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Krogstad Mudzingwa E, de Vos L, Atujuna M, Fynn L, Mugore M, Mabandla S, Hosek S, Celum C, Bekker LG, Daniels J, Medina-Marino A. High study participation but diverging adherence levels: qualitatively unpacking PrEP use among adolescent girls and young women over two years in Eastern Cape, South Africa. J Behav Med 2024; 47:320-333. [PMID: 38081955 PMCID: PMC10944421 DOI: 10.1007/s10865-023-00462-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 11/10/2023] [Indexed: 03/17/2024]
Abstract
In Southern and Eastern Africa, initiation of daily oral pre-exposure prophylaxis (PrEP) for HIV prevention has been high among adolescent girls and young women (AGYW) offered PrEP. However, persistence and prevention-effective use of PrEP among this critical group continues to be a challenge. We conducted a qualitative sub-study of AGYW from the Community PrEP Study in Eastern Cape Province, South Africa who had high rates of pick up for monthly PrEP refills over two years, but differing levels of PrEP adherence based on tenofovir-diphosphate (TFV-DP) measurements in dried blood spots (DBS). Contrasting 22 AGYW with low versus high levels of TFV-DP in DBS, we qualitatively explored factors which influenced PrEP persistence vs. non-persistence, unique patterns of PrEP use (e.g., discarding or stockpiling), and participant recommendations for improving AGYW prevention-effective use of PrEP in the future. Results showed that PrEP misconceptions and mistrust among participants' social networks negatively influenced adherence. In comparison, supportive families and/or partners and personal trust that PrEP works positively influenced adherence. Those with low adherence described being motivated to come to the site for other study benefits (e.g., reimbursement money, snacks, sanitary pads) and discarding PrEP to avoid stigma associated with being seen with pills. Future PrEP implementation strategies should focus on involving families and partners in PrEP support for AGYW and minimizing PrEP stigma at a community level.Trial registration NCT03977181. Retrospectively registered on June 6, 2019.
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Affiliation(s)
- Emily Krogstad Mudzingwa
- The Desmond Tutu HIV Centre, University of Cape Town, Desmond Tutu Health Foundation, 3 Woodlands Road, Woodstock, Cape Town, 7915, South Africa
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, CT, USA
| | - Lindsey de Vos
- Research Unit, Foundation for Professional Development, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Millicent Atujuna
- The Desmond Tutu HIV Centre, University of Cape Town, Desmond Tutu Health Foundation, 3 Woodlands Road, Woodstock, Cape Town, 7915, South Africa
| | - Lauren Fynn
- The Desmond Tutu HIV Centre, University of Cape Town, Desmond Tutu Health Foundation, 3 Woodlands Road, Woodstock, Cape Town, 7915, South Africa
| | - Matinatsa Mugore
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Selly Mabandla
- HIV/AIDS, STIs and TB Directorate, Buffalo City Health District, Eastern Cape Provincial Department of Health, Bisho, South Africa
| | - Sybil Hosek
- Department of Psychiatry, Stroger Hospital of Cook County, Chicago, IL, USA
- Division of Infectious Diseases, Stroger Hospital of Cook County, Chicago, IL, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Desmond Tutu Health Foundation, 3 Woodlands Road, Woodstock, Cape Town, 7915, South Africa
| | - Joseph Daniels
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Andrew Medina-Marino
- The Desmond Tutu HIV Centre, University of Cape Town, Desmond Tutu Health Foundation, 3 Woodlands Road, Woodstock, Cape Town, 7915, South Africa.
