In this cross-sectional study, we explored the willingness to use LAI-PrEP among KPs in Kampala when categorised into different PrEP use groups (i.e., those taking oral PrEP, those eligible but PrEP naïve, and those who discontinued oral PrEP). Of the 234 members of key populations in Uganda, two-thirds were willing to use LAI-PrEP. Those who were sexually active showed a greater interest in injectable PrEP compared to those not currently in a relationship. There was no significant difference in willingness to use LAI-PrEP between former oral PrEP users and individuals who were PrEP naive.
Our findings are consistent with previous research conducted in Nigeria and Thailand, which found a high willingness among KPs to use LAI-PrEP. In Nigeria, a study focusing on MSM reported an 88% willingness to use LAI-PrEP, while another study in Bangkok focusing on people who inject drugs reported a 73.5% willingness (24, 29). A separate study among KPs also found a strong interest in using LAI-PrEP among adolescents, transgender women, and FSW (17). However, our study found a lower level of willingness to use LAI-PrEP among MSM compared to a similar study conducted in the United States (80%), which may be attributed to the limited awareness of LAI-PrEP in Uganda (18). Additionally, a study among women in Zimbabwe, South Africa, and the United States showed that the majority (> 75%) rated injectable PrEP as acceptable (19).
Willingness to use LAI-PrEP varied across the study groups, with the highest reported among individuals who had previously discontinued oral PrEP and the lowest observed among those currently taking oral PrEP. These findings are consistent with the ÉCLAIR study, which also found a high level of willingness (79%) among participants to continue utilising LAI-PrEP, with an even higher percentage (87%) indicating they would recommend it to others (20). In comparison, a greater proportion of individuals who had discontinued oral PrEP expressed a willingness to switch to LAI-PrEP versus those currently taking oral PrEP or individuals within the eligible PrEP-naïve key populations. This difference is likely due to challenges in accessing necessary healthcare services or other challenges with adherence to oral formulations despite the need for PrEP (21). Among specific key population groups, willingness to switch to LAI-PrEP varied from ~ 60%-100%, higher than the 30.8%-66.7% reported in US-based studies of gay and bisexual men taking oral PrEP (21–23). Moreover, a study conducted in South Africa among heterosexual men found that 48% of participants favoured LAI-PrEP, while 33% and 20% opted for oral PrEP and condoms, respectively (18). Variations in knowledge levels may explain this disparity, as our study revealed high levels of knowledge regarding LAI-PrEP.
Our research revealed that individuals who were divorced, widowed, or separated had a decreased likelihood of being willing to use LAI-PrEP compared to those who were single. This finding is consistent with a study conducted in Uganda among adolescent boys and young men in Eastern Uganda, which identified a negative association between being unmarried and willingness to use LAI-PrEP (24). Another cohort study among FSWs in Tanzania also found that being married/cohabiting or separated/divorced/widowed was independently associated with the use of oral PrEP, which may also apply to LAI-PrEP (25). However, we did not observe significant differences in willingness to use LAI-PrEP among participants who discontinued oral PrEP and those who were PrEP naive relative to oral PrEP users. In contrast, studies involving gay and bisexual men have shown a higher level of willingness to use LAI-PrEP among oral PrEP users (26). Our research revealed that among those who were not willing not to take LAI-PrEP, reasons included myths/ misconceptions and potentially stigma-driven reasons. These will need to be addressed to effectively roll out a LAI-PreP programme. Others include preferences for taking tablets and that taking tablets served as a reminder to also take their other medications. However, other studies have shown that participants' main concern regarding LAI-PrEP is its potential long-term side effects (27).
Uganda currently ranks third in Africa for the number of PrEP initiations, with a total of 599,786, behind South Africa (1,323,845) and Zambia (697,980) (28). Despite high PrEP uptake, only < 15% of those who initiate PrEP return for their first refill. Reasons for discontinuing oral PrEP include side effects, transport costs to the clinic, stigma, and the inconvenience of a daily pill. The introduction of LAI-PrEP) has the potential to significantly improve PrEP persistence. However, even though Uganda's National Drug Authority approved the use of injectable cabotegravir (CAB-LA) as PrEP in February 2024, access is limited to demonstration projects. The slow global rollout of LA-CAB has hindered its population-level impact on reducing HIV incidence. Delays in scaling up CAB-LA in resource-limited settings can be attributed to slow regulatory approvals, production challenges, supply chain limitations, and its high cost, ranging from $170-$240 per year, according to estimates by PEPFAR (23, 29, 30).
Study limitations and strengths
The limitations of our study include its cross-sectional design, lack of access to LAI-PrEP in Uganda during the study period, and the potential for recall and social desirability bias. Furthermore, due to limitations caused by the COVID-19 lockdown, key populations had restricted access to healthcare services, which could have impacted their availability to participate in the study. Additionally, our sample was limited to an urban population and may not fully represent all KP in the country. However, despite these limitations, our study on the willingness of KP to use LAI-PrEP can provide valuable insights for future planning and implementation when LAI-PrEP becomes available in Uganda.