The Sexual Risk Context among the FEM-PrEP Study Population in Bondo, Kenya and Pretoria, South Africa Jennifer Headley 1 *, Ansley Lemons 1 , Amy Corneli 1 , Kawango Agot 2 , Khatija Ahmed 3 , Meng Wang 1 , Jacob Odhiambo 2 , Joseph Skhosana 3 , Jenae Tharaldson 1 , Lut Van Damme 1¤ , Kathleen MacQueen 1 for the FEM-PrEP Study Group 1 FHI 360, Durham, North Carolina, United States of America, 2 Impact Research and Development Organization, Kisumu, Kenya, 3 Setshaba Research Center, Soshanguve, South Africa Abstract Background: Incidence rates in the FEM-PrEP and VOICE trials demonstrate that women from diverse sub-Saharan African communities continue to be at substantial HIV risk. Objective: To describe and compare the sexual risk context of the study population from two FEM-PrEP trial sites–Bondo, Kenya, and Pretoria, South Africa. Methods: At baseline we collected information about demographics, sexual behaviors, and partnership beliefs through quantitative questionnaires with all participants (Bondo, n = 720; Pretoria, n = 750). To explore the sexual risk context, we also conducted qualitative, semi-structured interviews with HIV-negative participants randomly selected at several time points (Bondo, n = 111; Pretoria, n = 69). Results: Demographics, sexual behavior, and partnership beliefs varied significantly between the sites. Bondo participants were generally older, had fewer years of schooling, and were more likely to be employed and married compared to Pretoria participants. Bondo participants were more likely to report multiple partners and not knowing whether their partner had HIV than Pretoria participants. A significantly higher percentage of Bondo participants reported engaging in sex without a condom with their primary and other partners compared to Pretoria participants. We found a borderline association between participants who reported not using condoms in the 4 weeks prior to baseline and lower risk of HIV infection, and no association between having more than one sexual partner at baseline and HIV infection. Discussion: Despite significantly different demographics, sexual behaviors, and partnership beliefs, many women in the FEM-PrEP trial were at risk of acquiring HIV as demonstrated by the sites’ high HIV incidence. Though gender dynamics differed between the populations, they appear to play a critical role in women’s sexual practices. The findings highlight different ways women from diverse contexts may be at-risk for HIV and the importance of providing HIV prevention options that are both effective and feasible given personal and social circumstances. Citation: Headley J, Lemons A, Corneli A, Agot K, Ahmed K, et al. (2014) The Sexual Risk Context among the FEM-PrEP Study Population in Bondo, Kenya and Pretoria, South Africa. PLoS ONE 9(9): e106410. doi:10.1371/journal.pone.0106410 Editor: Alan Landay, Rush University, United States of America Received February 24, 2014; Accepted August 1, 2014; Published September 17, 2014 Copyright: ß 2014 Headley et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: FEM-PrEP was conducted under two grants funded by the United States Agency for International Development (USAID): The Contraceptive and Reproductive Health Technologies and Research Utilization Program, and the Preventive Technologies Agreement. Early support was also provided by the Bill & Melinda Gates Foundation. Gilead Sciences, Inc. donated Truvada and placebo. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. http://www.usaid.gov/; http://www.gilead.com/; http://www.gatesfoundation.org/. Competing Interests: Gilead Sciences, Inc. donated Truvada and placebo. This does not alter the authors’ adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors. * Email: jheadley@fhi360.org ¤ Current address: The Bill & Melinda Gates Foundation, Seattle, Washington, United States of America Introduction Breakthroughs in the field of HIV prevention have identified encouraging approaches to substantially reduce the number of new infections. In recent pre-exposure prophylaxis (PrEP) clinical trials, daily oral emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF) was demonstrated to reduce HIV infection by 75% among serodiscordant couples in Kenya and Uganda [1], by 62% among men and women in Botswana [2], and by 44% among transgender women and men who have sex with men in Peru, Ecuador, South Africa, Brazil, Thailand, and the United States [3]. Among injecting drug users in Thailand, daily oral TDF reduced HIV infection by 49% [4]. In contrast, two trials assessing daily oral FTC/TDF among women in Africa – FEM-PrEP and VOICE – were unable to demonstrate effectiveness for HIV prevention due to low adherence [5,6]. Women continue to be disproportionally burdened by HIV, particularly in sub-Saharan Africa [7]. The incidence rates from FEM-PrEP and VOICE (5.0 and 5.7 per 100 person years in the placebo arms, respectively) demonstrate that women from diverse PLOS ONE | www.plosone.org 1 September 2014 | Volume 9 | Issue 9 | e106410