HIV pre-exposure prophylaxis initiation in community safe spaces increases PrEP access among key populations in Zambia

Comprehensive HIV prevention initiatives in Zambia are significantly blunting the epidemic spread. Between 2010 and 2021, new HIV acquisitions decreased by >50% [1], due to increased access to antiretroviral therapy (ART), comprehensive prevention and scale-up of pre-exposure prophylaxis (PrEP) since 2018. With these advancements, Zambia is nearing HIV epidemic control, with 88.7% of people living with HIV aware of their status; 98.0% of those are on ART, 96.3% of whom are virally suppressed [2].

Yet, 1.5 million Zambians remain at high risk of acquiring HIV, with about 810,000 ever-initiating PrEP. Oral PrEP decreases the risk of HIV acquisition by more than 90% [3-5], poses few safety risks, and unlike barrier methods, can be taken discreetly and independently [6]. As of 2023, over four million people initiated PrEP globally [4, 7]. While sub-Saharan Africa represents over 70% of the global HIV burden, the region only accounts for 44% of global PrEP initiations, with Zambia contributing just 9% [1, 7, 8].

The CIRKUITS community PrEP programme expanded from four safe spaces in two districts to 13 safe spaces in 12 districts between October 2020 and September 2022. The programme now has 194 staff members, including 154 KP-CHWs, 13 community liaison officers and 27 nurses, in addition to 140 gatekeepers. CHW retention increased from 57% in year 1 to 82% in year 2 after implementing measures like standardized stipends and transport reimbursement.

From 1st October 2021 to 1st March 2023, among 6,583 individuals eligible for and willing to start PrEP, 6,567 (99.8%) initiated PrEP at prevention posts. Among KPs, TG had the highest PrEP uptake, with all 241 (100%) initiating PrEP. PrEP uptake was also high among FSW (3,254/3,262; 99.8%); MSM (2,674/2,681; 99.7%); and PWID (398/399; 99.7%) (Figure 1). PrEP initiation rates were consistently high across all KPs, age groups and provinces, with near 100% uptake. By region, the highest PrEP uptake was in Western Province; by age, PrEP uptake was the highest among persons aged 45 years and above.

For PrEP perseverance at month 1, 67.8% of initiated clients continued PrEP; this decreased to 36.2% at 3 months. Among KPs, TG had the highest PrEP continuation at 1 month (75.9%), while MSM had the highest continuation at month 3 (37.7%). PWID had the lowest PrEP continuation rates, at both 1 month (63.6%) and 3 months (26.6%).

We found community PrEP initiation through community prevention health posts to be an effective strategy for reaching underserved KPs in Zambia with biomedical HIV prevention interventions. However, PrEP persistence remained overall low, despite the implementation of multiple supportive strategies, including motivational interviewing regarding stigma and pill fatigue, peer support groups, flexible service delivery models like community-based refills and phone consultations, and injectable PrEP at three sites. Further research is needed to understand factors influencing PrEP uptake and persistence, and to identify implementation strategies that support continued PrEP use.

The authors declare that they have no conflicts of interest.

LKM, CWC and HS conceived the project. LKM and CB conducted literature searches. BL and PO verified the source data and conducted data analysis. LKM, CB and M-CCL wrote the initial draft. BL and CWC edited the manuscript and provided scientific and technical input. LKM, CB and CWC revised and finalized the manuscript. All authors have read and approved the final manuscript.

The CIRKUITS project and this publication have been supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC) under the terms of NU2GGH002123.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the funding agencies.