Pre-exposure prophylaxis (PrEP) uptake among female sex workers in northern Nigeria: A qualitative study of barriers and facilitators

ABSTRACT Background Female sex workers (FSWs) in sub-Saharan Africa, including Nigeria, face disproportionately high risks of HIV acquisition. While oral pre-exposure prophylaxis (PrEP) is highly effective, its uptake among FSWs remains low, especially in conservative, high-stigma settings like northern Nigeria. This study explored the multilevel barriers and enablers influencing PrEP uptake among this key population. Methods We conducted 13 semi-structured interviews, including 10 in-depth interviews with brothel-based and non-brothel-based FSWs and 3 key informant interviews with PrEP program implementers from One-Stop Shop clinics. Participants were purposively sampled across Kano metropolis. Using reflexive thematic analysis, guided by the Social Ecological Model, we examined individual, interpersonal, community, and structural factors influencing PrEP decision-making. Results Barriers to PrEP uptake included limited awareness, misconceptions regarding antiretroviral therapy, concerns about side effects, partner stigma, and service access constraints. The visual similarity between PrEP and ART packaging reinforced stigma and fears of partner violence or rejection. Facilitators included peer-led sensitization, provider rapport, transport stipends, and decentralized community-based delivery. FSWs and implementers emphasized the need for discreet, long-acting PrEP options and identified brothel managers, intimate partners, and community health workers as key gatekeepers. Conclusions PrEP uptake among FSWs in Nigeria is influenced by interconnected individual, social, and structural barriers. Enhancing uptake requires multi-level interventions, such as differentiated service delivery, stigma-sensitive packaging, and peer- and partner-engaged outreach. Integrating PrEP into trusted, accessible services tailored to the realities of FSWs’ lives can improve equity and ensure the sustainability of HIV prevention efforts in similar high-burden settings.