“Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?” The condom quandary among PrEP users and health care providers in Kenya.

Abstract

Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.

INTRODUCTION

Several interventions have been shown to reduce the risk of HIV acquisition or transmission, including condom use, knowledge of HIV status, male circumcision, treatment of curable STIs, effective treatment of HIV infected persons and pre-exposure prophylaxis (PrEP) for at-risk persons [1-7]. However, none of these efficacious interventions is likely to stop the spread of HIV singly. To reduce HIV transmission, the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended a “combination HIV prevention approach,” using a mix of evidence-based behavioral, biomedical and structural interventions to meet the needs of individuals and communities [8]. Multiple effective prevention strategies are likely to operate synergistically to reduce HIV incidence [9]. For instance, assisted partner notification services, PrEP for HIV uninfected individuals and test and treat for HIV infected persons are potentially synergistic in reducing transmissions within HIV serodiscordant partnerships. The combination prevention approach also recognizes that because people’s needs for HIV prevention change over time and in different contexts, multiple interventions are necessary [8].

Oral PrEP has shown great promise for reducing HIV transmission in serodiscordant partnerships as well as other high-risk populations [10-17]. In 2015, the World Health Organization (WHO) recommended PrEP use for people with substantial on-going HIV risk, as part of a HIV prevention package that includes condoms, a pregnancy and STI prevention intervention that has been available for centuries [18, 19]. In May 2017, the Ministry of Health in Kenya launched a national PrEP program, which seeks to provide PrEP services to HIV uninfected persons in HIV serodiscordant partnerships, persons with multiple partners, those engaging in transactional sex, those with recent STI diagnosis or those who inject drugs, among others [20].

The Kenyan guidelines recommend that PrEP counselling sessions inform clients about HIV prevention options available to them and tell them that PrEP does not protect against other sexually transmitted illnesses and unwanted pregnancies. PrEP users are also supposed to be informed that consistent use of condoms provides a high degree of protection. [21, 22]. It is not yet known how providers counsel on condom use and PrEP, two pillars of a combination HIV prevention approach, in routine service delivery within a scaled national implementation of PrEP. Nor is it known how clients, having been counselled, integrate PrEP and condoms into their sexual relationships.

Choosing among HIV prevention strategies has been referred to as a “preference-sensitive health decision” with the best option being the one that patients can most successfully incorporate into their daily lives.[23] Client-centered communication, which presents information about available HIV prevention options, shows interest and understanding of their clients’ context and concerns, and is supportive of choices made, has been associated with increased PrEP uptake and improved experience.[24-27] However, patient-provider communication around condom use and its relationship to patient centered care in routine PrEP delivery settings has not been studied in sub-Saharan Africa.

The Partners Scale-Up Project is an on-going implementation project to support PrEP delivery for HIV serodiscordant couples in 24 high volume public health facilities in western and central regions in Kenya [28]. PrEP services are integrated in HIV care clinics using existing facility personnel and infrastructure. The project staff trains health care providers on PrEP service delivery using MOH standard training materials which include counselling messages on using condoms in combination with PrEP [29]. Within this project we explored patient-provider communication and PrEP user perspectives relating to condom use in the context of nationally-scaled routine service delivery of PrEP.

METHODS

Between May and December 2018, health care providers involved in the delivery of PrEP services in participating facilities and individuals in HIV serodiscordant partnerships who had been using PrEP for at least a month were purposively selected and interviewed. Both members of the serodiscordant partnership were interviewed if the HIV infected partner was available and willing to participate. Experienced and well-trained qualitative researchers (MA, AD, FO) interviewed health care providers and PrEP users at 24 different public health facilities using semi-structured interview guides. Interviews with health care providers explored the communication between health care providers and PrEP users about condoms in the context of PrEP use, and how client experiences with condoms influenced their decision to start PrEP. Interviews were conducted in either English, Kiswahili or Dholuo depending on the interviewee’s preference. Interviews were audio recorded and digital recordings stored on a password-protected web-based drive and were reviewed by senior members of the study team. Interviews were translated to English where necessary and transcribed by the interviewer. Average interview duration was 45 minutes.

