Beyond the Pill: Contextual Effects of Community-Based PrEP Delivery on Pregnancy Risk among FSWs in Cameroon – A Propensity Score-Matched Analysis

Background: Female sex workers (FSWs) face elevated risks of both HIV acquisition and unintended pregnancies. While oral pre-exposure prophylaxis (PrEP) is an established HIV prevention tool, its broader impact on sexual and reproductive health (SRH) outcomes remains unclear in real-world settings. In Cameroon, PrEP is delivered via community-based platforms where SRH services are opportunistically offered alongside HIV prevention. Objective: To assess how exposure to an integrated, community-based oral PrEP–SRH programme influences the occurrence of pregnancy among FSWs in Cameroon. Methods: We conducted a cross-sectional analysis using propensity score–matched data from FSWs enrolled in a national PrEP programme. Age was centred at the median (24 years), and robust Poisson regression models were fitted to estimate adjusted risk ratios (aRRs) for pregnancy occurrence. An interaction term between age and PrEP exposure was introduced, and model stability was assessed via bootstrap resampling (1,000 iterations). Results: No significant association was found between PrEP exposure and pregnancy in unstratified models (aRR = 0.82; p = 0.522). However, a significant interaction with age emerged (aRR = 1.38; p = 0.021), suggesting younger women may benefit more from the programme. Bootstrap analysis confirmed this interaction (p = 0.024), but the confidence interval included the null, raising concerns about robustness. Findings likely reflect contextual effects of integrated, trusted service delivery rather than PrEP's pharmacological action alone. Supporting evidence from the ANRS PRINCESSE project in Côte d’Ivoire reinforces the role of holistic SRH–PrEP platforms in improving health outcomes and paves the way for future adoption of multipurpose prevention technologies (MPTs). Conclusion: Community-based delivery of PrEP within integrated SRH platforms may reduce pregnancy risk among FSWs, particularly younger women. Such models offer a promising foundation for future MPT rollouts.