Applying Mixed Methods to Understand Kusalidwa (Stigma) and Psychosocial Barriers to Pre-Exposure Prophylaxis (PrEP) Among Women Engaging in Sex Work in Lusaka, Zambia

Abstract

In Zambia, women engaging in sex work (WESW) are a key population (KP) disproportionately affected by the HIV pandemic, with prevalence significantly higher than the general population. Despite high initiation rates, persistence on pre-exposure prophylaxis (PrEP) remains low among sex workers. This dissertation explores the barriers and enablers to PrEP uptake and persistence among WESW in Lusaka, Zambia, through a mixed-methods approach.Chapter 2 examines the association between discrimination, multiple types of stigmas, and PrEP persistence among sex workers. Using a prospective cohort design, 298 cis-gendered WESW aged ≥18 years were enrolled and eligible from two urban community hubs. Surveys assessed chronic discrimination and validated scales for HIV and PrEP stigma, were linked to electronic medical records (N=262) to track PrEP persistence. High levels of chronic discrimination, primarily due to being identified as a sex worker, were significantly associated with immediate PrEP discontinuation (aPR=1.6; 95%CI:1.07,2.54; p=0.03). Chapter 3 qualitatively explores perceptions and preferences for oral and long-acting injectable PrEP (LAI-PrEP) among WESW and peer-navigators. Using the COM-B model, the study identified critical factors influencing PrEP engagement. Education by peer navigators and program staff was crucial in building trust and demystifying PrEP among participants, though persistent knowledge gaps, especially about adherence and alcohol use, remained significant barriers. Trustworthy program staff and reliable service provision facilitated continued PrEP use. Long-acting injectable PrEP (LAI-PrEP) was preferred for its reduced stigma and pill burden but concerns about side effects and supply inconsistency emerged as potential barriers. The findings underscore the need for holistic, person-centered approaches that address psychosocial and structural barriers, while leveraging available peer support and targeted prevention education to enhance PrEP engagement. By implementing stigma reduction interventions and creating trustworthy, KP-led services, HIV prevention efforts among WESW in Zambia can be significantly improved.