Socio-behavioral correlates of pre-exposure prophylaxis use and correct adherence in men who have sex with men in West Africa

Abstract BackgroundMultiple barriers compromise pre-exposure prophylaxis (PrEP) engagement (i.e., use and adherence) in men who have sex with men (MSM). In low/middle-income countries, little is known about PrEP engagement in this population. In West Africa, the CohMSM-PrEP study was one of the rare interventions providing PrEP to MSM. We estimated PrEP use and correct adherence rates in CohMSM-PrEP, together with associated factors.MethodsCohMSM-PrEP recruited MSM in four community-based clinics in Mali, Côte d’Ivoire, Burkina Faso, and Togo. Quarterly follow-up included collecting socio-behavioral data, and providing a comprehensive HIV prevention package, PrEP (daily or event-driven), and peer educator (PE)-led counselling (prevention and adherence). Multivariate generalized estimating equations (GEE) models were used to identify factors associated with self-reported i) PrEP use and ii) correct PrEP adherence during participants’ most recent anal intercourse.Results520 participants were retained for the present analysis. Median follow-up time was 12 months (IQR 6-21). Of the 2839 most recent anal intercourses declared over the follow-up period, PrEP use was self-reported for 1996 (70%), and correct PrEP adherence for 1461 (73%) of the latter. PrEP use was higher in participants who attended participating clinics outside of scheduled visits (adjusted odds ratio (aOR) [95% Confidence Interval, CI], p-value; 1.32 [1.01-1.71], 0.040), and in those who practiced condomless anal sex (1.86 [1.54-2.24], <0.001). Correct adherence was higher in those who often contacted PE outside of scheduled visits (2.16 [1.01-4.64], 0.047) and in participants who adopted receptive/versatile sexual positions with stable partners (1.36 [1.03-1.81], 0.030). Instead, it was lower in event-driven users with a difficult/very difficult financial situation (comfortable/just making ends meet & daily, 4.19 [2.56-6.86], <0.001; difficult/very difficult & daily, 6.47 [4.05-10.30], <0.001; comfortable/just making ends meet & event-driven, 1.63 [1.22-2.17], 0.001), and in participants who felt alone (0.76 [0.58-0.99], 0.042).ConclusionsCommunity-based clinic attendance and PE contact outside of scheduled visits were both associated with higher PrEP engagement. Some socially and economically marginalized participants struggled with adherence. Providing adherence support is crucial for PrEP effectiveness, especially in hostile sociocultural contexts. As PrEP scale-up continues in West Africa, we recommend using comprehensive community-based interventions to ensure adequate PrEP engagement.