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Mudzingwa EK, de Vos L, Fynn L, Atujuna M, Katz IT, Hosek S, Celum C, Daniels J, Bekker LG, Medina-Marino A. Youth-friendly services was the magic: Experiences of adolescent girls and young women in the community PrEP study, South Africa. Glob Public Health 2024; 19:2349918. [PMID: 38752416 PMCID: PMC11101151 DOI: 10.1080/17441692.2024.2349918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/24/2024] [Indexed: 05/19/2024]
Abstract
Adherence to daily oral pre-exposure prophylaxis (PrEP) for HIV prevention has been challenging for adolescent girls and young women (AGYW). As part of The Community PrEP Study (CPS), AGYW were randomised to HIV-prevention empowerment counselling (intervention) or basic medication pick-up (control). In this qualitative sub-study, we interviewed AGYW participants (n = 39) to explore PrEP use and study experiences by study arm, and study staff (n = 7) to explore study implementation, site environment, and participant engagement. Data were thematically analysed using a constant comparison approach. Comparative matrices assessed similarities and differences in study experiences and PrEP support preferences. Friendly, non-judgmental, non-stigmatizing study staff were described as central to participant's positive experiences. Participants highly valued CPS staff's holistic health support (e.g. physical and psycho-social). Intervention participants described empowerment counselling as helpful in supporting PrEP disclosure. However, control participants also described disclosing PrEP use to trusted individuals. Participants and staff recommended public-sector PrEP services provide holistic, confidential, and integrated sexual and reproductive health services, and community sensitisation. An adolescent and youth-friendly environment was the primary factor motivating AGYW's study engagement. While HIV-prevention empowerment counselling was well received, welcoming, respectful and non-judgmental staff may be the 'secret sauce' for implementing effective PrEP services to AGYW.
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Affiliation(s)
- Emily Krogstad Mudzingwa
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, Connecticut, USA
| | - Lindsey de Vos
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Lauren Fynn
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Millicent Atujuna
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Ingrid T. Katz
- Harvard Medical School, Boston, MA, USA
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Sybil Hosek
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, USA
| | - Connie Celum
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, USA
| | - Joseph Daniels
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, USA
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Andrew Medina-Marino
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Daniels J, De Vos L, Bezuidenhout D, Atujuna M, Celum C, Hosek S, Bekker LG, Medina-Marino A. "I know why I am taking this pill": Young women navigation of disclosure and support for PrEP uptake and adherence in Eastern Cape Province, South Africa. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000636. [PMID: 36962727 PMCID: PMC10021316 DOI: 10.1371/journal.pgph.0000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 12/22/2022] [Indexed: 01/21/2023]
Abstract
There is limited understanding of the dynamic interplay between adolescent girl's and young women's (AGYW) disclosure and social support for using oral pre-exposure prophylaxis (PrEP) and adherence. Towards this, we conducted interviews with 42 AGYW enrolled in The Community PrEP Study who exhibited either high or low blood concentrations of tenofovir-diphosphate (TFV-DP) in dried blood spots. Guided by Theories of Practice, interviews and analysis focused on AGYW perspectives and experiences with PrEP disclosure, support and adherence. AGYW with high TFV-DP blood concentrations described larger social support networks and disclosure events. In contrast, those with low TFV-DP blood concentrations described disclosing to fewer people, resulting in limited social support. Participants discussed partner support, however, this support was not described as consequential to adherence, irrespective of TFV-DP levels. Those with high levels of TFV-DP in their blood described the ability to navigate social scrutiny and changes in social support, while those with low levels of TFV-DP in their blood were more likely to question their own continued use of PrEP. To facilitate AGYW's prevention-effective use of PrEP, expanded skill-building for disclosure and resiliency against changes to social support should be examined as part of PrEP services.
