Attrition from Care and Barriers to PrEP Use Among Key Populations in Kinshasa, DRC: A Multiple Methods Study

Female sex workers (FSW) and gay and other men who have sex with men (MSM) are disproportionately affected by HIV. Oral pre-exposure prophylaxis (PrEP) is increasingly available in African countries, including the Democratic Republic of Congo (DRC), but data on factors influencing PrEP use remain limited. This multiple methods study examined PrEP attrition patterns and barriers to engagement among FSW and MSM in Kinshasa, DRC, using programmatic data from five sites, clinical records, and qualitative interviews. Logistic regression identified factors associated with attrition; qualitative data were thematically analyzed. Among 8,822 FSW and MSM eligible for PrEP in 2019-2021, only 24% (n = 2,070) initiated it. Of 809 FSW initiators, 33% (n = 268) were lost to follow-up by 1 month and 78% (n = 421) by 3 months. Among 1,261 MSM, 26% (n = 332) and 87% (n = 808) were lost by 1 and 3 months, respectively. For FSW, prior PrEP use and recent STIs were associated with higher attrition at 1 month. Older age, more sexual partners, income beyond sex work, and no prior PrEP use were linked to lower attrition at 3 months. Among MSM, no prior PrEP use predicted higher attrition at 1 month but lower attrition at 3 months. Qualitative findings identified stigma, side effects, dislike of daily dosing, and limited services for key populations at risk of HIV as major barriers. Findings underscore the need for improved PrEP messaging, including information on side effects decreasing over time. Raising awareness among key and general populations may reduce stigma and improve PrEP engagement.