Pharmacy-based PrEP for Young Women who Sell Sex in Zimbabwe

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Project Summary Global prevalence of HIV among female sex workers (FSW) is high. In Eastern and Southern Africa 10.4% and 33.3% of FSW are HIV infected. In Zimbabwe, prevalence estimates among FSW are as high as 78% in some regions and incidence is estimated at 5-10% per annum (over 10 times that in adult women more generally), with incidence highest among younger women and those recently engaged in sex work. Modelling suggests that with high uptake and continuation pre-exposure prophylaxis (PrEP) could potentially reduce HIV incidence in FSW by 40%, critical for its own sake but also for epidemic control. Modelling also suggests that 40-80% of all new infections in sub-Saharan Africa by 2035 are likely directly or indirectly attributable to transmission as a result of selling sex. Although PrEP is highly effective and demonstration projects show that PrEP is feasible to deliver and acceptable among FSW in Africa, the majority of sex workers who initiate PrEP stop taking it within the first few months due to a mix of structural and behavioral barriers. Many of these barriers can potentially be addressed through interventions that leverage psychosocial support, behavioral economics and structural issues. We propose to co-develop and evaluate an intervention to directly tackle poor PrEP continuation through a pharmacy-based intervention designed to increase access to PrEP and reduce stigma around its use. If successful, this preliminary study will pave the way for a future effectiveness trial to evaluate this intervention more comprehensively. Using a participatory process, we will work collaboratively with pharmacy owners and FSW to design safe and convenient spaces for PrEP refill pick-ups bundled with HIV self-testing (HIVST) and a gift card incentive (Aim 1); we will then pilot the intervention among women initiating PrEP through CeSHHAR’s existing Sisters with a Voice program to evaluate the impact on PrEP retention at 7 months (Aim 2); finally, using an implementation science approach, we will use mixed-methods to understand the potential for scale of the FSW-focused pharmacy program, and based on the findings, translate lessons learned into the design of a future effectiveness trial (Aim 3). The proposed study will explore whether pharmacies can be used to distribute PrEP refills among FSW. If effective the intervention could be adapted for other PrEP users and for new PrEP technologies as they become available. The results will provide guidance on the acceptability of pharmacy-based PrEP services, bundling PrEP with HIVST and a gift card incentive, and whether pharmacy-based distribution is feasible, acceptable, and worthy of future development.