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Affiliation(s)
- Joseph Daniels
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, United States of America
| | - Lindsey De Vos
- Research Unit, Foundation for Professional Development, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Dana Bezuidenhout
- Research Unit, Foundation for Professional Development, Buffalo City Metro, Eastern Cape Province, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, United States of America
| | - Millicent Atujuna
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Connie Celum
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Sybil Hosek
- Departments of Psychiatry and Infectious Disease, Stroger Hospital of Cook County, Chicago, IL, United States of America
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Andrew Medina-Marino
- Research Unit, Foundation for Professional Development, Buffalo City Metro, Eastern Cape Province, South Africa
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Departments of Psychiatry and Infectious Disease, Stroger Hospital of Cook County, Chicago, IL, United States of America
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
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Medina‐Marino A, Bezuidenhout D, Ngwepe P, Bezuidenhout C, Facente SN, Mabandla S, Hosek S, Little F, Celum CL, Bekker L. Acceptability and feasibility of leveraging community-based HIV counselling and testing platforms for same-day oral PrEP initiation among adolescent girls and young women in Eastern Cape, South Africa. J Int AIDS Soc 2022; 25:e25968. [PMID: 35872602 PMCID: PMC9309460 DOI: 10.1002/jia2.25968] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 07/06/2022] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Community-based delivery of HIV pre-exposure prophylaxis (PrEP) to South African adolescent girls and young women's (AGYW) could increase access but needs evaluation. We integrated PrEP services via home-based services and pop-up tents into existing community-based HIV testing services (CB-HTS) in Eastern Cape Province, South Africa. METHODS After accessing CB-HTS via a "pop-up" tent or home-based services, HIV-negative AGYW aged 16-25 years were invited to complete a baseline questionnaire and referred for PrEP services at a community-based PrEP site co-located with pop-up HTS tents. A 30-day supply of PrEP was dispensed. PrEP uptake, time-to-initiation, cohort characteristics and first medication refill within 90 days were measured using descriptive statistics. RESULTS Of the 1164 AGYW who tested for HIV, 825 (74.3%) completed a questionnaire and 806 (97.7%) were referred for community-based PrEP. Of those, 624 (77.4%) presented for PrEP (482/483 [99.8%] from pop-up HTS and 142/323 [44.0%] from home-based HTS), of which 603 (96.6%) initiated PrEP. Of those initiating PrEP following home-based HTS, 59.1% initiated within 0-3 days, 25.6% within 4-14 days and 15.3% took ≥15 days to initiate; 100% of AGYW who used pop-up HTS initiated PrEP the same day. Among AGWY initiating PrEP, 37.5% had a detectable sexually transmitted infection (STI). Although AGYW reported a low self-perception of HIV risk, post-hoc application of HIV risk assessment measures to available data classified most study participants as high risk for HIV acquisition. Cumulatively, 329 (54.6%) AGYW presented for a first medication refill within 90 days of accepting their first bottle of PrEP. CONCLUSIONS Leveraging CB-HTS platforms to provide same-day PrEP initiation and refill services was acceptable to AGYW. A higher proportion of AGYW initiated PrEP when co-located with CB-HTS sites compared to those referred following home-based HTS, suggesting that proximity of CB-HTS and PrEP services facilitates PrEP uptake among AGYW. The high prevalence of STIs among those initiating PrEP necessitates the integration of STI and HIV prevention programs for AGYW. Eligibility for PrEP initiation should not be required among AHYW in high HIV burden communities. Community-based service delivery will be crucial to maintaining access to PrEP services during the COVID-19 pandemic and future health and humanitarian emergencies.
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Affiliation(s)
- Andrew Medina‐Marino
- Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Dana Bezuidenhout
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- Department of EpidemiologyMailman School of Public HealthColumbia UniversityNew York CityNew YorkUSA
| | - Phuti Ngwepe
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- Department of Statistical SciencesUniversity of Cape TownCape TownSouth Africa
| | - Charl Bezuidenhout
- Research UnitFoundation for Professional Development, Buffalo City MetroEastern Cape ProvinceSouth Africa
- School of Public HealthBoston UniversityBostonMassachusettsUSA
| | | | - Selly Mabandla
- HIV/AIDSSTIs and TB ProgramBuffalo City Metro Health DistrictEastern Cape Province Department of HealthBhishoSouth Africa
| | - Sybil Hosek
- Departments of Psychiatry and Infectious DiseaseStroger Hospital of Cook CountyChicagoIllinoisUSA
| | - Francesca Little
- Department of Statistical SciencesUniversity of Cape TownCape TownSouth Africa
| | - Connie L. Celum
- Department of Global Health, Medicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
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