5.3. Descriptive Analysis
5.3.4. PrEP adoption intention and PrEP related attitudes and beliefs
These findings are scrutinised, taking into consideration those that emerge from the in-depth interviews.
However, there are some immediately dependable conclusions when considering the feasibility of an implementation programme for Msunduzi Local Municipality. It can be deduced that there is considerable interest in PrEP adoption by BMSM in the Municipality.
Table 5: PrEP Adoption Intention of BMSM (n=109)
PrEP Adoption Intention and Related Variables Frequency Percent (%) Willingness to take PrEP
Yes 97 (88.9)
No 12 (11.0)
Motivation for PrEP Use
Protection against HIV 81 (74.3)
Protection against STI's 10 (9.1)
Being able to have condom-less sex 8 (7.3)
Other 6 (5.5)
Protection against HIV + Being able to have condom-less sex 2 (1.8)
Protection Against STI’s + Other 1 (0.9)
Protection Against HIV + Protection Against STIs 1 (0.9)
Barriers to PrEP Use
High Cost 32 (29.3)
Bad Side Effects 24 (22.0)
Taking a pill daily 19 (17.4)
None 16 (14.6)
Pressure from sexual partner 6 (5.5)
Social Stigma-discrimination from friends and sexual partners 5 (4.5)
Other 2 (1.8)
Risk of STI transmission 2 (1.8)
Bad side-Effects + Taking a pill Daily +Risk of STI transmission 1 (0.9) High cost + Bad Side-Effect + Social stigma and discrimination 1 (0.9)
High Cost + Taking a pill daily + Social Pressure 1 (0.9)
The above results paint a promising picture for the feasibility of an implementation programme of PrEP targeted at BMSM in the Msunduzi Local Municipality. To enable an efficacious implementation programme, intention to adopt cannot be considered as totalising.
Therefore, the questionnaire set out to understand the barriers and facilitators should be considered when PrEP is made available to understand which were salient amongst BMSM in the Municipality.
In response to the question: ‘What would be your motivation for taking PrEP?’, a range of responses was elicited with two-thirds of the respondents (74.3%) indicating that protection against HIV transmission was the primary motivation for the uptake of PrEP. This was followed by a faction of the respondents (9.1%) indicating the protection against STIs was important to them and their motivator. About (7.3%) felt that having condomless sex was a prime motivator. Though not significantly apparent, the notion of having condomless sex was subtly recurring among other respondents (see Table 5, page 112) indicating that this formed part of their considerations when considering adopting PrEP.
In summary, these results show that protection against HIV was a concern for BMSM in Msunduzi Local Municipality and they would consider the adoption of PrEP to mitigate risks. These results are consistent with those of Karuga et al. (2016) who revealed that the main motivator among Kenyan MSM for taking PrEP was the need to stay HIV negative. Further to this, the main theoretical premise behind the intent to adopt PrEP to maintain a seronegative status is linked to the HBM construct of perceived benefit. The HBM asserts that the intention to adopt a health-promoting method is influenced the view that taking a particular action would be beneficial to reduce susceptibility to the disease or reduce its severity (Rosenstock et al., 1994b). It has emerged in earlier sections of this analysis that MSM, partake in risky sexual behaviour and thus perceive themselves to be highly susceptible to contracting HIV. Amid this perceived susceptibility they expressed concern with the adequacy of current preventative methods, hence they considered perceived benefit of using PrEP to maintain an HIV seronegative status.
As mentioned in the literature review, supplementary to the motivators, the concerns and barriers to acceptance and adoption of PrEP, included the burden of taking a pill daily, uncertainty regarding the side- effects, adverse effects of not using PrEP correctly, and the perceived high cost of PrEP. Including the issues of low-income and underinsured populations when considering the marginalisation that MSM experience in the current health system that is not sensitised to issues of homosexuality is important (Brooks et al., 2011;
Eisingerich et al., 2012; Gredig et al., 2016; Mitchell et al., 2016).
