{"paper_id":"e82e350d-bf09-4b1b-8bf6-cf9158857aa7","body_text":"Biomedical HIV prevention cascades and acceptability of community health worker-led services: a cross-sectional survey in Lesotho | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Biomedical HIV prevention cascades and acceptability of community health worker-led services: a cross-sectional survey in Lesotho Andréa Williams, Fabian Raeber, Felix Gerber, Giuliana Sanchez-Samaniego, and 15 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8220761/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Lesotho has one of the highest HIV incidences globally, yet awareness and uptake of HIV pre-exposure (PrEP) and post-exposure prophylaxis (PEP) remain low. We assessed gaps along HIV prevention cascades, determined predictors of PrEP and PEP awareness and explored the potential acceptability of community health worker (CHW)-led service delivery in rural Lesotho. Methods We conducted a cross-sectional survey among people aged ≥ 15 years living in 10 rural villages in northeastern Lesotho. Among individuals at risk of HIV, we assessed awareness, motivation, reach, and use for PrEP and PEP along prevention cascades. Multivariable logistic regressions estimated adjusted odds ratios (aORs) for predictors of awareness. Participants were also asked about the acceptability of HIV prevention services delivered by CHWs. Results Among 1083 participants, 926 were not living with HIV (median age 37 years; 57% female), and 218 (24%) of them were at increased risk of HIV. Of these, 56% were aware of PrEP, 46% motivated, 11% reached, and 8% current users; for PEP, 29% were aware, 17% were motivated, and 2% had used it in the past. PrEP awareness was higher among women (aOR 3.13, 95% CI: 1.56–6.42, 0.001). PEP awareness was higher among women (aOR 2.26, 95% CI: 1.01–5.17, p = 0.049), those with higher education (aOR 2.93, 95% CI: 1.29–7.06, p = 0.012), and those married or cohabiting (aOR 2.76, 95% CI: 1.17–6.89, p = 0.024). Overall, ≥ 87% of participants perceived CHW-delivered HIV prevention services as beneficial for their communities, and ≥ 75% of eligible individuals reported being comfortable receiving CHW-delivered counseling, testing, biomedical and dual prevention methods. Conclusion PrEP and PEP uptake in Lesotho remains low, with the largest gaps in PEP awareness and PrEP reach. The significant drop-off between motivation and use suggests that access barriers, rather than acceptability, may drive low uptake. Participants indicate high acceptance of CHW-led PreP and PEP services supporting CHW-led biomedical prevention as a strategy to improve their reach in Lesotho. HIV prevention pre-exposure prophylaxis (PrEP) post-exposure prophylaxis (PEP) HIV risk prevention cascade community health workers rural health Lesotho Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The HIV burden in Southern Africa remains disproportionately high despite substantial progress in recent years. Lesotho is a small, landlocked country in southern Africa with a population of 2.3 million, and an estimated adult HIV prevalence of 18.5% ( 1 ). While Lesotho has advanced toward the UNAIDS 95-95-95 testing and treatment targets, approximately 4,800 new HIV infections were reported in 2023 ( 1 ). Efforts focused on testing, treatment, and viral suppression alone are insufficient to curb ongoing HIV transmission in high-prevalence settings ( 2 ). Scaling up primary prevention including condoms and biomedical tools such as HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), along with emerging combination prevention products that offer dual protection against HIV and pregnancy for women, is essential to achieving the goal of ending HIV as a public health threat by 2030 ( 3 ). Lesotho has integrated biomedical HIV prevention into national health strategies to expand access to oral PrEP and PEP for individuals at increased risk of HIV ( 4 ). However, uptake for these prevention tools remains low, due to limited awareness, low self-perceived risk of HIV, stigma and misinformation, and structural barriers to care ( 5 – 7 ). The HIV prevention cascade is a useful framework for mapping a population's progression from awareness of HIV prevention tools and motivation to use them, to reach (access or interaction with prevention services), and finally to current or sustained use. Each stage of the cascade corresponds to a measurable indicator, visualising where drop-offs occur and highlighting implementation gaps that limit the effectiveness of prevention programs ( 8 , 9 ). Understanding how individuals progress or disengage along the cascade is essential for optimising service delivery models for HIV prevention. Addressing prevention cascade gaps requires an approach that brings prevention knowledge and services closer to communities. In Lesotho, where community-based delivery models are well established, community health workers (CHWs) can support HIV prevention by improving awareness and facilitating access to services, particularly in remote areas ( 10 , 11 ). In settings where healthcare services are limited by workforce shortages and distance to facilities, CHWs have become central to task-sharing and extending essential health services including HIV care to underserved populations ( 11 – 13 ). Within the HIV prevention cascade, CHWs could address gaps in access by expanding PrEP availability, facilitating timely PEP provision after potential exposure, and supporting condom distribution and demand creation for emerging dual prevention products. We conducted a population-based survey in Lesotho to assess PrEP and PEP prevention cascades and identify gaps along each stage, determine predictors of awareness, and assess the prospective acceptability of CHW-led HIV prevention services, with the potential to inform future expansion of the CHW role in remote settings. Methods Study design and setting We conducted a population-based, cross-sectional survey from 1 May to 30 September 2024 within the Community-Based Chronic Care Lesotho (ComBaCaL) pilot cohort. The ComBaCaL pilot cohort includes all consenting residents of ten villages in the rural districts of Butha-Buthe and Mokhotlong in northeastern Lesotho. Adult HIV prevalence in both districts is estimated at 15.4% ( 14 ). In these rural villages, most residents depend on small-scale farming, low-paid local work, or seasonal migrant labour in neighboring South Africa. The cohort was established in 2020 to evaluate CHW-led screening and management of hypertension and diabetes ( 15 ) and serves as a platform for community-based health research. Each village enrolled in the cohort has one community-elected CHW trained to collect and regularly update household and patient information using a clinical decision-support system built on the open-source Community Health Toolkit (CHT) platform on an Android tablet. At the time of this survey, CHWs initiated screening and follow-up for hypertension and diabetes. CHW-led HIV prevention and care have not yet been introduced. Participants and data collection All individuals aged ≥ 15 years enrolled in the ComBaCaL pilot cohort were eligible to participate in this survey. Data were collected by ten CHWs in their respective villages using electronic tablets equipped with the ComBaCaL application. The structured, 40-item questionnaire was administered in Sesotho and captured information on PrEP and PEP awareness, motivation, reach, and use, as well as the prospective acceptability of CHW-delivered HIV prevention services (Supplementary table S1 ). Using the existing participant data within the ComBaCaL pilot cohort, CHWs identified eligible individuals and linked survey responses with previously collected sociodemographic and health information. Unique participant identifiers enabled automatic linkage between survey and cohort records and guided the branching logic of the electronic questionnaire. All data was stored locally on encrypted tablets and synchronised at least weekly with a secure central server. Variables and measures Sociodemographic characteristics, including age, sex, education, employment, and marital status, were obtained from the baseline ComBaCaL pilot cohort dataset and linked to survey responses. For participants younger than 18 years, data on education, employment, and marital status were not collected as part of the cohort and was coded as missing. Participants self-reported their HIV status and the date of their most recent HIV test. Behavioral risk for HIV acquisition was assessed using a single screening question aligned with Lesotho's national PrEP eligibility criteria ( 16 ): “Have you had unprotected sex in the last six months with one or more partner(s) whose HIV status is unknown?” Participants who answered “yes” were classified as being at risk of acquiring HIV. Indicators for the PrEP and PEP prevention cascades were derived from sequential self-reported items capturing awareness (ever having heard of PrEP or PEP), motivation (interest in using PrEP for prevention or willingness to use PEP following potential exposure), reach (for PrEP only, ever having been offered PrEP by a healthcare provider), and use (reporting previous or current PrEP use, or any prior PEP use). Acceptability of CHW-led HIV prevention services was assessed at both individual and community levels. Community-level acceptability was assessed among all participants, by asking whether they believed CHW-delivered HIV prevention services such as counselling, testing, and the provision of prevention products, would benefit their community, with response options yes , no , or unknown/refused . Individual-level acceptability assessed participants' comfort with personally receiving HIV counseling, testing, and prevention products from a CHW. These included PrEP, PEP, condoms, and the dual prevention pill (combined oral PrEP-contraceptive). Questions were administered using branching logic based on age, sex and HIV status. Response options were comfortable , not comfortable , or unknown/refused . Statistical analyses Descriptive analyses were conducted to summarise participant characteristics, PrEP and PEP cascade indicators, and acceptability outcomes. Cascade indicators were calculated using two approaches: first, using the total eligible population as the denominator, and second, using the number of participants who reached the preceding step as denominator. Multivariable logistic regression models were fitted to identify factors associated with PrEP and PEP awareness among participants aged ≥ 18 years. For participants younger than 18 years, sociodemographic variables such as education, employment, and marital status were not collected; These individuals were therefore excluded from regression analyses. Results are reported as odds ratios (ORs) adjusted odds ratios (aORs) with 95% confidence intervals (CIs). All analyses were conducted in R (version 4.3.3). Ethical considerations The survey was approved by the National Health Research Ethics Committee of Lesotho as part of the established ComBaCaL pilot cohort study (Ref. NHREC/2024/05). The study was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation. For