Introduction
The HIV epidemic in Eswatini (also known as the Kingdom of Eswatini, formerly known as the Kingdom of Swaziland ) reflects wide sex disparities. Female adult HIV prevalence is 35%, whereas male prevalence is 19% [1] [2] [3]
Although Eswatini has implemented the WHO's 2015 Integrated HIV Treatment Guidelines [4] [5] [6] [6,7]
With efficacy well established [8–10] [11,12] [13] [14] [15] [12] [16]
The scale up of PrEP for women at high risk of HIV infection is expected to reduce HIV incidence when high levels of adherence are achieved [17] [6] [6,18–20]
Understanding challenges to PrEP implementation is important, but an emphasis on difficulties – a ‘deficit-based approach’ [21] [22] [23] [21,22]
In this article, we examine for the first time the relationships between PrEP and resilience. We examine this in the context of a government-led demonstration project of PrEP for the general population in Eswatini. We highlight the environment of risk exposure in which Emaswati women live, the assets and resources women draw upon and interact with in relation to initiating PrEP, and the manner in which a resilience-focused approach could create a more supportive environment for PrEP implementation.
Methods
In 2017, the MOH, in partnership with the Clinton Health Access Initiative, began a demonstration project in six public-sector primary-care clinics in rural and urban locations across Hhohho Region. A formative research component was built into this project, to investigate client and stakeholder knowledge, attitudes and experiences in relation to PrEP. Because women comprised approximately three quarters of early PrEP clients in this project, only women's perspectives were included in the study [24]
Study setting
The Hhohho Region is located in the north west of Eswatini and has a population of 282 734 [25] [2] [1]
Data collection
Five Emaswati research assistants were trained for 5 days to collect qualitative data using standardized instruments. Instruments were piloted and revised. All research assistants had college-level education and were fluent in siSwati and English. We purposively sampled women across the six intervention facilities based on their decision to initiate PrEP. Sampling among stakeholders drew from purposive and snowball sampling. We began by inviting leaders representing HIV policy, implementation and donor sectors to participate in semistructured, in-depth interviews (IDIs). Upon the conclusion of each stakeholder interview, we asked respondents to suggest two additional stakeholders with whom we could speak. All IDIs were audio recorded and conducted one-on-one, in a private place following written consent. IDIs with PrEP clients were conducted in siSwati or English. IDIs with stakeholders were conducted in English. Transcripts were simultaneously translated and transcribed, and quality controlled by bilingual research assistants. Although resilience was not the initial focus of this study, the theme emerged in early interviews and was probed as data collection progressed.
Data analysis
The current study was informed by the tenets of Grounded Theory [26] [27] [28] [29]
Ethical approval
The study received ethical approval from the Eswatini Ministry of Health National Health Research Review Board (MH/599C/IRB 0009688/NHRRB538/17) and the Chesapeake Institutional Review Board, USA (Pro00021864). This study was exempted from additional ethical review from the Ethics Committee of the Medical School of Heidelberg University because of preexisting in-country and international ethical approvals, and because of the anonymized nature of data analysis.
Results
We interviewed 24 female PrEP clients across the six public-sector primary-care clinics in Hhohho Region that participated in the government demonstration project of PrEP for the general population. In addition, we interviewed 30 stakeholders. Table 1 presents client characteristics; Table 2 presents stakeholder characteristics.
Table 1: Respondent characteristics: female preexposure prophylaxis clients.
Table 2: Respondent characteristics: preexposure prophylaxis stakeholders.
Nearly all female clients emphasized that PrEP made them feel they could claim some measure of control over their lives. Women described feeling initially skeptical and then elated at the prospect of being able to take a pill to protect against HIV infection. They talked at length about the relief, happiness and optimism this sparked in them as they felt they could remain HIV negative (using a technology that was in their control) and this could allow them to live long, rewarding lives.
Equally often (though with less enthusiasm), women discussed the role that PrEP played in their partnerships. In this regard, PrEP was described primarily as a means to share responsibility for ‘protecting’ the family, but several women noted that PrEP had the potential to generate discord with partners. Many women further described how PrEP would enhance their ability to draw upon external resources, such as visiting the clinic more often for counseling and testing, and many discussed developing a community dialog around PrEP and community ownership of its promotion.
Stakeholders included individuals from PrEP implementation, policy and donor organizations. Overall, stakeholders were optimistic about the potential for PrEP to reduce HIV incidence but they also voiced reservations about PrEP's ability to have a lasting, meaningful impact on the HIV epidemic in Eswatini. Stakeholders described their fears in relation to the potential for inconsistent use or nonadherence of PrEP. They spoke about the failures of previous HIV-prevention interventions, and how these failures fomented distrust. Stakeholders said PrEP would first need to be proposed and discussed at the community level by respected community members. After this, community-based health providers could begin sensitizing and educating clients. Although some stakeholders viewed PrEP as a ‘game-changing’ intervention, several felt PrEP would do little to mitigate risk among women and girls who are subjected to deeply embedded inequalities, and who would – for example – still need to ask their partner for money to reach the clinic or would fear of being caught with PrEP because it was not obtained with their partner's consent. Stakeholders consistently mentioned low condom use rates across Eswatini, and nearly all reiterated the need to continue to promote condoms and the ‘prevention package’ alongside PrEP.
