design, thereby limiting our ability to make causal inferences from the findings. Second, study participants were young and sampled from a single region of Kenya, thus findings may not be generalizable to GBMSM from other regions of the country.

Despite these limitations, this is among the first known quantitative analyses of PrEP awareness/acceptability among Kenyan GBMSM. The findings contribute to the growing call for data on PrEP implementation especially in low-and middle-income countries (Atwoli et al., 2014) by providing information on PrEP awareness/acceptability among African GBMSM. Additionally, with the recent roll- out of PrEP in Kenya (Ogila, 2017), this study provides important information regarding factors that might be important to consider for Kenyan GBMSM.

In conclusion, this study demonstrates relatively high awareness and low acceptability of PrEP among GBMSM in Kenya. Also, we found that individual and interpersonal factors are associated with PrEP acceptability/awareness, and thus interventions should utilize a multilevel approach. Our findings underscore the need to promote awareness and understanding of PrEP as an effective and safe prevention tool in combination with other safer-sex methods that are appropriate given an individual’s personal circumstances. Also, it is important to note that perceived PrEP acceptability does not equate to PrEP uptake, which underscores the need for healthcare providers to present PrEP as an option to GBMSM that meet eligibility criteria and address barriers to PrEP uptake among these populations. Lastly, longitudinal cohort studies among Kenyan GBMSM will allow us to better investigate the mechanisms of uptake, adherence, and retention in PrEP care.

Acknowledgments

We will like to thank all the participants of the study as this manuscript will not be possible without their participation.

Funding

This work was supported by the University of Michigan School of Public Health Office of Global Health; African Studies Center’s African Social Research Initiative at the University of Michigan. Robert Wood Johnson Foundation under the Health Policy Research Program.

Footnotes

Disclosure Statement

No conflict of interests to disclose.

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