Data were analyzed using a combination of inductive and deductive approaches. The initial codebook was developed drawing from questions in the interview guide and researchers’ prior experience in HIV prevention research. As the codes were applied, additional codes emerged and through an iterative process the codebook was finalized. The final codebook was applied individually to all transcripts using Dedoose software (Sociocultural Research Consultants LLC, Los Angeles, CA) by three members of the research team, with each transcript coded independently by two people. Coded quotations were organized into themes (EMI, KN, GO) and reviewed by interviewers and coders to ensure accuracy and consistency of interpretation. Any inconsistencies were resolved through discussion, overseen by senior social scientists on the study team until consensus was reached. Major themes were discussed amongst the investigators and agreement reached on the organizing themes for this paper.

Ethics statement

The Scientific and Ethics Review Unit of the Kenya Medical Research Institute and the Human Subjects Division of the University of Washington approved the protocol. Written informed consent was provided by all participants.

RESULTS

Sixty-one in-depth interviews were conducted among PrEP users, 26 (43%) of whom were men. Six interviews were conducted with both members of the HIV serodiscordant partnership. Forty-one interviews were conducted among health care providers, of whom 21(51%) were men. Health care providers are described in Table 1.

Table 1:

Demographic characteristics of health care providers participating in the key informant interviews (N = 41)

	N (%) or median (IQR)
Gender, male	21 (51.2%)
Age, years	34 (26,65)
Cadre
Clinical officers	14 (34%)
HIV counselors	10 (24%)
Nurses	10 (24%)
Linkage officers	3 (7%)
Social workers	2 (5%)
Pharmaceutical technologists	1 (2%)
Health records officers	1 (2%)
Working experience, years	4.6 (0.5, 17.0)

Health care provider perspectives

All health care providers counselled persons initiating PrEP to consistently use condoms during the first seven days of PrEP, by which time the HIV protective effect is expected to have been achieved. However, there was a divergence among health care providers in their counselling on condom use beyond the initial seven-day period.

Perfect prevention - Insistence on condoms in addition to PrEP

Many health care providers counselled PrEP clients to use condoms every time they had sex, beyond the initial 7 days after PrEP uptake. They elaborated that condom use alongside PrEP was necessary since PrEP would not protect against unintended pregnancies and sexually transmitted infections other than HIV. They also advised clients that since neither one was perfectly preventive, using both methods would enhance protection against HIV.

.. [W]e also tell them that PrEP only prevents a person from HIV but does not prevent other diseases like STIs or pregnancy so we still insist that they have to use condoms … (Nurse manager)

“What we tell them is that these [condoms and PrEP] are two methods of prevention and they have both been proven to prevent HIV infection… PrEP brings an added advantage [to condoms] and two [methods] are better than one.” (Clinical Officer)

Leeway on condom use - Specific conditions under which PrEP alone is enough

Some health providers presented more nuanced counselling messages about condom use, i.e. specifying conditions under which clients could have condomless sex. The most frequently mentioned of these conditions was when the couple wanted to conceive and the HIV negative partner was on PrEP, if they were in a monogamous relationship, and if they knew their partner’s viral load was suppressed.

“They ask you ‘will I continue using the condom every day?’ And so, we tell [them]… it will depend on the kind of client you are dealing with. If he or she has multiple partners they have to use condoms but if it is only one partner we tell them until your partner is virally suppressed, [it is] not always that you [have to] use condoms.” (Nurse)

Permissive pragmatic - Meeting patients where they are

Though a minority, some health care providers reported a very pragmatic approach to counseling clients about the advantages of using PrEP, without emphasizing condom use, especially when they knew or suspected clients were not using condoms.

