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Some will be knowing that he is sick, he becomes rough with us because he wants the condom to break. This added protection also related to sex with Prostitutes eSikhaleni partners, where condoms were not usually employed.

Women who acknowledged condom use, Prostitutes eSikhaleni lack thereof, tended to define a romantic relationship versus sex with clients. Among women who had main partners e. PrEP was there to keep them safe within such relationships where condom use was less common.

This theme subdivides into three inter-connected sub-themes, which convey the complexity of PrEP awareness, Prostitutes eSikhaleni and emerging confidence in the technology. Over and above the motivation to use a product that could help to protect them from HIV and relieve some of the psychological burden in their lives, women needed to grapple with interpreting and understanding the stated efficacy of an entirely new technology.

Like what Prostitutes eSikhaleni was saying that people they wanna know if Prostitutes eSikhaleni tablets they are working or they are not working. Missy related how some of Prostitutes eSikhaleni colleagues did not believe that PrEP was real, and how she and Prostitutes eSikhaleni sisters investigated the PrEP product:. And my friends, I explained to them. Reflecting on initial disbelief Prostitutes eSikhaleni PrEP came more often in later interviews.

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In her third IDI, Brenda reported how Prostitutes eSikhaleni had found colleagues in her room going through her bag. She worried they Prostitutes eSikhaleni stealing her pills, but she later found that they were actually trying to figure out what the pills were and whether they Prostitutes eSikhaleni real. I am still negative. They expressed genuine disbelief that preventive pills even existed.

Prostitutes eSikhaleni participants described their initial apprehension about potentially being guinea pigs for drug testing, which was usually laid to rest during the first few months of participation. However, interactions in the community were a different story. I told him [boyfriend] but at first he could not understand that. This process seemed to contribute to a commitment from these participants to take PrEP, and also circled back to the motivation of managing and mitigating risk.

Disbelief Prostitutes eSikhaleni PrEP eventually dissipated for those who continued in the study, and part of Prostitutes eSikhaleni the personal scepticism was by repeated HIV-negative test results.

Over time, personal belief paved the way for participants to prove to others that PrEP was real, since they were still HIV-negative.

Because I want them to get the same services I got. I have a boyfriend. Is it possible for him to come and take this PrEP? Growing out of the acknowledgement of personal risks and Prostitutes eSikhaleni, as well Prostitutes eSikhaleni a confirmed belief that PrEP was real and playing a part in keeping women negative, was the notion of health and well-being reinforced by taking PrEP and through continuous engagement in care.

This translated into a commitment to health, hope for the future, and a sense of strength and pragmatism in the present in relation to their work.

I am doing this for my own life. This, Prostitutes eSikhaleni with access to PrEP, created a level of added control in their lives, especially when armed with the knowledge that PrEP was not a forever regimen. Practically, women were given the option to cycle on and off PrEP through the course of the study, and they were counselled on if or how they might do so with the support of a clinician.

Many women explained how they decided to cycle off on their own, and would come back for retesting to be able to restart PrEP a few months later. Some of these women related how they would take a break when they went back to their home villages or if they stopped sex work for a time, which seemed again to contribute to a discourse of enhanced control that ran through many of the transcripts.

I feel Prostitutes eSikhaleni taking Truvada. Healthiness and happiness was important and underscored by all of the participants in one way or another. Some women felt that the pill was helping them beyond preventing HIV. I used to feel like weakin the morning when I'm waking up. When discussing how PrEP made them feel about sex, most women talked about the feeling of added safety, but not in a way which made them want to have more, or to have condomless sex.

Most perceived changes in sex was related to their work. As one participant related:. You were so hot! Prostitutes eSikhaleni added to the sentiment of hope and the possibility of improving their perceived and physical positions in their work and life realities. Another participant Prostitutes eSikhaleni that the act of offering PrEP to FSWs was a sign Prostitutes eSikhaleni change in how sex workers were perceived by wider society:.

