Acceptability of same-day HIV pre-exposure prophylaxis initiation among individuals with depression symptoms during emergency care in Nairobi, Kenya.

Abstract

University of WashingtonAbstract Acceptability of same-day HIV pre-exposure prophylaxis initiation among individuals with depression symptoms during emergency care in Nairobi, Kenya. IntroductionHIV pre-exposure prophylaxis (PrEP) is an important prevention strategy, but its integration into routine care faces challenges, especially in low- and middle-income countries. Emergency departments (EDs) present a unique, yet underutilized, opportunity for PrEP delivery, particularly for people with less access to care or who are marginalized and face challenges accessing care, such as those from key populations. Emergency care utilization is high among people with depression and may influence health decision-making, including PrEP uptake. This study aimed to determine the acceptability of same-day PrEP initiation among ED patients with varying depression severities and identify associated patient-level factors. The hypothesis was that patients screening positive for moderate to severe depression would be less likely to accept same-day PrEP than those with screening scores consistent with a lower risk of depression due to the potential impact of depression-related cognitive impairment on health decision-making. Methods This cross-sectional study utilized secondary data from the ED-PrEP study, conducted from July 5, 2024, to August 18, 2024, at the ED of Kenyatta National Hospital in Nairobi, Kenya. 1 The study population included 295 adult ED patients (aged ≥18) who were not critically ill or pregnant and had a Patient Health Questionnaire 9 (PHQ-9) scores of 1 or higher. The primary outcome was the acceptability of same-day PrEP initiation, defined as willingness to start PrEP if eligible. Depression severity was the primary exposure, categorized by PHQ-9 scores: minimal to mild (scores 1-8), moderate (scores 9-14), and moderately severe to severe (scores 15-27). Statistical analysis was conducted using chi-square tests, simple, univariate, and multivariate logistic regression to calculate unadjusted and adjusted odds ratios (aOR) with 95% confidence intervals (CI), adjusting for sociodemographic and behavioral confounders. Results Of the 295 participants analyzed, 46% had minimal to mild depression, 39% moderate, and 15% moderately severe to severe depressive symptoms. Willingness to initiate same-day ED-PrEP was high across all groups: 76.3% (minimal to mild), 76.5% (moderate), and 84.4% (moderately severe to severe). There was no statistically significant association between depression severity and PrEP acceptability. However, being unmarried (aOR=2.93, 95% CI: 1.42-6.06), reporting consistent condom use (aOR=3.72, 95% CI: 1.22-11.34), knowing a partner's HIV status (aOR=2.07, 95% CI: 1.18-3.64), and experiencing intimate partner violence (IPV) (aOR=2.34, 95% CI: 1.15-4.76) were significantly associated with higher PrEP acceptability. Conclusions Depressive symptom severity did not influence the acceptability of same-day PrEP initiation among ED patients in Nairobi. The high overall PrEP acceptability highlights the feasibility of integrating PrEP services into the emergency departments. Factors such as marital status, condom use, awareness of partner HIV status, and history of IPV were strong predictors of PrEP acceptability. These results underscore the importance of comprehensive, person-centered approaches in EDs that address both HIV risk and co-occurring vulnerabilities like IPV, to effectively improve PrEP uptake in high-burden settings