Research ArticleHIV

A stepped-wedge randomized trial and qualitative survey of HIV pre-exposure prophylaxis uptake in the Eswatini population

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Science Translational Medicine  23 Sep 2020:
Vol. 12, Issue 562, eaba4487
DOI: 10.1126/scitranslmed.aba4487

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PrEPping to prevent HIV

Clinical trials have demonstrated that pre-exposure prophylaxis (PrEP) can prevent HIV infection in high-risk populations. Geldsetzer et al. conducted a randomized study of health care facilities in Eswatini to see whether promoting PrEP could increase uptake among the general population at high risk of acquiring HIV. They found that the promotion package resulted in a small increase in PrEP uptake, but only one third of at-risk adults, mostly women, agreed to participate in PrEP. Crucially, interviews with study participants and health care workers revealed that PrEP promotion activities needed to be expanded beyond health care facilities into community settings to raise awareness, particularly among men.


Clinical trials have shown that antiretroviral drugs used as pre-exposure prophylaxis (PrEP) are highly effective for preventing HIV acquisition. PrEP efforts, including in sub-Saharan Africa, have almost exclusively focused on certain priority groups, particularly female sex workers, men having sex with men, pregnant women, serodiscordant couples, and young women. As part of a PrEP demonstration project involving the general population at six primary health care facilities in Eswatini (formerly Swaziland), we conducted a randomized trial of a health care facility–based PrEP promotion package designed to increase PrEP uptake. Over the 18-month study duration, 33.6% (517 of 1538) of adults identified by health care workers as being at risk of acquiring HIV took up PrEP, and 30.0% of these individuals attended all scheduled appointments during the first 6 months after initiation of PrEP. The PrEP promotion package was associated with a 55% (95% confidence interval, 15 to 110%; P = 0.036) relative increase in the number of individuals taking up PrEP, with an absolute increase of 2.2 individuals per month per health care facility. When asked how PrEP uptake could be improved in 217 accompanying in-depth qualitative interviews, interviewees recommended an expansion of PrEP promotion activities beyond health care facilities to communities. Although a health care facility–based promotion package improved PrEP uptake, both uptake and retention remained low. Expanding promotion activities to the community is needed to achieve greater PrEP coverage among adults at risk of HIV infection in Eswatini and similar settings.

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