participants under 16 years of age, written informed consent was obtained from a parent or legal guardian, in addition to written assent from the participant. As the survey was conducted under the general consent framework of the ComBaCaL cohort, no additional written informed consent was obtained. Results A total of 1,083 participants completed the survey. The median age was 39 years (interquartile range [IQR]: 23–60), and 614 (57%) were female. Overall, 157 participants (15%) reported living with HIV, and 252 (23%) lived in a household with at least one person living with HIV. Among 926 participants without HIV, 218 (24%) self-reported HIV risk behaviour. Within this subgroup, 90 (41%) were aged 15–24 years, and 113 (52%) were female. Sociodemographic and HIV-related characteristics of all participants and of participants at risk of HIV are presented in Table 1 . Table 1 Participants Characteristics Characteristics Total, n (%) Participants at risk of acquiring HIV, n(%) n = 1,083 1 n = 218 1 Sex Female 613 (56.6%) 113 (51.8%) Male 470 (43.4%) 105 (48.2%) Age Category (Median, IQR) 39 (23,61) 28 (21,39) 15–24 294 (27.1%) 90 (41.3%) 25–49 414 (38.2%) 101 (46.3%) 50+ 375 (34.6%) 27 (12.4%) Marital Status 1 Not married or cohabiting 456 (46.0%) 94 (46.8%) Married or cohabiting 530 (53.5%) 106 (52.7%) Unknown/ refused 5 (0.5%) 1 (0.5%) Missing 92 17 Education 1 < 12 years of education 590 (59.5%) 94 (46.8%) ≥ 12 years of education 401 (40.5%) 107 (53.2%) Missing 92 17 Employment 1 Unemployed 172 (17.4%) 32 (15.9%) Employed or self-employed 701 (80.3%) 131 (65.2%) Unknown/ refused 118 (11.9%) 38 (18.9%) Missing 92 17 HIV-Status Living with HIV 157 (14.5%) - Not living with HIV 926 (84.5%) 218 (100%) Household Member with HIV At least one household member living with HIV 252 (23.3%) 37 (17.0%) No household members living with HIV 831 (76.7%) 181 (83.0%) 1 Marital status, education and employment status were collected from respondents over the age of 16 years at the time of the baseline data collection for the cohort study (Missing values are ‘true unknowns’ and excluded from the multivariable regression analysis) PrEP cascade Among the 218 participants classified at risk of acquiring HIV, 123/218 (56%) had heard of PrEP. Of those aware, 101/123 (82%) expressed motivation to use it, and 24/101 (24%) of motivated participants had ever been offered PrEP by a healthcare provider. Among those offered PrEP, 21/24 (88%) reported previous use, and 17/21 (81%) were current users. Overall, this corresponds to 17/218 (8%) PrEP coverage among participants at risk of HIV (Fig. 1 ). Top percentages indicate the proportion of the total population at risk; bottom percentages indicate conditional progression from the previous cascade step. PEP cascade Among participants at risk of HIV, 63/218 (29%) were aware of PEP. Of those aware, 37/63 (59%) expressed motivation to use it in the event of HIV exposure, and 5/37 (14%) reported previous use. Overall, this corresponds to 5/218 (2%) PEP coverage among participants at risk of HIV (Fig. 2 ). Top percentages indicate the proportion of the total population at risk; bottom percentages indicate conditional progression from the previous cascade step. Predictors of PrEP and PEP awareness Of the 218 participants at risk of HIV, complete sociodemographic data were available for 201, who were included in the uni- and multivariable analyses. In univariate analyses, female participants (OR 4.85, 95% CI: 2.76–8.72, p < 0.001) and those with more than 12 years of education (OR 2.55, 95% CI: 1.45–4.55, p = 0.001) had higher odds of being aware of PrEP (Table 2 ). Associations with predictors of PEP awareness followed similar patterns. Female participants (OR 5.50, 95% CI: 2.89–11.00, p < 0.001), those with higher education (OR 3.28, 95% CI: 1.72–6.50, p = 0.001), and married or cohabiting individuals (OR 1.94, 95% CI: 1.05–3.68, p = 0.038) were more likely to be aware of PEP, while employed participants were less likely to be aware (OR 0.42, 95% CI: 0.18–0.95, p = 0.035). In multivariable models, being female remained significantly associated with PrEP awareness (aOR 3.13, 95% CI: 1.56–6.42, p = 0.001) (Table 2 ). For PEP, awareness remained associated with being female (aOR 2.26, 95% CI: 1.01–5.27, p = 0.049), higher education (aOR 2.93, 95% CI: 1.29–7.06, p = 0.012), being married or cohabiting (aOR 2.76, 95% CI: 1.17–6.89; p = 0.024) (Table 3 ). Table 2 Predictors of PrEP awareness among participants at risk of HIV Characteristics n OR (95% CI) p-value n aOR (95% CI) p-value Sex 201 201 Female sex 4.85 (2.76–8.72) < 0.001 3.13 (1.56–6.42) 0.001 Age Category 201 201 25–49 1.17 (0.66–2.08) 0.59 1.09 (0.49–2.42) 0.83 50+ 0.70 (0.28–1.68) 0.43 0.76 (0.23–2.41) 0.64 Education 201 201 >12 years 2.55 (1.45–4.55) 0.001 1.61 (0.81–3.22) 0.18 Marital status 201 201 Married/cohabiting 1.71 (0.98–3.02) 0.060 1.75 (0.85–3.66) 0.13 Employment 201 201 Employed/self-employed 0.60 (0.27–1.30) 0.20 0.88 (0.35–2.20) 0.79 Household member with HIV 201 201 ≥1 member with HIV 1.66 (0.81–3.43) 0.17 1.79 (0.66–4.99) 0.25 OR = odds ratio; aOR = adjusted odds ratio; CI = Confidence Interval. Multivariable analyses were conducted using complete case analysis. Reference categories: male sex; age 18–25 years; ≤12 years of education; single; unemployed; no household members living with HIV. Table 3 Predictors of PEP awareness among participants at risk of HIV Characteristics n OR (95% CI) p-value n aOR (95% CI) p-value Sex 201 201 Female sex 5.50 (2.89–11.0) < 0.001 2.26 (1.01–5.17) 0.049 Age Category 201 201 25–49 1.04 (0.56–1.95) 0.90 1.03 (0.40–2.70) 0.95 50+ 0.86 (0.31–2.21) 0.76 1.68 (0.44–6.27) 0.44 Education 201 201 >12 years 3.28 (1.72–6.50) < 0.001 2.93 (1.29–7.06) 0.012 Marital status 201 201 Married/cohabiting 1.94 (1.05–3.68) 0.038 2.76 (1.17–6.89) 0.024 Employment 201 201 Employed/self-employed 0.42 (0.18–0.95) 0.035 0.49 (0.18–1.32) 0.16 Household member with HIV 201 201 ≥1 member with HIV 2.17 (1.04–4.50) 0.037 2.18 (0.70–6.65) 0.17 OR = odds ratio; aOR = adjusted odds ratio; CI = Confidence Interval. Analyses were conducted using complete case analysis. Reference categories: male sex; age 18–25 years; ≤12 years of education; single; unemployed; no household members living with HIV. Community-level acceptability of CHW-delivered HIV prevention services All 1,083 participants were asked whether they believed CHW-delivered HIV prevention services would benefit their community. Perceived benefits were high across all services: 90% for PEP, 89% for PrEP, 88% for HIV counseling and testing, and 87% for the dual prevention pill. Between 7–10% of participants expressed uncertainty or declined to respond; 1–3% believed that such services would not benefit their community (Fig. 3 ). Individual-level prospective acceptability of CHW-delivered integrated HIV prevention services Among all participants (n = 1083), 91% reported being comfortable receiving HIV counseling from a CHW. Among those not living with HIV (n = 926), 93% were comfortable with CHW-delivered oral self-testing and 83% with finger-prick testing. Among participants not living with HIV aged 15–49 and those reporting increased risk (n = 649), 85% were comfortable receiving PEP and 83% receiving PrEP. For condom distribution, 82% of participants aged 15–49 years (n = 708) were comfortable receiving external condoms, while 75% of women aged 15–49 years (n = 363) were comfortable receiving internal condoms. Finally, 83% of women of aged 15–49 years reported being comfortable receiving the dual prevention pill. Between 7–10% of participants expressed uncertainty or declined to respond, while 8–18% reported discomfort depending on the service (Fig. 4 ). Discussion We conducted a population-based survey in ten rural villages in northeastern Lesotho to assess gaps along biomedical HIV prevention cascades and to evaluate the prospective acceptability of CHW-led delivery of HIV prevention services. Among individuals at increased risk of HIV, awareness of PrEP and PEP was low, and substantial drop-offs were observed at the stages of service reach and use. Although most participants who were offered PrEP reported initiating it, overall coverage remained low, since very few people had ever been reached by prevention services. For PEP, both awareness and prior use were particularly low. Across all services, however, participants expressed high acceptability of CHW-delivered counseling, testing, and biomedical prevention products, indicating strong community support for expanding CHW roles in HIV prevention. Approximately one quarter of participants in our study were at increased risk of HIV, consistent with national findings which reported that 11% of women and 32% of men aged 15–49 had multiple sexual partners in the past year, and that only 40% of women and 57% of men used a condom at last intercourse ( 14 ). Similar patterns of reported sexual risk have been observed in other Southern African countries ( 17 , 18 ), emphasising the continued need to expand access to and uptake of PrEP and PEP. We identified three main implementation gaps in the cascades: limited service reach among individuals motivated to use PrEP, low awareness of PEP among individuals at risk of HIV, and low PEP use among those willing to access it after exposure. For PrEP, despite high motivation to use it, only a small proportion of participants had ever been offered it, suggesting that demand exists, but service delivery has not reached those who need it. Studies from similar settings have documented barriers such as limited provider knowledge, discomfort discussing sexual risk, and supply or policy constraints that reduce proactive PrEP offering ( 19 , 20 ). In our study, nearly all participants (88%) initiated PrEP once it was offered, suggesting that PrEP uptake is limited by access rather than by acceptability. Strengthening provider-initiated PrEP offers may help close this gap. For PEP, both awareness and use were low in this population. In similar settings, awareness among people at risk has been reported at around 40% ( 21 , 22 ). Low awareness likely reflects gaps in prevention communication and limited access to health information, especially in remote areas ( 23 ). Among participants who were motivated to use PEP, only 14% had accessed it, suggesting potential barriers related to access, timing, and service delivery. Other studies describe similar challenges, including limited provider and patient knowledge, stigma, and inconsistent PEP availability in primary care ( 23 – 25 ). Beyond overall cascade gaps, we examined predictors of PrEP and PEP awareness to identify population groups where targeted prevention interventions may be most needed. Awareness of both PrEP and PEP was higher among women. This finding contrasts with much of the regional literature, which often reports lower awareness and knowledge of biomedical prevention options among women ( 26 , 27 ). In Lesotho, however, higher awareness among women aligns with national data showing that almost half of young women, compared with one third of young men, demonstrated comprehensive knowledge of HIV