Awareness and Barriers to Pre-Exposure Prophylaxis (PrEP) among Commercial Female Sex Workers in Mekelle City, Tigray, Ethiopia: A Cross – Sectional Study, 2025

Awareness and Barriers to Pre-Exposure Prophylaxis (PrEP) among Commercial Female Sex Workers in Mekelle City, Tigray, Ethiopia: A Cross – Sectional Study, 2025 | 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 Awareness and Barriers to Pre-Exposure Prophylaxis (PrEP) among Commercial Female Sex Workers in Mekelle City, Tigray, Ethiopia: A Cross – Sectional Study, 2025 Leake Amaha Kahsay, Bethel Abraham Gebremedhin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7415141/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Background: Nationally, Ethiopia's HIV epidemic is concentrated among key populations, with female sex workers showing a disproportionately high prevalence of HIV, averaging 18.7% across urban centers. In Mekelle, recent data indicate a rising HIV prevalence of 8.5% among CSWs, underscoring the urgent need for accessible and effective prevention strategies. However, barriers including low PrEP awareness, misinformation, stigma, and limited healthcare access significantly hinder PrEP utilization. Methodology: a cross sectional study was done. Result: The study surveyed 335 female sex workers, with a mean age of 30.25 years, most of whom were divorced, Orthodox Christians, and had at least secondary education. Nearly 88% had heard of PrEP, but only 27.2% correctly identified it as an HIV prevention method, with health workers being the main information source. Most participants (79.4%) had used PrEP, and 89.9% were currently taking it daily, mainly from government facilities. Counseling before starting PrEP was rare, and over 74% reported experiencing side effects. While 13.6% had discontinued PrEP at some point, the majority expressed willingness to resume its use. Conclusion: This study expressed that female sex workers in Mekelle had high awareness and usage of PrEP, though consistent condom use was low and misconceptions about PrEP were common. Despite strong uptake, most users lacked proper counseling and many experienced side effects, which could hinder adherence. Strengthening education, counseling, and support services is essential to improve the effectiveness of HIV prevention among this high-risk group. PrEP HIV/AIDS Female sex workers 1. Background 1.1. Background of the study The Human Immunodeficiency Virus (HIV) continues to be a major global public health issue, with significant social, economic, and health-related implications. As of 2023, approximately 39.9 million people globally were living with HIV, with 1.3 million new infections and 630,000 AIDS-related deaths recorded that year (1). Sub-Saharan Africa bears the heaviest burden, accounting for over two-thirds of all people living with HIV (2) . In response to the epidemic, pre-exposure prophylaxis (PrEP) has emerged as a highly effective biomedical prevention strategy. Studies have shown that consistent use of PrEP can reduce the risk of HIV acquisition by more than 90% among individuals at substantial risk (3). Despite its efficacy, global uptake of PrEP remains uneven, particularly in low- and middle-income countries, due to barriers such as high costs, limited awareness, healthcare system constraints, and social stigma (2, 4). In the Horn of Africa, the HIV epidemic is characterized by concentrated prevalence among key populations, including female sex workers (FSWs), men who have sex with men, and people who inject drugs (1). While overall national prevalence in some countries remains relatively low, these groups experience disproportionately high rates of infection. The region’s capacity to implement PrEP interventions has been challenged by weak healthcare infrastructure, sociocultural resistance, and the destabilizing effects of political conflict (5). Access to PrEP is further constrained by insufficient program funding and limited integration into national health strategies (4) . This underscores the need for context-specific approaches that address both structural and individual-level barriers to PrEP use. In Ethiopia, the HIV epidemic similarly exhibits a concentrated pattern, particularly among FSWs. A national cross-sectional study conducted across 16 major cities found a pooled HIV prevalence of 18.7% among FSWs, with significant variation—Bahir Dar had the highest rate at 28.2%, while Shashemene recorded the lowest at 14.0% (6). These figures point to the continued vulnerability of this population, despite Ethiopia’s efforts to incorporate PrEP into its national HIV prevention strategy. The Ministry of Health has recognized PrEP as a key component in curbing new infections and has begun integrating it into service delivery for high-risk groups. Nevertheless, challenges such as stigma, inconsistent healthcare access, and limited provider training have hindered its effective implementation (6). Addressing these bottlenecks is critical to improving PrEP coverage and reducing new infections in key populations. The context of Mekelle City in the Tigray region illustrates the compounded challenges faced at the sub-national level. Following the recent armed conflict in Tigray, healthcare services—including HIV prevention, testing, and treatment—were severely disrupted (7). In this fragile setting, HIV prevalence has risen sharply. A 2024 study conducted by the UNFPA and regional health authorities reported that HIV prevalence among FSWs in Tigray had reached 8.5%, with over 65% of participants identifying economic hardship and displacement as major contributors to increased vulnerability (8). Mekelle’s situation is exacerbated by widespread poverty, population displacement, and the collapse of health infrastructure, which have all hindered access to PrEP and related services. Moreover, entrenched stigma and social marginalization of sex workers further deter service utilization. To ensure effective HIV prevention in Mekelle, efforts must focus on rebuilding the healthcare system, expanding targeted awareness campaigns, and ensuring that PrEP services are accessible, culturally sensitive, and resilient to future disruptions. 1.2. Statement of the Problem Despite global and national advancements in HIV prevention, female sex workers (FSWs) in Mekelle City, Tigray, continue to face a heightened risk of HIV infection due to a critical gap in knowledge and awareness of pre-exposure prophylaxis (PrEP). PrEP, a biomedical intervention with proven effectiveness in reducing HIV acquisition among high-risk populations, has been successfully implemented in many contexts; yet its uptake and utilization remain alarmingly low among FSWs in northern Ethiopia (1, 6). In post-conflict Tigray, the situation is exacerbated by the socio-economic aftermath of war, which has led to widespread displacement, economic insecurity, and a disrupted health system. A recent study indicated that HIV prevalence among FSWs in the region has surged to 8.5%, with the majority reporting that economic hardship has driven them into transactional sex, often under unsafe conditions (8). Despite the urgent need for effective HIV prevention, there is limited evidence of structured PrEP education, promotion, or accessibility in Mekelle, a city that is central to the region’s recovery. The low uptake of PrEP is not merely a matter of supply but is deeply rooted in limited awareness, misconceptions, and stigma surrounding HIV and PrEP usage among sex workers. FSWs are often marginalized in healthcare systems, facing discrimination that deters them from seeking preventive services. Compounding this is the inadequate training and preparedness of healthcare providers to deliver PrEP in a way that is both sensitive and accessible to key populations (6). Consequently, the absence of targeted education and awareness strategies on PrEP among FSWs in Mekelle significantly contributes to persistent HIV vulnerability. This underscores a critical public health challenge: without addressing the knowledge gap surrounding PrEP, Ethiopia’s broader HIV prevention strategy may fail to reach one of its most at-risk groups. This study is aimed to explore the understanding of the level of knowledge, and barriers to PrEP among CSWs in Mekelle. 