Pre-Exposure Prophylaxis Uptake and Associated Factors Among Key Populations in the Nylon and New Bell Health Districts, Cameroon

2.1. Study Design and Setting

A cross-sectional study was conducted between January and June 2024 to assess PrEP uptake and factors influencing PrEP use among key populations in Nylon and New Bell health districts located in the Douala Littoral region of Cameroon. The HIV prevalence rate in Douala is 2.4%. These regions were important for our study because they are the largest urban centers and major centers of economic and social activities. We selected these areas for our study due to their high concentration of key populations. All these aspects make them a good place to examine PrEP uptake and its predictors among this population at risk of infection. We followed the Sex and Gender Equity in Research (SAGER) guidelines to ensure appropriate consideration of sex and gender in the design, analysis, and reporting of findings [11].

2.2. Study Population

The study targeted key populations, specifically MSM and FSWs, aged 20 years or older who had resided in the Nylon and New Bell health districts for at least six months and had some knowledge of PrEP.

2.3. Sample Size and Sampling Procedures

A purposive non-probability sampling method was employed, as it focused on key populations that are typically difficult to reach [12]. Nylon and New Bell health districts were selected based on the high concentrations of key populations and ongoing Public Health efforts to prevent HIV in these areas. In these districts, the sample size was determined based on practical considerations, including resource availability, time constraints, and the expected willingness of individuals to participate. We aimed to recruit a sample size that would ensure reliable statistical analyses and sufficient representation of Key Populations (KPs), targeting 282 participants. Recruitment took place through health facilities that provided PrEP services (Nylon District Hospital, New Bell District Hospital, and Congo District Medical Center) and was facilitated by peer leaders who employed social network strategies to engage this population.

2.4. Data Collection

Data collection was conducted using structured questionnaires administered face-to-face by trained Research assistants and the principal investigator of this study. The questionnaire was written in English and then translated into French to ensure clarity and understanding by most French-speaking populations. The data collection tool was also pre-tested among the peer leaders we selected from these communities based on their consistent attendance and adherence to PrEP services at local healthcare facilities. The questionnaire included sections on sociodemographic characteristics, knowledge about PrEP, current and past use of PrEP, compliance behaviors, perceived risk of HIV, and access to health services. Confidentiality was maintained throughout.

2.5. Variables and Measurements

The primary outcome variable was PrEP uptake, defined as the proportion of participants who reported ever using PrEP among all the key populations to whom PrEP was proposed based on the risk assessment. Independent variables included sociodemographic characteristics (age, sex, education level, marital status, and monthly income), behavioral factors (substance use, sexual activity, and risk perception), and healthcare access-related factors (proximity to services).

2.6. Data Management and Quality Control

Completed questionnaires were reviewed daily for accuracy and completeness. The data was digitized using Kobo Collect software, facilitating efficient and secure entry into a centralized database. The data validation rules were introduced into the collection tool to minimize errors, and periodic quality checks were set. To maintain the confidentiality of our data, we encrypted and stored it on password-protected systems.

2.7. Statistical Analysis

Data analysis was performed using R version 4.4.1. Using descriptive statistics, we summarized participants' characteristics, including demographic information and PrEP uptake rates. Bivariate analyses and significance tests were performed to examine the association between predictor variables and PrEP uptake using Pearson's chi-square tests.

We included the multivariate logistic regression variables with p values < 0.2 in the bivariate analyses to identify independent predictors of PrEP initiation. We calculated Odds Ratios (ORs), their 95% Confidence Intervals (CIs), and p-values to determine the strength and direction of associations. Findings were presented in tables and figures, highlighting the relationships between predictors and outcomes.

2.8. Ethical Considerations

Ethical clearance was obtained from the Faculty of Health Sciences Institutional Review Board at the University of Buea (reference number: 2024/2374-01/ UB/SG/IRB/FHS). Administrative authorization was obtained from the Littoral Delegate of Public Health and the services of the Nylon and New Bell Health Districts. Written informed consent was obtained from each participant before their involvement in the study.