prevention ( 14 ). This pattern may reflect women's greater engagement with the health system through sexual and reproductive health services, as well as targeted activities under Lesotho's National HIV and AIDS Strategic Plan which increasingly targets adolescent girls and young women ( 28 ). While education was associated with greater PrEP awareness in univariate analyses, this association did not remain significant after adjustment, suggesting that education alone may not independently influence awareness. Similar observations have been made elsewhere, where higher general health literacy does not necessarily translate into specific knowledge of HIV prevention tools ( 29 , 30 ). Awareness of PEP was higher among women, those with higher education, participants who were married or cohabiting, and those living in households with someone living with HIV. These associations likely reflect social proximity to HIV information and services. Married or cohabiting individuals may have more contact with healthcare services through reproductive or couples-based testing programs, facilitating exposure to HIV prevention messaging ( 14 , 31 , 32 ). We assessed the acceptability of CHWs to deliver HIV prevention services to potentially improve awareness and service reach. Lesotho's National Health Strategy recognises the role of CHWs in expanding community-based prevention services as part of integrated primary care and national prevention scale-up ( 28 ). Our findings suggest high acceptability for CHW-delivered HIV prevention services within this population. At the community level, the perceived benefit of CHW delivery was high across all services, with the highest acceptability for PEP. This aligns with guidance that timely access is critical for effectiveness and can be supported through task-sharing and community delivery ( 10 , 12 , 33 ). The strong acceptability of CHW-provided PrEP reflects overall trust in community-based models for HIV prevention. However, some uncertainty about specific CHW-delivered services may be linked to the perceived scope of CHW roles. Similarly, while overall acceptability of the dual prevention pill was high, some uncertainty may stem from limited familiarity with the product and its formulation. At the individual level, participants reported confidence receiving counseling/testing and preventive products (PrEP, PEP, condoms) from CHWs. Evidence on CHW-delivered PrEP services is still limited but shows promise for improving access and uptake among people underserved by facility-based programs ( 12 , 13 ). Studies also suggest that PEP can be delivered effectively in community settings ( 25 , 33 ), improving timeliness of access, and helping close the awareness-to-use gap seen in our cascades. Strengths and Limitations The strength of this study is its population-based design across several villages likely resulting in a study population representative for the rural population in Lesotho. However, several limitations should be noted. The cross-sectional design cannot capture changes in HIV risk, awareness, or service acceptability over time; findings therefore reflect participants' perceptions at the time of data collection. Self-reported data may be subject to recall or social desirability bias, particularly for sensitive topics such as HIV risk and prevention behaviors. As CHWs collected the data, participants may also have overstated their confidence in CHW-delivered services. The limited sample size also reduces the precision of some estimates. Additionally, sociodemographic data were not collected for participants under 18 years, resulting in missing data and their exclusion from regression analyses. Finally, acceptability was measured prospectively and may not necessarily translate into uptake once services are implemented. Conclusion In Lesotho, there are substantial gaps in awareness and access to biomedical HIV prevention, despite high motivation to use both PrEP and PEP once offered. In this setting, uptake appears to be constrained by limited service reach rather than acceptability. Awareness of PrEP and PEP was higher among women and those with higher levels of education. Further, awareness of PEP was also greater among participants who were married or cohabiting and among those living in households with a person living with HIV. Across all interventions, CHWs were stated as highly acceptable providers of HIV prevention services, and participants expressed confidence in receiving counseling, testing, and preventive products from them. These findings point to the potential of leveraging CHWs to extend prevention services into communities, thereby improving access to PrEP, enabling timely PEP, and supporting combination-prevention strategies. Abbreviations AIDS - Acquired Immune Deficiency Syndrome CHT - Community Health Toolkit CHWs - Community Health Workers CI - Confidence Interval ComBaCaL - Community-Based chronic Care Lesotho HIV - Human Immunodeficiency Virus IQR - Interquartile Range NHREC - National Health Research Ethics Committee OR - Odds Ratio aOR - Adjusted Odds Ratio PEP - Post-Exposure Prophylaxis PrEP - Pre-Exposure Prophylaxis UNAIDS - Joint United Nations Program on HIV/AIDS WHO - World Health Organization Declarations Ethics approval The Community-based Chronic Care Lesotho (ComBaCaL) pilot study received ethical approval from the National Health Research and Ethics Committee (NH‑REC) of Lesotho (ID 176–2021). Village chiefs provided community-level consent; household heads provided household consent, and individual participants gave written informed consent to participate in the ComBaCaL pilot cohort. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Availability of data and materials The datasets used and analysed in this study are available from the corresponding author on request. Funding statement This pilot study was conducted as part of the Community-Based Chronic Care Lesotho (ComBaCaL) project, funded by the TRANSFORM grant from the Swiss Agency for Development and Cooperation (project number: 7F-10345.01.01) and the World Diabetes Foundation (grant number: WDF-1778). AA and NDL are co-principal investigators of ComBaCaL. The funders had no role in the design of the pilot study, data collection, analysis, interpretation, or the decision to submit the manuscript for publication. NDL received salary support through an Eccellenza Professorship Grant from the Swiss National Science Foundation (PCEFP3_181355). Authors’ contributions AW and FR conceptualised the study, conducted the analysis, and drafted the manuscript. 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Fam Med Community Health. 2021;9(4): e000958 . doi:10.1136/fmch-2021-000958. Allan-Blitz LT, Mayer KH. Missed opportunities: a narrative review on why nonoccupational postexposure prophylaxis for HIV is underutilized. Open Forum Infect Dis. 2024;11(8): ofae332. doi:10.1093/ofid/ofae332. Kennedy CE, Dawit R, Yeh PT, et. al. HIV post-exposure prophylaxis in community settings and by lay health workers or through task sharing: a systematic review of effectiveness, case studies, values and preferences, and costs. J Int AIDS Soc. 2025;28(5) :e26448. doi:10.1002/jia2.26448. Nkosi L, Mmem QD, Tsafa TN, Gwar JN, Agaku IT. Awareness and openness to the use of PrEP among a nationally representative sample of South African adults. Pan Afr Med J. 2024;48:95. doi:10.11604/pamj.2024.48.95.34137. Kapola AJ, Musoke R, Manayon GM, et al. Pre-exposure prophylaxis awareness and endorsement among adolescents and young adults in Tanzania: insights from the 2022 Demographic and Health Survey. East Afr Health Res J. 2024;8(2). Lesotho Ministry of Health. National HIV and AIDS Strategic Plan 2023-2028. Maseru: Ministry of Health; 2023. Wilandika A, Yusuf A, Kurniawati ND, Yusof S, Widianti AT. Factors That Enhance Health Literacy in Dealing with HIV Stigma: A Scoping Review. J Health Lit 2024;8(4):62-76. doi:10.22038/JHL.2023.74344.1468. Chimukuche RS, Kawuma R, Mahapa N, et al. Examining oral pre-exposure prophylaxis (PrEP) literacy among participants in an HIV vaccine trial preparedness cohort study. BMC Health Serv Res 2022;22:1336. doi:10.1186/s12913-022-08730-8. World Health Organization (WHO). Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. Geneva: WHO; 2021. Sabo KG, Seifu BL, Kase BF, et. al. Factors influencing HIV testing uptake in sub-Saharan Africa: a comprehensive multi-level analysis using Demographic and Health Survey data (2015–2022). BMC Infect Dis. 2024;24(1):1182. World Health Organization (WHO). Guidelines on post-exposure prophylaxis for HIV and the use of co-trimoxazole prophylaxis for HIV-related infections among adults, adolescents and children. Geneva: WHO; 2014. Additional Declarations No competing interests reported. Supplementary Files BMCPHSupplementaryFile1.SurveyitemsusedintheHIVpreventioncascadeandCHWacceptabilityanalysisEnglish.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 24 Feb, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviews received at journal 18 Feb, 2026 Reviewers agreed at journal 18 Feb, 2026 Reviewers invited by journal 16 Feb, 2026 Editor assigned by journal 10 Dec, 2025 Editor invited by journal 01 Dec, 2025 Submission checks completed at journal 01 Dec, 2025 First submitted to journal 01 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8220761\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":593416931,\"identity\":\"7af1ba70-020e-4422-8bc3-2d2aaba79114\",\"order_by\":0,\"name\":\"Andréa Williams\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University Hospital Basel\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Andréa\",\"middleName\":\"\",\"lastName\":\"Williams\",\"suffix\":\"\"},{\"id\":593416932,\"identity\":\"9f902ad5-57d8-4903-9dcb-5a3d3b591de4\",\"order_by\":1,\"name\":\"Fabian 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10:08:27\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8220761/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8220761/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":102992936,\"identity\":\"9bef0397-59bd-40d6-8166-2ce28317e550\",\"added_by\":\"auto\",\"created_at\":\"2026-02-19 11:43:07\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":97902,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePrEP cascade among participants at risk of HIV in Lesotho Top percentages indicate the proportion of the total population at risk; bottom percentages indicate conditional progression from the previous cascade step.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8220761/v1/898b4f36cfccc9cba840e6fc.png\"},{\"id\":103050032,\"identity\":\"d6aa59de-50f5-4126-ac48-110e20d701c1\",\"added_by\":\"auto\",\"created_at\":\"2026-02-20 07:47:47\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":67392,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePEP cascade among participants at risk of HIV in Lesotho Top percentages indicate the proportion of the total population at risk; bottom percentages indicate conditional progression from the previous cascade step.