1.3. Significance of the Study This research helps policy makers to develop targeted education and awareness campaigns for the CSW. By identifying both barriers and facilitators to PrEP uptake in the aftermath of conflict, the research could inform post-conflict health recovery strategies, ensuring that PrEP is accessible, culturally sensitive, and accepted in the most affected communities. Beyond Mekelle City and Ethiopia, this study has the potential to contribute to global research on HIV prevention for key populations. 2. Methodology 2.1. Study Setting and Period The study was taken place in Mekelle, Ethiopia, involving CFSW in Mekelle city around kedamay weyane sub city. Data collection was done from May, 2025 to Jun 2025. 2.2. Study Design A cross-sectional study design with self-administered questions was employed to explore an insight about pre exposure prophylaxis practices, knowledge and barriers for using Pre exposure prophylaxis among CFSW in kedamay weyane sub city setting in Mekelle of Tigray region. 2.3. Source of population All FCSWs who are currently engaged in sex work Mekelle City, Tigray, Ethiopia 2.4. Study Population The target Population was FCSWs in Mekelle City, Tigray, Ethiopia selected by snow-ball sampling method. 2.5. Inclusion and exclusion criteria 2.5.1. Inclusion criteria FCSWs who are currently engaged in sex work. Willing to participate and provide informed consent was included. 2.5.2. Exclusion criteria Those who are not willing to participate or unable to give informed consent was excluded. 2.6. Sample Size determination For this cross-sectional study, the sample size was determined using the single population proportion formula The formula is: n = Z a/2 2 P (1-P) D 2 Where, n is the sample size, Zα/2 is the standard normal variate corresponding to the desired confidence level (1.96 for 95% confidence), p is the expected prevalence of the condition (in this case, the proportion of CFSW with adequate knowledge of Prexposure prophylaxis mechanism), D is the precision or margin of error (commonly set at 0.05 for a 5% margin of error). P-value from a study done at Addis Ababa on a similar study (Acceptability of pre-exposure prophylaxis among female sex workers was 67.9%) ( 9 ). n = Z 2 P (1-P) D 2 n= (1.96) 2 × 0.679(1 − 0.679) = 335 was sample size 2.7 Sampling method Snow ball sampling method among female individuals who are currently engaged in commercial sex work was used in data collection process. 2.8 Study Variables 2 .8.1 Independent variable Socioeconomic and demographic factors such as: Religion, Age, Ethnicity, Educational level, marital status, Sex, Year of study, Original place of study 2 .8.2 Dependent variables Awareness and Barriers to Pre-Exposure Prophylaxis (PrEP) Uptake 2.9 Data Collection Methods A semi-structured questionnaire was designed to collect data on awareness of PrEP: Participants’ knowledge of PrEP, barriers to PrEP, and PrEP utilization. Data on whether participants are currently using PrEP, whether they have enough knowledge about PrEP, and barriers to use PrEP. To collect data accurately and precisely, data collectors underwent training on the study's objectives and understanding participants how to answer the questionnaire. This training ensured that the data collectors are fully equipped to conduct the data collection process effectively. The surveys were anonymous to respect participants’ confidentiality and minimize potential biases. 2.9.1 Data Collection Procedure: The data collection was conducted in a private, confidential setting to ensure participants feel safe sharing their experiences. Participants were recruited from kedamay Weyane sub city Drop- in centers. An individual who met the criteria and expressed their interest in participation was reached out to the researcher through phone communication or by visiting in person. Those who were meet the inclusion criteria were distributed the questionnaire to them. Data collection was conducted between May - Jun, 2025. Prior to distributing the questionnaire, the researcher was read an information sheet about the study, and participants expected to provide verbal consent to participate. Additional comments were captured in written form on the note pad. All data to be collected was anonymous. The researcher translated the Tigrinya questionnaire into English. 2.10 Data Management and Statistical Analysis Data was encoded first then data was entered and analyzed using the Statistical Package for Social Sciences version 20. Data was represented by frequency and percentages and presented with tables, pie charts. Identification codes to participants instead of using their names during data collection, analysis, and reporting. 3. Result 3.1 Sociodemographic Characteristics The study included a total of 335 female sex workers with a mean age of 30.25 years (range: 24–41). The majority of participants were Orthodox Christians 318 (94.9%), followed by Muslims 13 (3.9%) and Protestants 4 (1.2%). Regarding marital status, most were divorced 217 (64.8%), followed by single 97 (29.0%) and widowed 21 (6.3%). Educationally, 170 (50.7%) had attended secondary education or above, while 165 (49.3%) were only able to read and write. In terms of occupation, 178 (53.1%) were engaged only in sex work, while 157 (46.9%) combined it with other work. The duration in sex work varied, with the highest proportion having worked for 3 years 68 (20.3%), followed by 6 years 57 (17.0%), 2 years 51 (15.2%), and 5 years 41 (12.2%). A total of 150 (44.8%) reported working several times a week in the past 3 months, 66 (19.7%) weekly, 50 (14.9%) daily, 42 (12.5%) several times a day, and 27 (8.1%) rarely. The reasons for entering sex work included financial problems 109 (32.5%), conflict with parents 107 (31.9%), peer pressure 67 (20.0%), addiction and others 34 (10.1%), and other unspecified reasons 18 (5.4%). The average monthly income was 12,789.55 ETB, ranging from 5,000 to 112,000 ETB. Condom use during sexual intercourse was reported by only 99 (29.6%), while 236 (70.4%) did not use condoms. 3.2 Awareness about PrEP Out of the total participants, 294 (87.8%) had heard of PrEP, while 41 (12.2%) had not or responded incorrectly. However, only 91 (27.2%) correctly identified PrEP as a medicine to prevent HIV; 123 (36.7%) believed it is a cure for HIV, 113 (33.7%) thought it is a form of emergency contraception, and 8 (2.4%) did not know. The main source of information was health workers 235 (70.1%), followed by social media 66 (19.7%) and friends/peers 34 (10.1%). When asked if they knew PrEP prevents HIV, 260 (77.6%) said yes, 34 (10.1%) said no, and 41 (12.2%) were unsure. Awareness that PrEP must be taken daily was reported by 293 (87.5%), while 35 (10.4%) said no and 7 (2.1%) were unsure. A total of 328 (97.9%) correctly stated PrEP is intended for people at high risk of HIV, while 7 (2.1%) incorrectly said it is for people living with HIV. All participants 335 (100.0%) knew that PrEP services are available in Mekelle. Regarding how PrEP is taken, 229 (68.4%) said one pill daily, 82 (24.5%) said only before sex, and 24 (7.2%) said once a week. When asked if PrEP replaces condom use, 229 (68.4%) agreed, 82 (24.5%) disagreed, and 24 (7.2%) were unsure. Lastly, 300 (89.6%) believed PrEP reduces HIV transmission, while 35 (10.4%) did not. Only 24 (7.2%) thought PrEP protects against other STIs, whereas 150 (44.8%) said no and 161 (48.1%) were not sure. 3.3 Utilization of PrEP Among the participants, 266 (79.4%) had ever used PrEP, and 301 (89.9%) were currently taking it. All current users 301 (100.0%) reported taking it daily. Most accessed PrEP from government health facilities 285 (94.7%), while 16 (5.3%) obtained it from private clinics. Regarding duration of use, 127 (42.2%) had used it for less than 1 month, 50 (16.6%) for 1–6 months, and 124 (41.2%) reported not currently using it. Counseling before initiation of PrEP was reported by only 16 (5.3%), while 94 (31.2%) did not receive any, and 191 (63.5%) were not sure. Side effects were reported by 224 (74.4%), while 77 (25.6%) did not experience any. A total of 41 (13.6%) had stopped taking PrEP at some point, with reasons including forgetting to take it regularly 9 (36.0%), feeling no longer at risk 8 (32.0%), and side effects 8 (32.0%). Among the 34 participants not currently on PrEP, 25 (73.5%) were willing to take it in the future, and 9 (26.5%) were unsure. 