“They [PrEP clients] ask, ‘now that I am using PrEP, is it a must I use a condom?’ Okay you tell them you are supposed to use; you don’t tell them it is a must. And even if you told them that it is a must they wouldn’t use.” (Nurse Manager)

A few health care providers were concerned about clients getting confused about the dual messaging of PrEP use in addition to condom use.

“…and I remember last night there is even a client who called me and told me that this thing is so confusing. We are taking PrEP at the same time we are using condoms. Why can’t I use one and stop the other? So, it is very confusing and most of our clients are open; they don’t use condoms. They tell you they don’t.” (HIV Counselor)

Health care providers who did not insist on condom use explained that they knew clients were interested in PrEP as an alternative to condoms. In these contexts, their counselling approach focused on how PrEP uptake could prevent HIV as well as improve their clients’ quality of life.

“Now that we have PrEP, at least we are giving them another option. PrEP is going to improve their positive living and dignity …They do not use condoms, so it is okay. And these guys are happy and am also happy to give them the confidence that these drugs are going to make you not to get infected and they are happy.” (Clinical Officer)

PrEP client perspectives

Before initiating PrEP, all interviewed clients reported knowing that condoms could prevent HIV infection, however most reported rarely or inconsistently using condoms. Most clients were motivated to start PrEP because of its relative advantage over condoms. They saw PrEP as a more desirable HIV prevention method which they could more feasibly incorporate into their sexual relationships.

Ability to meet conception goals

Couples who desired conception were especially relieved they could have condomless sex while still protecting themselves from HIV.

“What happened that was good was that we got PrEP and we were told that we can now use it and it will help us get a baby as we don’t have to use a condom all the time.” (PrEP User, Female)

Reducing conflict

Female clients frequently reported PrEP use decreased conflict in the home related to negotiations around condom use.

“[W]hen it was time to have sex, we would argue a lot because I would refuse to have sex without a condom with him and he … didn’t want to use a condom. So, this drug … has brought some level of peace in my relationship.” (PrEP User, Female)

Reducing anxiety around HIV acquisition

Clients also reported PrEP helped reduce their anxieties about risk of acquiring HIV infection if they failed to use a condom or the condom broke.

“Yes, there is a way this [PrEP] has brought peace in my relationship because before I started taking this medication, I was always having anxiety that I may get HIV and pass to my baby every time we had sex. So that is the fear that I was always having.” (PrEP User, Female)

Increased intimacy

With PrEP, clients reported having more intimacy within their partnerships and having more pleasurable sex compared to when they used condoms.

“I feel that it [PrEP] has made us to be more close with my HIV positive partner that I [used to] always use condoms with every time that I had sex with her.” (PrEP user, male)

Reducing stigma

Some clients reported PrEP made them feel like ‘normal’ people and alleviated feelings of stigma associated with condom use.

“When I use a condom, I start wondering why I should use it [since] I am doing it with my wife, and this stresses me. So, when I use PrEP it lowers my stigma and I just feel like I am not sick since I am [having] sex like a person who is not infected.” (HIV Infected Partner of PrEP User, Male)

“So, PrEP is good because when I am having sex with my partner, I forget that she is infected and look at her as normal person because I am confident that it will protect me from HIV.” (PrEP user, Male)

DISCUSSION

Within a large PrEP implementation project in Kenya, we found that health care providers’ and client communication around condom and PrEP use was often at cross purposes. Though health care provider messaging ranged from an insistence on continued condom use along with PrEP to counselling that de-emphasized condom use after seven days of daily PrEP, most providers stressed using condoms in addition to PrEP for “double protection,” even though they knew their clients had challenges with using condoms consistently. PrEP clients on the other hand, were primarily motivated to use PrEP as an alternative HIV prevention method to condoms.

