Beyond awareness: navigating structural and cognitive barriers to pre-exposure prophylaxis sustainability among female sex workers in a context of declining human immunodeficiency virus financing-lessons from Maseru, Lesotho
1
Environmental Health, University of Johannesburg, Johannesburg, South Africa
2
Optometry, University of Johannesburg, Johannesburg, South Africa
3
School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
INTRODUCTION:
Optimizing the effectiveness and impact of evidence-based interventions, such as pre-exposure prophylaxis (PrEP), has become a critical programmatic imperative amid a decline in global HIV financing. The sustainability of PrEP as a preventive pillar is threatened by ongoing gaps including low uptake, in many low- and middle-income countries, including iLesotho, a country that depends heavily on outside health funding. This study investigated the complex interplay of knowledge, attitudes, and structural determinants influencing the PrEP care continuum among FSWs in Maseru, generating actionable evidence for resilient, cost-effective service delivery.
METHODS:
A qualitative exploratory study was conducted at Lesotho Planned Parenthood Association in Maseru facilities in Maseru district in Maseru. In-depth interviews with ten purposively sampled, HIV-negative FSWs actively on PrEP were analyzed using reflexive thematic analysis.
RESULTS:
A crucial paradox emerged from the analysis: high motivation and basic PrEP awareness were undermined by specific, actionable knowledge gaps—most notably, misunderstandings regarding indefinite use and confusion between PrEP and PEP. Mobility-driven care disruptions, clinic access issues, and stigma associated with service centralization were the main structural barriers, worsen by resource limitations. Daily adherence was directly threatened by side effects and food insecurity. Sustainable solutions were indicated by enablers such as trustworthy client-provider relationships encouraged perseverance, and peer-support networks served as an essential adherence scaffold.
CONCLUSIONS:
This study highlights both individual barriers and systemic issues in PrEP delivery that comes with tight funding. The findings make a strong case for a strategic pivot towards differentiated, community-driven PrEP models. This approach would weave in peer-led education, decentralized access, and preparation for long-acting formulations, all aimed at boosting efficiency, safeguarding progress, and ensuring sustainable prevention for key populations in Lesotho and similar financial contexts. The evidence serves as a clear guide for policymakers to protect public health investments during times of budget constraints.
Optimizing the effectiveness and impact of evidence-based interventions, such as pre-exposure prophylaxis (PrEP), has become a critical programmatic imperative amid a decline in global HIV financing. The sustainability of PrEP as a preventive pillar is threatened by ongoing gaps including low uptake, in many low- and middle-income countries, including iLesotho, a country that depends heavily on outside health funding. This study investigated the complex interplay of knowledge, attitudes, and structural determinants influencing the PrEP care continuum among FSWs in Maseru, generating actionable evidence for resilient, cost-effective service delivery.
METHODS:
A qualitative exploratory study was conducted at Lesotho Planned Parenthood Association in Maseru facilities in Maseru district in Maseru. In-depth interviews with ten purposively sampled, HIV-negative FSWs actively on PrEP were analyzed using reflexive thematic analysis.
RESULTS:
A crucial paradox emerged from the analysis: high motivation and basic PrEP awareness were undermined by specific, actionable knowledge gaps—most notably, misunderstandings regarding indefinite use and confusion between PrEP and PEP. Mobility-driven care disruptions, clinic access issues, and stigma associated with service centralization were the main structural barriers, worsen by resource limitations. Daily adherence was directly threatened by side effects and food insecurity. Sustainable solutions were indicated by enablers such as trustworthy client-provider relationships encouraged perseverance, and peer-support networks served as an essential adherence scaffold.
CONCLUSIONS:
This study highlights both individual barriers and systemic issues in PrEP delivery that comes with tight funding. The findings make a strong case for a strategic pivot towards differentiated, community-driven PrEP models. This approach would weave in peer-led education, decentralized access, and preparation for long-acting formulations, all aimed at boosting efficiency, safeguarding progress, and ensuring sustainable prevention for key populations in Lesotho and similar financial contexts. The evidence serves as a clear guide for policymakers to protect public health investments during times of budget constraints.
| eISSN: | 2654-1459 |
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