4. Discussion The current study among 335 female sex workers (FSWs) in Mekelle revealed that the mean age was 30.25 years, which is higher compared to earlier studies conducted in Bahir Dar ( 10 ), Nazareth ( 11 ), and Addis Ababa( 12 ), where the mean age was approximately 22.1 years. A majority (64.8%) of participants in the Mekelle study were divorced, whereas national surveys in 2002 and 2005 reported that only 57% and 48%, respectively, of FSWs were ever married. Educational attainment in Mekelle was relatively balanced, with 50.7% having completed secondary school or above, which is substantially higher than the 14.7% reported in earlier studies. Furthermore, 53.1% of the participants in Mekelle engaged solely in sex work, a trend that aligns with findings from Addis Ababa, though in other regions many FSWs also had alternative income sources. Condom use during sexual intercourse was reported by only 29.6% of FSWs in Mekelle, which is lower than figures reported in other parts of Ethiopia, where inconsistent but somewhat higher condom use has been observed. Awareness about PrEP among participants in this study was high, with 87.8% having heard about it. However, only 27.2% correctly identified PrEP as a medicine to prevent HIV. This is lower than the findings from a study in Addis Ababa, where 82% had heard of PrEP and 45% correctly identified its preventive role. Health workers were the main source of PrEP information in both studies, emphasizing their key role in public health communication. Nevertheless, misconceptions persisted in both settings—many believed PrEP was a cure for HIV or a form of emergency contraception, indicating a need for better-targeted education and awareness campaigns. Notably, 100% of participants in Mekelle knew that PrEP services were available locally, suggesting good service visibility. PrEP utilization in Mekelle was notably high, with 79.4% having ever used it and 89.9% currently on it, all of whom reported daily use. These rates are significantly higher compared to a study in Bahir Dar, where only 46.2% of FSWs reported using PrEP. The greater uptake in Mekelle may be attributed to better service availability and stronger public health outreach. Despite this, only 5.3% of participants reported receiving counseling before starting PrEP, pointing to a critical gap in service delivery. Additionally, 74.4% of users experienced side effects, which could potentially affect adherence. Among those who stopped taking PrEP, common reasons included forgetting to take it (36%), feeling no longer at risk (32%), and experiencing side effects (32%). Encouragingly, 73.5% of those not currently on PrEP expressed willingness to use it in the future, reflecting a positive attitude toward HIV prevention efforts. 5. Conclusion This study highlights critical findings on the Sociodemographic characteristics, awareness, and utilization of PrEP among female sex workers (FSWs) in Mekelle, Ethiopia. Compared to previous studies conducted in regions such as Addis Ababa, Bahir Dar, and Nazareth, the FSWs in Mekelle were slightly older and more likely to have attained secondary education or higher. However, consistent condom use remained low, suggesting ongoing vulnerability to HIV and other sexually transmitted infections. Awareness of PrEP was impressively high in Mekelle, yet significant misconceptions persist regarding its purpose and usage. Although nearly all participants had heard of PrEP and were aware of its availability, many misidentified it as a cure for HIV or emergency contraception, indicating gaps in accurate health education. Encouragingly, most participants recognized PrEP’s role in preventing HIV, and the majority were actively using it, reflecting strong engagement with HIV prevention services. Despite the high uptake of PrEP, challenges remain. A large proportion of users reported experiencing side effects, and only a small fraction received pre-initiation counseling both of which could affect long-term adherence. The willingness of non-users to initiate PrEP use in the future is promising and suggests a favorable attitude that health programs can build upon. To enhance the effectiveness of HIV prevention strategies, interventions should focus on improving the quality of counseling, correcting misconceptions, and promoting adherence while also addressing the broader social and economic determinants that influence FSWs’ health behaviors. Abbreviations AGYW Adolescent Girls and Young Women AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy BCC Behavior Change Communication BSS Behavioral Surveillance Survey CDC Centers for Disease Control and Prevention DHIS2 District Health Information Software 2 DIC Drop-In Center EPHA Ethiopian Public Health Association EPHI Ethiopian Public Health Institute FHAPCO Federal HIV/AIDS Prevention and Control Office FMOH Federal Ministry of Health FCSW Female Commercial Sex Workers FSW Female Sex Workers GBV Gender-Based Violence HCT HIV Counseling and Testing HMIS Health Management Information System HRST HIV Risk Screening Tool ICT Index Case Testing KPP Key and Priority Populations MARPs Most At-Risk Populations NSP National Strategic Plan PEPFAR President’s Emergency Plan for AIDS Relief PLHIV People Living with HIV/AIDS PrEP Pre-Exposure Prophylaxis PSI Population Services International Declarations Ethics approval and consent to participate The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki . Ethical clearance was obtained from the Ethical Review Committee of Mekelle University College of Health Sciences (Reference No: MU-IRB 2538/2025 ). Written informed consent was obtained from all participants before data collection. Participation was voluntary, and confidentiality was maintained throughout the study. Consent of publication Not applicable Availability of data and materials Yes, all data are included in the manuscript Competing interest I have no competing interest. Funding No financial funds were gained to conduct this study Author’s contribution Conceptualization: Leake Amaha Kahsay Data curation: Leake Amaha Kahsay, Bethel Abraham Gebremedhin Formal analysis : Leake Amaha Kahsay Investigation: Leake Amaha Kahsay, Bethel Abraham Gebremedhin Methodology: Leake Amaha Kahsay, Bethel Abraham Gebremedhin Project administration : Leake Amaha Kahsay, Bethel Abraham Gebremedhin Resources: Leake Amaha Kahsay, Bethel Abraham Gebremedhin Software: Leake Amaha Kahsay Supervision: Leake Amaha Kahsay Visualization : Leake Amaha Kahsay, Bethel Abraham Gebremedhin Writing – original draft : Leake Amaha Kahsay, Bethel Abraham Gebremedhin Writing – review & editing: Leake Amaha Kahsay, Bethel Abraham Gebremedhin Acknowledgment In the first, praises and thanks to God, the almighty, for granting me the capability to proceed successfully. I would like to thank Mekelle University, college of health sciences, school of pharmacy, and department of clinical pharmacy for giving me the opportunity to develop this scientific research paper. References UNAIDS. UNAIDS data 2023. [Internet]. 2023. Available from: https://www.unaids.org/en/resources/fact-sheet UNICEF. Impact of the humanitarian crisis on healthcare delivery in Tigray. 2022. Available from: https://www.unicef.org/ethiopia/impact-humanitarian-crisis-healthcare-delivery Lopez G. We’ve made huge progress against HIV. But we still don’t have a cure. Vox . 2023. Available from: https://www.vox.com/explain-it-to-me/396016/hiv-aids-cure-pepfar-who-progress Ducharme J. STIs are rising worldwide. Why aren’t we doing more? Time . 2024. Available from: https://time.com/6980783/sti-world-health-organization-new-report/ Burke J. Funding cuts threaten global progress on HIV, say health experts. The Guardian . 