The lack of congruence between patient motivation to use PrEP as an HIV prevention alternative to condoms and health care provider emphasis on continued condom use may have implications for patient-provider communication and could negatively impact effective uptake and delivery of PrEP at scale. Effective patient-centered care includes understanding patients in the context of their own social worlds. Literature suggests that patients have better communication with their providers and have improved medication adherence when they perceive that the provider is listening to them and treating them holistically [30-33]. In addition, supporting patient autonomy, i.e. providing clients with information about available health interventions and allowing them to make voluntary informed choices about what works for them, has been associated with positive outcomes, including the uptake of new interventions [34, 35] and behavior change [36, 37].

Similar to what has been reported elsewhere, our interview participants had experienced anxiety around condom negotiation and worry of HIV infection prior to beginning PrEP [38-43]. They reported that PrEP (unlike condoms) allowed them to derive pleasure from sex, experience increased intimacy in relationships, reduced stigma and conflicts in the home, and opened-up the possibility of conception without fear of HIV acquisition. The perceived advantage of a new intervention over an existing one has been identified in the literature as a driver of innovation adoption, and for our PrEP users this was clearly the case [44].

Results from our qualitative interviews suggest that PrEP is likely filling a space where condoms were not being used consistently anyway. Though all PrEP initiators in our study knew condoms could protect them against HIV, most reported lack of consistent condom use. This pattern around inconsistent condom use aligns with extensive literature on this topic [45-50]. For decades, HIV serodiscordant couples, a population at high risk for HIV infection, have been counselled to use condoms correctly and consistently to reduce HIV transmission [51]. However, a national survey conducted in Kenya found that correct and consistent condom use was reported in less than 30% of HIV serodiscordant partnerships [52]. Similar trends have been observed globally. In South Africa, a quarter of HIV positive persons in HIV serodiscordant partnerships reported condomless sex prior to ART initiation [53], while more than a third of HIV serodiscordant couples in a prospective cohort in Uganda reported condomless sex [54].

Health providers in our study may have insisted on condom use for PrEP users (in spite of the fact that they knew condoms were not consistently used) due to concerns about risk compensation accompanying widespread availability of PrEP. These concerns among health providers have been widely documented in other settings [55-59]. Meta-analyses of risk compensation in large observational cohorts using PrEP have not been totally conclusive, though they suggest that condomless sex among PrEP users is more prominent among those already engaging in condomless sex prior to starting PrEP, [6, 60, 61]. A reduction in condom use with resultant increases in unintended pregnancies and sexually transmitted infections were not observed in initial PrEP clinical trials and demonstration projects among heterosexual HIV serodiscordant couples [62-64], but population-level data about sexual behavior and non-HIV consequences of condomless sex among heterosexuals using PrEP are limited. There was no evidence of risk compensation reported by our study participants, and PrEP is likely filling a space where condoms were not being used consistently anyway.

Our analysis is within work that is taking place in a large-scale PrEP roll out in 24 public HIV care clinics in two diverse regions in Kenya. There may be limitations associated with the fact that this work was conducted in specified high volume public HIV clinics which may differ from HIV clinics in the rest of the country and other regions globally. Social desirability bias may have led providers to overemphasize the degree to which they counselled clients to always use condoms. However, even if this bias existed, our data still show some variability and flexibility in provider counselling regarding condom use. Similarly, even if it is likely that clients may have overemphasized condom use due to social desirability, our data still showed most PrEP clients had not been using condoms consistently before starting PrEP.

CONCLUSION

In this early phase of the PrEP program for HIV serodiscordant couples in Kenya, we found that while health providers varied in their counselling messages regarding condom use with PrEP, clients were often motivated to use PrEP because it offered them a feasible and desirable alternative to condoms for HIV prevention. These findings highlight a disconnect and possible challenge between counselling messages offered by health providers and the choices that PrEP users made for HIV prevention. For PrEP to reach its full potential as an HIV prevention intervention, refined and patient-centered approaches to counselling should be emphasized in which clients are informed about benefits and limitations of HIV prevention options available to them (including PrEP and condoms), permitted to make an informed choice of an intervention or interventions that work for them and supported to use the option(s) they choose.