What do young people think of on-demand PrEP?

A new study from South Africa, Uganda and Zimbabwe is the first to examine young people’s views on taking on-demand PrEP compared to a daily regimen.

What is the research about?

On-demand PrEP is when you take two PrEP pills between 2 to 24 hours before having sex, one PrEP pill after 24 hours of the first dose, and one after 48 hours. Daily PrEP is when you take one pill every day for as long as you are at risk of HIV.

To understand young people’s views on the two options, researchers spoke to around 190 young people (ages 13-24) in Soweto, Cape Town, Wakiso district and Chitungwiza.

Why is this research important?

PrEP gives young people an HIV prevention tool they are completely in control of (unlike condoms, which have to be negotiated with partners). Understanding what young people think of the two different types of oral PrEP is essential for designing PrEP services that work for them.

What did they find out?

Overall, participants preferred the idea of on-demand PrEP to daily PrEP.

There were four main reasons for this:

1. HIV-related stigma

Some participants didn’t want to use daily PrEP because they were worried other people might think they had HIV if they took antiretrovirals (ARVs) every day.

2. Difficulties taking pills every day

Some participants said they would get tired of taking a daily pill or would forget to take it.

3. The hope for reduced side effects

Young men from Uganda and Zimbabwe were worried about increased side effects if they took daily PrEP.

4. Not having frequent sex  

Some participants said they weren’t having frequent sex so on-demand PrEP would better suit their lifestyle. More young men than young women gave this as a reason. One 22-year-old man from Zimbabwe explained: “Since you are not engaging sexually every day, you may end up seeing it as an unnecessary burden.”

Not all participants preferred the idea of on-demand PrEP. Those that preferred daily PrEP gave three reasons for doing so.

1. Having frequent unplanned sex

In Cape Town, Johannesburg and Zimbabwe, participants spoke of regularly having unplanned, high-risk sex, including transactional sex.

One adolescent girl in Zimbabwe explained: “[It’s] the issue of not knowing. Maybe, I might meet a guy who would want to give me money. So, it is better for me to take it beforehand so that when I have sex with him, I will not be infected...”

In all countries, some young men and young women said they were worried about being raped and getting HIV, so they preferred the idea of daily PrEP.

2. Road accidents

Some participants, mainly young men, said they liked the idea of daily PrEP because they were worried about getting in a car or motorbike accident and coming into contact with someone else’s blood, increasing the risk of HIV transmission.

3. Increased protection from a daily dose

A few participants, mainly young men in Uganda and Zimbabwe, said they would prefer to use daily PrEP to increase the drug’s effectiveness in the body.

What does this mean for HIV services?

Young people are likely to want to have a choice between daily and on-demand PrEP. It is possible that many will opt for on-demand PrEP to avoid HIV-related stigma and because it is better suited to their lifestyle.

However, recently published evidence from America and West Africa looking at on-demand PrEP use found most of the men who have sex with men, including young men who took part in the research found it hard to predict when they were going to have sex. Some also found it difficult to remember to take post-sex pills. For young people with similar experiences, daily PrEP may be more effective. This shows the importance of providing clear information and non-judgemental counselling so that young people fully understand what each PrEP regimen requires and which is most likely to suit their lifestyle.

HIV-related stigma also remains a challenge to be tackled, as it is likely to prevent some young people from choosing daily PrEP, even if it would be more beneficial to them than the on-demand version.