"At the end of the day I'd have to use a condom!": A qualitative investigation of knowledge, motivations, and barriers to use of HIV pre-exposure prophylaxis among young gay and bisexual men in Nairobi, Kenya

Despite availability of highly effective oral HIV pre-exposure prophylaxis (PrEP) for close to a decade, uptake and adherence among at-risk young men who have sex with men (YMSM) in Kenya, remain significantly low. This study investigated levels of PrEP knowledge, motivations, facilitators and barriers influencing PrEP initiation, persistence and adherence among YMSM, in efforts to optimise use and reduce risk of new HIV infections. In September 2021, 22 YMSM purposively selected from 248 YMSM who had previously participated in an integrated bio-behavioural sexual health survey, took part in semi-structured in-depth interviews. Interview guides were developed based on the Information-Motivation-Behavioural skills (IMB) model. Questions focused on each of the three IMB model constructs: information about PrEP, motivational factors influencing decision to use or not to use PrEP, and ability to initiate and adhere to PrEP. Data analysis generated three key themes: knowledge, motivation, and barriers to using oral and on-demand PrEP. Participants expressed its awareness and effectiveness in HIV prevention, but were concerned about PrEP- and HIV-related stigma, with the fear that family, friends, and potential romantic partners might perceive them as being promiscuous, or as living with HIV. Participants reported being capable of seeking PrEP services provided in MSM-friendly facilities, with public health facilities perceived as hostile considering the criminalization of, and societal stigma toward same-sex practices. These findings highlight the crucial need to re-strategize PrEP promotion not only as an effective but also a safe HIV-prevention option for at-risk populations. This study recommends expediting the integration of long acting lenacapavir and cabotegravir in the Kenyan health system as a means to diversify PrEP modalities and potentially reduce the stigma experienced in oral PrEP use.