2025 Mar 18. Available from: https://www.theguardian.com/global-development/2025/mar/18/global-health-trump-usaid-cuts-hiv-aids-2030-drugs-vaccine-research-africa Abdella S, Demissie M, Worku A, Dheresa M, Berhane Y. HIV prevalence and associated factors among female sex workers in Ethiopia, East Africa: A cross-sectional study using a respondent-driven sampling technique. eClinicalMedicine . 2022;51:101540. Available from: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00270-X/fulltext Tigray Health Research Institute (THRI). HIV prevalence doubles in Tigray following war, study reveals. Addis Standard. 2024. Available from: https://addisstandard.com/hiv-prevalence-doubles-in-tigray-following-war-study-reveals/ Haile DA. HIV prevalence rate doubles in post-conflict Tigray, study finds. UNFPA Ethiopia . 2024. Available from: https://ethiopia.unfpa.org/en/news/hiv-prevalence-rate-doubles-post-conflict-tigray-study-finds Berehe T, Asfaw E, Tedla G. Assessment of acceptance and associated factors of HIV pre-exposure prophylaxis among commercial female sex workers in drop-in centers selected sub-cities of Addis Ababa, Ethiopia. Front Public Health. 2024;12:1462648. 10.3389/fpubh.2024.1462648 . Fetene NW, Mekonnen SA. Socio-demographic characteristics of female sex workers in Bahir Dar City Administration, Ethiopia: Baseline assessment for HIV prevention planning. ResearchGate Dataset . 2021. Available from: https://www.researchgate.net/figure/Socio-demographic-characteristics-of-female-sex-workers-in-Bahir-Dar-city-Administration_tbl1_348011376 Tadele G, Yimer G, Azale T. Uptake of retroviral pre-exposure prophylaxis and its associated factors among female sex workers, Northwest Ethiopia: A cross-sectional study. ResearchGate Preprint . 2023. Available from: https://www.researchgate.net/publication/375450390 Tadesse E, Mengesha S, Endalamaw A, Enyew M. Awareness, attitudes, and utilization of HIV pre-exposure prophylaxis (PrEP) among female sex workers in Addis Ababa, Ethiopia: A cross-sectional study. Front Public Health. 2024;12:1462648. https://doi.org/10.3389/fpubh.2024.1462648 . Additional Declarations No competing interests reported. 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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-7415141","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":504333537,"identity":"f59fbae2-d979-41e4-a582-1a2b2d373406","order_by":0,"name":"Leake Amaha Kahsay","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACPgYGZjDDgIGx4cAHIIONnYAWNoQW5saDM0AizMRrYW8+zANiEdTC3vzY4EPNNnlz9oMNh21+bZPnY2Zg/PAxB48WnmPGiTOO3Tbc2ZPYcDi377ZhGzMDs+TMbXi0SCQYH+Zhu8244QBIS89tRqAWNmZefFrkn38+/OffbfsN5x82HLbsuW1PWIsEj3EyY9vtxA03gLYw/LidSFgLT06xYW/f7eQNNx42HOxtuJ3cxszYjNcv/OzHN0v8+HbbdsP59Mcffvy5bTu/vfngh494tKACxjYw2UCsehD4Q4riUTAKRsEoGCkAAIQ4WGDZ+4rKAAAAAElFTkSuQmCC","orcid":"","institution":"Mekelle University","correspondingAuthor":true,"prefix":"","firstName":"Leake","middleName":"Amaha","lastName":"Kahsay","suffix":""},{"id":504333538,"identity":"cfc5446b-ab44-4e83-9b82-658c57519566","order_by":1,"name":"Bethel Abraham Gebremedhin","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Bethel","middleName":"Abraham","lastName":"Gebremedhin","suffix":""}],"badges":[],"createdAt":"2025-08-20 08:23:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7415141/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7415141/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89894661,"identity":"5f0163bd-0660-4c98-b362-2e8333d055b0","added_by":"auto","created_at":"2025-08-26 08:19:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":872434,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7415141/v1/539ee0e7-b964-46b6-a338-22809b0eb4e0.pdf"},{"id":89894660,"identity":"3bee4870-3285-4799-b99c-d0db26e695f1","added_by":"auto","created_at":"2025-08-26 08:19:10","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":27503,"visible":true,"origin":"","legend":"","description":"","filename":"LeakeAmahaKahsayBethelquestionniare.docx","url":"https://assets-eu.researchsquare.com/files/rs-7415141/v1/9cdb8c7101bc5e76e83e8534.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Awareness and Barriers to Pre-Exposure Prophylaxis (PrEP) among Commercial Female Sex Workers in Mekelle City, Tigray, Ethiopia: A Cross – Sectional Study, 2025","fulltext":[{"header":"1. Background","content":"\u003cp\u003e\u003cstrong\u003e1.1. \u0026nbsp; \u0026nbsp; \u0026nbsp;Background\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc195511675\"\u003eThe Human Immunodeficiency Virus (HIV) continues to be a major global public health issue, with significant social, economic, and health-related implications. As of 2023, approximately 39.9 million people globally were living with HIV, with 1.3 million new infections and 630,000 AIDS-related deaths recorded that year \u003cstrong\u003e(1).\u003c/strong\u003e Sub-Saharan Africa bears the heaviest burden, accounting for over two-thirds of all people living with HIV \u003cstrong\u003e(2)\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan id=\"_Toc195511676\"\u003eIn response to the epidemic, pre-exposure prophylaxis (PrEP) has emerged as a highly effective biomedical prevention strategy. Studies have shown that consistent use of PrEP can reduce the risk of HIV acquisition by more than 90% among individuals at substantial risk \u003cstrong\u003e(3).\u003c/strong\u003e Despite its efficacy, global uptake of PrEP remains uneven, particularly in low- and middle-income countries, due to barriers such as high costs, limited awareness, healthcare system constraints, and social stigma \u003cstrong\u003e(2, 4).\u003c/strong\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp id=\"_Toc195511677\"\u003eIn the Horn of Africa, the HIV epidemic is characterized by concentrated prevalence among key populations, including female sex workers (FSWs), men who have sex with men, and people who inject drugs \u003cstrong\u003e(1).\u003c/strong\u003e While overall national prevalence in some countries remains relatively low, these groups experience disproportionately high rates of infection.\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc195511678\"\u003eThe region\u0026rsquo;s capacity to implement PrEP interventions has been challenged by weak healthcare infrastructure, sociocultural resistance, and the destabilizing effects of political conflict \u003cstrong\u003e(5).\u003c/strong\u003e Access to PrEP is further constrained by insufficient program funding and limited integration into national health strategies \u003cstrong\u003e(4)\u003c/strong\u003e. This underscores the need for context-specific approaches that address both structural and individual-level barriers to PrEP use.\u003c/p\u003e\n\u003cp id=\"_Toc195511679\"\u003eIn Ethiopia, the HIV epidemic similarly exhibits a concentrated pattern, particularly among FSWs. A national cross-sectional study conducted across 16 major cities found a pooled HIV prevalence of 18.7% among FSWs, with significant variation\u0026mdash;Bahir Dar had the highest rate at 28.2%, while Shashemene recorded the lowest at 14.0% \u003cstrong\u003e(6).\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc195511680\"\u003eThese figures point to the continued vulnerability of this population, despite Ethiopia\u0026rsquo;s efforts to incorporate PrEP into its national HIV prevention strategy. The Ministry of Health has recognized PrEP as a key component in curbing new infections and has begun integrating it into service delivery for high-risk groups.\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc195511681\"\u003eNevertheless, challenges such as stigma, inconsistent healthcare access, and limited provider training have hindered its effective implementation \u003cstrong\u003e(6).\u003c/strong\u003e Addressing these bottlenecks is critical to improving PrEP coverage and reducing new infections in key populations.\u003c/p\u003e\n\u003cp id=\"_Toc195511682\"\u003eThe context of Mekelle City in the Tigray region illustrates the compounded challenges faced at the sub-national level. Following the recent armed conflict in Tigray, healthcare services\u0026mdash;including HIV prevention, testing, and treatment\u0026mdash;were severely disrupted \u003cstrong\u003e(7).