Biomedical HIV prevention cascades and acceptability of community health worker-led services: a cross-sectional survey in Lesotho

Background Lesotho has one of the highest HIV incidences globally, yet awareness and uptake of HIV pre-exposure (PrEP) and post-exposure prophylaxis (PEP) remain low. We assessed gaps along HIV prevention cascades, determined predictors of PrEP and PEP awareness and explored the potential acceptability of community health worker (CHW)-led service delivery in rural Lesotho. Methods We conducted a cross-sectional survey among people aged ≥ 15 years living in 10 rural villages in northeastern Lesotho. Among individuals at risk of HIV, we assessed awareness, motivation, reach, and use for PrEP and PEP along prevention cascades. Multivariable logistic regressions estimated adjusted odds ratios (aORs) for predictors of awareness. Participants were also asked about the acceptability of HIV prevention services delivered by CHWs. Results Among 1083 participants, 926 were not living with HIV (median age 37 years; 57% female), and 218 (24%) of them were at increased risk of HIV. Of these, 56% were aware of PrEP, 46% motivated, 11% reached, and 8% current users; for PEP, 29% were aware, 17% were motivated, and 2% had used it in the past. PrEP awareness was higher among women (aOR 3.13, 95% CI: 1.56–6.42, 0.001). PEP awareness was higher among women (aOR 2.26, 95% CI: 1.01–5.17, p = 0.049), those with higher education (aOR 2.93, 95% CI: 1.29–7.06, p = 0.012), and those married or cohabiting (aOR 2.76, 95% CI: 1.17–6.89, p = 0.024). Overall, ≥ 87% of participants perceived CHW-delivered HIV prevention services as beneficial for their communities, and ≥ 75% of eligible individuals reported being comfortable receiving CHW-delivered counseling, testing, biomedical and dual prevention methods. Conclusion PrEP and PEP uptake in Lesotho remains low, with the largest gaps in PEP awareness and PrEP reach. The significant drop-off between motivation and use suggests that access barriers, rather than acceptability, may drive low uptake. Participants indicate high acceptance of CHW-led PreP and PEP services supporting CHW-led biomedical prevention as a strategy to improve their reach in Lesotho.