The current study within the low socio-economic context of Msunduzi Local Municipality found that a sizeable group of respondents (29.3%) felt that a high price point would be their main barrier to adopting PrEP. This was followed by the fear of side effects (22.0%), concerns of medication adherence that were exacerbated by the need to take the pill every day (17.4%).
One unanticipated finding was that some respondents (15.7%) conversely reported that there were no barriers that would prevent them from taking PrEP. Suggesting that there is great anticipation for a biomedical preventative method like PrEP among BMSM is peri-urban cities in South Africa. The above findings are suggestive of the effects that the current socio-economic climate has on decision making of BMSM with regards to preventative health. This is exhibited by the high cost of PrEP being a prominent barrier to adoption. Theoretically, this barrier is best interrogated by using an Intersectional lens. To effectively do this, attention must be paid to the data presented above (see Table 2: page 98) the constructs that inform this population of BMSM are namely; race (black), sexual orientation (straight-identified - MSM), class (secondary educated, unemployed, with monthly disposable income of <R1 000). Therefore, from this vantage point, these various constructs intersect to define the lived experiences of most BMSM in Msunduzi Local Municipality who reported an awareness of PrEP, and a willingness to adopt it. An Intersectional lens contests conventional methods of reasoning which urge that all MSM be submerged in the same totalising category.
Many respondents in this study as illustrated in Table 2, were unemployed, this unemployment cannot be separated from issues of low educational levels which make them desirable candidates in the job market.
The above cannot be separated from issues of race, and the subjugation that is pitted against black semi or low skilled individuals in the job market. Finally, this unemployment cannot be separated from issues of not having the disposable income to partake in social life and the exclusion that happens due to a lack of disposable income. How all these constructs intersect is with regards to the accessibility to PrEP, due to the various constructs that intersect to marginalise a black, secondary educated, unemployed, straight-identified MSM living in a peri-urban community. The decision to view the high cost of PrEP as a barrier is illuminated by the various aspects of their identity that intersect to exclude them from being able to access life-saving preventative methods. Therefore, the theoretical assumption behind a choice of high-cost as a barrier should
reflect on the varied social ills that need to be addressed not only regarding PrEP but also socially if PrEP is going to be efficacious amongst this population.
Hence, it is evident that an Intersectional lens offers a better understanding of what informs the perceptions held by the majority of BMSM about PrEP in this study. Furthermore, it allows for an improved perspective on the aspects that need to be interrogated socially in order to improve on the social justice imperatives needed for PrEP’s successful implementation.
Even though this section does not propagate to conduct bivariate analysis on nominal and ordinal variables such as socio-demographic characteristics and PrEP adoption intention, a comparison of the two results as depicted in Table 5 below reveal a suggestive profile of the BMSM who would be willing to take PrEP. This is one of the subgroup comparisons this study undertook. The purpose of these subgroup comparison is described as mainly descriptive with the intention to define subgroups, including an additional element of comparison Babbie and Mouton (2001). Using subgroup comparisons, which, like univariate analysis is largely descriptive, this form of descriptive analysis describes the independent subgroups and then adds an element of comparison to this effect. In the below table, a comparison is made between the groups that indicate a high and low PrEP adoption intention, with the aim to establish the variables present in each sub- group and to ultimately create a profile of the individuals with diverging PrEP adoption outlooks. This kind of suggestive statistics could be proficient foreground data to better understand with the assistance of bivariate analysis, [discussed in later sections of this chapter] the target of future PrEP implementation plans. This table is quite revealing in several ways.