\u003c/strong\u003e In this fragile setting, HIV prevalence has risen sharply.\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc195511683\"\u003eA 2024 study conducted by the UNFPA and regional health authorities reported that HIV prevalence among FSWs in Tigray had reached 8.5%, with over 65% of participants identifying economic hardship and displacement as major contributors to increased vulnerability \u003cstrong\u003e(8).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan id=\"_Toc195511684\"\u003eMekelle\u0026rsquo;s situation is exacerbated by widespread poverty, population displacement, and the collapse of health infrastructure, which have all hindered access to PrEP and related services. Moreover, entrenched stigma and social marginalization of sex workers further deter service utilization. To ensure effective HIV prevention in Mekelle, efforts must focus on rebuilding the healthcare system, expanding targeted awareness campaigns, and ensuring that PrEP services are accessible, culturally sensitive, and resilient to future disruptions.\u003c/span\u003e\u003c/p\u003e\n\u003cp id=\"_Toc199671864\"\u003e\u003cstrong\u003e1.2. \u0026nbsp; \u0026nbsp; \u0026nbsp;Statement of the Problem\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite global and national advancements in HIV prevention, female sex workers (FSWs) in Mekelle City, Tigray, continue to face a heightened risk of HIV infection due to a critical gap in knowledge and awareness of pre-exposure prophylaxis (PrEP). PrEP, a biomedical intervention with proven effectiveness in reducing HIV acquisition among high-risk populations, has been successfully implemented in many contexts; yet its uptake and utilization remain alarmingly low among FSWs in northern Ethiopia \u003cstrong\u003e(1, 6).\u0026nbsp;\u003c/strong\u003eIn post-conflict Tigray, the situation is exacerbated by the socio-economic aftermath of war, which has led to widespread displacement, economic insecurity, and a disrupted health system. A recent study indicated that HIV prevalence among FSWs in the region has surged to 8.5%, with the majority reporting that economic hardship has driven them into transactional sex, often under unsafe conditions \u003cstrong\u003e(8).\u003c/strong\u003e Despite the urgent need for effective HIV prevention, there is limited evidence of structured PrEP education, promotion, or accessibility in Mekelle, a city that is central to the region\u0026rsquo;s recovery.\u003c/p\u003e\n\u003cp\u003eThe low uptake of PrEP is not merely a matter of supply but is deeply rooted in limited awareness, misconceptions, and stigma surrounding HIV and PrEP usage among sex workers. FSWs are often marginalized in healthcare systems, facing discrimination that deters them from seeking preventive services. Compounding this is the inadequate training and preparedness of healthcare providers to deliver PrEP in a way that is both sensitive and accessible to key populations \u003cstrong\u003e(6).\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cspan id=\"_Toc195511687\"\u003eConsequently, the absence of targeted education and awareness strategies on PrEP among FSWs in Mekelle significantly contributes to persistent HIV vulnerability. This underscores a critical public health challenge: without addressing the knowledge gap surrounding PrEP, Ethiopia\u0026rsquo;s broader HIV prevention strategy may fail to reach one of its most at-risk groups. This study is aimed to explore the understanding of the level of knowledge, and barriers to PrEP among CSWs in Mekelle.\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp id=\"_Toc199671865\"\u003e\u003cstrong\u003e1.3. \u0026nbsp; \u0026nbsp; \u0026nbsp;Significance of the Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research helps policy makers to develop targeted education and awareness campaigns for the CSW.\u003c/p\u003e\n\u003cp\u003eBy identifying both barriers and facilitators to PrEP uptake in the aftermath of conflict, the research could inform post-conflict health recovery strategies, ensuring that PrEP is accessible, culturally sensitive, and accepted in the most affected communities.\u003c/p\u003e\n\u003cp\u003eBeyond Mekelle City and Ethiopia, this study has the potential to contribute to global research on HIV prevention for key populations.\u0026nbsp;\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study Setting and Period\u003c/h2\u003e\u003cp\u003eThe study was taken place in Mekelle, Ethiopia, involving CFSW in Mekelle city around kedamay weyane sub city. Data collection was done from May, 2025 to Jun 2025.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Study Design\u003c/h2\u003e\u003cp\u003eA cross-sectional study design with self-administered questions was employed to explore an insight about pre exposure prophylaxis practices, knowledge and barriers for using Pre exposure prophylaxis among CFSW in kedamay weyane sub city setting in Mekelle of Tigray region.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Source of population\u003c/h2\u003e\u003cp\u003eAll FCSWs who are currently engaged in sex work Mekelle City, Tigray, Ethiopia\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Study Population\u003c/h2\u003e\u003cp\u003eThe target Population was FCSWs in Mekelle City, Tigray, Ethiopia selected by snow-ball sampling method.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.5. Inclusion and exclusion criteria\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.5.1. Inclusion criteria\u003c/h2\u003e\u003cp\u003eFCSWs who are currently engaged in sex work. Willing to participate and provide informed consent was included.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\u003ch2\u003e2.5.2. Exclusion criteria\u003c/h2\u003e\u003cp\u003e Those who are not willing to participate or unable to give informed consent was excluded.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.6. Sample Size determination\u003c/h2\u003e\u003cp\u003eFor this cross-sectional study, the sample size was determined using the single population proportion formula\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe formula is: \u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eZ\u003c/span\u003e\u003csub\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003ea/2\u003c/span\u003e\u003c/sub\u003e\u003csup\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eP (1-P)\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eD\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhere,\u003c/p\u003e\u003cp\u003e\u003cb\u003en\u003c/b\u003e is the sample size,\u003c/p\u003e\u003cp\u003e\u003cb\u003eZα/2\u003c/b\u003e is the standard normal variate corresponding to the desired confidence level (1.96 for 95% confidence),\u003c/p\u003e\u003cp\u003e\u003cb\u003ep\u003c/b\u003e is the expected prevalence of the condition (in this case, the proportion of CFSW with adequate knowledge of Prexposure prophylaxis mechanism),\u003c/p\u003e\u003cp\u003e\u003cb\u003eD\u003c/b\u003e is the precision or margin of error (commonly set at 0.05 for a 5% margin of error).\u003c/p\u003e\u003cp\u003eP-value from a study done at Addis Ababa on a similar study (Acceptability of pre-exposure prophylaxis among female sex workers was 67.9%) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eZ\u003c/span\u003e\u003csup\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eP (1-P)\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eD\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003en= \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(1.96)\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026times; 0.679(1\u0026thinsp;\u0026minus;\u0026thinsp;0.679)\u003c/span\u003e\u0026thinsp;=\u0026thinsp;\u003cb\u003e335\u003c/b\u003e was sample size\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e2.7 Sampling method\u003c/h2\u003e\u003cp\u003eSnow ball sampling method among female individuals who are currently engaged in commercial sex work was used in data collection process.