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8220761/v1/864293f3339ef9dd8cb1c733.png\"},{\"id\":102992939,\"identity\":\"fb6e7d77-54b5-420f-b276-2d5292f7cfda\",\"added_by\":\"auto\",\"created_at\":\"2026-02-19 11:43:07\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":59807,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eCommunity-level acceptability of CHW-delivered HIV prevention services\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8220761/v1/f98db33d5accc41b04cdc185.png\"},{\"id\":104779165,\"identity\":\"5554823e-09fb-4542-8ad6-8400e1311e89\",\"added_by\":\"auto\",\"created_at\":\"2026-03-17 07:36:01\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":95324,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eIndividual-level prospective acceptability of CHW-delivered integrated HIV prevention services\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8220761/v1/f1a63791ca1f16cb34d71db4.png\"},{\"id\":104783905,\"identity\":\"f59e9572-fbe7-4205-a055-4b3081a41615\",\"added_by\":\"auto\",\"created_at\":\"2026-03-17 08:04:01\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1510335,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8220761/v1/5b985529-fac3-4d1a-bc7b-f3192f407320.pdf\"},{\"id\":102992940,\"identity\":\"19d9270f-d613-4f68-a8de-c65cb2dc72c1\",\"added_by\":\"auto\",\"created_at\":\"2026-02-19 11:43:07\",\"extension\":\"docx\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":20385,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"BMCPHSupplementaryFile1.SurveyitemsusedintheHIVpreventioncascadeandCHWacceptabilityanalysisEnglish.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8220761/v1/c4349c51e06168d9e2251b60.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Biomedical HIV prevention cascades and acceptability of community health worker-led services: a cross-sectional survey in Lesotho\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eThe HIV burden in Southern Africa remains disproportionately high despite substantial progress in recent years. Lesotho is a small, landlocked country in southern Africa with a population of 2.3\\u0026nbsp;million, and an estimated adult HIV prevalence of 18.5% (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). While Lesotho has advanced toward the UNAIDS 95-95-95 testing and treatment targets, approximately 4,800 new HIV infections were reported in 2023 (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). Efforts focused on testing, treatment, and viral suppression alone are insufficient to curb ongoing HIV transmission in high-prevalence settings (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). Scaling up primary prevention including condoms and biomedical tools such as HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), along with emerging combination prevention products that offer dual protection against HIV and pregnancy for women, is essential to achieving the goal of ending HIV as a public health threat by 2030 (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eLesotho has integrated biomedical HIV prevention into national health strategies to expand access to oral PrEP and PEP for individuals at increased risk of HIV (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). However, uptake for these prevention tools remains low, due to limited awareness, low self-perceived risk of HIV, stigma and misinformation, and structural barriers to care (\\u003cspan additionalcitationids=\\\"CR6\\\" citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). The HIV prevention cascade is a useful framework for mapping a population's progression from \\u003cem\\u003eawareness\\u003c/em\\u003e of HIV prevention tools and \\u003cem\\u003emotivation\\u003c/em\\u003e to use them, to \\u003cem\\u003ereach\\u003c/em\\u003e (access or interaction with prevention services), and finally to current or sustained use. Each stage of the cascade corresponds to a measurable indicator, visualising where drop-offs occur and highlighting implementation gaps that limit the effectiveness of prevention programs (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). Understanding how individuals progress or disengage along the cascade is essential for optimising service delivery models for HIV prevention.\\u003c/p\\u003e \\u003cp\\u003eAddressing prevention cascade gaps requires an approach that brings prevention knowledge and services closer to communities. In Lesotho, where community-based delivery models are well established, community health workers (CHWs) can support HIV prevention by improving awareness and facilitating access to services, particularly in remote areas (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). In settings where healthcare services are limited by workforce shortages and distance to facilities, CHWs have become central to task-sharing and extending essential health services including HIV care to underserved populations (\\u003cspan additionalcitationids=\\\"CR12\\\" citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). Within the HIV prevention cascade, CHWs could address gaps in access by expanding PrEP availability, facilitating timely PEP provision after potential exposure, and supporting condom distribution and demand creation for emerging dual prevention products.\\u003c/p\\u003e \\u003cp\\u003eWe conducted a population-based survey in Lesotho to assess PrEP and PEP prevention cascades and identify gaps along each stage, determine predictors of awareness, and assess the prospective acceptability of CHW-led HIV prevention services, with the potential to inform future expansion of the CHW role in remote settings.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy design and setting\\u003c/h2\\u003e \\u003cp\\u003eWe conducted a population-based, cross-sectional survey from 1 May to 30 September 2024 within the Community-Based Chronic Care Lesotho (ComBaCaL) pilot cohort.\\u003c/p\\u003e \\u003cp\\u003eThe ComBaCaL pilot cohort includes all consenting residents of ten villages in the rural districts of Butha-Buthe and Mokhotlong in northeastern Lesotho. Adult HIV prevalence in both districts is estimated at 15.4% (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). In these rural villages, most residents depend on small-scale farming, low-paid local work, or seasonal migrant labour in neighboring South Africa.\\u003c/p\\u003e \\u003cp\\u003eThe cohort was established in 2020 to evaluate CHW-led screening and management of hypertension and diabetes (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e) and serves as a platform for community-based health research. Each village enrolled in the cohort has one community-elected CHW trained to collect and regularly update household and patient information using a clinical decision-support system built on the open-source Community Health Toolkit (CHT) platform on an Android tablet. At the time of this survey, CHWs initiated screening and follow-up for hypertension and diabetes. CHW-led HIV prevention and care have not yet been introduced.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eParticipants and data collection\\u003c/h3\\u003e\\n\\u003cp\\u003eAll individuals aged\\u0026thinsp;\\u0026ge;\\u0026thinsp;15 years enrolled in the ComBaCaL pilot cohort were eligible to participate in this survey.\\u003c/p\\u003e \\u003cp\\u003eData were collected by ten CHWs in their respective villages using electronic tablets equipped with the ComBaCaL application. The structured, 40-item questionnaire was administered in Sesotho and captured information on PrEP and PEP awareness, motivation, reach, and use, as well as the prospective acceptability of CHW-delivered HIV prevention services (Supplementary table \\u003cspan refid=\\\"MOESM1\\\" class=\\\"InternalRef\\\"\\u003eS1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eUsing the existing participant data within the ComBaCaL pilot cohort, CHWs identified eligible individuals and linked survey responses with previously collected sociodemographic and health information. Unique participant identifiers enabled automatic linkage between survey and cohort records and guided the branching logic of the electronic questionnaire. All data was stored locally on encrypted tablets and synchronised at least weekly with a secure central server.\\u003c/p\\u003e\\n\\u003ch3\\u003eVariables and measures\\u003c/h3\\u003e\\n\\u003cp\\u003eSociodemographic characteristics, including age, sex, education, employment, and marital status, were obtained from the baseline ComBaCaL pilot cohort dataset and linked to survey responses. For participants younger than 18 years, data on education, employment, and marital status were not collected as part of the cohort and was coded as missing.\\u003c/p\\u003e \\u003cp\\u003eParticipants self-reported their HIV status and the date of their most recent HIV test. Behavioral risk for HIV acquisition was assessed using a single screening question aligned with Lesotho's national PrEP eligibility criteria (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e): \\u0026ldquo;Have you had unprotected sex in the last six months with one or more partner(s) whose HIV status is unknown?\\u0026rdquo; Participants who answered \\u0026ldquo;yes\\u0026rdquo; were classified as being at risk of acquiring HIV.\\u003c/p\\u003e \\u003cp\\u003eIndicators for the PrEP and PEP prevention cascades were derived from sequential self-reported items capturing \\u003cem\\u003eawareness\\u003c/em\\u003e (ever having heard of PrEP or PEP), \\u003cem\\u003emotivation\\u003c/em\\u003e (interest in using PrEP for prevention or willingness to use PEP following potential exposure), \\u003cem\\u003ereach\\u003c/em\\u003e (for PrEP only, ever having been offered PrEP by a healthcare provider), and \\u003cem\\u003euse\\u003c/em\\u003e (reporting previous or current PrEP use, or any prior PEP use).\\u003c/p\\u003e \\u003cp\\u003eAcceptability of CHW-led HIV prevention services was assessed at both individual and community levels.\\u003c/p\\u003e \\u003cp\\u003eCommunity-level acceptability was assessed among all participants, by asking whether they believed CHW-delivered HIV prevention services such as counselling, testing, and the provision of prevention products, would benefit their community, with response options \\u003cem\\u003eyes\\u003c/em\\u003e, \\u003cem\\u003eno\\u003c/em\\u003e, or \\u003cem\\u003eunknown/refused\\u003c/em\\u003e.\\u003c/p\\u003e \\u003cp\\u003e Individual-level acceptability assessed participants' comfort with personally receiving HIV counseling, testing, and prevention products from a CHW. These included PrEP, PEP, condoms, and the dual prevention pill (combined oral PrEP-contraceptive). Questions were administered using branching logic based on age, sex and HIV status. Response options were \\u003cem\\u003ecomfortable\\u003c/em\\u003e, \\u003cem\\u003enot comfortable\\u003c/em\\u003e, or \\u003cem\\u003eunknown/refused\\u003c/em\\u003e.\\u003c/p\\u003e\\n\\u003ch3\\u003eStatistical analyses\\u003c/h3\\u003e\\n\\u003cp\\u003eDescriptive analyses were conducted to summarise participant characteristics, PrEP and PEP cascade indicators, and acceptability outcomes.