Multilevel Barriers and Facilitators to Pre-Exposure Prophylaxis Uptake among Men Who Have Sex with Men and People Who Inject Drugs in Kano State, Northern Nigeria

Despite the proven efficacy of oral pre-exposure prophylaxis (PrEP), uptake among key populations in Nigeria, particularly men who have sex with men (MSM) and people who inject drugs (PWID) remains low. In conservative northern settings such as Kano State, intersecting legal, religious, and socio-cultural constraints intensify stigma and limit access to HIV prevention services. This study explored multilevel barriers and facilitators shaping PrEP uptake among MSM and PWID in this context. Using a phenomenological qualitative design, we conducted 13 in-depth interviews with MSM (n = 10) and PWID (n = 3), and 7 key informant interviews with healthcare providers, program managers, and community stakeholders. Participants were purposively recruited from key population hotspots and One-Stop-Shop clinics. Data were thematically analyzed using Braun and Clarke’s reflexive approach, guided by the Social Ecological Model and HIV Stigma Framework. Barriers to PrEP uptake operated across individual, interpersonal, community, and structural levels, including limited awareness, confusion with antiretroviral therapy, low perceived risk, adherence fatigue, fear of stigma, community misrecognition of PrEP as HIV treatment, transportation costs, clinic wait times, and economic hardship, particularly among PWID. Facilitators included heightened perceived HIV risk, peer support, trust in key population–friendly counselors, access to confidential One-Stop-Shop clinics, and integration with harm reduction services. Key informants emphasized the importance of sustainable domestic financing and supportive policy environments. These findings underscore the need for culturally responsive, multilevel strategies that strengthen peer-led outreach, expand confidential service delivery models, and promote enabling health system and policy conditions for sustainable PrEP scale-up in northern Nigeria. Clinical trial number : Not applicable.