Multilevel Barriers and Facilitators to Pre-Exposure Prophylaxis Uptake among Men Who Have Sex with Men and People Who Inject Drugs in Kano State, Northern Nigeria

Multilevel Barriers and Facilitators to Pre-Exposure Prophylaxis Uptake among Men Who Have Sex with Men and People Who Inject Drugs in Kano State, Northern Nigeria | 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 Multilevel Barriers and Facilitators to Pre-Exposure Prophylaxis Uptake among Men Who Have Sex with Men and People Who Inject Drugs in Kano State, Northern Nigeria Abubakar Sadiq Abubakar, Musa Bello Muhammad, Yahaya Bright Waziri, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8909678/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Despite the proven efficacy of oral pre-exposure prophylaxis (PrEP), uptake among key populations in Nigeria, particularly men who have sex with men (MSM) and people who inject drugs (PWID) remains low. In conservative northern settings such as Kano State, intersecting legal, religious, and socio-cultural constraints intensify stigma and limit access to HIV prevention services. This study explored multilevel barriers and facilitators shaping PrEP uptake among MSM and PWID in this context. Using a phenomenological qualitative design, we conducted 13 in-depth interviews with MSM (n = 10) and PWID (n = 3), and 7 key informant interviews with healthcare providers, program managers, and community stakeholders. Participants were purposively recruited from key population hotspots and One-Stop-Shop clinics. Data were thematically analyzed using Braun and Clarke’s reflexive approach, guided by the Social Ecological Model and HIV Stigma Framework. Barriers to PrEP uptake operated across individual, interpersonal, community, and structural levels, including limited awareness, confusion with antiretroviral therapy, low perceived risk, adherence fatigue, fear of stigma, community misrecognition of PrEP as HIV treatment, transportation costs, clinic wait times, and economic hardship, particularly among PWID. Facilitators included heightened perceived HIV risk, peer support, trust in key population–friendly counselors, access to confidential One-Stop-Shop clinics, and integration with harm reduction services. Key informants emphasized the importance of sustainable domestic financing and supportive policy environments. These findings underscore the need for culturally responsive, multilevel strategies that strengthen peer-led outreach, expand confidential service delivery models, and promote enabling health system and policy conditions for sustainable PrEP scale-up in northern Nigeria. Clinical trial number : Not applicable. INTRODUCTION The global HIV epidemic remains a major public health concern, with an estimated 40.8 million people living with HIV worldwide by the end of 2024, the majority residing in sub-Saharan Africa [ 1 ]. Nigeria bears a substantial share of this burden, with approximately 1.9 million people living with HIV and a national adult prevalence of 1.4% [ 2 ]. The epidemic is disproportionately concentrated among key populations (KPs), including men who have sex with men (MSM) and people who inject drugs (PWID), who experience heightened biological, behavioral, and structural vulnerability [ 3 , 4 ]. Globally, MSM and PWID are estimated to be 13 and 22 times more likely, respectively, to acquire HIV than the general population [ 1 ]. In Nigeria, HIV prevalence among MSM (25.0%) and PWID (10.9%) far exceeds that of the general population [ 2 , 5 ]. In Kano State, a predominantly Muslim and socially conservative setting in northern Nigeria, prevalence among MSM and PWID remains substantial at 10.8% and 5.2%, respectively [ 5 ]. These disparities persist despite the availability of effective biomedical prevention strategies. Oral pre-exposure prophylaxis (PrEP) is a highly efficacious HIV prevention intervention, capable of reducing HIV acquisition by over 90% when used consistently [ 6 , 7 ]. However, awareness and uptake of PrEP among key populations in Kano State remain critically low. As of 2020, only 39.0% of MSM and 1.4% of PWID in the state were aware of PrEP, with uptake reported at 13.1% among MSM and 0% among PWID [ 5 ]. Engagement with PrEP in northern Nigeria is shaped by complex social and structural contexts. Men who have Sex with Men and PWID navigate environments characterized by strong religious norms, pervasive stigma, and legally restrictive frameworks that generate fear of social or institutional repercussions [ 8 , 9 ]. Although One-Stop-Shop (OSS) clinic has been established to provide confidential, KP-friendly HIV prevention services, PrEP uptake within these settings remains suboptimal [ 10 ]. This suggests that service availability alone is insufficient to address deeper barriers influencing prevention behaviors. Qualitative studies from other sub-Saharan African settings have identified barriers to PrEP uptake, including low perceived HIV risk, misconceptions about PrEP, concerns about side effects, adherence fatigue, and stigma arising from the misidentification of PrEP as HIV treatment [ 11 – 13 ]. However, evidence from northern Nigeria remains limited. Most existing studies are drawn from southern Nigeria or other African contexts, reducing their relevance to settings such as Kano, where open discussion of sexuality, drug use, and HIV prevention is highly constrained [ 14 ]. To address this gap, this study explored the multilevel barriers and facilitators influencing PrEP uptake among MSM and PWID in Kano State using qualitative methods. The analysis was guided by the Social Ecological Model, which situates individual behavior within interpersonal, community, and structural contexts and the HIV Stigma Framework, which conceptualizes stigma as anticipated, enacted, and internalized across these levels [ 15 , 16 ]. Together, these frameworks enable a comprehensive examination of how social norms, service environments, and policy contexts interact to shape PrEP-related decision-making. By centering the lived experiences of MSM and PWID alongside the perspectives of program implementers, this study provides context-specific evidence to inform culturally responsive HIV prevention strategies. The findings have implications for strengthening peer-led outreach, optimizing OSS service delivery, and promoting supportive health system and policy conditions necessary for sustainable PrEP scale-up in conservative settings. The objective of this study was to explore the multilevel barriers and facilitators influencing PrEP uptake among MSM and PWID in Kano State, Nigeria. METHODS Study Design This study employed a qualitative design grounded in interpretive (Heideggerian) phenomenology, which emphasizes how individuals construct meaning within socially constrained contexts [17]. This approach was appropriate for exploring how MSM and PWID in Kano State understand and navigate PrEP use amid stigma, social surveillance, and structural exclusion. Study Setting The study was conducted in Kano State, northwest Nigeria, a predominantly Muslim and socially conservative region with an estimated population of 21.3 million [18]. Data collection was centered around a One-Stop-Shop (OSS) clinic operating in partnership with key population–led community-based organizations (CBOs) and overseen by the Kano State Agency for the Control of AIDS. The OSS provides confidential, KP-sensitive HIV prevention services, including PrEP [19]. Study Population and Recruitment Participants included MSM and PWID who were aware of, willing to use, or had experience with PrEP, as well as key informants comprising healthcare providers, program managers, and leaders of CBOs involved in HIV prevention. Purposive sampling was used to capture variation in age, socio-economic status, and PrEP experience. Peer educators affiliated with CBOs facilitated recruitment to enhance trust and ethical access to highly stigmatized populations. In total, 13 in-depth interviews (IDIs) were conducted with MSM (n = 10) and PWID (n = 3), alongside 7 key informant interviews (KIIs) with representatives from the Kano State Agency for the Control of AIDS, Society for Family Health, OSS clinic staff, and CBO leadership. Data Collection Data were collected using semi-structured interview guides informed by the Social Ecological Model and HIV Stigma Framework. The guides explored PrEP awareness, perceived barriers and facilitators to uptake, and experiences of stigma. Guides were developed in English, translated into Hausa, and back-translated to ensure linguistic and conceptual accuracy. Interviews were conducted by trained, gender-congruent interviewers fluent in English and Hausa in private settings within the OSS clinic or CBO offices. Interviewers received training in trauma-informed care, key population sensitivity, and confidentiality protocols. Interviews lasted approximately 30–60 minutes, were audio-recorded with informed consent, and supplemented with field notes. Interview tools were pretested in key population hotspots outside the study sites and refined accordingly. Data Analysis Audio recordings were transcribed verbatim and, where necessary, translated into English. A subset of transcripts was reviewed by a second researcher to ensure accuracy. Data were analyzed using Braun and Clarke’s reflexive thematic analysis, following the six-phase approach of familiarization, coding, theme development, review, definition, and reporting [20]. Coding was iterative, supported by analytic memos and thematic matrices. An interpretive phenomenological stance guided analysis, prioritizing depth and contextual meaning over generalizability. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) to ensure methodological rigor and transparency [21]. Data from IDIs and KIIs were triangulated to enhance analytical depth and credibility. Reflexivity and Analytical Rigor Three qualitative researchers independently coded approximately 20% of transcripts. Coding consistency was enhanced through collaborative coding, reflexive discussion, and iterative refinement of the codebook. Discrepancies were resolved through discussion and refinement of the codebook. The research team comprised Nigerian social scientists and public health professionals with experience in key population research. Reflexivity was maintained through analytic discussions and reflexive notes documenting how researchers’ positionality and assumptions shaped interpretation. Ethical Considerations Ethical approval was obtained from the Aminu Kano Teaching Hospital Ethics Committee (NHREC/28/01/2020/AKTH/EC/3422). All participants provided written informed consent; for participants with limited literacy, consent forms were read aloud in Hausa and thumbprint consent was obtained in the presence of a witness. To protect confidentiality, no personal identifiers were collected, and all data were stored in encrypted, password-protected files. Given the sensitivity of the study population, additional safeguards included strict privacy protocols and enhanced interviewer training in key population–sensitive research practices. RESULTS A total of 13 in-depth interviews were conducted with MSM (n = 10) and PWID (n = 3), alongside 7 key informant interviews with healthcare providers, program managers, and community stakeholders involved in HIV prevention programming in Kano State. Participants varied in age, education, marital status, residence, and PrEP experience. Demographic characteristics of IDI participants are summarized in Table 1 . Table 1 Demographic characteristics of IDI participants Participant ID Age Gender Identity Sexual Orientation Drug Use Status Marital Status Education Level Religion Residence PrEP Use Status Access Point MSM001 28 Cisgender Male Gay - Single Tertiary Islam Peri-urban Never Used CBO MSM002 25 Cisgender Male Gay - Single Secondary Islam Urban Past User Peer Outreach MSM003 33 Cisgender Male Bisexual - Married Primary Islam Urban Past User OSS Clinic MSM004 32 Cisgender Male Bisexual - Married Secondary Islam Peri-urban Current User CBO MSM005 32 Cisgender Male Bisexual - Married Secondary Islam Peri-urban Current User Peer Outreach MSM006 29 Cisgender Male Bisexual - Married Primary Christianity Urban Past User Peer Outreach MSM007 28 Cisgender Male Gay - Single Tertiary Christianity Peri-urban Past User CBO MSM008 27 Cisgender Male Gay - Single Secondary Islam Peri-urban Current User OSS Clinic MSM009 38 Cisgender Male Bisexual - Separated Tertiary Islam Urban Current User Peer Outreach MSM0010 26 Cisgender Male Gay - Single Tertiary Christianity Peri-urban Current User Peer Outreach PWID001 25 Cisgender Male Heterosexual Current User Single Primary Islam Urban Never Used Peer Outreach PWID002 27 Cisgender Male Heterosexual Past User Married Primary Islam Peri-urban Current User OSS Clinic PWID003 31 Cisgender Male Heterosexual Current User Single Primary Islam Urban Current User Peer Outreach Thematic analysis identified multilevel barriers and facilitators influencing PrEP uptake among MSM and PWID, mapped across individual, interpersonal, community, and structural levels of the Social Ecological Model and informed by the HIV Stigma Framework. Findings are presented thematically, with illustrative quotes used to contextualize key patterns. Barriers to PrEP Uptake Individual-Level Factors Limited awareness and misinformation emerged as prominent barriers. Several participants reported confusion between PrEP and antiretroviral therapy (ART), which undermined willingness to initiate or continue PrEP. As one MSM participant explained, “Some of the challenges… is ignorance… or lack of awareness of the benefit of using PrEP” (MSM001). Challenges related to daily adherence and side effects were also commonly reported. Participants described pill fatigue and transient physical discomfort, including nausea, dizziness, and gastrointestinal symptoms. One participant stated, “Taking the drug every day is tiring and boring” (MSM004). These experiences reduced motivation for consistent use, particularly among those with competing daily stressors. Low perceived HIV risk further limited uptake. Some participants acknowledged the existence of HIV but did not view themselves as sufficiently vulnerable to justify preventive medication, reflecting gaps between awareness and personal risk appraisal. Interpersonal-Level Factors Fear of disclosure and anticipated stigma strongly influenced PrEP decision-making. Many participants expressed concern that being seen with PrEP would lead others to assume they were living with HIV. One MSM participant noted, “I have the fear that when people see me with the drug, they will think that I am HIV positive” (MSM002). This fear was reinforced by experiences within family and social networks, where PrEP was misidentified as HIV treatment. Such incidents led to emotional distress and, in some cases, discontinuation of PrEP use. These narratives illustrate how interpersonal dynamics amplified stigma and discouraged sustained engagement with prevention services. Community-Level Factors At the community level, stigma was embedded within broader socio-cultural norms that discouraged open discussion of sexual health and HIV prevention. Participants described a climate of silence and moral judgment, where PrEP use was viewed with suspicion or misinterpreted as evidence of illness. As one participant stated, “Some people in the community are looking at those using PrEP as HIV positive” (MSM009). Religious conservatism and prevailing social expectations further limited opportunities for accurate information sharing, reinforcing internalized stigma and reducing visibility of PrEP as a legitimate prevention option. Structural-Level Factors Structural constraints significantly affected PrEP access and continuation. Transportation costs, long clinic waiting times, and procedural delays were frequently cited barriers. One participant remarked, “Time is wasted on investigations before they can collect the drug again” (MSM009). Economic hardship disproportionately affected PWID participants, who described prioritizing basic needs over clinic visits. “We’d rather use the money to buy injection materials than spend it on transport,” one PWID participant explained (PWID003). These findings highlight how poverty and service delivery barriers intersect to limit prevention uptake. Facilitators to PrEP Uptake Individual-Level Factors Despite multiple barriers, some participants demonstrated strong motivation to remain HIV-negative. Heightened perceived susceptibility to HIV and personal health consciousness encouraged PrEP initiation and persistence. One MSM participant stated, “I want to stay negative, that’s why I keep coming for the PrEP refill” (MSM005). Interpersonal-Level Factors Peer support emerged as a critical facilitator of PrEP uptake. Participants emphasized the importance of counseling delivered by peers or providers with shared lived experiences, which fostered trust and reduced fear of judgment. “The person counseling me is someone like me, and that makes it easier to trust,” noted one participant (MSM008). Incentives such as transportation support and small material items further enhanced engagement, particularly during outreach activities. “ Yes, during counselling... we provide incentives in the form of perfume, indomie, or transportation... this can encourage more people ” noted one participant (MSM001). Community-Level Factors Community-based organizations (CBOs) played a central role in facilitating PrEP uptake by serving as trusted intermediaries. Participants highlighted the effectiveness of engaging community leaders and gatekeepers to reach hidden populations. “If you talk to their leaders, they’ll help you reach more people who need the service,” explained one MSM participant (MSM006). These community-led approaches created culturally congruent entry points for PrEP education and service linkage. Structural-Level Factors The availability of One-Stop-Shop (OSS) clinics was widely regarded as a major enabler. Participants described OSS clinics as safe, confidential spaces where they could access services without fear. One participant shared (MSM010). “The OSS helps us feel free to talk and collect drugs without fear,” For PWID, integration of PrEP messaging into harm reduction services, including the Needle and Syringe Program, facilitated engagement. Through NSP contacts, clients can be introduced to PrEP and encouraged to return for follow-up services. “ When they come for injection materials, and we could give them information about PrEP also ” (PWID003). Providing PrEP information alongside existing services reduced stigma and lowered barriers to initial contact. Policy-Level Perspectives from Key Informants Key informants underscored systemic challenges affecting PrEP sustainability, particularly limited domestic financing and reliance on donor-funded programs. One informant noted, “There is currently no stand-alone state budget for PrEP… which limits focused planning and scale-up” (KII001). In addition, KIIs reinforced concerns expressed by MSM and PWID participants, especially regarding community-level stigma and mislabeling of PrEP as HIV treatment. An OSS health professional noted, “ We’ve had clients drop out simply because someone in their community saw the pills and assumed, they were positive. It’s a real threat to retention ” (KII003). This statement corroborated the experience shared by MSM001, who described the social consequences of being seen with PrEP. Key themes, Sub-themes, and Illustrative quotes To provide a comprehensive overview of the qualitative findings, we summarized the key themes and sub-themes identified from the IDIs with MSM and PWID, as well as KIIs with key stakeholders and officials. Each theme and sub-theme is supported by illustrative verbatim quotes from participants, offering direct insights into their experiences and perceptions regarding PrEP uptake in Kano State, Nigeria Table 2 Key themes, sub themes and illustrative quotes Theme Sub-theme Illustrative Quote Source ID Barriers to PrEP Uptake Individual-Level Factors Lack of awareness and misinformation “Some of the challenges like I have earlier mentioned is ignorance on the part of those that did not understand the importance or lack of awareness of the benefit of using PrEP.” MSM001 “Yes, there is lack of awareness, and is another challenge.” MSM001 Low-risk perception towards HIV "They believe that HIV is real but they will not use condom or take PrEP." MSM001 Challenges with daily adherence and managing side effects “The reason why I stopped taking it is that, I used to have side effects like nausea, vomiting, and for me I used to feel depressed, it feels like someone chewing metal, and its not like for some weeks but for months I was still having it.” MSM003 “Taking the drug every day is tiring and boring.” MSM004 “Some of them complained of headache, dizziness at the initial usage, but with time, the side effect disappeared and everything became normal.” MSM002 Interpersonal-Level Factors Fear of Disclosure, Perceived and Enacted Stigma (Misidentification of PrEP as HIV Treatment) “I have the fear that when people see me with the drug, they will think that I am HIV positive.” MSM002 “We introduced a friend to PrEP, but when his family saw him with the pill, they thought it was HIV drug and concluded that he had HIV, they took the PrEP pill to a doctor for confirmation and the doctor confirm that it is HIV drug because of the resemblance with the HIV drug.” MSM003 “Yes, because both ART and PrEP are packaged in a similar container, because once people see you with the container, they conclude that you have HIV.” MSM008 Community-Level Factors Pervasive Community-Level Stigma and Internalized Stigma (Socio-cultural and Legal Context) “Some people are not sure about its ability to prevent them from HIV infection... like there is trust issue.” MSM005 “Yes, some people in the community are looking to those