\\u003c/p\\u003e \\u003cp\\u003eCascade indicators were calculated using two approaches: first, using the total eligible population as the denominator, and second, using the number of participants who reached the preceding step as denominator.\\u003c/p\\u003e \\u003cp\\u003eMultivariable logistic regression models were fitted to identify factors associated with PrEP and PEP awareness among participants aged\\u0026thinsp;\\u0026ge;\\u0026thinsp;18 years. For participants younger than 18 years, sociodemographic variables such as education, employment, and marital status were not collected; These individuals were therefore excluded from regression analyses. Results are reported as odds ratios (ORs) adjusted odds ratios (aORs) with 95% confidence intervals (CIs). All analyses were conducted in R (version 4.3.3).\\u003c/p\\u003e\\n\\u003ch3\\u003eEthical considerations\\u003c/h3\\u003e\\n\\u003cp\\u003e The survey was approved by the National Health Research Ethics Committee of Lesotho as part of the established ComBaCaL pilot cohort study (Ref. NHREC/2024/05). The study was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation. For participants under 16 years of age, written informed consent was obtained from a parent or legal guardian, in addition to written assent from the participant. As the survey was conducted under the general consent framework of the ComBaCaL cohort, no additional written informed consent was obtained.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eA total of 1,083 participants completed the survey. The median age was 39 years (interquartile range [IQR]: 23\\u0026ndash;60), and 614 (57%) were female. Overall, 157 participants (15%) reported living with HIV, and 252 (23%) lived in a household with at least one person living with HIV. Among 926 participants without HIV, 218 (24%) self-reported HIV risk behaviour. Within this subgroup, 90 (41%) were aged 15\\u0026ndash;24 years, and 113 (52%) were female. Sociodemographic and HIV-related characteristics of all participants and of participants at risk of HIV are presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eParticipants Characteristics\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eCharacteristics\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTotal, n (%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eParticipants at risk of acquiring HIV, n(%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003en\\u0026thinsp;=\\u0026thinsp;1,083\\u003c/b\\u003e\\u003csup\\u003e\\u003cem\\u003e1\\u003c/em\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003en\\u0026thinsp;=\\u0026thinsp;218\\u003c/b\\u003e\\u003csup\\u003e\\u003cem\\u003e1\\u003c/em\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSex\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFemale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e613 (56.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e113 (51.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e470 (43.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e105 (48.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eAge Category\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003e\\u003cb\\u003e(Median, IQR)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e39 (23,61)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e28 (21,39)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e15\\u0026ndash;24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e294 (27.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e90 (41.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e25\\u0026ndash;49\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e414 (38.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e101 (46.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e50+\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e375 (34.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e27 (12.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMarital Status\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003e1\\u003c/b\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNot married or cohabiting\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e456 (46.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e94 (46.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMarried or cohabiting\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e530 (53.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e106 (52.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnknown/\\u003c/p\\u003e \\u003cp\\u003erefused\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5 (0.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1 (0.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMissing\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e92\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e17\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEducation\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003e1\\u003c/b\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;12 years of education\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e590 (59.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e94 (46.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026ge;\\u0026thinsp;12 years of education\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e401 (40.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e107 (53.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMissing\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e92\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e17\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEmployment\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003e1\\u003c/b\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnemployed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e172 (17.4%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e32 (15.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEmployed or self-employed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e701 (80.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e131 (65.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnknown/\\u003c/p\\u003e \\u003cp\\u003erefused\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e118 (11.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e38 (18.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMissing\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e92\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e17\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eHIV-Status\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLiving with HIV\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e157 (14.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNot living with HIV\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e926 (84.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e218 (100%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eHousehold Member with HIV\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAt least one household member living with HIV\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e252 (23.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e37 (17.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNo household members living with HIV\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e831 (76.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e181 (83.0%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"3\\\"\\u003e\\u003csup\\u003e1\\u003c/sup\\u003e Marital status, education and employment status were collected from respondents over the age of 16 years at the time of the baseline data collection for the cohort study (Missing values are \\u0026lsquo;true unknowns\\u0026rsquo; and excluded from the multivariable regression analysis)\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\\n\\u003ch3\\u003ePrEP cascade\\u003c/h3\\u003e\\n\\u003cp\\u003eAmong the 218 participants classified at risk of acquiring HIV, 123/218 (56%) had heard of PrEP. Of those aware, 101/123 (82%) expressed motivation to use it, and 24/101 (24%) of motivated participants had ever been offered PrEP by a healthcare provider. Among those offered PrEP, 21/24 (88%) reported previous use, and 17/21 (81%) were current users. Overall, this corresponds to 17/218 (8%) PrEP coverage among participants at risk of HIV (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eTop percentages indicate the proportion of the total population at risk; bottom percentages indicate conditional progression from the previous cascade step.\\u003c/p\\u003e\\n\\u003ch3\\u003ePEP cascade\\u003c/h3\\u003e\\n\\u003cp\\u003eAmong participants at risk of HIV, 63/218 (29%) were aware of PEP. Of those aware, 37/63 (59%) expressed motivation to use it in the event of HIV exposure, and 5/37 (14%) reported previous use. Overall, this corresponds to 5/218 (2%) PEP coverage among participants at risk of HIV (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eTop percentages indicate the proportion of the total population at risk; bottom percentages indicate conditional progression from the previous cascade step.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePredictors of PrEP and PEP awareness\\u003c/h2\\u003e \\u003cp\\u003eOf the 218 participants at risk of HIV, complete sociodemographic data were available for 201, who were included in the uni- and multivariable analyses. In univariate analyses, female participants (OR 4.85, 95% CI: 2.76\\u0026ndash;8.72, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and those with more than 12 years of education (OR 2.55, 95% CI: 1.45\\u0026ndash;4.55, p\\u0026thinsp;=\\u0026thinsp;0.001) had higher odds of being aware of PrEP (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eAssociations with predictors of PEP awareness followed similar patterns. Female participants (OR 5.50, 95% CI: 2.89\\u0026ndash;11.00, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), those with higher education (OR 3.28, 95% CI: 1.72\\u0026ndash;6.50, p\\u0026thinsp;=\\u0026thinsp;0.001), and married or cohabiting individuals (OR 1.94, 95% CI: 1.05\\u0026ndash;3.68, p\\u0026thinsp;=\\u0026thinsp;0.038) were more likely to be aware of PEP, while employed participants were less likely to be aware (OR 0.42, 95% CI: 0.18\\u0026ndash;0.95, p\\u0026thinsp;=\\u0026thinsp;0.035).