INTRODUCTION: HIV pre-exposure prophylaxis (PrEP) is an effective biomedical intervention for preventing HIV; however, PrEP adoption initially lagged across sub-Saharan Africa (SSA) and may have been affected by barriers to engagement in PrEP care. Stable, heterosexual HIV-serodifferent couples are a priority population of PrEP expansion efforts. We assessed factors associated with PrEP awareness and willingness among HIV-serodifferent couples in SSA to guide PrEP interventions for this population. METHODS: We conducted a cross-sectional analysis using pooled data from nationally representative, two-stage cluster sampling, HIV-focused household surveys completed during 2019-2022 in seven African countries. We analysed data from 1738 persons without HIV aged ≥15 years in stable, heterosexual HIV-serodifferent couples and included clinical information from their partners with HIV. Higher HIV risk was defined by unawareness of a partner's HIV-positive status or having a partner with an unsuppressed viral load (≥200 copies/ml). Lower HIV risk was defined by awareness of a partner's HIV-positive status and having a partner with a suppressed viral load (<200 copies/ml). We conducted multivariable logistic regression using survey weights and jackknife variance estimation to assess factors associated with PrEP awareness and willingness. RESULTS: Overall, 18.1% were aware of PrEP, 69.1% were willing to use PrEP and 5.1% had ever used PrEP. Forty-four percent had higher HIV risk. Higher odds of PrEP awareness were associated with being female (adjusted odds ratio [aOR]: 1.73; 95% confidence interval [CI]: 1.15-2.59), secondary education or higher (aOR: 6.42; 95% CI: 2.97-13.91) and lower HIV risk (aOR: 1.58; 95% CI: 1.00-2.48). Higher odds of PrEP willingness were associated with employment in the past year (aOR: 1.55; 95% CI: 1.01-2.37), previous PrEP awareness (aOR: 2.44; 95% CI: 1.36-4.36) and lower HIV risk (aOR: 1.70; 95% CI: 1.07-2.70). CONCLUSIONS: Persons in stable, heterosexual HIV-serodifferent couples with lower HIV risk were more aware of and willing to use PrEP than those with higher risk. Our findings highlight the importance of encouraging HIV status disclosure, educating about HIV-serodifference and PrEP, and providing PrEP linkage during HIV testing and prevention counselling to increase PrEP awareness, willingness and use among HIV-serodifferent couples in SSA.

BACKGROUND: The World Health Organization recommends Pre-Exposure Prophylaxis (PrEP) for all populations at substantial risk of HIV infection. Understanding PrEP awareness and interest is crucial for designing PrEP programs; however, data are lacking in sub-Saharan Africa. In Malawi, oral PrEP was introduced in 2018. We analyzed data from the 2020 Malawi Population-based HIV Impact Assessment (MPHIA) to assess PrEP awareness and factors associated with PrEP interest in Malawi. METHODS: MPHIA 2020 was a national cross-sectional household-based survey targeting adults aged 15 + years. Oral PrEP was first described to the survey participants as taking a daily pill to reduce the chance of getting HIV. To assess awareness, participants were asked if they had ever heard of PrEP and to assess interest, were asked if they would take PrEP to prevent HIV, regardless of previous PrEP knowledge. Only sexually active HIV-negative participants are included in this analysis. We used multivariable logistic regression to assess sociodemographic factors and behaviors associated with PrEP interest. All results were weighted. RESULTS: We included 13,995 HIV-negative sexually active participants; median age was 29 years old. Overall, 15.0%, 95% confidence interval (CI): 14.2-15.9% of participants were aware of PrEP. More males (adjusted odds ratio (aOR): 1.3, 95% CI: 1.2-1.5), those with secondary (aOR: 1.5, 95% CI: 1.2-2.0) or post-secondary (aOR: 3.4, 95% CI: 2.4-4.9) education and the wealthiest (aOR: 1.6, 95% CI: 1.2-2.0) were aware of PrEP than female, those without education and least wealthy participants, respectively. Overall, 73.0% (95% CI: 71.8-74.1%) of participants were willing to use PrEP. Being male (aOR: 1.2; 95% CI: 1.1-1.3) and having more than one sexual partner (aOR: 1.7 95% CI: 1.4-1.9), were associated higher willingness to use PrEP. CONCLUSIONS: In this survey, prior PrEP knowledge and use were low while PrEP interest was high. High risk sexual behavior was associated with willingness to use PrEP. Strategies to increase PrEP awareness and universal access, may reduce HIV transmission.