that are using PrEP as HIV positive.” MSM009 Structural-Level Factors Transportation barriers, long waiting times, and limited service availability “Transportation to where you will get the drug.” MSM002 “Time wasted on investigations before they can collect the drug again.” MSM009 Economic hardship “We rather use the money to buy injection…” PWID003 Facilitators to PrEP Uptake Individual-Level Factors Health consciousness and risk perception “I want to stay negative, that’s why I keep coming for the PrEP refill.” MSM005 Positive Perceived Physical Effects “Yes. Most of the people tell me when they take PrEP, they feel stronger. It also builds their immune system and makes their immune system stronger.” PWID002 Interpersonal-Level Factors Peer support and targeted counseling “Yes, during counselling... we provide incentives in the form of perfume, indomie, or transportation... this can encourage more people.” MSM001 “The person counseling me is someone like me, and that makes it easier to trust.” MSM008 Community-Level Factors Community advocacy led by local CBOs and community leaders “If you talk to their leaders, they’ll help you reach more people that need the service.” MSM006 "The best way to use, is to engage mobilizers to talk about the meaning and benefits of using PrEP in different social gatherings within the community." MSM004 Structural-Level Factors Availability of One-Stop-Shop (OSS) clinics “The OSS helps us feel free to talk and collect drugs without fear.” MSM010 Needle and Syringe Program (NSP) as a gateway “When they come for injection materials, and we could give them information about PrEP also.” PWID003 Provision of free services and commodities (including self-testing kits) “It is free, that’s the good part... they don’t have to worry about paying.” MSM009 Policy-Level Insights (Barriers) Limited funding allocation and absence of dedicated state-level policies “So my, the only challenge here is the sustainability. Sustainability, like I said in my opening remarks, this is donor funded, and donor enough to stay here for life. At the point in time, we exit the state. What then happens thereafter? So that is the more reason the states must have to take ownership and then make this their responsibility.” MSM010 Community-level stigma and mislabeling of PrEP as HIV treatment “We’ve had clients drop out simply because someone in their community saw the pills and assumed, they were positive. It’s a real threat to retention.” KII003 Policy-Level Insights (Facilitators) KP-led model of OSS clinics, peer navigation, community gatekeeper engagement “Our community mobilizers and peer educators are the real heroes. They know where to find the clients and how to speak their language.” KII005 Idea of injectable PrEP “Yes, there is, one of the ways is to transform the PrEP pill to injectable that will be done once in a month or two months or even yearly. this will encourage more people to take it, because for example if it’s done every three months once you take it, you know you will not come back until another three months.” MSM001 Integrating PrEP messaging into harm reduction services “If we link PrEP to harm reduction, PWID will be more open to listen. It's a softer entry point.” KII005 DISCUSSION This study explored multilevel barriers and facilitators influencing PrEP uptake among MSM and PWID in Kano State, a socially conservative setting in northern Nigeria. Guided by the Social Ecological Model and the HIV Stigma Framework, the findings illustrate how individual decision-making around PrEP is shaped by intersecting interpersonal, community, and structural forces. The study contributes context-specific evidence from a region where HIV prevention efforts operate within highly constrained social and institutional environments. Consistent with prior studies from Nigeria and other sub-Saharan African settings, limited awareness, misconceptions about PrEP, and confusion with antiretroviral therapy emerged as persistent barriers [ 11 – 13 ]. These challenges were compounded by low perceived HIV risk and concerns about side effects, particularly among PWID, whose daily priorities often centered on economic survival and harm reduction. These findings underscore how individual-level barriers cannot be understood in isolation from broader material and social conditions. Despite these challenges, individual agency remained evident. Several participants described strong motivation to remain HIV-negative and attributed continued PrEP use to heightened risk perception and perceived health benefits. Framing PrEP as a proactive health-preserving strategy rather than solely as an HIV prevention tool may therefore enhance acceptability, particularly in settings where illness is highly stigmatized. Messaging that emphasizes well-being, strength, and continuity of daily functioning may resonate more effectively than risk-focused narratives alone. Stigma operating at interpersonal and community levels emerged as a central determinant of PrEP uptake. Anticipated and enacted stigma particularly the misidentification of PrEP as HIV treatment discouraged disclosure and undermined adherence. Similar patterns have been reported among MSM in China and Vietnam, where visual resemblance between PrEP and ART heightened fears of social labeling [ 22 , 23 ]. In Kano, these dynamics were reinforced by strong moral norms and limited community-level dialogue around sexual health, further embedding silence and internalized stigma. Peer-led outreach and KP-sensitive service delivery played a critical role in mitigating these barriers. Trust was enhanced when counselors shared lived experiences with clients, reducing fear of judgment and fostering sustained engagement. This finding aligns with evidence from South Africa and Kenya demonstrating the effectiveness of peer navigation in stigmatized populations [ 24 , 25 ]. Community-based organizations functioned as discreet and culturally congruent entry points, highlighting the importance of community ownership in HIV prevention programming. Structural barriers including transportation costs, clinic wait times, and economic hardship consistently limited access to PrEP, particularly for PWID. These findings mirror studies from Malawi and the United States, where logistical and financial constraints undermined prevention uptake among marginalized populations [ 26 , 27 ]. In contrast, One-Stop-Shop clinic were widely perceived as enabling environments that reduced stigma and facilitated access through integrated, confidential services. Integration of PrEP messaging into harm reduction platforms, such as needle and syringe programs, further expanded reach among PWID by leveraging existing points of contact. At the policy level, reliance on donor funding and the absence of dedicated state-level financing for PrEP were viewed as significant threats to sustainability. Key informants emphasized that without domestic ownership and supportive policy frameworks, gains achieved through community-led and peer-driven models remain fragile. While community innovations can buffer stigma and improve access, their impact is constrained in environments characterized by fear of surveillance or social repercussions. Long-term progress requires policy approaches that prioritize public health, harm reduction, and dignity, while engaging religious and traditional leaders to foster culturally legitimate pathways for change. This study has several limitations. Participants were primarily recruited through OSS clinic and community organizations, potentially excluding individuals who are more hidden or disengaged from services. The small number of PWID participants may also limit the depth of subgroup-specific analysis. Although efforts were made to reduce social desirability bias through trauma-informed and gender-congruent interviewing, some bias may remain. Despite these limitations, this study provides rare qualitative insight into PrEP uptake in northern Nigeria. By integrating lived experiences with programmatic perspectives, the findings highlight the necessity of multi-level, culturally responsive strategies that strengthen peer-led outreach, optimize OSS service delivery, and promote supportive health system and policy environments. Such approaches are essential to advancing equitable HIV prevention and ensuring that key populations are not left behind in efforts to end the HIV epidemic. CONCLUSION Sustainable PrEP uptake among MSM and PWID in northern Nigeria requires coordinated, multi-level strategies that address barriers operating across individual, interpersonal, community, health system, and policy contexts. This study demonstrates that stigma, misinformation, economic hardship, and service access constraints continue to shape PrEP engagement in conservative settings, even where confidential and KP-friendly services are available. Strengthening peer-led outreach, expanding and optimizing One-Stop-Shop clinics, and leveraging community-based organizations are critical for reducing stigma and improving access to prevention services. Integrating PrEP delivery with harm reduction platforms offers a particularly effective approach for reaching PWID and minimizing barriers related to visibility and trust. At the system level, long-term sustainability will depend on increased domestic investment, integration of PrEP into routine state health financing, and policy environments that support public health–oriented service delivery. Engagement with traditional and faith leaders may further facilitate culturally legitimate pathways for improving HIV prevention uptake while maintaining social cohesion. Ultimately, effective PrEP scale-up in northern Nigeria must be grounded in equity, dignity, and inclusion, ensuring that populations most at risk of HIV are not excluded from the benefits of biomedical prevention. Declarations Ethical Considerations Ethical approval for this study was obtained from the Aminu Kano Teaching Hospital Ethics Committee (NHREC/28/01/2020/AKTH/EC/3422). The study was conducted in accordance with the ethical standards of the institutional research committee and with the principles of the Declaration of Helsinki. Consent to Participate Written informed consent was obtained from all participants prior to data collection. For participants with limited literacy, the consent form was read aloud in Hausa, and consent was documented using a thumbprint in the presence of an independent witness. Participation was voluntary, and participants were informed of their right to withdraw at any time without consequences. Declaration of Conflicting Interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding Statement This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Data Availability Due to the sensitive nature of the study population and the potential risk of participant identification, the qualitative datasets generated and analyzed during the current study are not publicly available. De-identified data may be made available from the corresponding author upon reasonable request and subject to ethical approval. Acknowledgements The authors acknowledge the support of community-based organizations, peer educators, and study participants who generously shared their experiences. We also acknowledge the contributions of healthcare providers and program staff involved in HIV prevention services in Kano State. Author Contributions A.S.A. contributed to the study conceptualization and design, led data collection, conducted data analysis, and drafted the first version of the manuscript. 