Understanding barriers to HIV pre-exposure prophylaxis initiation among men who have sex with men in Sindh, Pakistan

Background: Pre-exposure prophylaxis (PrEP) is a highly effective intervention to prevent HIV acquisition. Oral PrEP was introduced for men who have sex with men (MSM) in Sindh province of Pakistan in June 2022, yet the uptake remains suboptimal. Here we present an assessment of barriers to PrEP uptake among MSM accessing HIV prevention services in Sindh. Methods: We conducted a cross-sectional survey among MSM clients attending HIV prevention services from community-based organizations in Sindh province. Those who consented to participate were administered a paper-based questionnaire by providers to collect barriers to uptake of PrEP. Results: We enrolled 742 MSM between November 2023 and May 2024. Among enrolled clients, 149 (20.1%) agreed to initiate PrEP, while 593 (79.9%) refused to initiate PrEP. Among those who refused PrEP, fear of stigma and discrimination at facilities (430, 72.5%) and fear of side effects (416, 70.2%) were the leading reported barriers to PrEP initiation, followed by lack of time to attend the facilities (325, 54.8%), low risk perception (“I have no risk of HIV” [273, 46.0%] and “I am healthy” [265, 44.7%]), difficulty in taking medicine daily (263, 44.4%), transportation issue (229, 38.6%), out of pocket expenses (166, 28.0%), and using condoms during sex (97, 16.4%) as major barriers to PrEP initiation. Conclusion: The results highlight a need for addressing stigma and discrimination in healthcare settings, raising awareness about HIV risk factors, removing structural barriers to access and offering differentiated client-centered services to remove structural barriers to PrEP uptake.