3.1. Socio-demographic Characteristics

Table 1 highlights the main trends in the socio-demographic characteristics of key populations in Nylon and New Bell health districts, where data were collected from 193 Female Sex Workers (FSW) and 91 men who have Sex with men (MSM). The majority of participants were female, comprising 193 (68%). Among the age group, the most significant proportion was those under 25 to 29 years, with 102 individuals in total, including 72 (70.6%) Female Sex Workers (FSW) and 30 (29.4%) men who have sex with men (MSM). Regarding monthly income, most participants (144) earned between 0 and 50,000 FCFA, including 83 (57.6%) FSW and 61 (42.4%) MSM. Regarding marital status, most participants were single, with 266 participants, a predominance of FSW at 68.4%. The largest occupational group was students, with 108 in total. Education levels revealed that 152 participants held a university degree or higher, comprising 99 (65.1%) Female Social Workers (FSW) and 53 (34.9%) males. Among religious affiliations, Catholics were the predominant group, accounting for 142 of the total.

3.2. Uptake of Pre-exposure Prophylaxis

The PrEP uptake cascade shows substantial gaps in uptake among Key Populations (KP). Out of the 284 KPs seen, only 220 (77.5%) were eligible for PrEP service after screening for eligibility according to WHO standards and were offered the service. Among these, only 62 (28.2%) accepted PrEP and were initiated on it Fig. (1).

3.3. Factors Associated with PrEP Uptake Among HIV Key Populations

Table 2 below outlines the factors associated with PrEP uptake among key populations in the Nylon and New Bell health districts. This table shows us that the age range has an impact on the PrEP uptake by our respondents since the majority of individuals who adopted PREP are between 25 and 29 years old, with a rate of 54.8%, which indicates that the latter are more likely to adopt PREP compared to those in the age group between 20 and 24 years old. However, this association is not statistically significant (aOR = 1.51, 95% CI: 0.64 - 3.63, p-value = 0.352). The education level of our participants is also positively associated with the PrEP uptake. We note that the group of participants with a secondary education level had a higher rate of adoption compared to the others (41.9%), though this relationship is not statistically significant (aOR = 2.65, 95% CI: 0.93 - 7.87, p-value = 0.072) However, participants with a university education level have a rate of adoption to the PrEP of (35.5%) and the adjusted odds ratios show that they are significantly less likely to use the PrEP compared to those with only a primary level (aOR = 0.36, CI95%: 0.13 - 0.92, p-value = 0.034).

Key population types also strongly influenced PrEP uptake, particularly MSM, who have a PrEP uptake rate of 45.2% with a significantly higher adjusted odds ratio compared to FSW (aOR = 2.97, 95% CI: 1.24 - 7.30), highlighting that MSM are twice as likely to adopt PrEP as an HIV prevention method compared to FSW. On the other hand, sexual behavior, namely having had condomless Sex in the last three days, is associated with reduced PrEP use. Indeed, individuals who had not had condomless Sex observed a higher proportion (71.0%) of adoption than those who had a low odds ratio (aOR = 0.35, 95% CI: 0.15 - 0.75). Having Sex as a primary source of income in the last 6 months was also found to be a factor reducing PrEP adoption by our participants (aOR = 0.10, 95% CI: 0.02 - 0.37) with a p-value of less than 0.001. Finally, the monthly income of our participants was also found to be a factor associated with PrEP adoption, as individuals with a monthly income greater than 100,000 FCFA had a higher proportion of PrEP initiation (43.5%) (aOR = 0.10, 95% CI: 0.02 - 0.37). Multivariate analysis of the association between monthly income and PrEP uptake confirmed that individuals earning more than 100,000 FCFA per month were significantly more likely to adopt PrEP than the reference group (aOR = 4.37, 95% CI: 1.76 - 11.5). This trend suggests that individuals with higher incomes may have better access to PrEP due to financial constraints.

The multivariate analysis further clarifies the key predictors of PrEP uptake among the populations studied in the Nylon and New Bell health districts. Higher income is a strong positive predictor, with individuals earning more than 100,000 FCFA having substantially higher odds of PrEP uptake. Being MSM also significantly increases the likelihood of PrEP usage, whereas university education and reliance on income from sex work are associated with lower odds of uptake. Additionally, recent engagement in condomless sex is a negative predictor of PrEP usage. These findings underscore the importance of targeted interventions to address income disparities, risk behaviors, and access barriers, thereby improving PrEP uptake among these key populations.

4.1. PrEP Uptake Among KP in Nylon and New Bell Health Districts

Although PrEP as a means of HIV prevention was offered to all these eligible clients, only 28.2% of them accepted PrEP. This rate is significantly lower than the UNAIDS target of 80% by 2025 [13].