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e2.8 Study Variables\u003c/h2\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e2\u003cb\u003e.8.1 Independent variable\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eSocioeconomic and demographic factors such as: Religion, Age, Ethnicity, Educational level, marital status, Sex, Year of study, Original place of study\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e2\u003cb\u003e.8.2 Dependent variables\u003c/b\u003e\u003c/h2\u003e\u003cp\u003eAwareness and Barriers to Pre-Exposure Prophylaxis (PrEP) Uptake\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e2.9 Data Collection Methods\u003c/h2\u003e\u003cp\u003eA semi-structured questionnaire was designed to collect data on awareness of PrEP: Participants\u0026rsquo; knowledge of PrEP, barriers to PrEP, and PrEP utilization. Data on whether participants are currently using PrEP, whether they have enough knowledge about PrEP, and barriers to use PrEP. To collect data accurately and precisely, data collectors underwent training on the study's objectives and understanding participants how to answer the questionnaire. This training ensured that the data collectors are fully equipped to conduct the data collection process effectively.\u003c/p\u003e\u003cp\u003eThe surveys were anonymous to respect participants\u0026rsquo; confidentiality and minimize potential biases.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\u003ch2\u003e2.9.1 Data Collection Procedure:\u003c/h2\u003e\u003cp\u003eThe data collection was conducted in a private, confidential setting to ensure participants feel safe sharing their experiences. Participants were recruited from kedamay Weyane sub city Drop- in centers. An individual who met the criteria and expressed their interest in participation was reached out to the researcher through phone communication or by visiting in person.\u003c/p\u003e\u003cp\u003eThose who were meet the inclusion criteria were distributed the questionnaire to them. Data collection was conducted between May - Jun, 2025. Prior to distributing the questionnaire, the researcher was read an information sheet about the study, and participants expected to provide verbal consent to participate. Additional comments were captured in written form on the note pad. All data to be collected was anonymous. The researcher translated the Tigrinya questionnaire into English.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e2.10 Data Management and Statistical Analysis\u003c/h2\u003e\u003cp\u003eData was encoded first then data was entered and analyzed using the Statistical Package for Social Sciences version 20. Data was represented by frequency and percentages and presented with tables, pie charts.\u003c/p\u003e\u003cp\u003eIdentification codes to participants instead of using their names during data collection, analysis, and reporting.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Result","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Sociodemographic Characteristics\u003c/h2\u003e\u003cp\u003eThe study included a total of 335 female sex workers with a mean age of 30.25 years (range: 24\u0026ndash;41). The majority of participants were Orthodox Christians 318 (94.9%), followed by Muslims 13 (3.9%) and Protestants 4 (1.2%). Regarding marital status, most were divorced 217 (64.8%), followed by single 97 (29.0%) and widowed 21 (6.3%). Educationally, 170 (50.7%) had attended secondary education or above, while 165 (49.3%) were only able to read and write. In terms of occupation, 178 (53.1%) were engaged only in sex work, while 157 (46.9%) combined it with other work. The duration in sex work varied, with the highest proportion having worked for 3 years 68 (20.3%), followed by 6 years 57 (17.0%), 2 years 51 (15.2%), and 5 years 41 (12.2%). A total of 150 (44.8%) reported working several times a week in the past 3 months, 66 (19.7%) weekly, 50 (14.9%) daily, 42 (12.5%) several times a day, and 27 (8.1%) rarely. The reasons for entering sex work included financial problems 109 (32.5%), conflict with parents 107 (31.9%), peer pressure 67 (20.0%), addiction and others 34 (10.1%), and other unspecified reasons 18 (5.4%). The average monthly income was 12,789.55 ETB, ranging from 5,000 to 112,000 ETB. Condom use during sexual intercourse was reported by only 99 (29.6%), while 236 (70.4%) did not use condoms.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Awareness about PrEP\u003c/h2\u003e\u003cp\u003eOut of the total participants, 294 (87.8%) had heard of PrEP, while 41 (12.2%) had not or responded incorrectly. However, only 91 (27.2%) correctly identified PrEP as a medicine to prevent HIV; 123 (36.7%) believed it is a cure for HIV, 113 (33.7%) thought it is a form of emergency contraception, and 8 (2.4%) did not know. The main source of information was health workers 235 (70.1%), followed by social media 66 (19.7%) and friends/peers 34 (10.1%). When asked if they knew PrEP prevents HIV, 260 (77.6%) said yes, 34 (10.1%) said no, and 41 (12.2%) were unsure. Awareness that PrEP must be taken daily was reported by 293 (87.5%), while 35 (10.4%) said no and 7 (2.1%) were unsure. A total of 328 (97.9%) correctly stated PrEP is intended for people at high risk of HIV, while 7 (2.1%) incorrectly said it is for people living with HIV. All participants 335 (100.0%) knew that PrEP services are available in Mekelle. Regarding how PrEP is taken, 229 (68.4%) said one pill daily, 82 (24.5%) said only before sex, and 24 (7.2%) said once a week. When asked if PrEP replaces condom use, 229 (68.4%) agreed, 82 (24.5%) disagreed, and 24 (7.2%) were unsure. Lastly, 300 (89.6%) believed PrEP reduces HIV transmission, while 35 (10.4%) did not. Only 24 (7.2%) thought PrEP protects against other STIs, whereas 150 (44.8%) said no and 161 (48.1%) were not sure.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Utilization of PrEP\u003c/h2\u003e\u003cp\u003eAmong the participants, 266 (79.4%) had ever used PrEP, and 301 (89.9%) were currently taking it. All current users 301 (100.0%) reported taking it daily. Most accessed PrEP from government health facilities 285 (94.7%), while 16 (5.3%) obtained it from private clinics. Regarding duration of use, 127 (42.2%) had used it for less than 1 month, 50 (16.6%) for 1\u0026ndash;6 months, and 124 (41.2%) reported not currently using it. Counseling before initiation of PrEP was reported by only 16 (5.3%), while 94 (31.2%) did not receive any, and 191 (63.5%) were not sure. Side effects were reported by 224 (74.4%), while 77 (25.6%) did not experience any. A total of 41 (13.6%) had stopped taking PrEP at some point, with reasons including forgetting to take it regularly 9 (36.0%), feeling no longer at risk 8 (32.0%), and side effects 8 (32.0%). Among the 34 participants not currently on PrEP, 25 (73.5%) were willing to take it in the future, and 9 (26.5%) were unsure.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe current study among 335 female sex workers (FSWs) in Mekelle revealed that the mean age was 30.25 years, which is higher compared to earlier studies conducted in Bahir Dar (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), Nazareth (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), and Addis Ababa(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), where the mean age was approximately 22.1 years.\u003c/p\u003e\u003cp\u003eA majority (64.8%) of participants in the Mekelle study were divorced, whereas national surveys in 2002 and 2005 reported that only 57% and 48%, respectively, of FSWs were ever married. Educational attainment in Mekelle was relatively balanced, with 50.7% having completed secondary school or above, which is substantially higher than the 14.7% reported in earlier studies. Furthermore, 53.1% of the participants in Mekelle engaged solely in sex work, a trend that aligns with findings from Addis Ababa, though in other regions many FSWs also had alternative income sources. Condom use during sexual intercourse was reported by only 29.6% of FSWs in Mekelle, which is lower than figures reported in other parts of Ethiopia, where inconsistent but somewhat higher condom use has been observed.