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BMC Infect Dis. 2021;21(1):1–10. Eakle R, Bothma R, Bourne A, Gumede S, Motsosi K, Rees H. I am still negative: Female sex workers’ perspectives on uptake and use of daily preexposure prophylaxis for HIV prevention in South Africa. PLoS ONE. 2019;14(4):1–17. Jackson-Gibson M, Ezema AU, Orero W, Were I, Ohiomoba RO, Mbullo PO, et al. Facilitators and barriers to HIV pre-exposure prophylaxis (PrEP) uptake through a community-based intervention strategy among adolescent girls and young women in Seme Sub-County, Kisumu, Kenya. BMC Public Health. 2021;21(1):1–13. Allen ST, O’Rourke A, White RH, Smith KC, Weir B, Lucas GM, et al. Barriers and Facilitators to PrEP Use Among People Who Inject Drugs in Rural Appalachia: A Qualitative Study. AIDS Behav. 2020;24(6):1942–50. Shea J, Bula A, Dunda W, Hosseinipour MC, Golin CE, Hoffman IF, et al. The drug will help protect my tomorrow: Perceptions of integrating prep into hiv prevention behaviors among female sex workers in Lilongwe, Malawi. AIDS Educ Prev. 2019;31(5):421–32. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 May, 2026 Reviews received at journal 12 May, 2026 Reviewers agreed at journal 12 May, 2026 Reviewers invited by journal 16 Mar, 2026 Editor invited by journal 12 Mar, 2026 Editor assigned by journal 24 Feb, 2026 Submission checks completed at journal 24 Feb, 2026 First submitted to journal 18 Feb, 2026 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-8909678","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":606912561,"identity":"3d9d1eb9-336a-49ac-99da-8f89959666f4","order_by":0,"name":"Abubakar Sadiq Abubakar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYJCCAzxsQJK9+eADIMXDR7wWnmPJBiCKjShrwMokcswkQByCWvj7jz888KbMRo7vzLG0yq85djJsDMwPH93Ao0XiRo7BwTnn0owljzcfuy27LRloI5uxcQ4+a27wMBzmbTucuAFoy23JbcxALTxs0vi0yJ8//gCo5X/9hhs5ZsWS2+oJazE4kGAA1AIkgVoYP247TFiLIcQvyYYzzxxLlmbcdpyHjZmAX+TOH3/84U2ZnTzf8eaDH39uq7bnZ29++Biv9+HgAAMDMw+IwUyUcqgWxh9Eqx4Fo2AUjIKRBABZrE/3Soma1QAAAABJRU5ErkJggg==","orcid":"","institution":"Aminu Kano Teaching Hospital","correspondingAuthor":true,"prefix":"","firstName":"Abubakar","middleName":"Sadiq","lastName":"Abubakar","suffix":""},{"id":606912563,"identity":"2e10f6b0-c1d4-446c-994a-a071c5dadf40","order_by":1,"name":"Musa Bello Muhammad","email":"","orcid":"","institution":"Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Musa","middleName":"Bello","lastName":"Muhammad","suffix":""},{"id":606912564,"identity":"717a29ee-b0ee-4b45-962a-ca400c5baa72","order_by":2,"name":"Yahaya Bright Waziri","email":"","orcid":"","institution":"Impact Catalyst","correspondingAuthor":false,"prefix":"","firstName":"Yahaya","middleName":"Bright","lastName":"Waziri","suffix":""},{"id":606912566,"identity":"53c60f82-3d85-4c70-8e9d-39080ae38f5e","order_by":3,"name":"Suraj Musa Inuwa","email":"","orcid":"","institution":"Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Suraj","middleName":"Musa","lastName":"Inuwa","suffix":""},{"id":606912567,"identity":"cb20094b-7be1-476f-8355-4b3b146c8066","order_by":4,"name":"Rukayat Aramide Sanusi","email":"","orcid":"","institution":"Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Rukayat","middleName":"Aramide","lastName":"Sanusi","suffix":""},{"id":606912570,"identity":"b0741ad6-9419-4e2b-b2ef-9e482f34ef03","order_by":5,"name":"Mukhtar Mahmud","email":"","orcid":"","institution":"Katsina State Primary Health Care Agency","correspondingAuthor":false,"prefix":"","firstName":"Mukhtar","middleName":"","lastName":"Mahmud","suffix":""},{"id":606912571,"identity":"cd2bebfb-968e-43a3-ad7a-ab8aced007ed","order_by":6,"name":"Ganiyat Folashade Rasheed","email":"","orcid":"","institution":"Aminu Kano Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ganiyat","middleName":"Folashade","lastName":"Rasheed","suffix":""},{"id":606912572,"identity":"80b2fcec-bfe5-4400-8c14-64f92d4083e9","order_by":7,"name":"Muhammad Shamsuddeen Yusuf","email":"","orcid":"","institution":"Ahmadu Bello University","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Shamsuddeen","lastName":"Yusuf","suffix":""}],"badges":[],"createdAt":"2026-02-18 13:09:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8909678/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8909678/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106401457,"identity":"d478b5b7-c610-448c-aa34-a68ac85598b4","added_by":"auto","created_at":"2026-04-08 08:57:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1079275,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8909678/v1/f9f43bb4-b9ac-4b69-b659-ece8cdbaf999.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Multilevel Barriers and Facilitators to Pre-Exposure Prophylaxis Uptake among Men Who Have Sex with Men and People Who Inject Drugs in Kano State, Northern Nigeria","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe global HIV epidemic remains a major public health concern, with an estimated 40.8\u0026nbsp;million people living with HIV worldwide by the end of 2024, the majority residing in sub-Saharan Africa [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Nigeria bears a substantial share of this burden, with approximately 1.9\u0026nbsp;million people living with HIV and a national adult prevalence of 1.4% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The epidemic is disproportionately concentrated among key populations (KPs), including men who have sex with men (MSM) and people who inject drugs (PWID), who experience heightened biological, behavioral, and structural vulnerability [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGlobally, MSM and PWID are estimated to be 13 and 22 times more likely, respectively, to acquire HIV than the general population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Nigeria, HIV prevalence among MSM (25.0%) and PWID (10.9%) far exceeds that of the general population [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In Kano State, a predominantly Muslim and socially conservative setting in northern Nigeria, prevalence among MSM and PWID remains substantial at 10.8% and 5.2%, respectively [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These disparities persist despite the availability of effective biomedical prevention strategies.\u003c/p\u003e \u003cp\u003eOral pre-exposure prophylaxis (PrEP) is a highly efficacious HIV prevention intervention, capable of reducing HIV acquisition by over 90% when used consistently [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, awareness and uptake of PrEP among key populations in Kano State remain critically low. As of 2020, only 39.0% of MSM and 1.4% of PWID in the state were aware of PrEP, with uptake reported at 13.1% among MSM and 0% among PWID [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEngagement with PrEP in northern Nigeria is shaped by complex social and structural contexts. Men who have Sex with Men and PWID navigate environments characterized by strong religious norms, pervasive stigma, and legally restrictive frameworks that generate fear of social or institutional repercussions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although One-Stop-Shop (OSS) clinic has been established to provide confidential, KP-friendly HIV prevention services, PrEP uptake within these settings remains suboptimal [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This suggests that service availability alone is insufficient to address deeper barriers influencing prevention behaviors.\u003c/p\u003e \u003cp\u003eQualitative studies from other sub-Saharan African settings have identified barriers to PrEP uptake, including low perceived HIV risk, misconceptions about PrEP, concerns about side effects, adherence fatigue, and stigma arising from the misidentification of PrEP as HIV treatment [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, evidence from northern Nigeria remains limited. Most existing studies are drawn from southern Nigeria or other African contexts, reducing their relevance to settings such as Kano, where open discussion of sexuality, drug use, and HIV prevention is highly constrained [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address this gap, this study explored the multilevel barriers and facilitators influencing PrEP uptake among MSM and PWID in Kano State using qualitative methods. The analysis was guided by the Social Ecological Model, which situates individual behavior within interpersonal, community, and structural contexts and the HIV Stigma Framework, which conceptualizes stigma as anticipated, enacted, and internalized across these levels [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Together, these frameworks enable a comprehensive examination of how social norms, service environments, and policy contexts interact to shape PrEP-related decision-making.\u003c/p\u003e \u003cp\u003eBy centering the lived experiences of MSM and PWID alongside the perspectives of program implementers, this study provides context-specific evidence to inform culturally responsive HIV prevention strategies. The findings have implications for strengthening peer-led outreach, optimizing OSS service delivery, and promoting supportive health system and policy conditions necessary for sustainable PrEP scale-up in conservative settings.\u003c/p\u003e \u003cp\u003eThe objective of this study was to explore the multilevel barriers and facilitators influencing PrEP uptake among MSM and PWID in Kano State, Nigeria.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a qualitative design grounded in interpretive (Heideggerian) phenomenology, which emphasizes how individuals construct meaning within socially constrained contexts [17]. This approach was appropriate for exploring how MSM and PWID in Kano State understand and navigate PrEP use amid stigma, social surveillance, and structural exclusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in Kano State, northwest Nigeria, a predominantly Muslim and socially conservative region with an estimated population of 21.3 million [18]. Data collection was centered around a One-Stop-Shop (OSS) clinic operating in partnership with key population\u0026ndash;led community-based organizations (CBOs) and overseen by the Kano State Agency for the Control of AIDS. The OSS provides confidential, KP-sensitive HIV prevention services, including PrEP [19].