\\u003c/p\\u003e \\u003cp\\u003eIn multivariable models, being female remained significantly associated with PrEP awareness (aOR 3.13, 95% CI: 1.56\\u0026ndash;6.42, p\\u0026thinsp;=\\u0026thinsp;0.001) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). For PEP, awareness remained associated with being female (aOR 2.26, 95% CI: 1.01\\u0026ndash;5.27, p\\u0026thinsp;=\\u0026thinsp;0.049), higher education (aOR 2.93, 95% CI: 1.29\\u0026ndash;7.06, p\\u0026thinsp;=\\u0026thinsp;0.012), being married or cohabiting (aOR 2.76, 95% CI: 1.17\\u0026ndash;6.89; p\\u0026thinsp;=\\u0026thinsp;0.024) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003ePredictors of PrEP awareness among participants at risk of HIV\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCharacteristics\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003en\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOR (95% CI)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eaOR (95% CI)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSex\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFemale sex\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.85 (2.76\\u0026ndash;8.72)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e3.13 (1.56\\u0026ndash;6.42)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eAge Category\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e25\\u0026ndash;49\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.17 (0.66\\u0026ndash;2.08)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.59\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1.09 (0.49\\u0026ndash;2.42)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.83\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e50+\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.70 (0.28\\u0026ndash;1.68)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.43\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.76 (0.23\\u0026ndash;2.41)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.64\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEducation\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026gt;12 years\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2.55 (1.45\\u0026ndash;4.55)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1.61 (0.81\\u0026ndash;3.22)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.18\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMarital status\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMarried/cohabiting\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.71 (0.98\\u0026ndash;3.02)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.060\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1.75 (0.85\\u0026ndash;3.66)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.13\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEmployment\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEmployed/self-employed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.60 (0.27\\u0026ndash;1.30)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.88 (0.35\\u0026ndash;2.20)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.79\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eHousehold member with HIV\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026ge;1 member with HIV\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.66 (0.81\\u0026ndash;3.43)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1.79 (0.66\\u0026ndash;4.99)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.25\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eOR\\u0026thinsp;=\\u0026thinsp;odds ratio; aOR\\u0026thinsp;=\\u0026thinsp;adjusted odds ratio; CI\\u0026thinsp;=\\u0026thinsp;Confidence Interval. Multivariable analyses were conducted using complete case analysis.\\u003c/p\\u003e \\u003cp\\u003eReference categories: male sex; age 18\\u0026ndash;25 years; \\u0026le;12 years of education; single; unemployed; no household members living with HIV.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003ePredictors of PEP awareness among participants at risk of HIV\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCharacteristics\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003en\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOR (95% CI)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eaOR (95% CI)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSex\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFemale sex\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5.50 (2.89\\u0026ndash;11.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2.26 (1.01\\u0026ndash;5.17)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.049\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eAge Category\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e25\\u0026ndash;49\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.04 (0.56\\u0026ndash;1.95)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.90\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1.03 (0.40\\u0026ndash;2.70)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.95\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e50+\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.86 (0.31\\u0026ndash;2.21)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.76\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e1.68 (0.44\\u0026ndash;6.27)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.44\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEducation\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026gt;12 years\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.28 (1.72\\u0026ndash;6.50)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2.93 (1.29\\u0026ndash;7.06)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.012\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMarital status\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMarried/cohabiting\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.94 (1.05\\u0026ndash;3.68)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.038\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2.76 (1.17\\u0026ndash;6.89)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.024\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEmployment\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEmployed/self-employed\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.42 (0.18\\u0026ndash;0.95)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.035\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.49 (0.18\\u0026ndash;1.32)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.16\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eHousehold member with HIV\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e201\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026ge;1 member with HIV\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2.17 (1.04\\u0026ndash;4.50)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.037\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e2.18 (0.70\\u0026ndash;6.65)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.17\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eOR\\u0026thinsp;=\\u0026thinsp;odds ratio; aOR\\u0026thinsp;=\\u0026thinsp;adjusted odds ratio; CI\\u0026thinsp;=\\u0026thinsp;Confidence Interval. Analyses were conducted using complete case analysis.\\u003c/p\\u003e \\u003cp\\u003eReference categories: male sex; age 18\\u0026ndash;25 years; \\u0026le;12 years of education; single; unemployed; no household members living with HIV.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCommunity-level acceptability of CHW-delivered HIV prevention services\\u003c/h2\\u003e \\u003cp\\u003eAll 1,083 participants were asked whether they believed CHW-delivered HIV prevention services would benefit their community. Perceived benefits were high across all services: 90% for PEP, 89% for PrEP, 88% for HIV counseling and testing, and 87% for the dual prevention pill. Between 7\\u0026ndash;10% of participants expressed uncertainty or declined to respond; 1\\u0026ndash;3% believed that such services would not benefit their community (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eIndividual-level prospective acceptability of CHW-delivered integrated HIV prevention services\\u003c/h2\\u003e \\u003cp\\u003eAmong all participants (n\\u0026thinsp;=\\u0026thinsp;1083), 91% reported being comfortable receiving HIV counseling from a CHW. Among those not living with HIV (n\\u0026thinsp;=\\u0026thinsp;926), 93% were comfortable with CHW-delivered oral self-testing and 83% with finger-prick testing.\\u003c/p\\u003e \\u003cp\\u003eAmong participants not living with HIV aged 15\\u0026ndash;49 and those reporting increased risk (n\\u0026thinsp;=\\u0026thinsp;649), 85% were comfortable receiving PEP and 83% receiving PrEP. For condom distribution, 82% of participants aged 15\\u0026ndash;49 years (n\\u0026thinsp;=\\u0026thinsp;708) were comfortable receiving external condoms, while 75% of women aged 15\\u0026ndash;49 years (n\\u0026thinsp;=\\u0026thinsp;363) were comfortable receiving internal condoms. Finally, 83% of women of aged 15\\u0026ndash;49 years reported being comfortable receiving the dual prevention pill. Between 7\\u0026ndash;10% of participants expressed uncertainty or declined to respond, while 8\\u0026ndash;18% reported discomfort depending on the service (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eWe conducted a population-based survey in ten rural villages in northeastern Lesotho to assess gaps along biomedical HIV prevention cascades and to evaluate the prospective acceptability of CHW-led delivery of HIV prevention services. Among individuals at increased risk of HIV, awareness of PrEP and PEP was low, and substantial drop-offs were observed at the stages of service reach and use. Although most participants who were offered PrEP reported initiating it, overall coverage remained low, since very few people had ever been reached by prevention services. For PEP, both awareness and prior use were particularly low. Across all services, however, participants expressed high acceptability of CHW-delivered counseling, testing, and biomedical prevention products, indicating strong community support for expanding CHW roles in HIV prevention.\\u003c/p\\u003e \\u003cp\\u003eApproximately one quarter of participants in our study were at increased risk of HIV, consistent with national findings which reported that 11% of women and 32% of men aged 15\\u0026ndash;49 had multiple sexual partners in the past year, and that only 40% of women and 57% of men used a condom at last intercourse (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). Similar patterns of reported sexual risk have been observed in other Southern African countries (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e), emphasising the continued need to expand access to and uptake of PrEP and PEP.\\u003c/p\\u003e \\u003cp\\u003eWe identified three main implementation gaps in the cascades: limited service reach among individuals motivated to use PrEP, low awareness of PEP among individuals at risk of HIV, and low PEP use among those willing to access it after exposure. For PrEP, despite high motivation to use it, only a small proportion of participants had ever been offered it, suggesting that demand exists, but service delivery has not reached those who need it. Studies from similar settings have documented barriers such as limited provider knowledge, discomfort discussing sexual risk, and supply or policy constraints that reduce proactive PrEP offering (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). In our study, nearly all participants (88%) initiated PrEP once it was offered, suggesting that PrEP uptake is limited by access rather than by acceptability. Strengthening provider-initiated PrEP offers may help close this gap.