\u003c/p\u003e\u003cp\u003eAwareness about PrEP among participants in this study was high, with 87.8% having heard about it. However, only 27.2% correctly identified PrEP as a medicine to prevent HIV. This is lower than the findings from a study in Addis Ababa, where 82% had heard of PrEP and 45% correctly identified its preventive role. Health workers were the main source of PrEP information in both studies, emphasizing their key role in public health communication. Nevertheless, misconceptions persisted in both settings\u0026mdash;many believed PrEP was a cure for HIV or a form of emergency contraception, indicating a need for better-targeted education and awareness campaigns. Notably, 100% of participants in Mekelle knew that PrEP services were available locally, suggesting good service visibility.\u003c/p\u003e\u003cp\u003ePrEP utilization in Mekelle was notably high, with 79.4% having ever used it and 89.9% currently on it, all of whom reported daily use. These rates are significantly higher compared to a study in Bahir Dar, where only 46.2% of FSWs reported using PrEP. The greater uptake in Mekelle may be attributed to better service availability and stronger public health outreach. Despite this, only 5.3% of participants reported receiving counseling before starting PrEP, pointing to a critical gap in service delivery. Additionally, 74.4% of users experienced side effects, which could potentially affect adherence. Among those who stopped taking PrEP, common reasons included forgetting to take it (36%), feeling no longer at risk (32%), and experiencing side effects (32%). Encouragingly, 73.5% of those not currently on PrEP expressed willingness to use it in the future, reflecting a positive attitude toward HIV prevention efforts.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study highlights critical findings on the Sociodemographic characteristics, awareness, and utilization of PrEP among female sex workers (FSWs) in Mekelle, Ethiopia. Compared to previous studies conducted in regions such as Addis Ababa, Bahir Dar, and Nazareth, the FSWs in Mekelle were slightly older and more likely to have attained secondary education or higher. However, consistent condom use remained low, suggesting ongoing vulnerability to HIV and other sexually transmitted infections.\u003c/p\u003e\u003cp\u003eAwareness of PrEP was impressively high in Mekelle, yet significant misconceptions persist regarding its purpose and usage. Although nearly all participants had heard of PrEP and were aware of its availability, many misidentified it as a cure for HIV or emergency contraception, indicating gaps in accurate health education. Encouragingly, most participants recognized PrEP\u0026rsquo;s role in preventing HIV, and the majority were actively using it, reflecting strong engagement with HIV prevention services.\u003c/p\u003e\u003cp\u003eDespite the high uptake of PrEP, challenges remain. A large proportion of users reported experiencing side effects, and only a small fraction received pre-initiation counseling both of which could affect long-term adherence. The willingness of non-users to initiate PrEP use in the future is promising and suggests a favorable attitude that health programs can build upon. To enhance the effectiveness of HIV prevention strategies, interventions should focus on improving the quality of counseling, correcting misconceptions, and promoting adherence while also addressing the broader social and economic determinants that influence FSWs\u0026rsquo; health behaviors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAGYW\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdolescent Girls and Young Women\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAIDS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcquired Immune Deficiency Syndrome\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eART\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAntiretroviral Therapy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBehavior Change Communication\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBSS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBehavioral Surveillance Survey\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCDC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCenters for Disease Control and Prevention\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDHIS2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDistrict Health Information Software 2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDIC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDrop-In Center\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEPHA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEthiopian Public Health Association\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEPHI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEthiopian Public Health Institute\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFHAPCO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFederal HIV/AIDS Prevention and Control Office\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFMOH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFederal Ministry of Health\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFCSW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale Commercial Sex Workers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFSW\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale Sex Workers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGBV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender-Based Violence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHIV Counseling and Testing\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHMIS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth Management Information System\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHRST\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHIV Risk Screening Tool\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndex Case Testing\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKPP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKey and Priority Populations\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMARPs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMost At-Risk Populations\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNSP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNational Strategic Plan\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePEPFAR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePresident\u0026rsquo;s Emergency Plan for AIDS Relief\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePLHIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeople Living with HIV/AIDS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrEP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Exposure Prophylaxis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePSI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePopulation Services International\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the ethical principles outlined in the \u003cem\u003eDeclaration of Helsinki\u003c/em\u003e. Ethical clearance was obtained from the Ethical Review Committee of Mekelle University College of Health Sciences (Reference No:\u0026nbsp;\u003cstrong\u003eMU-IRB 2538/2025\u003c/strong\u003e). Written informed consent was obtained from all participants before data collection. Participation was voluntary, and confidentiality was maintained throughout the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent of publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYes, all data are included in the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI have no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo financial funds were gained to conduct this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization:\u003c/strong\u003e Leake Amaha Kahsay\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData curation:\u003c/strong\u003e Leake Amaha Kahsay, Bethel Abraham Gebremedhin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFormal analysis\u003c/strong\u003e: Leake Amaha