\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population and Recruitment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants included MSM and PWID who were aware of, willing to use, or had experience with PrEP, as well as key informants comprising healthcare providers, program managers, and leaders of CBOs involved in HIV prevention.\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to capture variation in age, socio-economic status, and PrEP experience. Peer educators affiliated with CBOs facilitated recruitment to enhance trust and ethical access to highly stigmatized populations. In total, 13 in-depth interviews (IDIs) were conducted with MSM (n = 10) and PWID (n = 3), alongside 7 key informant interviews (KIIs) with representatives from the Kano State Agency for the Control of AIDS, Society for Family Health, OSS clinic staff, and CBO leadership.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using semi-structured interview guides informed by the Social Ecological Model and HIV Stigma Framework. The guides explored PrEP awareness, perceived barriers and facilitators to uptake, and experiences of stigma. Guides were developed in English, translated into Hausa, and back-translated to ensure linguistic and conceptual accuracy.\u003c/p\u003e\n\u003cp\u003eInterviews were conducted by trained, gender-congruent interviewers fluent in English and Hausa in private settings within the OSS clinic or CBO offices. Interviewers received training in trauma-informed care, key population sensitivity, and confidentiality protocols. Interviews lasted approximately 30\u0026ndash;60 minutes, were audio-recorded with informed consent, and supplemented with field notes. Interview tools were pretested in key population hotspots outside the study sites and refined accordingly.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAudio recordings were transcribed verbatim and, where necessary, translated into English. A subset of transcripts was reviewed by a second researcher to ensure accuracy.\u003c/p\u003e\n\u003cp\u003eData were analyzed using Braun and Clarke\u0026rsquo;s reflexive thematic analysis, following the six-phase approach of familiarization, coding, theme development, review, definition, and reporting [20]. Coding was iterative, supported by analytic memos and thematic matrices. An interpretive phenomenological stance guided analysis, prioritizing depth and contextual meaning over generalizability. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) to ensure methodological rigor and transparency [21]. Data from IDIs and KIIs were triangulated to enhance analytical depth and credibility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReflexivity and Analytical Rigor\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree qualitative researchers independently coded approximately 20% of transcripts. Coding consistency was enhanced through collaborative coding, reflexive discussion, and iterative refinement of the codebook. Discrepancies were resolved through discussion and refinement of the codebook.\u003c/p\u003e\n\u003cp\u003eThe research team comprised Nigerian social scientists and public health professionals with experience in key population research. Reflexivity was maintained through analytic discussions and reflexive notes documenting how researchers\u0026rsquo; positionality and assumptions shaped interpretation.\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Aminu Kano Teaching Hospital Ethics Committee (NHREC/28/01/2020/AKTH/EC/3422). All participants provided written informed consent; for participants with limited literacy, consent forms were read aloud in Hausa and thumbprint consent was obtained in the presence of a witness.\u003c/p\u003e\n\u003cp\u003eTo protect confidentiality, no personal identifiers were collected, and all data were stored in encrypted, password-protected files. Given the sensitivity of the study population, additional safeguards included strict privacy protocols and enhanced interviewer training in key population\u0026ndash;sensitive research practices.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 13 in-depth interviews were conducted with MSM (n\u0026thinsp;=\u0026thinsp;10) and PWID (n\u0026thinsp;=\u0026thinsp;3), alongside 7 key informant interviews with healthcare providers, program managers, and community stakeholders involved in HIV prevention programming in Kano State. Participants varied in age, education, marital status, residence, and PrEP experience. Demographic characteristics of IDI participants are summarized 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\u003eDemographic characteristics of IDI participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender Identity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSexual Orientation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDrug Use Status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEducation Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePrEP Use Status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAccess Point\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSM001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePeri-urban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNever Used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCBO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSM002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePast User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePeer Outreach\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSM003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePast User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOSS Clinic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSM004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePeri-urban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCurrent User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCBO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSM005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePeri-urban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCurrent User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePeer Outreach\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSM006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eChristianity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePast User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePeer Outreach\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSM007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eChristianity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePeri-urban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePast User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCBO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSM008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePeri-urban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCurrent User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOSS Clinic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSM009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSeparated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCurrent User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePeer Outreach\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSM0010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eChristianity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePeri-urban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCurrent User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePeer Outreach\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePWID001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHeterosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCurrent User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNever Used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePeer Outreach\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePWID002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHeterosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePast User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePeri-urban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCurrent User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOSS Clinic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePWID003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCisgender Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHeterosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCurrent User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCurrent User\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePeer Outreach\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\u003eThematic analysis identified multilevel barriers and facilitators influencing PrEP uptake among MSM and PWID, mapped across individual, interpersonal, community, and structural levels of the Social Ecological Model and informed by the HIV Stigma Framework. Findings are presented thematically, with illustrative quotes used to contextualize key patterns.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to PrEP Uptake\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eIndividual-Level Factors\u003c/h2\u003e \u003cp\u003eLimited awareness and misinformation emerged as prominent barriers. Several participants reported confusion between PrEP and antiretroviral therapy (ART), which undermined willingness to initiate or continue PrEP. As one MSM participant explained, \u003cem\u003e\u0026ldquo;Some of the challenges\u0026hellip; is ignorance\u0026hellip; or lack of awareness of the benefit of using PrEP\u0026rdquo;\u003c/em\u003e (MSM001).\u003c/p\u003e \u003cp\u003eChallenges related to daily adherence and side effects were also commonly reported. Participants described pill fatigue and transient physical discomfort, including nausea, dizziness, and gastrointestinal symptoms. One participant stated, \u003cem\u003e\u0026ldquo;Taking the drug every day is tiring and boring\u0026rdquo;\u003c/em\u003e (MSM004). These experiences reduced motivation for consistent use, particularly among those with competing daily stressors.\u003c/p\u003e \u003cp\u003eLow perceived HIV risk further limited uptake. Some participants acknowledged the existence of HIV but did not view themselves as sufficiently vulnerable to justify preventive medication, reflecting gaps between awareness and personal risk appraisal.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eInterpersonal-Level Factors\u003c/h2\u003e \u003cp\u003eFear of disclosure and anticipated stigma strongly influenced PrEP decision-making. Many participants expressed concern that being seen with PrEP would lead others to assume they were living with HIV. One MSM participant noted, \u003cem\u003e\u0026ldquo;I have the fear that when people see me with the drug, they will think that I am HIV positive\u0026rdquo;\u003c/em\u003e (MSM002).