Understanding barriers and challenges to PrEP adherence: experiences of PrEP discontinuation among MSM and Transwomen in Peru - The ImPrEP Demonstration Study

BACKGROUND: The ImPrEP Study is a Pre-Exposure Prophylaxis (PrEP) implementation study, which since 2018 has provided Daily-oral PrEP to over 2000 MSM and Transgender Women (TW) in Peru. However, various circumstances have led several participants to discontinue PrEP. This qualitative study sought to understand the reasons behind PrEP discontinuation.
METHODS: Individual in-depth interviews (IDI) were conducted with 14 former ImPrEP participants (10 MSM and 4 TW) from 3 sites in Peru. We adapted a five-domain ecological model to theoretically explore the reasons for PrEP discontinuation: individual, sexual behavior and preventive practices, disclosure with the community, health care interactions, and structural barriers.
RESULTS: PrEP discontinuers had multiple (including some serodiscordant) sexual partners; and many were sex workers, but their HIV risk perception was low. Most were offered PrEP when visiting the clinic for testing or condoms rather than seeking out PrEP. Some felt that PrEP could allow them to experiment sex without condoms. However, they found several issues with PrEP, such as: difficulties maintaining the daily regimen and overcoming side effects; managing PrEP disclosure (e.g. to family, friends and partners, as PrEP-related stigma led to criticism about the effectiveness and utility of PrEP, their sexual identity and HIV status, and affected adherence); concerns about real PrEP effectiveness; health providers' indications about concomitant condom use; and preference for condoms given their capacity to prevent STIs (although their condom use was inconsistent). Their PrEP use was often circumstantial, based on their partnership situation, or sex perceived as risky. While health providers played an important role in PrEP adherence, the limited capacity of health facilities to deliver PrEP was a structural barrier for participants, especially for those who required more tailored support (e.g. more frequent follow-ups, more permanent communication, or flexible visit schedules).
CONCLUSIONS: PrEP discontinuers in ImPrEP-Peru stopped using PrEP due to a combination of: low HIV-risk perception, lack of commitment to PrEP use, limited belief in PrEP effectiveness, and difficulties dealing with PrEP "demands". PrEP-related stigma poses uptake and adherence barriers that arise from their social environment, and Health services should adapt further to meet the needs of marginalized populations.