Effectiveness of the national HIV pre-exposure prophylaxis (PrEP) programme among female sex workers in Rwanda: a retrospective cohort study

Background In 2018, Rwanda incorporated oral pre-exposure prophylaxis (PrEP) with tenofovir and emtricitabine (Truvada) into national HIV guidelines as part of a comprehensive HIV prevention programme for female sex workers (FSWs). This study assessed the impact of PrEP on HIV incidence among FSWs in urban Rwanda. Methods We conducted a retrospective cohort study among HIV-negative FSWs aged≥18 years at 20 health facilities in Kigali from January 2019 to October 2021. All participants received standard HIV prevention services including routine condom distribution, peer education activities and the option to receive daily oral PrEP. Those who consented to receive PrEP formed the exposed group and those who declined or were not eligible to receive PrEP formed the control group. We used Cox regression to assess HIV seroconversion and logistic regression to assess retention in care. Results Among 1897 FSWs (median age 30.1 years, IQR: 25.2–35.6), 1129 (59.5%) initiated PrEP. The HIV incidence rate was 0.40 per 100 person-years (PYs) among FSWs in the PrEP group versus 1.83 per 100 PYs for those in the non-PrEP group. In multivariate analysis, PrEP was associated with a reduced risk of HIV seroconversion (adjusted HR: 0.25; 95% CI: 0.09 to 0.71). Retention in the HIV prevention programme at 12 months was 77.6% among FSW who used PrEP versus 73.6% among non-users (adjusted OR: 1.29 (95% CI: 1.03 to 1.60). Conclusions Oral PrEP was associated with reduced HIV risk of HIV seroconversion among FSWs in Kigali. However, the small number of HIV seroconversions and limitations of the observational design warrant cautious interpretation of study findings.