Background: Since Kenya began scaling up oral PrEP in May 2017, uptake has been slower than expected among adolescent girls and young women (AGYW), and overall continuation rates consistently low. Stigma was documented as a substantial barrier during clinical trials, hence understanding how PrEP-related stigma is experienced in routine service delivery is critical to improve PrEP outcomes. The Jilinde project, funded by the Bill & Melinda Gates Foundation, provides PrEP to female sex workers (FSW), men who have sex with men (MSM) and AGYW. This abstract describes how stigma is manifested and its impact on PrEP uptake and continuation.
Methods: Between October 2017 and November 2018, qualitative data were collected from 222 respondents via 22 focus group discussions (FGD) and 30 in-depth interviews: 86 AGYW, 12 parents of AGYW, 10 male partners of AGYW, 36 MSM, 28 FSW, 29 health care providers, and 20 peer educators. All interviews and FGDs were audio-recorded, transcribed and translated, then thematically analyzed.
Results: Stigma negatively influenced PrEP uptake and continuation among AGYW, FSW and MSM, who self-stigmatized and were stigmatized by others. Stigma was manifested through stereotypes, prejudice, and discrimination by peers, sexual partners, family, health care providers, and the community. For MSM and FSW, PrEP-related stigma was intertwined with identity stigma, while for AGYW it was manifested through stigma toward sexual behavior. Some health providers equated giving PrEP to these populations to promoting immorality. All individuals disguised their PrEP use since it was associated with ''recklessness''. PrEP users were labelled as promiscuous and subjected to similar stigma associated with being HIV-positive. Consequently, PrEP use was hampered by: fear of violence and rejection by an intimate partner, family or community members; discrimination by providers; loss of ''business''; reputational damage; and shame.
Conclusions: Stigma remains a critical barrier to PrEP use among priority communities in Kenya and was directed towards the product, clients'' behavior and identity. While stigma was manifested differently for diverse populations, results were similar in terms of PrEP uptake and continuation. Health care providers and communities should be prioritized in stigma interventions to improve uptake and optimize the outcomes of PrEP.