Perceived pre-exposure prophylaxis stigma among female sex workers: A potential barrier for intervention effectiveness

Introduction: The antiretroviral medication pre-exposure prophylaxis (PrEP) provides 99% protection against HIV infection if taken daily. While PrEP is being rolled-out in Tanzania to female sex workers, uptake and adherence has proven to be a challenge during the demonstration trial in the country and beyond. Perceived PrEP stigma, the idea that people may come to stigmatize you because of taking PrEP, has been identified as a potential barrier to intervention effectiveness. Objectives/Aims: To assess perceived PrEP stigma and associated predictors among female sex workers initiating PrEP in Dar es Salaam. Methodology: Using respondent driven sampling, female sex workers in Dar es Salaam were recruited to a study in collaboration with a health clinic offering PrEP. We used a 5-point 10 item Likert scale to assess perceived PrEP stigma at baseline, with Cronbach’s alpha of 0.84. The stigma scale was dichotomized at score > 3 reflecting “higher perceived stigma”. We conducted bivariate analysis to assess for predictors, with confidence level at 5%. Results: A total of 470 female sex workers with a median age of 26 years (IQR:22-30) were recruited. More than half (58.9%, 95% CI: 36.7-45.6) had some secondary education. The median stigma score was 2.4 (IQR 2-3). A quarter (24.3%, 95% CI: 20.6-28.4) experienced “higher perceived stigma”. Factors associated with higher levels of perceived stigma were low social support (OR: 1.8, 95% CI: 1.2-2.8), limited access to condoms (OR 1.8, 95% CI:1.1-3.1) and having fewer clients per month (p-value 0.01). Conclusion: Higher perceived PrEP stigma was present among a quarter of female sex workers initiating PrEP in Dar es Salaam, with low social support, limited access to condoms, and having few clients being associated factors. We have not found any study of female sex workers that have examined this construct using a comparable scale limiting the opportunity for cross-context comparisons. Recommendation: Findings suggests that addressing socio-structural factors alongside PrEP provision can be important for the PrEP continuum of care.