Community-Based Delivery Model for HIV Pre-exposure Prophylaxis Among Bar Patrons in Rural South Africa
South Africa, home to the world’s largest HIV epidemic, has made great strides in improving access to HIV services, but specific groups, particularly young men, remain difficult to engage in the HIV care cascade. Congregate settings where alcohol is served, known as shebeens, are an ideal place to engage young people for HIV testing, treatment, and prevention including pre-exposure prophylaxis (PrEP). Here we characterize the uptake of PrEP in shebeen patrons and explore the effect of alcohol consumption on PrEP uptake by piloting a community-based delivery model. In the rural Kwazulu-Natal province (KZN) of South Africa, a field team made up of all men offered screenings outside of shebeens. Screenings included rapid HIV testing and Alcohol Use Disorder Identification Test (AUDIT). Participants who tested negative for HIV were offered PrEP as once daily oral tenofovir disoproxil fumarate/emtricitabine. Predictors of uptake were identified and short term retention was characterized. Among 229 approached, 162 underwent screening, and 136 (84%) were eligible for PrEP. Among those eligible, 37 (27%) completed clinical evaluation and initiated PrEP. Among PrEP initiators, 91.9% were men, median age was 26.0 years (Interquartile range (IQR) 21-31), 32.4% were employed, 18.9% had running water, and 70.3% had AUDIT scores indicating hazardous drinking. Among 37 initiators, 25 (68%) were retained at 1 month, and 19 (51%) were retained at 4 months. Independent predictors of PrEP uptake among all bar patrons, and only men (108 screened, 34 initiators), included younger age (OR 0.92 (0.88-0.97) and lifetime number of sexual partners (OR 1.07 (1.02-1.13). In conclusion, community-based PrEP delivery after engagement at shebeens in rural South Africa is a feasible and novel approach to reach a traditionally difficult-to-engage population, particularly young men. In this small sample, sexual risk behaviours predicted PrEP uptake. Hazardous drinking was not a barrier to PrEP initiation.