They love us. They put us together as one people because they care. For PrEP to be effective in women Prostitutes eSikhaleni is a need for high adherence and daily pill taking [ 3435 ]. Though not as prominent a theme in the interviews as compared to the others presented here, the practicalities of managing PrEP Prostitutes eSikhaleni and the activities relating to it were still important to Prostitutes eSikhaleni. In particular were the practical issues of daily pill taking, managing personal relationships in relation to PrEP use, developing supportive structures, considerations around behavioural disinhibition, and managing the practicalities of clinic attendance.

Developing innovative strategies for pill taking was universal, including stashing a pill or two in a bra or a tissue in case of late or unpredictable nights, setting phone alarms, and placing the pill bottle in a routine location like next to a tooth brush. These were not always perfect. Before I was forgettingI don't wanna lie.

You told us not to share, but if we run out we do share. We just told ourself it is one thing. We said how can we not share, but this is one thing. When I run out I can just say give me two. Some suggested, after taking PrEP for a while, that having an injectable would be better than the pill, to alleviate the burden of daily adherence, most likely related to their experiences with or knowledge of injectable contraception. One way or another, support systems for pill taking were important in maintaining use.

Others Prostitutes eSikhaleni up losing family, friends, or partners over their participation in the study and PrEP use. This was an unfortunate development, but it Prostitutes eSikhaleni usually resulted in a reaction of asserting a sense of empowerment or control.

Prostitutes eSikhaleni instance, Missy decided to stay in the study and lose her Prostitutes eSikhaleni who would not believe that she was taking ARVs for prevention, rather than give up taking PrEP:. Disinhibition, or discontinuing condom use while using PrEP, was not reflected among most of the participants.

Only one woman admitted to sometimes giving more oral sex without a condom than before she started taking PrEP, and a few women spoke of how they had considered not using condoms on occasion.

Others asserted the importance of maintaining broader sexual health, and highlighted the important, but incomplete, contribution that PrEP made in this regard:. Because without my health I will not be able to provide for my family …. This is one of the first reports of Prostitutes eSikhaleni experiences and perspectives of actual use of oral PrEP among a group of FSWs outside of a clinical trial setting. This research provides insight into the risks and responsibilities that women perceive in their lives, the ways in which women adopted PrEP Prostitutes eSikhaleni mitigate their risk or Prostitutes eSikhaleni realities, and the characteristics of PrEP that Prostitutes eSikhaleni most valued, all of which are critical to consider within the context of implementation.

The Prostitutes eSikhaleni produced from this research are Prostitutes eSikhaleni within the MSEM framework, where personal views and factors interact with and are influenced by social and sexual networks, community, societal Prostitutes eSikhaleni public policy, and the HIV epidemic itself. The components of this framework are visible within the themes where community perceptions of PrEP influenced personal beliefs and experiences of use, or where knowledge of the vast epidemic made it difficult to believe there were still HIV-negative FSWs left to take advantage of new prevention methods.

The themes Prostitutes eSikhaleni in this paper make clear the significant role that family, friends and peers play in shaping perceptions of HIV risk, of the efficacy and potential impact of PrEP and, ultimately, Prostitutes eSikhaleni PrEP uptake.

The role of Prostitutes eSikhaleni networks in propagating accurate information about PrEP, and in shaping narratives of PrEP confidence and acceptability should Prostitutes eSikhaleni be underestimated.

When those around users are constantly questioning whether such a preventive product can be Prostitutes eSikhaleni, it may be difficult to continue use. This could speak to reasons for dropout in the larger TAPS study for which the primary, programmatic results have been presented [ 19 ]. As PrEP had not been widely introduced as a national policy when these interviews were undertaken, there was no generalised community education about its use which may have contributed to mistrust of the product.

Both Normalization Theory [ 38 ] and the Diffusion of Innovations [ Prostitutes eSikhaleni ] speak to the imperative of community assimilation of interventions for successful implementation. Indeed, without belief in and demonstration of efficacy on a personal level e. This was underscored by the participants through the course of the IDIs, and often raised ethical quandaries around not being able to provide others with PrEP.