\\u003c/p\\u003e \\u003cp\\u003eFor PEP, both awareness and use were low in this population. In similar settings, awareness among people at risk has been reported at around 40% (\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). Low awareness likely reflects gaps in prevention communication and limited access to health information, especially in remote areas (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e). Among participants who were motivated to use PEP, only 14% had accessed it, suggesting potential barriers related to access, timing, and service delivery. Other studies describe similar challenges, including limited provider and patient knowledge, stigma, and inconsistent PEP availability in primary care (\\u003cspan additionalcitationids=\\\"CR24\\\" citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eBeyond overall cascade gaps, we examined predictors of PrEP and PEP awareness to identify population groups where targeted prevention interventions may be most needed. Awareness of both PrEP and PEP was higher among women. This finding contrasts with much of the regional literature, which often reports lower awareness and knowledge of biomedical prevention options among women (\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e). In Lesotho, however, higher awareness among women aligns with national data showing that almost half of young women, compared with one third of young men, demonstrated comprehensive knowledge of HIV prevention (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). This pattern may reflect women's greater engagement with the health system through sexual and reproductive health services, as well as targeted activities under Lesotho's National HIV and AIDS Strategic Plan which increasingly targets adolescent girls and young women (\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eWhile education was associated with greater PrEP awareness in univariate analyses, this association did not remain significant after adjustment, suggesting that education alone may not independently influence awareness. Similar observations have been made elsewhere, where higher general health literacy does not necessarily translate into specific knowledge of HIV prevention tools (\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eAwareness of PEP was higher among women, those with higher education, participants who were married or cohabiting, and those living in households with someone living with HIV. These associations likely reflect social proximity to HIV information and services. Married or cohabiting individuals may have more contact with healthcare services through reproductive or couples-based testing programs, facilitating exposure to HIV prevention messaging (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eWe assessed the acceptability of CHWs to deliver HIV prevention services to potentially improve awareness and service reach. Lesotho's National Health Strategy recognises the role of CHWs in expanding community-based prevention services as part of integrated primary care and national prevention scale-up (\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e). Our findings suggest high acceptability for CHW-delivered HIV prevention services within this population. At the community level, the perceived benefit of CHW delivery was high across all services, with the highest acceptability for PEP. This aligns with guidance that timely access is critical for effectiveness and can be supported through task-sharing and community delivery (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e). The strong acceptability of CHW-provided PrEP reflects overall trust in community-based models for HIV prevention. However, some uncertainty about specific CHW-delivered services may be linked to the perceived scope of CHW roles. Similarly, while overall acceptability of the dual prevention pill was high, some uncertainty may stem from limited familiarity with the product and its formulation. At the individual level, participants reported confidence receiving counseling/testing and preventive products (PrEP, PEP, condoms) from CHWs. Evidence on CHW-delivered PrEP services is still limited but shows promise for improving access and uptake among people underserved by facility-based programs (\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). Studies also suggest that PEP can be delivered effectively in community settings (\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e), improving timeliness of access, and helping close the awareness-to-use gap seen in our cascades.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStrengths and Limitations\\u003c/h2\\u003e \\u003cp\\u003eThe strength of this study is its population-based design across several villages likely resulting in a study population representative for the rural population in Lesotho. However, several limitations should be noted. The cross-sectional design cannot capture changes in HIV risk, awareness, or service acceptability over time; findings therefore reflect participants' perceptions at the time of data collection. Self-reported data may be subject to recall or social desirability bias, particularly for sensitive topics such as HIV risk and prevention behaviors. As CHWs collected the data, participants may also have overstated their confidence in CHW-delivered services. The limited sample size also reduces the precision of some estimates. Additionally, sociodemographic data were not collected for participants under 18 years, resulting in missing data and their exclusion from regression analyses. Finally, acceptability was measured prospectively and may not necessarily translate into uptake once services are implemented.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eIn Lesotho, there are substantial gaps in awareness and access to biomedical HIV prevention, despite high motivation to use both PrEP and PEP once offered. In this setting, uptake appears to be constrained by limited service reach rather than acceptability. Awareness of PrEP and PEP was higher among women and those with higher levels of education. Further, awareness of PEP was also greater among participants who were married or cohabiting and among those living in households with a person living with HIV. Across all interventions, CHWs were stated as highly acceptable providers of HIV prevention services, and participants expressed confidence in receiving counseling, testing, and preventive products from them. These findings point to the potential of leveraging CHWs to extend prevention services into communities, thereby improving access to PrEP, enabling timely PEP, and supporting combination-prevention strategies.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAIDS\\u0026nbsp;\\u003c/strong\\u003e- Acquired Immune Deficiency Syndrome\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eCHT\\u0026nbsp;\\u003c/strong\\u003e- Community Health Toolkit\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eCHWs\\u0026nbsp;\\u003c/strong\\u003e- Community Health Workers\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eCI\\u0026nbsp;\\u003c/strong\\u003e- Confidence Interval\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eComBaCaL\\u0026nbsp;\\u003c/strong\\u003e- Community-Based chronic Care Lesotho\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eHIV\\u0026nbsp;\\u003c/strong\\u003e- Human Immunodeficiency Virus\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eIQR\\u0026nbsp;\\u003c/strong\\u003e- Interquartile Range\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eNHREC\\u0026nbsp;\\u003c/strong\\u003e- National Health Research Ethics Committee\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eOR\\u0026nbsp;\\u003c/strong\\u003e- Odds Ratio\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eaOR\\u0026nbsp;\\u003c/strong\\u003e- Adjusted Odds Ratio\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003ePEP\\u0026nbsp;\\u003c/strong\\u003e- Post-Exposure Prophylaxis\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003ePrEP\\u0026nbsp;\\u003c/strong\\u003e- Pre-Exposure Prophylaxis\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eUNAIDS\\u0026nbsp;\\u003c/strong\\u003e- Joint United Nations Program on HIV/AIDS\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eWHO\\u0026nbsp;\\u003c/strong\\u003e- World Health Organization\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe Community-based Chronic Care Lesotho (ComBaCaL) pilot study received ethical approval from the National Health Research and Ethics Committee (NH‑REC) of Lesotho (ID 176–2021). Village chiefs provided community-level consent; household heads provided household consent, and individual participants gave written informed consent to participate in the ComBaCaL pilot cohort.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003cbr\\u003e\\u0026nbsp;Not applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003cbr\\u003e\\u0026nbsp;The authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and analysed in this study are available from the corresponding author on request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis pilot study was conducted as part of the Community-Based Chronic Care Lesotho (ComBaCaL) project, funded by the TRANSFORM grant from the Swiss Agency for Development and Cooperation (project number: 7F-10345.01.01) and the World Diabetes Foundation (grant number: WDF-1778). AA and NDL are co-principal investigators of ComBaCaL. The funders had no role in the design of the pilot study, data collection, analysis, interpretation, or the decision to submit the manuscript for publication. NDL received salary support through an Eccellenza Professorship Grant from the Swiss National Science Foundation (PCEFP3_181355).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors’ contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAW and FR conceptualised the study, conducted the analysis, and drafted the manuscript. NDL, AA, MW, FG, GSS, IE, MP and MC provided methodological guidance and support. RG, TL, MS, and MK coordinated fieldwork and data management. PG and IA were implementing partners for the ComBaCaL project. TT, NM, and RPL contributed as advisors from the Centers for Disease Control/Ministry of Health in Lesotho. All authors reviewed and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors thank the study participants, community health workers, and the Lesotho Ministry of Health for their support, as well as the ComBaCaL team for their contributions to data collection and management.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eJoint United Nations Program on HIV/AIDS (UNAIDS). Lesotho: Country Factsheet 2023. Geneva: UNAIDS; 2023.\\u003c/li\\u003e\\n \\u003cli\\u003eUNAIDS. The Path That Ends AIDS: UNAIDS Global AIDS Update 2023. Geneva: Joint United Nations Program on HIV/AIDS (UNAIDS); 2023.\\u003c/li\\u003e\\n \\u003cli\\u003eUNAIDS. Fast Track: Ending the AIDS Epidemic by 2030. Geneva: Joint United Nations Program on HIV/AIDS (UNAIDS); 2014.\\u003c/li\\u003e\\n \\u003cli\\u003eLesotho Ministry of Health. National Guidelines on HIV Prevention and Treatment. Maseru: Ministry of Health; 2022.\\u003c/li\\u003e\\n \\u003cli\\u003eWHO. Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring: Recommendations for a Public Health Approach. Geneva: World Health Organization; 2021.