The uptake rate in our study aligns with a study conducted in rural areas of Kenya and Uganda by Koss et al. (2020), where they reported a 27% uptake despite awareness and willingness. Highlighting a large number of barriers that still hinder PrEP initiation, including stigma, healthcare accessibility, and structural inequities [14]. However, our proportion is relatively low compared to a study conducted in Cameroon in 2020 on key populations followed by CBOs with a PrEP uptake of 45% [10], which could be justified by certain factors that can influence PrEP initiation, including service delivery models, actors involved in initiating a person on PrEP, as well as structural barriers. The uptake obtained in this study is also comparable to that of a study conducted in the USA under the same conditions among high-risk groups, including MSM, but with clients who have a higher income level [15], which highlights that the significant gaps are not limited only to low-income countries but also to developed countries.

4.2. Factors Associated with PrEP Uptake Among KP in Nylon and New Bell Health Districts

In this study, we also aimed to understand the factors that influence the use of PrEP. To do this, we used bivariate and multivariate analyses. A higher monthly income was significantly associated with using PrEP; people earning more than 100,000 FCFA per month were over four times more likely to accept PrEP (aOR = 4.37, 95% CI: 1.76–11.5, p = 0.002), highlighting monthly income as a critical factor. This finding is consistent with recent studies in the East region of Cameroon in 2024 on ART initiation, which identified financial barriers as key determinants for patients to start treatment. In particular, low-income individuals are less likely to accept medication use as the costs of visits, transportation, and other indirect treatment-related expenses may limit their access to medical and PrEP services [16, 17]. Addressing these economic barriers is, therefore, essential to improving PrEP uptake among vulnerable populations.

Being MSM was another strong predictor of PrEP use in this study (aOR = 2.97, 95% CI: 1.24–7.30, p = 0.015), doubly influencing PrEP use. Our result is consistent with work by Hillis et al. in 2020, who reported that MSM were more likely to be aware of and use PrEP due to targeted public health interventions and increased awareness among this high-risk group [18, 19]. Similarly, a meta-analysis conducted in 2020 demonstrated that MSM had a higher rate of PrEP uptake than other at-risk populations; this work reflects the ongoing efforts of public health interventions to prioritize this group in HIV prevention strategies [20].

It is also interesting to note that our study revealed that the educational level of key populations is also one of the factors strongly influencing their acceptance of PrEP; according to the results, people with a university education level were less likely to accept PrEP than those with a primary education level, with an aOR of 0.36 (p-value = 0.034). This counterintuitive result may be explained by several factors. Educated individuals may have a lower perceived risk of HIV due to their awareness of HIV prevention methods, which could result in less urgency in adopting PrEP. Furthermore, educated individuals might have greater access to other HIV prevention strategies, such as condoms or ART, that they may perceive as more accessible or effective, leading to a decreased reliance on PrEP, as reported by a study conducted in New England [21]. Alternatively, stigma and misinformation also play a role. However, our results contrast with the findings of several studies, such as that of Huang et al., who found that higher education levels were generally associated with greater acceptance of PrEP [22].

Our results suggest that individuals reporting condomless Sex in the past 3 days may underestimate their HIV risk, which appears to be a factor significantly associated with lower odds of PrEP use (aOR = 0.35, 95% CI: 0.15-0.75, p = 0.009). This result is consistent with that of the work carried out by Brooks et al. in 2021 in the USA, where he highlighted that sexual behavior, in particular condom use, is positively associated with condom use; in other words, people who have sex without condoms are often less likely to perceive themselves as at risk for HIV and therefore less likely to use PrEP [23].

Finally, having sex as a primary source of income reduced the odds of using PrEP according to our results, with aOR = 0.10 (p-value < 0.001). This result is in line with the conclusions of a study conducted in Latin America in 2021, where it was noted that sex workers often faced significant barriers such as stigma, discrimination, and limited access to care, which hindered their ability to access PrEP service [24]. In addition, Escudero et al. (2021), in their work on youth therapy, highlighted that economic vulnerability and reliance on sex work would often limit the ability of the latter to prioritize preventive health care, in this case, PrEP, which requires more tailored interventions that respond to these structural challenges [25]. These results sufficiently underscore the importance of addressing specific demographic and socioeconomic barriers to improve PEP uptake among the most at-risk populations. Tailored interventions that focus on improving access, awareness, and financial support, particularly for low monthly income groups and people who have sex as their primary source of income, are essential to ensure broader coverage of PrEP and even reduce HIV incidence in these populations. Future research should consider longitudinal designs and include measures of adherence as well as barriers and facilitators to PrEP use.