The clinic did, however, allow and promote couples testing as desired by the participants. The repeated discourse on disbelief or distrust in the existence and efficacy of PrEP also points to a need for concerted community based messaging beyond target populations.

While mathematical modelling has suggested that focused PrEP delivery to those at highest risk will have the greatest impact in the most cost-effective manner [ 3440 ], the findings in this study combined with those from VOICE-D and ADAPT, imply that those at Prostitutes eSikhaleni risk may be reticent to engage with PrEP without community endorsement.

Development of implementation strategies will necessitate an initial contextual review of community perceptions of PrEP and relevant education campaigns to balance messaging around HIV risk, PrEP use, and efficacy, keeping in mind the risk of stigmatizing the PrEP Prostitutes eSikhaleni.

Risk, and risk perception [ 41 ], have been extensively researched and debated in regards to translating into effective HIV prevention uptake [ 42 Prostitutes eSikhaleni 44 ]. In the TAPS study, the primary results suggest that the population accessing PrEP are women who may be at self-acknowledged high risk, which was confirmed repeatedly through the IDIs [ 19 ]. However, it is unclear whether those who dropped out were accurately assessing their own risk, though one woman who dropped out of the PrEP arm early returned later with an HIV-positive result.

The risks articulated in these IDIs, however, were directly linked to Prostitutes eSikhaleni dangers of sex work and closely intertwined with the acknowledgement of personal responsibilities. At the same time, stress around condomless sex Prostitutes eSikhaleni main partners seemed to be reduced for some women who worried they might be at risk when partner fidelity was unclear.

While sex work can be Prostitutes eSikhaleni choice and Prostitutes eSikhaleni women have been empowered in their engagement in it [ 46 ], women in Prostitutes eSikhaleni sample of sex workers overwhelmingly felt that they currently had no options to transition out.

In these IDIs, Prostitutes eSikhaleni had differing ideas about how to move on to other employment, with some asking for Prostitutes eSikhaleni in the clinic and others pursuing educations with the hope of empowering themselves to advance.

The notions Prostitutes eSikhaleni empowerment and control were underlying currents throughout the findings of these IDIs. While most of their worries remained constant throughout the progression of the interviews, there was also an alleviation of stress which occurred as PrEP efficacy became a personal reality.

Interestingly, the findings in this paper at Prostitutes eSikhaleni thematic level are very similar to what has been published so far from qualitative Prostitutes eSikhaleni of PrEP use among MSM.

Research published from an open-label PrEP study following the iPrEX efficacy trial described relief from stress around the possibility of HIV infection and a sense of security as additional benefits of using PrEP [ 48 ].

These feelings did not seem to change sexual behaviour, which from analyses conducted thus far and what has been Prostitutes eSikhaleni in our qualitative research, is also what happened in TAPS [ 19 ]. Encouragingly, this research suggests that PrEP use may provide sources of critical, constructive, and empowering HIV protection for those at highest risk of HIV without subsequent risk compensation, as was widely feared [ Prostitutes eSikhaleni50 — 53 ].

Not as many women returned for second and third IDIs as hoped, which is a risk with any longitudinal research and in particular with more transient populations such as sex workers. It is difficult to assess why participants drop out over time when they do not provide specific reasons themselves. However, based on what we learned here and what was learned in earlier research preparing for the TAPS study [ 2526 ], it is likely that a combination of social dynamics around belief in PrEP and its efficacy including stigmatization of taking ARVs as a sign of Prostitutes eSikhalenipersonal risk assessment which may fluctuate over time, Prostitutes eSikhaleni responsibilities which supersede clinic visits and participation in research, and potential issues with substance use probably contributed to retention.

For these reasons and to further unpack the dropout seen in TAPS to help support PrEP programming, additional research is being considered to potentially interview women who were lost to follow up, to determine the reasons. Despite the limited number of second and third round IDIs, the process of serial interviews enabled us to examine progression of thinking and feeling around PrEP use. In most Prostitutes eSikhaleni, the participants became more committed over time, and discovered personal strength in their commitment, even if adherence was not always perfect.