\u003c/p\u003e \u003cp\u003eThis fear was reinforced by experiences within family and social networks, where PrEP was misidentified as HIV treatment. Such incidents led to emotional distress and, in some cases, discontinuation of PrEP use. These narratives illustrate how interpersonal dynamics amplified stigma and discouraged sustained engagement with prevention services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCommunity-Level Factors\u003c/h2\u003e \u003cp\u003eAt the community level, stigma was embedded within broader socio-cultural norms that discouraged open discussion of sexual health and HIV prevention. Participants described a climate of silence and moral judgment, where PrEP use was viewed with suspicion or misinterpreted as evidence of illness. As one participant stated, \u003cem\u003e\u0026ldquo;Some people in the community are looking at those using PrEP as HIV positive\u0026rdquo;\u003c/em\u003e (MSM009).\u003c/p\u003e \u003cp\u003eReligious conservatism and prevailing social expectations further limited opportunities for accurate information sharing, reinforcing internalized stigma and reducing visibility of PrEP as a legitimate prevention option.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStructural-Level Factors\u003c/h2\u003e \u003cp\u003eStructural constraints significantly affected PrEP access and continuation. Transportation costs, long clinic waiting times, and procedural delays were frequently cited barriers. One participant remarked, \u003cem\u003e\u0026ldquo;Time is wasted on investigations before they can collect the drug again\u0026rdquo;\u003c/em\u003e (MSM009).\u003c/p\u003e \u003cp\u003eEconomic hardship disproportionately affected PWID participants, who described prioritizing basic needs over clinic visits. \u003cem\u003e\u0026ldquo;We\u0026rsquo;d rather use the money to buy injection materials than spend it on transport,\u0026rdquo;\u003c/em\u003e one PWID participant explained (PWID003). These findings highlight how poverty and service delivery barriers intersect to limit prevention uptake.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFacilitators to PrEP Uptake\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eIndividual-Level Factors\u003c/h2\u003e \u003cp\u003eDespite multiple barriers, some participants demonstrated strong motivation to remain HIV-negative. Heightened perceived susceptibility to HIV and personal health consciousness encouraged PrEP initiation and persistence. One MSM participant stated, \u003cem\u003e\u0026ldquo;I want to stay negative, that\u0026rsquo;s why I keep coming for the PrEP refill\u0026rdquo;\u003c/em\u003e (MSM005).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eInterpersonal-Level Factors\u003c/h2\u003e \u003cp\u003ePeer support emerged as a critical facilitator of PrEP uptake. Participants emphasized the importance of counseling delivered by peers or providers with shared lived experiences, which fostered trust and reduced fear of judgment. \u003cem\u003e\u0026ldquo;The person counseling me is someone like me, and that makes it easier to trust,\u0026rdquo;\u003c/em\u003e noted one participant (MSM008).\u003c/p\u003e \u003cp\u003eIncentives such as transportation support and small material items further enhanced engagement, particularly during outreach activities. \u0026ldquo;\u003cem\u003eYes, during counselling... we provide incentives in the form of perfume, indomie, or transportation... this can encourage more people\u003c/em\u003e\u0026rdquo; noted one participant (MSM001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCommunity-Level Factors\u003c/h2\u003e \u003cp\u003eCommunity-based organizations (CBOs) played a central role in facilitating PrEP uptake by serving as trusted intermediaries. Participants highlighted the effectiveness of engaging community leaders and gatekeepers to reach hidden populations. \u003cem\u003e\u0026ldquo;If you talk to their leaders, they\u0026rsquo;ll help you reach more people who need the service,\u0026rdquo;\u003c/em\u003e explained one MSM participant (MSM006).\u003c/p\u003e \u003cp\u003eThese community-led approaches created culturally congruent entry points for PrEP education and service linkage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eStructural-Level Factors\u003c/h2\u003e \u003cp\u003eThe availability of One-Stop-Shop (OSS) clinics was widely regarded as a major enabler. Participants described OSS clinics as safe, confidential spaces where they could access services without fear. One participant shared (MSM010). \u003cem\u003e\u0026ldquo;The OSS helps us feel free to talk and collect drugs without fear,\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFor PWID, integration of PrEP messaging into harm reduction services, including the Needle and Syringe Program, facilitated engagement. Through NSP contacts, clients can be introduced to PrEP and encouraged to return for follow-up services. \u0026ldquo;\u003cem\u003eWhen they come for injection materials, and we could give them information about PrEP also\u003c/em\u003e\u0026rdquo; (PWID003). Providing PrEP information alongside existing services reduced stigma and lowered barriers to initial contact.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePolicy-Level Perspectives from Key Informants\u003c/h2\u003e \u003cp\u003eKey informants underscored systemic challenges affecting PrEP sustainability, particularly limited domestic financing and reliance on donor-funded programs. One informant noted, \u003cem\u003e\u0026ldquo;There is currently no stand-alone state budget for PrEP\u0026hellip; which limits focused planning and scale-up\u0026rdquo;\u003c/em\u003e (KII001).\u003c/p\u003e \u003cp\u003eIn addition, KIIs reinforced concerns expressed by MSM and PWID participants, especially regarding community-level stigma and mislabeling of PrEP as HIV treatment. An OSS health professional noted, \u0026ldquo;\u003cem\u003eWe\u0026rsquo;ve had clients drop out simply because someone in their community saw the pills and assumed, they were positive. It\u0026rsquo;s a real threat to retention\u003c/em\u003e\u0026rdquo; (KII003). This statement corroborated the experience shared by MSM001, who described the social consequences of being seen with PrEP.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eKey themes, Sub-themes, and Illustrative quotes\u003c/h2\u003e \u003cp\u003eTo provide a comprehensive overview of the qualitative findings, we summarized the key themes and sub-themes identified from the IDIs with MSM and PWID, as well as KIIs with key stakeholders and officials. Each theme and sub-theme is supported by illustrative verbatim quotes from participants, offering direct insights into their experiences and perceptions regarding PrEP uptake in Kano State, Nigeria\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\u003eKey themes, sub themes and illustrative quotes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIllustrative Quote\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSource ID\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarriers to PrEP Uptake\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndividual-Level Factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of awareness and misinformation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Some of the challenges like I have earlier mentioned is ignorance on the part of those that did not understand the importance or lack of awareness of the benefit of using PrEP.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Yes, there is lack of awareness, and is another challenge.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow-risk perception towards HIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"They believe that HIV is real but they will not use condom or take PrEP.\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChallenges with daily adherence and managing side effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;The reason why I stopped taking it is that, I used to have side effects like nausea, vomiting, and for me I used to feel depressed, it feels like someone chewing metal, and its not like for some weeks but for months I was still having it.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Taking the drug every day is tiring and boring.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Some of them complained of headache, dizziness at the initial usage, but with time, the side effect disappeared and everything became normal.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eInterpersonal-Level Factors\u003c/b\u003e\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFear of Disclosure, Perceived and Enacted Stigma (Misidentification of PrEP as HIV Treatment)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I have the fear that when people see me with the drug, they will think that I am HIV positive.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We introduced a friend to PrEP, but when his family saw him with the pill, they thought it was HIV drug and concluded that he had HIV, they took the PrEP pill to a doctor for confirmation and the doctor confirm that it is HIV drug because of the resemblance with the HIV drug.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Yes, because both ART and PrEP are packaged in a similar container, because once people see you with the container, they conclude that you have HIV.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCommunity-Level Factors\u003c/b\u003e\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePervasive Community-Level Stigma and Internalized Stigma (Socio-cultural and Legal Context)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Some people are not sure about its ability to prevent them from HIV infection... like there is trust issue.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Yes, some people in the community are looking to those that are using PrEP as HIV positive.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStructural-Level Factors\u003c/b\u003e\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransportation barriers, long waiting times, and limited service availability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Transportation to where you will get the drug.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Time wasted on investigations before they can collect the drug again.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEconomic hardship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We rather use the money to buy injection\u0026hellip;\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePWID003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFacilitators to PrEP Uptake\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIndividual-Level Factors\u003c/b\u003e\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth consciousness and risk perception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I want to stay negative, that\u0026rsquo;s why I keep coming for the PrEP refill.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive Perceived Physical Effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Yes. Most of the people tell me when they take PrEP, they feel stronger. It also builds their immune system and makes their immune system stronger.