\\u003c/li\\u003e\\n \\u003cli\\u003eHaberer JE, Mujugira A, Mayer KH. The future of HIV pre-exposure prophylaxis adherence: reducing barriers and increasing opportunities. Lancet HIV. 2023;10(6) :e404-11.\\u003c/li\\u003e\\n \\u003cli\\u003eWere DK, Musau A, Atkins K, Shrestha P, Reed J, Curran K, Mohan D. Health system adaptations and considerations to facilitate optimal oral pre-exposure prophylaxis scale-up in sub-Saharan Africa. Lancet HIV. 2020;7(4) :e259 \\u0026ndash;e266.\\u003c/li\\u003e\\n \\u003cli\\u003eUNAIDS. Creating HIV prevention cascades: Operational guidance on a tool for monitoring programs. Geneva: Joint United Nations Program on HIV/AIDS; 2021.\\u003c/li\\u003e\\n \\u003cli\\u003eHargreaves JR, Delany-Moretlwe S, Hallett TB, et al. The HIV prevention cascade: integrating theories of epidemiological, behavioral, and social science into program design and monitoring. Lancet HIV. 2016;3(7) :e318-22\\u003c/li\\u003e\\n \\u003cli\\u003eWHO. WHO guideline on health policy and system support to optimize community health worker programs. Geneva: World Health Organization; 2018.\\u003c/li\\u003e\\n \\u003cli\\u003eMwai GW, Mburu G, Torpey K, et al. Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review. BMC Health Serv Res. 2013;13:256.\\u003c/li\\u003e\\n \\u003cli\\u003eWorld Health Organization (WHO). Task shifting global recommendations and guidelines. Geneva: WHO; 2008.\\u003c/li\\u003e\\n \\u003cli\\u003eCallaghan M, Ford N, Schneider H. A systematic review of task-shifting for HIV treatment and care in Africa. Hum Resour Health. 2010;8:8.\\u003c/li\\u003e\\n \\u003cli\\u003eMinistry of Health (Lesotho) and ICF. Lesotho Demographic and Health Survey 2023-24: Final Report. Maseru (Lesotho) and Rockville (MD, USA): Ministry of Health and ICF; 2024.\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eGerber F, Sanchez-Samaniego G, Tahirsylaj et. al. Cohort profile: the open, prospective Community-Based Chronic Care Lesotho (ComBaCaL) cohort-design, baseline chronic disease risk factors and hypertension and diabetes care cascades. BMJ Open. 2025;15(7) :e093852 . doi:10.1136/bmjopen-2024-093852.\\u003c/li\\u003e\\n \\u003cli\\u003eLesotho Ministry of Health. National Guidelines for Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP). Maseru: Ministry of Health; 2021.\\u003c/li\\u003e\\n \\u003cli\\u003eNyangara B, Mavhandu-Mudzusi AH, Makhubele JC. Sexual risk-taking behavior among emerging adults in Africa: a systematic review and meta-analysis. PLoS One. 2022;17(9) :e0274368.\\u003c/li\\u003e\\n \\u003cli\\u003eTanser F, B\\u0026auml;rnighausen T, Hund L, Garnett GP, McGrath N, Newell ML. Effect of concurrent sexual partnerships on rate of new HIV infections in a high-prevalence, rural South African population: a cohort study. Lancet . 2011;378(9787):247-55. doi:10.1016/S0140-6736(11)60779-4.\\u003c/li\\u003e\\n \\u003cli\\u003eChebet JJ, McMahon SA, Chase RP, et. al. Stakeholder perspectives on interventions to improve HIV pre-exposure prophylaxis uptake and continuation in Lesotho: a participant-ranked preferences study. PLOS Glob Public Health. 2023;3(4) :e0001983 . doi:10.1371/journal.pgph.0001983.\\u003c/li\\u003e\\n \\u003cli\\u003eKarim SSA, Baxter C. HIV pre-exposure prophylaxis implementation in Africa: some early lessons. Lancet Glob Health. 2021;9(12):e1634-5.\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eAjayi AI, Yusuf MS, Mudefi E, Adeniyi OV, Rala N, Goon DT. Low awareness and use of post-exposure prophylaxis among adolescents and young adults in South Africa: implications for the prevention of new HIV infections. Afr J AIDS Res. 2020;19(3):242\\u0026ndash;8.\\u003c/li\\u003e\\n \\u003cli\\u003eSultan B, Benn P, Waters L. Current perspectives in HIV post-exposure prophylaxis. HIV AIDS (Auckl). 2014;6:147-58. doi:10.2147/HIV.S46585.\\u003c/li\\u003e\\n \\u003cli\\u003eKhumalo GE, Lutge EE, Naidoo P, et. al. Barriers and facilitators of rendering HIV services by community health workers in sub-Saharan Africa: a meta-synthesis. Fam Med Community Health. 2021;9(4): e000958 . doi:10.1136/fmch-2021-000958.\\u003c/li\\u003e\\n \\u003cli\\u003eAllan-Blitz LT, Mayer KH. Missed opportunities: a narrative review on why nonoccupational postexposure prophylaxis for HIV is underutilized. Open Forum Infect Dis. 2024;11(8): ofae332. doi:10.1093/ofid/ofae332.\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eKennedy CE, Dawit R, Yeh PT, et. al. HIV post-exposure prophylaxis in community settings and by lay health workers or through task sharing: a systematic review of effectiveness, case studies, values and preferences, and costs. J Int AIDS Soc. 2025;28(5) :e26448. doi:10.1002/jia2.26448.\\u003c/li\\u003e\\n \\u003cli\\u003eNkosi L, Mmem QD, Tsafa TN, Gwar JN, Agaku IT. Awareness and openness to the use of PrEP among a nationally representative sample of South African adults. Pan Afr Med J. 2024;48:95. doi:10.11604/pamj.2024.48.95.34137.\\u003c/li\\u003e\\n \\u003cli\\u003eKapola AJ, Musoke R, Manayon GM, et al. Pre-exposure prophylaxis awareness and endorsement among adolescents and young adults in Tanzania: insights from the 2022 Demographic and Health Survey. East Afr Health Res J. 2024;8(2).\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eLesotho Ministry of Health. National HIV and AIDS Strategic Plan 2023-2028. Maseru: Ministry of Health; 2023.\\u003c/li\\u003e\\n \\u003cli\\u003eWilandika A, Yusuf A, Kurniawati ND, Yusof S, Widianti AT. Factors That Enhance Health Literacy in Dealing with HIV Stigma: A Scoping Review. J Health Lit 2024;8(4):62-76. doi:10.22038/JHL.2023.74344.1468.\\u003c/li\\u003e\\n \\u003cli\\u003eChimukuche RS, Kawuma R, Mahapa N, et al. Examining oral pre-exposure prophylaxis (PrEP) literacy among participants in an HIV vaccine trial preparedness cohort study. BMC Health Serv Res 2022;22:1336. doi:10.1186/s12913-022-08730-8.\\u003c/li\\u003e\\n \\u003cli\\u003eWorld Health Organization (WHO). Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. Geneva: WHO; 2021.\\u003c/li\\u003e\\n \\u003cli\\u003eSabo KG, Seifu BL, Kase BF, et. al. Factors influencing HIV testing uptake in sub-Saharan Africa: a comprehensive multi-level analysis using Demographic and Health Survey data (2015\\u0026ndash;2022). BMC Infect Dis. 2024;24(1):1182.\\u003c/li\\u003e\\n \\u003cli\\u003eWorld Health Organization (WHO). Guidelines on post-exposure prophylaxis for HIV and the use of co-trimoxazole prophylaxis for HIV-related infections among adults, adolescents and children. Geneva: WHO; 2014.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pubh\",\"sideBox\":\"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pubh/default.aspx\",\"title\":\"BMC Public Health\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"HIV prevention, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), HIV risk, prevention cascade, community health workers, rural health, Lesotho\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8220761/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8220761/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eLesotho has one of the highest HIV incidences globally, yet awareness and uptake of HIV pre-exposure (PrEP) and post-exposure prophylaxis (PEP) remain low. We assessed gaps along HIV prevention cascades, determined predictors of PrEP and PEP awareness and explored the potential acceptability of community health worker (CHW)-led service delivery in rural Lesotho.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eWe conducted a cross-sectional survey among people aged\\u0026thinsp;\\u0026ge;\\u0026thinsp;15 years living in 10 rural villages in northeastern Lesotho. Among individuals at risk of HIV, we assessed awareness, motivation, reach, and use for PrEP and PEP along prevention cascades. Multivariable logistic regressions estimated adjusted odds ratios (aORs) for predictors of awareness. Participants were also asked about the acceptability of HIV prevention services delivered by CHWs.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eAmong 1083 participants, 926 were not living with HIV (median age 37 years; 57% female), and 218 (24%) of them were at increased risk of HIV. Of these, 56% were aware of PrEP, 46% motivated, 11% reached, and 8% current users; for PEP, 29% were aware, 17% were motivated, and 2% had used it in the past. PrEP awareness was higher among women (aOR 3.13, 95% CI: 1.56\\u0026ndash;6.42, 0.001). PEP awareness was higher among women (aOR 2.26, 95% CI: 1.01\\u0026ndash;5.17, p\\u0026thinsp;=\\u0026thinsp;0.049), those with higher education (aOR 2.93, 95% CI: 1.29\\u0026ndash;7.06, p\\u0026thinsp;=\\u0026thinsp;0.012), and those married or cohabiting (aOR 2.76, 95% CI: 1.17\\u0026ndash;6.89, p\\u0026thinsp;=\\u0026thinsp;0.024). Overall, \\u0026ge;\\u0026thinsp;87% of participants perceived CHW-delivered HIV prevention services as beneficial for their communities, and \\u0026ge;\\u0026thinsp;75% of eligible individuals reported being comfortable receiving CHW-delivered counseling, testing, biomedical and dual prevention methods.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003ePrEP and PEP uptake in Lesotho remains low, with the largest gaps in PEP awareness and PrEP reach. The significant drop-off between motivation and use suggests that access barriers, rather than acceptability, may drive low uptake. Participants indicate high acceptance of CHW-led PreP and PEP services supporting CHW-led biomedical prevention as a strategy to improve their reach in Lesotho.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Biomedical HIV prevention cascades and acceptability of community health worker-led services: a cross-sectional survey in Lesotho\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-19 11:43:02\",\"doi\":\"10.21203/rs.3.rs-8220761/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"37119069761603593586797426225221116819\",\"date\":\"2026-02-24T11:40:29+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"155703704371136707415226767591163138750\",\"date\":\"2026-02-23T16:26:41+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-18T15:35:06+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"308740793748217529045956764016586239971\",\"date\":\"2026-02-18T12:06:51+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-02-16T11:20:54+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-12-11T04:54:57+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-12-01T16:33:06+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-12-01T15:54:47+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Public Health\",\"date\":\"2025-12-01T15:26:37+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pubh\",\"sideBox\":\"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/pubh/default.aspx\",\"title\":\"BMC Public Health\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"ef18eee2-1ec6-48ed-bb70-f034d2dbc2e9\",\"owner\":[],\"postedDate\":\"February 19th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-02-19T11:43:02+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-02-19 11:43:02\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8220761\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8220761\",\"identity\":\"rs-8220761\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}