Multilevel model of resilience
Building on a framework for psychological resilience among children affected by parental HIV created by Li et al. [30] Fig. 1 ). The risk exposure category (far left, Fig. 1 ) was drawn from both stakeholder and client interviews. The multilevel model of resilience (text within the circle, Fig. 1 ) was drawn almost exclusively from female participants’ interviews. Below, we describe the framework sequentially.
Fig. 1: Preexposure prophylaxis's relationship to resilience among Eswatini women, a multi-level model.
Risk exposure: structural and policy level
Stakeholders said several factors create or reinforce an environment that places Emaswati women at an exceptional risk for HIV infection. Along with highlighting Eswatini's extremely high HIV prevalence, stakeholders also discussed how strict sex roles limit Emaswati women's autonomy regarding marriage and sex (with a particular emphasis on sexual debut and condom use). Stakeholders said that intergenerational sex, sex-based violence, polygamy and early female sexual debut are socially accepted and endanger women. Stakeholders underscored that at the policy level, women are expected to have the same rights as men, but that in practice, much of the country operates in a manner that systematically disadvantages women (e.g. while women are legally permitted to own and inherent land under common law, customary law – which is widely practiced – generally does not allow women to inherit or own property) [31]
Risk exposure: interpersonal and individual level
Women's descriptions of their lives reflected their disadvantaged status. In nearly every interview, women described condom use negotiation as an example of their powerlessness. Women said that attempting to negotiate condom use was futile because men insist that condoms have ‘no place in marriage’, symbolize ‘distrust’, and can ‘lead to erectile dysfunction’. Women explained that it was a man's right to reject condoms. Most women said that they did not know their partner's HIV status. The HIV status of cowives was another source of concern for women in polygamous marriages. Without being asked, women spontaneously described hardship in marriages marked by ‘no trust’, in which a spouse was often absent, ‘likes other women’, or has been ‘caught cheating’ several times. Although women mostly talked about infidelity of male partners, some women described how they themselves had engaged in concurrent partnerships during a primary partner's prolonged absence. Women detailed how stress and fear were routine features in their intimate lives. They described living in constant ‘fear of HIV’ infection and they feared a negative – yet seemingly inescapable – trajectory associated with sex [including HIV and other sexually transmitted infections (STIs)]. In the event of HIV infection, many women said they may need to start taking antiretroviral therapy (ART) ‘behind (the partner's) back’ and they may be forced to ‘leave the homestead’.
Resilience assets and resources: internal, interpersonal and external levels
Below we describe the assets and resources that foster resilience at individual, interpersonal and environmental levels. Supporting quotes for the descriptions of each level are in Table 3 and can be identified by the row number highlighted in the text.
Table 3: Participant quotations.
Internal assets: control, choice and protection of one's health
Women said PrEP enhanced feelings of protection and control, which we characterized as internal assets. Women said they could take comfort in the notion that a drug could help them maintain a negative status. Women used the words ‘protect’ and ‘protection’ not only in terms of PrEP's ability to prevent HIV, but also in relation to protecting oneself from a partner who makes ‘bad choices’. Although PrEP did not remove the emotional burden of a partner's infidelity or the infidelity itself, women felt that taking PrEP increased their control and protection, which mitigated the effects of these behaviors (Table 3 , rows 1 and 2).
Women said PrEP required less negotiation and maneuvering than condoms. PrEP also appeared to reduce stress associated with condomless sex. Women said that with PrEP, ‘I am still protected’, even if they failed to negotiate condom use, and ‘If I drink the pills, I am protecting myself’.
Women described PrEP as not only allowing them to protect themselves from HIV, but also allowing them to choose when to protect themselves. Women explained that it is ‘up to you’ when to start, pause, resume or stop taking PrEP. This seemed to resonate particularly with women who described partners as ‘living away’ and ‘staying at work’ for periods of several months or more. This notion also resonated among women engaging in concurrent sexual partnerships, which PrEP allowed them to undertake without, in their view, compromising their health (Table 3 , row 3).
Counseling helped women identify HIV risk periods and make autonomous HIV-prevention choices informed by expected partner absences and returns (Table 3 , row 4).
Internal assets: happiness, relief and optimism for future health
Women described PrEP as promoting happiness, sexual pleasure and relief from the risk of HIV infection. These feelings were described particularly in relation to sexual intercourse and optimism for future health. In terms of sexual intercourse, women said a persistent fear of HIV infection during every sexual encounter could be mitigated or removed. With this worry removed, participants described being able to ‘enjoy sex again’, and they described looking forward to an improved sex life. Women described feeling happiness at the prospect of living longer, fuller, healthier lives. Happiness and relief were described primarily as the removal of fear regarding premature death, which extended specifically to being able to care for children (Table 3 , row 5).
