Programmatic and service delivery determinants of PrEP initiation and 3-month continuation among adolescents and young adults in Eastern Uganda

Oral pre-exposure prophylaxis is effective for HIV preventing HIV acquisition; however, PrEP initiation and continuation among adolescents and young adults (AYAs) in sub-Saharan Africa remain suboptimal despite ongoing scale-up efforts. This study examined PrEP initiation, 3-month continuation, and associated factors among AYAs aged 15-29 years receiving HIV prevention services in Eastern Uganda from January 2019 to June 2025. Among 10,698 AYAs, 10,132 (94.7%) were assessed for eligibility, 5,190 (51.2%) were eligible, and 2,986 (57.5%) initiated PrEP. Among 2,851 initiators eligible for 3-month assessment, 913 (32.0%) continued PrEP. In multivariate analyses, previous peer outreach contact was strongly associated with both initiation (aOR = 534.63, 95% CI: 276.89-1032.28) and continuation (aOR = 12.41, 95% CI: 9.41-16.35). Facility-based service delivery (aOR = 14.88, 95% CI: 5.05-43.86), psychoactive drug use (aOR = 5.15, 95% CI: 2.97-8.93), and HIV status disclosure (aOR = 4.44, 95% CI: 2.31-8.53) were associated with initiation, while MSM had lower odds of continuation than sex workers (aOR = 0.57, 95% CI: 0.45-0.71). Firth sensitivity analysis produced similar continuation estimates. These findings highlight a substantial gap between PrEP initiation and early continuation, and support sustained peer-based, youth-responsive strategies to strengthen PrEP uptake and retention.