The PrEP care continuum among men who have sex with men and transwomen: ImPrEP Mexico

BACKGROUND: To succeed, pre-exposure prophylaxis (PrEP) programs need to promote adequate levels of PrEP awareness, acceptability, uptake, adherence, and retention (i.e., engagement in the PrEP care continuum) among people with high HIV risk. Mexico implemented a PrEP demonstration project (ImPrEP) targeting two key populations: men who have sex with men (MSM) and transwomen (TW). This study's goal was to describe the perceptions and experiences related to the PrEP care continuum of MSM and TW, and to identify barriers and facilitators for scaling up PrEP services.'
METHODS: From June to July 2020, online semi-structured interviews were conducted with MSM and TW: PrEP users, ex-users, and potential users (screened, but not enrolled). Through purposive sampling, these profiles were balanced by sexual identity (MSM/TW), age, and education level. The interviews underwent a directed content analysis to identify factors per step of the PrEP care continuum.
RESULTS: Ten users, six ex-users and eight potential users (fourteen MSM and ten TW) were interviewed. Awareness: MSM commonly learned about PrEP and ImPrEP during HIV testing. TW mainly did so through informative talks about PrEP and TW associations, but knowledge gaps persisted. Acceptability: Participants principally wanted to start PrEP because of its HIV protection during risky sex behaviors. However, potential users expressed doubts about wanting PrEP due to its potential side effects (e.g., interacting with hormonal treatment, for TW). Uptake: Potential users missed their enrollment visit for varied reasons (e.g., work/school, the distance, forgetting, and COVID-19) and did not know how to reschedule. Adherence: Users and ex-users overall reported taking PrEP adequately, yet some mentioned barriers like fear of side-effects, routine changes, and PrEP-related stigma. Retention: Ex-users quit ImPrEP services, mostly without reducing their HIV risk, due to fearing the medication's effects and difficulties keeping their trimestral appointments.
CONCLUSIONS: The PrEP care continuum's barriers must be addressed for PrEP's scale-up to be effective. Awareness activities are crucial to reach persons who do not attend health services and to dispel PrEP myths, especially among TW, as misconceptions can diminish PrEP acceptability, adherence, and retention. PrEP services should also offer a more flexible schedule to facilitate uptake and retention.

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