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePWID002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eInterpersonal-Level Factors\u003c/b\u003e\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeer support and targeted counseling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Yes, during counselling... we provide incentives in the form of perfume, indomie, or transportation... this can encourage more people.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;The person counseling me is someone like me, and that makes it easier to trust.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCommunity-Level Factors\u003c/b\u003e\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity advocacy led by local CBOs and community leaders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;If you talk to their leaders, they\u0026rsquo;ll help you reach more people that need the service.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"The best way to use, is to engage mobilizers to talk about the meaning and benefits of using PrEP in different social gatherings within the community.\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStructural-Level Factors\u003c/b\u003e\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvailability of One-Stop-Shop (OSS) clinics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;The OSS helps us feel free to talk and collect drugs without fear.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeedle and Syringe Program (NSP) as a gateway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;When they come for injection materials, and we could give them information about PrEP also.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePWID003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvision of free services and commodities (including self-testing kits)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;It is free, that\u0026rsquo;s the good part... they don\u0026rsquo;t have to worry about paying.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePolicy-Level Insights (Barriers)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited funding allocation and absence of dedicated state-level policies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;So my, the only challenge here is the sustainability. Sustainability, like I said in my opening remarks, this is donor funded, and donor enough to stay here for life. At the point in time, we exit the state. What then happens thereafter? So that is the more reason the states must have to take ownership and then make this their responsibility.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity-level stigma and mislabeling of PrEP as HIV treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We\u0026rsquo;ve had clients drop out simply because someone in their community saw the pills and assumed, they were positive. It\u0026rsquo;s a real threat to retention.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKII003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePolicy-Level Insights (Facilitators)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKP-led model of OSS clinics, peer navigation, community gatekeeper engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Our community mobilizers and peer educators are the real heroes. They know where to find the clients and how to speak their language.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKII005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdea of injectable PrEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Yes, there is, one of the ways is to transform the PrEP pill to injectable that will be done once in a month or two months or even yearly. this will encourage more people to take it, because for example if it\u0026rsquo;s done every three months once you take it, you know you will not come back until another three months.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMSM001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntegrating PrEP messaging into harm reduction services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;If we link PrEP to harm reduction, PWID will be more open to listen. It's a softer entry point.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKII005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study explored multilevel barriers and facilitators influencing PrEP uptake among MSM and PWID in Kano State, a socially conservative setting in northern Nigeria. Guided by the Social Ecological Model and the HIV Stigma Framework, the findings illustrate how individual decision-making around PrEP is shaped by intersecting interpersonal, community, and structural forces. The study contributes context-specific evidence from a region where HIV prevention efforts operate within highly constrained social and institutional environments.\u003c/p\u003e \u003cp\u003eConsistent with prior studies from Nigeria and other sub-Saharan African settings, limited awareness, misconceptions about PrEP, and confusion with antiretroviral therapy emerged as persistent barriers [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These challenges were compounded by low perceived HIV risk and concerns about side effects, particularly among PWID, whose daily priorities often centered on economic survival and harm reduction. These findings underscore how individual-level barriers cannot be understood in isolation from broader material and social conditions.\u003c/p\u003e \u003cp\u003eDespite these challenges, individual agency remained evident. Several participants described strong motivation to remain HIV-negative and attributed continued PrEP use to heightened risk perception and perceived health benefits. Framing PrEP as a proactive health-preserving strategy rather than solely as an HIV prevention tool may therefore enhance acceptability, particularly in settings where illness is highly stigmatized. Messaging that emphasizes well-being, strength, and continuity of daily functioning may resonate more effectively than risk-focused narratives alone.\u003c/p\u003e \u003cp\u003eStigma operating at interpersonal and community levels emerged as a central determinant of PrEP uptake. Anticipated and enacted stigma particularly the misidentification of PrEP as HIV treatment discouraged disclosure and undermined adherence. Similar patterns have been reported among MSM in China and Vietnam, where visual resemblance between PrEP and ART heightened fears of social labeling [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In Kano, these dynamics were reinforced by strong moral norms and limited community-level dialogue around sexual health, further embedding silence and internalized stigma.\u003c/p\u003e \u003cp\u003ePeer-led outreach and KP-sensitive service delivery played a critical role in mitigating these barriers. Trust was enhanced when counselors shared lived experiences with clients, reducing fear of judgment and fostering sustained engagement. This finding aligns with evidence from South Africa and Kenya demonstrating the effectiveness of peer navigation in stigmatized populations [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Community-based organizations functioned as discreet and culturally congruent entry points, highlighting the importance of community ownership in HIV prevention programming.\u003c/p\u003e \u003cp\u003eStructural barriers including transportation costs, clinic wait times, and economic hardship consistently limited access to PrEP, particularly for PWID. These findings mirror studies from Malawi and the United States, where logistical and financial constraints undermined prevention uptake among marginalized populations [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In contrast, One-Stop-Shop clinic were widely perceived as enabling environments that reduced stigma and facilitated access through integrated, confidential services. Integration of PrEP messaging into harm reduction platforms, such as needle and syringe programs, further expanded reach among PWID by leveraging existing points of contact.\u003c/p\u003e \u003cp\u003eAt the policy level, reliance on donor funding and the absence of dedicated state-level financing for PrEP were viewed as significant threats to sustainability. Key informants emphasized that without domestic ownership and supportive policy frameworks, gains achieved through community-led and peer-driven models remain fragile. While community innovations can buffer stigma and improve access, their impact is constrained in environments characterized by fear of surveillance or social repercussions. Long-term progress requires policy approaches that prioritize public health, harm reduction, and dignity, while engaging religious and traditional leaders to foster culturally legitimate pathways for change.\u003c/p\u003e \u003cp\u003eThis study has several limitations. Participants were primarily recruited through OSS clinic and community organizations, potentially excluding individuals who are more hidden or disengaged from services. The small number of PWID participants may also limit the depth of subgroup-specific analysis. Although efforts were made to reduce social desirability bias through trauma-informed and gender-congruent interviewing, some bias may remain.\u003c/p\u003e \u003cp\u003eDespite these limitations, this study provides rare qualitative insight into PrEP uptake in northern Nigeria. By integrating lived experiences with programmatic perspectives, the findings highlight the necessity of multi-level, culturally responsive strategies that strengthen peer-led outreach, optimize OSS service delivery, and promote supportive health system and policy environments. Such approaches are essential to advancing equitable HIV prevention and ensuring that key populations are not left behind in efforts to end the HIV epidemic.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eSustainable PrEP uptake among MSM and PWID in northern Nigeria requires coordinated, multi-level strategies that address barriers operating across individual, interpersonal, community, health system, and policy contexts. This study demonstrates that stigma, misinformation, economic hardship, and service access constraints continue to shape PrEP engagement in conservative settings, even where confidential and KP-friendly services are available.\u003c/p\u003e \u003cp\u003eStrengthening peer-led outreach, expanding and optimizing One-Stop-Shop clinics, and leveraging community-based organizations are critical for reducing stigma and improving access to prevention services. Integrating PrEP delivery with harm reduction platforms offers a particularly effective approach for reaching PWID and minimizing barriers related to visibility and trust. At the system level, long-term sustainability will depend on increased domestic investment, integration of PrEP into routine state health financing, and policy environments that support public health\u0026ndash;oriented service delivery.