Gaps in Effective HIV Pre-exposure Prophylaxis Screening and Uptake Among Fishermen in Kenya

Despite oral daily HIV pre-exposure prophylaxis (PrEP) effectiveness, uptake remains a challenge. Awareness of one's HIV status and engagement in prevention is essential to interrupting transmission among populations at high risk of HIV. We explored gaps in HIV risk perception, screening, and PrEP uptake among high HIV-risk fishermen living and working along Lake Victoria, Kenya. Data are from the Owete study (NCT04772469), which evaluated the impact of secondary distribution of HIV self-tests and supported linkage to health facilities within social-networks on prevention engagement. Using self-reported sexual behavior data and clinical records, we (1) identified PrEP-eligible men based on self-reported sexual behavior, per Kenya national guidelines; (2) reported the proportion of fishermen who (a) linked to a healthcare facility post-testing, (b) initiated PrEP per clinic records; and 3) analyzed the relationship between PrEP eligibility and perceived HIV risk using logistic regression, controlling for socio-demographic characteristics. Among 733 fishermen, 715 were sexually active in the past 6 months. The median age was 37.2, 68.4% had ≤ primary education, and 87% were married. PrEP eligibility was prevalent (474; 65%); of eligible men, 222 (47%) linked to a healthcare facility after testing, of whom 127 (57%) received a confirmatory HIV test, 31 (14%) initiated PrEP and 2 (0.1%) were already on PrEP. Primary reasons for non-initiation include screening as low risk at the facility (n = 66; 30%), declining PrEP (n = 41; 18%), and stock-outs (n = 5; 2%). Participants reporting moderate or high self-perceived HIV acquisition risk had 1.80 (95% CI: 1.09, 2.98, p = 0.023) and 1.75 (95% CI: 1.01, 3.03, p = 0.045) times the risk of screening as PrEP eligible, respectively, compared to those reporting no risk. A substantial proportion of fishermen were eligible for PrEP based on sexual behaviors self-reported during the study surveys which align with standardized PrEP eligibility criteria. Nevertheless, we identified a high discordance between these self-reported criteria which renders one PrEP eligible and actually screening PrEP-eligible at a healthcare facility, highlighting potential gaps in effective screening for and subsequent coverage of PrEP to men at risk for HIV acquisition. Understanding the potential limitations of current PrEP screening protocols, as well as clients' experiences with PrEP screening in the clinic, may increase the sensitivity of PrEP screening and close gaps in effective PrEP coverage.Clinical Trial Registration: NCT04772469.