Their willingness to be more open about issues with product use grew over time, which was a benefit of this method. The practicalities of use were not the central themes for any of the IDI participants, however, women were able to share how they managed adherence or cycled off and on PrEP over time.

One prominent component of managing PrEP use, which became more apparent over time, was the development of supportive structures for pill taking. Some women found support from partners, but many more had family members or friends who were already HIV-positive and could provide inside knowledge of pill taking habits. In fact, the high prevalence of HIV in the community, and particularly among other women in sex work, could be another contributing Prostitutes eSikhaleni for staying Prostitutes eSikhaleni and a motivation for PrEP use.

These notions reinforce the idea that synergies can be found among HIV-negative and positive populations, which may also help to destigmatise interventions. The study ended up only enrolling just over half the originally planned sample size, which therefore limited the range of perspectives possible to include.

Additionally, we planned to capture perspectives of women using PrEP as well as those cycling off, however those women who cycled off rarely stayed in the study. The study sites were Prostitutes eSikhaleni limited to urban settings, therefore findings may not translate to other contexts. While these are Prostitutes eSikhaleni limitations of this Prostitutes eSikhaleni, it should also be noted that the interviews did reach saturation of data, where personal stories did vary but themes were consistent across FSW Prostitutes eSikhaleni.

PrEP represents a valuable new HIV prevention option for women in sex work who are able to remain in care. Risks and responsibilities were the main expressed drivers of PrEP uptake and use in Prostitutes eSikhaleni interviews, however, personal and community disbelief in the reality of PrEP efficacy challenged this.

As PrEP programming is scaled-up, it will be important to ensure accurate, relevant, and widespread messaging is employed in communities to generate demand and support for PrEP use, even if use is to be focused for those at highest risk. The authors thank the women who participated in the study and shared their experiences.

The entire TAPS team was instrumental in the successful completion of the project and this work. Peter Weatherburn provided invaluable support for the analysis and writing of this manuscript as part of a PhD project. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field.

Introduction The efficacy of dual drug combination tenofovir and emtricitabine oral pre-exposure prophylaxis PrEP for preventing acquisition of HIV has been extensively investigated and reported [ 1 ]. Methods This qualitative research was conducted as a component of the TAPS Demonstration Project and included as part of the main study protocol [ 22 ]. Download: PPT. Dis believing in a pill to prevent HIV This Prostitutes eSikhaleni subdivides into three inter-connected sub-themes, which convey the complexity of PrEP awareness, beliefs and emerging confidence in the technology.

Beliefs about PrEP Prostitutes eSikhaleni. Personal and societal awareness of PrEP.

Emerging PrEP confidence. Finding health, control, and well-being in PrEP Growing out of the acknowledgement of personal risks and responsibilities, as well as Prostitutes eSikhaleni confirmed belief that PrEP was real and Prostitutes eSikhaleni a Prostitutes eSikhaleni in keeping women negative, was the notion of health and well-being reinforced by taking PrEP and through continuous engagement in care. Prostitutes eSikhaleni the practical complexities around PrEP use For PrEP to be effective in women there is a need for high adherence and daily pill taking [ 3435 ].

Discussion This is one of the first reports of personal experiences and perspectives of actual use of oral PrEP among a group of FSWs outside of a clinical trial setting.

Limitations The study ended up only enrolling just over half the originally planned sample size, which therefore limited the range of perspectives possible to include. Acknowledgments The Prostitutes eSikhaleni thank the women who participated Prostitutes eSikhaleni the study and shared their experiences. References Prostitutes eSikhaleni. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. Country Updates. The new role of antiretrovirals in combination HIV prevention: a mathematical modelling analysis.

PLoS Med. Prevention Gap Report [Internet]. Atlanta, Georgia; N Engl J Med. AIDS Behav. Combination HIV prevention for female sex workers: what is the evidence?