\u003c/p\u003e \u003cp\u003eEngagement with traditional and faith leaders may further facilitate culturally legitimate pathways for improving HIV prevention uptake while maintaining social cohesion. Ultimately, effective PrEP scale-up in northern Nigeria must be grounded in equity, dignity, and inclusion, ensuring that populations most at risk of HIV are not excluded from the benefits of biomedical prevention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Aminu Kano Teaching Hospital Ethics Committee (NHREC/28/01/2020/AKTH/EC/3422). The study was conducted in accordance with the ethical standards of the institutional research committee and with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants prior to data collection. For participants with limited literacy, the consent form was read aloud in Hausa, and consent was documented using a thumbprint in the presence of an independent witness. Participation was voluntary, and participants were informed of their right to withdraw at any time without consequences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the sensitive nature of the study population and the potential risk of participant identification, the qualitative datasets generated and analyzed during the current study are not publicly available. De-identified data may be made available from the corresponding author upon reasonable request and subject to ethical approval.\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the support of community-based organizations, peer educators, and study participants who generously shared their experiences. We also acknowledge the contributions of healthcare providers and program staff involved in HIV prevention services in Kano State.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.S.A. contributed to the study conceptualization and design, led data collection, conducted data analysis, and drafted the first version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eM.B.M. contributed to data collection and critically reviewed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eW.Y.B. provided overall supervision and contributed to interpretation of findings. I.S.M. contributed to data analysis and manuscript editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eS.R.A. supported the literature review and manuscript editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eM.M. contributed to project coordination and implementation support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eR.G.F. contributed to ethical considerations and data management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eY.M.S. contributed to policy interpretation and critically reviewed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript and agreed to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organisation. HIV statistics, globally and by WHO region, 2024. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederal Ministry of Health. 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Shari\u0026rsquo;ah Criminal Law in Northern Nigeria United States Commission on International Religious Freedom. 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOchonye BB, Umoh P, Sanni OF, Kalaiwo A, Abang R, Oguntonade A, et al. Pre-Exposure Prophylaxis and HIV Prevention Among Key Populations in Nigeria. Int J Maternal Child Health AIDS. 2024;13:e013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReyniers T, Babo SAY, Ouedraogo M, Kanta I, Ekon Agb\u0026eacute;gnigan L, Rojas D, et al. Strategies to improve PrEP uptake among West African men who have sex with men: a multi-country qualitative study. Front Public Health. 2023;11:1165327.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNicholas SC, Matewere M, Bula A, Tsidya M, Hosseinipour MC, Matoga M, et al. Barriers and facilitators to oral pre-exposure prophylaxis uptake among adolescents girls and young women at elevated risk of HIV acquisition in Lilongwe, Malawi: A qualitative study. PLOS Global Public Health. 2025;5(4):e0004006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eApreku A, Guure C, Dery S, Yakubu A, Abu-Ba\u0026rsquo;are GR, Addo SA, et al. Awareness, willingness, and uptake of pre-exposure prophylaxis (PrEP) among men who have sex with men in Ghana. BMC Infect Dis. 2025;25(1):1\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmmanuel GO, Sanni OF, Roger A, Umoh P, Boniface OB, Paul A, et al. Improving HIV Prevention for Key Populations in Nigeria: Insights on Access, Barriers, Stigma, and Service Utilization. Int J Maternal Child Health AIDS. 2025;14:e005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBronfenbrenner U. Ecological models of human development. 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Differentiated Prevention Testing and ART delivery for Modified General populations and Key Populations in Nigeria 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V, Hayfield N, Davey L, Jenkinson E. Doing Reflexive Thematic Analysis. Supporting Research in Counselling and Psychotherapy: Qualitative, Quantitative, and Mixed Methods Research. 2022;19\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu C, Ding Y, Ning Z, Gao M, Liu X, Wong FY, et al. Factors influencing uptake of pre-exposure prophylaxis: Some qualitative insights from an intervention study of men who have sex with men in China. Sex Health. 2018;15(1):39\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen LH, Nguyen HLT, Tran BX, Larsson M, Rocha LEC, Thorson A, et al. A qualitative assessment in acceptability and barriers to use pre-exposure prophylaxis (PrEP) among men who have sex with men: implications for service delivery in Vietnam. BMC Infect Dis. 2021;21(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEakle R, Bothma R, Bourne A, Gumede S, Motsosi K, Rees H. I am still negative: Female sex workers\u0026rsquo; perspectives on uptake and use of daily preexposure prophylaxis for HIV prevention in South Africa. PLoS ONE. 2019;14(4):1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJackson-Gibson M, Ezema AU, Orero W, Were I, Ohiomoba RO, Mbullo PO, et al. Facilitators and barriers to HIV pre-exposure prophylaxis (PrEP) uptake through a community-based intervention strategy among adolescent girls and young women in Seme Sub-County, Kisumu, Kenya. BMC Public Health. 2021;21(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllen ST, O\u0026rsquo;Rourke A, White RH, Smith KC, Weir B, Lucas GM, et al. Barriers and Facilitators to PrEP Use Among People Who Inject Drugs in Rural Appalachia: A Qualitative Study. AIDS Behav. 2020;24(6):1942\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShea J, Bula A, Dunda W, Hosseinipour MC, Golin CE, Hoffman IF, et al. The drug will help protect my tomorrow: Perceptions of integrating prep into hiv prevention behaviors among female sex workers in Lilongwe, Malawi. AIDS Educ Prev. 2019;31(5):421\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\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":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8909678/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8909678/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDespite the proven efficacy of oral pre-exposure prophylaxis (PrEP), uptake among key populations in Nigeria, particularly men who have sex with men (MSM) and people who inject drugs (PWID) remains low. In conservative northern settings such as Kano State, intersecting legal, religious, and socio-cultural constraints intensify stigma and limit access to HIV prevention services. This study explored multilevel barriers and facilitators shaping PrEP uptake among MSM and PWID in this context. Using a phenomenological qualitative design, we conducted 13 in-depth interviews with MSM (n\u0026thinsp;=\u0026thinsp;10) and PWID (n\u0026thinsp;=\u0026thinsp;3), and 7 key informant interviews with healthcare providers, program managers, and community stakeholders. Participants were purposively recruited from key population hotspots and One-Stop-Shop clinics. Data were thematically analyzed using Braun and Clarke\u0026rsquo;s reflexive approach, guided by the Social Ecological Model and HIV Stigma Framework. Barriers to PrEP uptake operated across individual, interpersonal, community, and structural levels, including limited awareness, confusion with antiretroviral therapy, low perceived risk, adherence fatigue, fear of stigma, community misrecognition of PrEP as HIV treatment, transportation costs, clinic wait times, and economic hardship, particularly among PWID. Facilitators included heightened perceived HIV risk, peer support, trust in key population\u0026ndash;friendly counselors, access to confidential One-Stop-Shop clinics, and integration with harm reduction services. Key informants emphasized the importance of sustainable domestic financing and supportive policy environments. These findings underscore the need for culturally responsive, multilevel strategies that strengthen peer-led outreach, expand confidential service delivery models, and promote enabling health system and policy conditions for sustainable PrEP scale-up in northern Nigeria.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClinical trial number\u003c/b\u003e: Not applicable.\u003c/p\u003e","manuscriptTitle":"Multilevel Barriers and Facilitators to Pre-Exposure Prophylaxis Uptake among Men Who Have Sex with Men and People Who Inject Drugs in Kano State, Northern Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-19 16:44:20","doi":"10.21203/rs.3.rs-8909678/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"204109310590181234284748259545817827119","date":"2026-05-13T14:54:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-12T14:32:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50965162420011094366263075441229575632","date":"2026-05-12T11:17:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-16T12:32:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-12T04:22:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-24T13:14:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-24T13:12:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-02-18T12:57:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"901ae5a1-089a-4ade-9c46-497c5d51908e","owner":[],"postedDate":"March 19th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"204109310590181234284748259545817827119","date":"2026-05-13T14:54:38+00:00","index":59,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-12T14:32:56+00:00","index":58,"fulltext":""},{"type":"reviewerAgreed","content":"50965162420011094366263075441229575632","date":"2026-05-12T11:17:43+00:00","index":57,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-19T16:44:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-19 16:44:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8909678","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8909678","identity":"rs-8909678","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}