Why men are reluctant about PrEP, the pill that protects against HIV infection

When the Kenya government launched the Post Exposure Prophylaxis (PrEP) in 2017, Caleb (not his real name) was one happy man.

The 24-year-old says he considered himself among the high-risk population since he had multiple sexual partners.

He noted that the drug remained one of the best ways to stay protected from contracting the HIV/AIDS virus.

While the drugs had been made available in public health facilities, Caleb says he opted to pick the commodity at a private pharmacy.

His decision was inspired by the reaction he got from some of his friends who had gone for the commodity in public health facilities.

Caleb says his male friends had expressed dissatisfaction with the packaging of the drugs in a container, which would shake with its contents making those around suspicious.

“I was also made to understand that I would pick the pills at the same place where HIV-positive patients picked their Antiretroviral drugs," he said.

“It becomes hard to explain to those around you that you are picking the drugs meant for protection against HIV rather than the disease management in case they get to see you at a health facility,” says Caleb.

“This creates stigma”, he noted. 

At the private pharmacy, Caleb recalls asking the expert for the event-driven prep, which was placed in a blister pack, just the way he wanted it packaged.

Caleb explains that the health expert had explained that he needed to take one of the four pills two hours before engaging in sexual intercourse.

He was required to take the second pill within 24 hours while the third pill would be taken within 36 hours.

The pill would offer 72 hours of protection from HIV.

“I experienced several side effects including loss of appetite, nausea, fatigue, and diarrhea,” he recounted.

The now 31-year-old says he later enrolled on daily pills until 2021 when he had to stop since he fell ill from an infection, he would later resume the medication in early 2023,

“I decided to opt out since I got into a relationship with one partner, after getting our negative HIV tests, we decided to remain faithful to each other,” says Caleb.

Caleb is among the few men in Kisumu County who have opted to use PrEP for prevention against HIV infection.

According to the Kisumu Sub County HIV/STI coordinator Mr Justus Olando, more women visit health facilities to pick the HIV commodities compared to men despite the County’s high HIV prevalence.

The latest statistics by the National Syndemic Disease Control Council revealed that Kisumu is among the top four Counties with the highest HIV prevalence.

The 2023 report revealed that Homa Bay and Kisumu Counties took the first and second positions respectively at 15.2 and 14.5 percent HIV prevalence.

Within the county, Nyando Sub County leads in the viral disease prevalence at 18.9 percent followed by Seme at 18.3 percent.

Nyakach, Muhoroni, and Kisumu Central take the third position at 16.2, 14.9, and 12.5 percent respectively while Kisumu West and East close the list at 11.2 and 11.9 percent.

“The high prevalence in Nyando and Seme Sub County could be because of rice farming and fisher folk activities, but we are yet to ascertain this,” says Mr Olando.

The coordinator also says that in 2023, the county recorded 1,350 HIV-related deaths with adults aged 15 and above accounting for the highest mortality at 1,237.

The adolescents and youths aged 15 to 24 years accounted for 193 deaths while 113 children aged 0-14 recorded 113 mortalities.

PrEP is one of the prevention measures against HIV with various studies showing that it is effective when taken as prescribed by people at risk of HIV infection with 65 to 95 percent protection.

In Kenya, the available prep options include daily oral pills taken daily for the duration of the risk and event-driven PrEP.

The daily oral pill should be taken seven days before the anticipated sexual exposure among females and 24 hours among men.

A client is also required to continue taking the pills for the duration of the risk and seven days post.

“Kisumu is among counties taking part in the implementation study of Dapivirine ring and cabotegravir (CABLA),” said Mr Olando adding that once proven, the prevention options will be made available in facilities.

Despite efforts to make available the prevention options in public hospitals, Mr Olando says the uptake has remained low.

Mr Olando warned that the low uptake increases the risk of HIV transmission to those yet to be infected with the viral disease.

“In terms of case identification, as a county, we are currently at 95 percent meaning the remaining five percent are out there unaware of their status. These are the people who form a larger percentage of sources for new HIV infections,” said Mr Olando.

The county statistics show that within the last 12 months, the public health facilities within the county have failed to achieve 100 percent initiation of PrEP uptake.

The uptake of the preventive option ranked highest among adults aged 20 to 24 years and 25 to 29 years while the number remained low among adults aged 60 to 64 years.

The county statistics also show that more women than men across all ages recorded a high number of PrEP uptake within the last year.

“Among adults aged 20 to 24 years, we had 44 percent of men and over 75 percent of females collecting the pills from facilities. Under the age bracket of 25 to 29 years, we had 30 percent of males and 70 percent of females utilising the commodities,” said Mr Olando.

The Kisumu County PrEP ambassador, Thomasn Okal, says the pill remains a major preventive option for the high-risk population who might not have bargaining power against their sexual clients, those allergic to condom lubricant, and persons with multiple sex partners.

However, he noted that fewer men opt for the pill due to fear of stigmatization, feeling the ‘shame’ of carrying the pills in the ‘noisy’ bottles, and fear of having people confuse the drugs for ARVs.

He says some of the clients also opt to visit pharmacies to save themselves from the interrogation by health experts on why they need the tablets.

“Men also have poor health-seeking behaviors and that is one of the reasons why they may fail to visit health centers for the drugs,” says Okal adding that there is a need to create private rooms where men can comfortably pick the drugs.

Mr Olando also notes that continuation of the uptake of the pill always drops within one month of initiation.

He has also shared that there is a need to provide prevention options for children below 14 years of age.

“We are not doing well beyond the first month of administration. We foresee a situation where we may think we protected the high-risk population from acquiring HIV and end up being exposed,” said Mr Olando.

To ensure a high uptake of the pill, Mr Olando notes that the county has made available prep commodities in adequate quantities.

The county has also identified safe community spaces to ensure privacy among users especially men and created a continuous demand creation activity in both health facilities and communities to increase the uptake.

Dr Felix Mogaka, a clinical research Scientist at the Kenya Medical Research Institute, observed that while the number of men taking the commodities at health facilities remains low, it is also important to note that some of the men prefer getting the services in private facilities.