Clinic distance impedes PrEP programme success in Uganda

14 May 2019

Understanding the unique barriers to pre-exposure prophylaxis (PrEP) uptake and retention in sub-Saharan Africa remains critical to its successful roll-out.

A small hospital in Uganda, Africa.

Geography and transportation barriers are associated with poor uptake of pre-exposure prophylaxis (PrEP) and care retention, reveals a new study from rural Uganda. Among those eligible to start PrEP, uptake was very low at 39% and of those who started PrEP just 17% attended the initial four-week follow-up. 

The study took place in Ruhoko, a rural community in southwestern Uganda among members enrolled in the larger SEARCH study, a cluster randomised control trial evaluating test-and-treat in Kenya and Uganda. The model included a hybrid mobile HIV testing approach incorporating multiple-disease community health campaigns (CHCs), followed by home-based testing (HBT) of people who did not participate in the CHCs.

The intervention arm of the ongoing Phase II of SEARCH is looking at the effect of a population-based approach to increasing knowledge and access to PrEP for those at-risk of HIV. People were eligible for PrEP based on a risk-assessment score, having an HIV-positive partner, or if they self-referred following a home visit or the CHC.

In total, 701 people were identified as being eligible for PrEP, and data was collected via GPS, measuring the distance to clinic, the walking time to clinic and road difficulty. A sample of participants was also asked to identify their primary barriers to PrEP use with a semi-quantitative questionnaire.

Eligible participants who lived 2 km or more from the clinic were less likely to have started PrEP at the outset and less likely to be retained in care. Participants who could not be offered same-day PrEP were also significantly less likely to uptake. Walking time to clinic of 30 minutes or more and higher degrees of road difficulty were also associated with lower PrEP uptake and poorer retention – however these associations were not significant.

Among 98 people who completed the questionnaire on PrEP barriers, the most frequently cited barriers to PrEP were “needing to take it every day” (N = 18) and low risk perception (N = 18). Around 10% of the participants named travel-related barriers including “clinic is too far away” (N = 6).

Understanding barriers to uptake in the context of sub-Saharan Africa is critical to the successful roll-out of PrEP. On top of challenges for individuals, people in this setting may face unique structural barriers relating to PrEP access.

“Low uptake and retention of PrEP in this community is indicative of the implementation challenges that PrEP programmes in [sub-Saharan Africa] may face when deployed on a population-level, as compared to a clinical trial setting,” comment the authors in their discussion. It is clear that distance alone may not be the primary driver of PrEP uptake given how few people started it in the first place. Other studies have pointed to low risk perception among some populations as a main reason why PrEP is so poorly received in Africa.

Research in Uganda has already revealed that people living with HIV who live far away from the clinics have lower odds of staying in care compared to those who live closer. While PrEP is not nationally available at all public health clinics in Uganda, scale-up is anticipated.

“In terms of implementation, this analysis contributes to other literature showing that delivery of PrEP must be optimized to improve uptake and retention, and that transportation-related barriers must be a part of this optimization package.”

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Photo credit:
istock/Delmas Lehman

Written by Caitlin Mahon

Content Specialist - HIV & Sexual Health