Feasibility of a community-based delivery model for HIV pre-exposure prophylaxis among bar patrons in rural South Africa

Abstract

Introduction: South Africa, home to the world's largest HIV epidemic, has made great strides in improving access to HIV services, but specific groups, particularly young men, remain difficult to engage in the HIV care cascade. Alcohol use disorder, prevalent in South Africa, further complicates engagement. Congregate settings where alcohol is served, known as shebeens, are an ideal place to engage young people for HIV testing, treatment and prevention, including pre-exposure prophylaxis (PrEP). Here, we characterize the uptake of PrEP in shebeen patrons and explore the effect of alcohol consumption on PrEP uptake by piloting a community-based delivery model.

Methods: In the rural Kwazulu-Natal province (KZN) of South Africa, a field team made up of all men offered screenings outside of shebeens at 27 events over 6 months in 2020. Screenings included rapid HIV testing and Alcohol Use Disorder Identification Test (AUDIT). Participants who tested negative for HIV were offered PrEP as once daily oral tenofovir disoproxil fumarate/emtricitabine. Short-term retention was determined. Logistic regression was performed to identify predictors of PrEP uptake, including unadjusted and adjusted odds ratios (OR) with 95% confidence interval.

Results: One hundred and sixty-two shebeen patrons were screened, and 136 (84%) were eligible for PrEP. Among those eligible, 37 (27%) completed clinical evaluation and initiated PrEP. Among PrEP initiators, 91.9% were men, median age was 26.0 years (interquartile range 21-31), 32.4% were employed, 18.9% had running water and 70.3% had AUDIT scores indicating hazardous drinking. Among 37 initiators, 25 (68%) were retained at 1 month, and 19 (51%) were retained at 4 months. Independent predictors of PrEP uptake among all bar patrons, and only men (108 screened and 34 initiators), included younger age (OR 0.92 [0.88-0.97]) and lifetime number of sexual partners (OR 1.07 [1.02-1.13]).

Conclusions: Community-based PrEP delivery after engagement at shebeens in rural South Africa is a feasible and novel approach to reach a traditionally difficult-to-engage population, particularly young men. In this small sample, sexual risk behaviours predicted PrEP uptake. Hazardous drinking was not a barrier to PrEP initiation.

Keywords: HIV prevention; PrEP; alcohol use disorder; differentiated service delivery; heterosexual; young men.