At initial glance, there are some characteristic differences between the profiles of BMSM who have reported a high PrEP adoption intention and those who have presented a low PrEP adoption. The profile reflecting a high PrEP adoption intention amongst respondents reveals that most of these respondents were relatively young (24–29 years), had a secondary education and were unemployed with a low monthly income (<R1 000). These respondents identified as gay and had an insertive sexual role preference and were single or dating at the time of data collection. While respondents with low intention were much younger (18–23 years), they had some tertiary education (diploma), were unemployed with a considerable amount employed (41.6%)
and a low monthly income (<R1 000). These BMSM were gay-identified, straight, and had an insertive sexual role preferences. What is evident from the above is that there were lower levels of intention amongst younger more educated respondents, this could be suggestive of BMSM making an informed decision based on more information accessibility. What is noteworthy between these profiles is that more employed, older and financially stable (>15001) and educated (tertiary + postgraduate) respondents were not willing to adopt PrEP.
Table 6: Socio-Demographics by PrEP Adoption Intention – Subgroup Comparison
Socio-demographic Characteristics
PrEP Adoption Intention High (n=97)
PrEP Adoption Intention Low
(n=12)
Total Population
(n=109)
Frequency Percent (%) Frequency Percent (%) Frequency Percent (%) Ethnicity
Black 97 (88.9) 12 (11.0) 109 (100.)
Age
18–23 33 (34.0) 6 (50.0) 39 (35.7)
24–29 40 (41.2) 3 (25.0) 43 (39.4)
30–35 22 (22.6) 2 (16.6) 24 (22.0)
36–40 2 (2.0) 1 (8.3) 3 (2.7)
>41 0 (0.0) 0 (0.0) 0 (0.0)
Education Completed Primary Education (Grade 7)
2 (2.0) 0 (0.0) 2 (1.8)
Secondary Education (Matric) 54 (55.6) 3 (25.0) 57 (52.2)
Diploma 24 (24.7) 4 (33.3) 28 (25.6)
Bachelor’s Degree 12 (12.3) 3 (25.0) 15 (13.7)
Postgraduate Diploma/
Honours
8 (8.2) 2 (16.6) 10 (9.1)
Masters or Doctorate 1 (1.0) 0 (0.0) 1 (0.9)
None 4 (4.1) 0 (0.0) 4 (3.6)
Employment Status
Unemployed 61 (62.8) 6 (50.0) 67 (61.4)
Student 16 (16.4) 1 (8.3) 17 (15.5)
Employed 19 (19.5) 5 (41.6) 24 (22.0)
Retired 1 (1.0) 0 (0.0) 1 (0.9)
Table 6 Continued
Socio-demographic Characteristics
PrEP Adoption Intention High (n=97)
PrEP Adoption Intention Low
(n=12)
Total Population
(n=109) Frequency Percent (%) Frequency Percent
(%)
Frequency Percent (%)
Monthly Income
<R1000 73 (75.2) 6 (50.0) 79 (72.4)
R1 001–R5 000 5 (5.1) 1 (8.3) 6 (5.5)
R5 001–R10 000 7 (6.4) 0 (0.0) 7 (5.8)
R10 001–R15 000 3 (3.0) 2 (16.6) 5 (4.5)
>R15 001 9 (9.2) 3 (25.0) 12 (11.0)
Sexual Orientation
Gay 53 (54.6) 5 (41.6) 58 (53.2)
Bisexual 16 (16.4) 1 (8.3) 17 (15.5)
Straight 24 (24.7) 4 (33.3) 28 (25.6)
Curious 4 (6.5) 2 (16.6) 6 (5.5)
Sexual Role
Insertive (Top) 43 (44.3) 7 (58.3) 50 (45.8)
Receptive (Bottom) 27 (27.8) 2 (16.6) 29 (26.6)
Both (Versatile) 25 (25.7) 3 (25.0) 28 (25.6)
Oral 2 (2.0) 0 (0.0) 2 (1.8)
Relationship Status
Single 54 (55.6) 8 (66.6) 62 (56.2)
Dating 41 (42.2) 3 (25.0) 44 (40.3)
Married 1 (1.0) 0 (0.0) 1 (0.9)
Divorced 1 (1.0) 1 (8.3) 2 (1.8)