Interpersonal assets: enhanced communication within serodiscordant partnerships
At the interpersonal level, women in relationships in which a serodiscordant status was known by both parties described PrEP as promoting partner communication regarding HIV prevention. For women who could talk about their HIV status and were in open serodiscordant relationships, PrEP was viewed as an additional method of managing HIV within marriage. Women said their partners had no reservations about PrEP as they were already taking ART, and understood how PrEP could ‘help’. Women said PrEP served as an additional layer of protection from HIV because they could not control two vital components of their partners’ behavior: condom use and ART adherence.
Interpersonal assets: collective efficacy, sense of shared responsibility for families’ HIV status
The feeling that PrEP enabled women to take shared responsibility for HIV prevention within their partnerships also extended to the health of the broader family. Women described how they and their partners felt happy and relieved at the thought of a being able to preserve a negative status, thus extending a negative status to future children (Table 3 , row 6).
Women in polygamous relationships explained that PrEP fostered communication with cowives in addition to husbands. Here – with PrEP – women were better able to discuss their HIV-negative status and to tell their ‘husband and the other women I’m married with’ about PrEP as a way of preventing further family infection (Table 3 , row 7).
External resources: community dialog and communication
At the level of external assets, women described feeling empowered to engage in a community-level dialog regarding PrEP promotion. Women frequently described notions of community ownership of PrEP and that it ‘does not belong to any individual’ but to the country of Eswatini as a whole. Ideas regarding PrEP as a community prevention method could be seen in statements such as ‘the virus is in all of us’ and that PrEP is for ‘us’, for ‘Swazis’, to remain HIV negative (Table 3 , row 8).
Furthermore, women described a sense of responsibility to promote PrEP within the community based on an acute sense of loss from AIDS. Women expressed that, with PrEP, ‘many lives would be saved’ and that ‘people would not be having the virus as today’. They wished friends and family who had died from AIDS could have had access to PrEP. Women spoke frequently about a community future ‘free from HIV and AIDS’ and that with PrEP ‘no more Swazis will die of AIDS’ (Table 3 , row 9).
External resources: enhanced HIV guidance and counseling from healthcare provider
Women described PrEP counseling in a generally positive light, saying clinicians were able to explain the purpose and process of taking PrEP. The exposure to more HIV counseling generally (via PrEP sensitization) was also seen as bolstering choice in relation to HIV-prevention methods. Women said that more counseling through PrEP uptake not only reiterated the HIV-prevention options available, but also reinforced messages and knowledge about condom use for prevention of STIs and pregnancy (Table 3 , row 10).
Discussion
With PrEP, Emaswati women in this study achieved a sense of personal control over their HIV acquisition risk, in a manner that was discrete and of their own choosing. PrEP thus bolstered several resilience assets, such as self-efficacy, happiness and relief from the risk and consequences of HIV infection. With this stress removed, women who previously found it hard to insist on condom use and thus feared sex were able to look forward to sexual intercourse. PrEP counseling empowered women to make informed choices regarding how and when to initiate, pause, resume or stop taking PrEP.
Our findings differ in important ways from the extant literature on PrEP implementation. In other studies, PrEP has been seen as intertwined with notions of family planning and as a means to having HIV-negative children [15,20,32]
Our study is the first study to look explicitly at how PrEP could bolster resilience in women. We developed this body of knowledge during the analysis process [33] et al. [30] [23] [34] [35]
Our framework is informed by self-perceptions of resilience such as subjective notions of happiness and relief, which is common in resilience literature for adults, but neglects others objective assessments of resilience – an approach more commonly used with children [36] [37] [38] [39]
Our work has several limitations. First, the results cannot be applied to men. Second, our participants likely do not represent all potential female PrEP clients in Eswatini, as the ‘early adopters’ of PrEP may be the most motivated and resilient individuals (as evidenced by their care-seeking behavior, and their ability to remain HIV-negative despite extensive HIV-risk exposure). Although this theory is speculative, it could be that women who take PrEP have developed other resilience assets over time. PrEP could then be part of a two-way relationship that creates a resilience-strengthening feedback. However, this possibility seems less likely given the severity of the risk environment that women in our study described, in which many viewed PrEP as their only source of protection. Third, our cross-sectional approach did not allow us to watch how resilience may develop over time with PrEP, and how it may or may not interact with PrEP adherence, which has been identified as a major challenge to the effectiveness of PrEP in women [20] [40]
Our findings have important implications for PrEP policy and practice, which have been shared with the MOH and their partners via presentations and an information brief (Appendix 1, https://links.lww.com/QAD/B457
Acknowledgements
We thank all respondents for their time and insights. We thank our research assistants for their dedication and hard work: Phiwayinkhosi Dlamini, Mxolisi Mavuso, Nelisiwe Masilela, David Fakudze and Phetsile Kunene.
Funding for this research was received from the Bob L Herd Foundation and the Alexander von Humboldt Foundation.
Conflicts of interest
There are no conflicts of interest.
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