Kahsay\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInvestigation:\u003c/strong\u003e Leake Amaha Kahsay, Bethel Abraham Gebremedhin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e Leake Amaha Kahsay, Bethel Abraham Gebremedhin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProject administration\u003c/strong\u003e: \u0026nbsp;Leake Amaha Kahsay, Bethel Abraham Gebremedhin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResources:\u003c/strong\u003e Leake Amaha Kahsay, Bethel Abraham Gebremedhin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSoftware:\u003c/strong\u003e Leake Amaha Kahsay\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupervision:\u003c/strong\u003e Leake Amaha Kahsay\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVisualization\u003c/strong\u003e: \u0026nbsp;Leake Amaha Kahsay, Bethel Abraham Gebremedhin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWriting \u0026ndash; original draft\u003c/strong\u003e: Leake Amaha Kahsay, Bethel Abraham Gebremedhin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWriting \u0026ndash; review \u0026amp; editing:\u0026nbsp;\u003c/strong\u003eLeake Amaha Kahsay, Bethel Abraham Gebremedhin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In the first, praises and thanks to God, the almighty, for granting me the capability to proceed successfully. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ethiopia.unfpa.org/en/news/hiv-prevalence-rate-doubles-post-conflict-tigray-study-finds\u003c/span\u003e\u003cspan address=\"https://ethiopia.unfpa.org/en/news/hiv-prevalence-rate-doubles-post-conflict-tigray-study-finds\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerehe T, Asfaw E, Tedla G. Assessment of acceptance and associated factors of HIV pre-exposure prophylaxis among commercial female sex workers in drop-in centers selected sub-cities of Addis Ababa, Ethiopia. Front Public Health. 2024;12:1462648. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2024.1462648\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2024.1462648\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFetene NW, Mekonnen SA. Socio-demographic characteristics of female sex workers in Bahir Dar City Administration, Ethiopia: Baseline assessment for HIV prevention planning. \u003cem\u003eResearchGate Dataset\u003c/em\u003e. 2021. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/figure/Socio-demographic-characteristics-of-female-sex-workers-in-Bahir-Dar-city-Administration_tbl1_348011376\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/figure/Socio-demographic-characteristics-of-female-sex-workers-in-Bahir-Dar-city-Administration_tbl1_348011376\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTadele G, Yimer G, Azale T. Uptake of retroviral pre-exposure prophylaxis and its associated factors among female sex workers, Northwest Ethiopia: A cross-sectional study. \u003cem\u003eResearchGate Preprint\u003c/em\u003e. 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/375450390\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/publication/375450390\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTadesse E, Mengesha S, Endalamaw A, Enyew M. Awareness, attitudes, and utilization of HIV pre-exposure prophylaxis (PrEP) among female sex workers in Addis Ababa, Ethiopia: A cross-sectional study. Front Public Health. 2024;12:1462648. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2024.1462648\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2024.1462648\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"aids-research-and-therapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arty","sideBox":"Learn more about [AIDS Research and Therapy](http://aidsrestherapy.biomedcentral.com/)","snPcode":"12981","submissionUrl":"https://submission.nature.com/new-submission/12981/3","title":"AIDS Research and Therapy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"PrEP, HIV/AIDS, Female sex workers","lastPublishedDoi":"10.21203/rs.3.rs-7415141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7415141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Nationally, Ethiopia's HIV epidemic is concentrated among key populations, with female sex workers showing a disproportionately high prevalence of HIV, averaging 18.7% across urban centers. In Mekelle, recent data indicate a rising HIV prevalence of 8.5% among CSWs, underscoring the urgent need for accessible and effective prevention strategies. However, barriers including low PrEP awareness, misinformation, stigma, and limited healthcare access significantly hinder PrEP utilization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e a cross sectional study was done.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult:\u003c/strong\u003eThe study surveyed 335 female sex workers, with a mean age of 30.25 years, most of whom were divorced, Orthodox Christians, and had at least secondary education. Nearly 88% had heard of PrEP, but only 27.2% correctly identified it as an HIV prevention method, with health workers being the main information source. Most participants (79.4%) had used PrEP, and 89.9% were currently taking it daily, mainly from government facilities. Counseling before starting PrEP was rare, and over 74% reported experiencing side effects. While 13.6% had discontinued PrEP at some point, the majority expressed willingness to resume its use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eThis study expressed that female sex workers in Mekelle had high awareness and usage of PrEP, though consistent condom use was low and misconceptions about PrEP were common. Despite strong uptake, most users lacked proper counseling and many experienced side effects, which could hinder adherence. Strengthening education, counseling, and support services is essential to improve the effectiveness of HIV prevention among this high-risk group.\u003c/p\u003e","manuscriptTitle":"Awareness and Barriers to Pre-Exposure Prophylaxis (PrEP) among Commercial Female Sex Workers in Mekelle City, Tigray, Ethiopia: A Cross – Sectional Study, 2025","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-26 08:03:06","doi":"10.21203/rs.3.rs-7415141/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-17T08:45:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-16T16:04:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-16T16:04:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-15T13:15:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13526960858033857151377608595119177817","date":"2025-10-29T06:40:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157863259181493646777414683856629878711","date":"2025-10-28T04:35:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"271171608850525129160102425610838835674","date":"2025-10-27T10:00:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75555537333892273895793098406421836506","date":"2025-10-25T17:18:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-06T18:43:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109954908978628047870824574575577937144","date":"2025-09-17T09:42:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-26T15:24:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-22T17:00:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-22T08:55:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"AIDS Research and Therapy","date":"2025-08-20T08:13:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"aids-research-and-therapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arty","sideBox":"Learn more about [AIDS Research and Therapy](http://aidsrestherapy.biomedcentral.com/)","snPcode":"12981","submissionUrl":"https://submission.nature.com/new-submission/12981/3","title":"AIDS Research and Therapy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d51f7697-ebae-497b-a33e-b1f4542e7e49","owner":[],"postedDate":"August 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T08:53:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-26 08:03:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7415141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7415141","identity":"rs-7415141","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}