1
|
Zia Y, Etyang L, Mwangi M, Njiru R, Mogaka F, June L, Njeru I, Makoyo J, Kimani S, Ngure K, Wanyama I, Bukusi E, Nyerere B, Nyamwaro C, Mugo N, Heffron R. The Effect of Stigma on Family Planning and HIV Pre-exposure Prophylaxis Decisions of Young Women Accessing Post-Abortion Care in Kenya. AIDS Behav 2024; 28:1834-1844. [PMID: 38451448 PMCID: PMC11161434 DOI: 10.1007/s10461-024-04274-6] [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] [Accepted: 01/22/2024] [Indexed: 03/08/2024]
Abstract
Adolescent girls and young women (AGYW) in Eastern and Southern Africa face parallel epidemics of unintended pregnancy and HIV. Their sexual health decisions are often dominated by intersecting stigmas. In an implementation science project integrating delivery of daily, oral pre-exposure prophylaxis (PrEP) for HIV prevention into 14 post-abortion care (PAC) clinics in Kenya, we enrolled a subset of PrEP initiating AGYW (aged 15 to 30 years) into a research cohort. Utilizing log binomial models, we estimated the effect of PrEP stigma on PrEP continuation (measured via self-report and urine assay for tenofovir) and abortion stigma on contraceptive initiation. Between April 2022 and February 2023, 401 AGYW were enrolled after initiating PrEP through their PAC provider, of which 120 (29.9%) initiated highly-effective contraception. Overall, abortion and PrEP stigmas were high in this cohort. Abortion stigma was more prevalent among those that were adolescents, unmarried, and reported social harm. Among 114 AGYW returning for the month 1 follow-up visit, 83.5% reported continuing PrEP and 52.5% had tenofovir detected. In this subset, higher levels of PrEP stigma were significantly associated with greater likelihood of PrEP adherence, but not PrEP continuation. For abortion stigma, greater scores in the subdomain of isolation were significantly associated with greater likelihood of initiating a highly-effective contraception, while greater scores in the subdomain of community condemnation were significantly associated with reduced likelihood of initiating a highly-effective contraception. Given the burden of stigma documented by our work, PAC settings are a pivotal space to integrate stigma-informed counseling and to empower young women to optimize contraceptive and PrEP decisions.
Collapse
Affiliation(s)
- Yasaman Zia
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Lydia Etyang
- Partners in Health and Research Development, Kenya Medical Research Institute, Nairobi, Kenya
| | - Margaret Mwangi
- Partners in Health and Research Development, Kenya Medical Research Institute, Nairobi, Kenya
| | - Roy Njiru
- Partners in Health and Research Development, Kenya Medical Research Institute, Nairobi, Kenya
| | - Felix Mogaka
- Research Care and Training Program, Kenya Medical Research Institute, Thika, Kenya
| | - Lavender June
- Research Care and Training Program, Kenya Medical Research Institute, Thika, Kenya
| | - Irene Njeru
- Partners in Health and Research Development, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, WA, USA
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | - Elizabeth Bukusi
- Department of Global Health, University of Washington, Seattle, WA, USA
- Research Care and Training Program, Kenya Medical Research Institute, Thika, Kenya
| | - Bernard Nyerere
- Research Care and Training Program, Kenya Medical Research Institute, Thika, Kenya
| | | | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA
- Partners in Health and Research Development, Kenya Medical Research Institute, Nairobi, Kenya
| | - Renee Heffron
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
- Department of Medicine, University of Alabama at Birmingham, 845 19th Street South / BBRB 256, Birmingham, AL, 35294-2170, USA.
| |
Collapse
|
2
|
Rousseau E, Sikkema KJ, Julies RF, Mazer K, O'Malley G, Heffron R, Morton JF, Johnson R, Celum C, Baeten JM, Bekker L. Exploring adolescent girls and young women's PrEP-user profiles: qualitative insights into differentiated PrEP delivery platform selection and engagement in Cape Town, South Africa. J Int AIDS Soc 2024; 27:e26254. [PMID: 38695101 PMCID: PMC11063778 DOI: 10.1002/jia2.26254] [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: 08/11/2023] [Accepted: 04/15/2024] [Indexed: 05/04/2024] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW), a priority population for HIV prevention in Africa, show high interest but difficulty in sustained effective use of pre-exposure prophylaxis (PrEP). With ongoing PrEP scale-up focused on increasing access, it is important to understand what influences AGYW's choice of PrEP delivery platforms. METHODS The POWER implementation study in Cape Town provided PrEP between 2017 and 2020 to AGYW (16-25 years) from four differentiated delivery platforms: mobile clinic, government facility, courier delivery or community-based youth club. Healthcare providers at government and mobile clinics provided PrEP (initiation and refills) as part of comprehensive, integrated sexual and reproductive health services. Courier and youth club platforms provided light-touch PrEP refill services incorporating rapid HIV self-testing. We conducted in-depth interviews with a purposive sample of AGYW who had ≥3 months of PrEP-use and accessed ≥2 PrEP delivery platforms. The thematic analysis explored AGYW's preferences, decision-making and habits related to PrEP access to inform market segmentation. RESULTS We interviewed 26 AGYW (median age 20) PrEP-users between November 2020 and March 2021. AGYW PrEP-users reported accessing different services with, 24 accessing mobile clinics, 17 courier delivery, 9 government health facilities and 6 youth clubs for their PrEP refills. Qualitative findings highlighted four potential behavioural profiles. The "Social PrEP-user" preferred PrEP delivery in peer spaces, such as youth clubs or adolescent-friendly mobile clinics, seeking affirmation and social support for continued PrEP use. The "Convenient PrEP-user" favoured PrEP delivery at easily accessible locations, providing quick (courier) or integrated contraception-PrEP refill visits (mobile and government clinic). The "Independent PrEP-user" preferred PrEP delivery that offered control over delivery times that fit into their schedule, such as the courier service. The "Discreet PrEP-user" highly valued privacy regarding their PrEP use (courier delivery) and avoided delivery options where unintentional disclosure was evident (youth club). Comfort with HIV self-testing had minimal influence on PrEP delivery choice. CONCLUSIONS Market segmentation of AGYW characterizes different types of PrEP-users and has the potential to enhance tailored messaging and campaigns to reach specific segments, with the aim of improving sustained PrEP use and HIV prevention benefits.
Collapse
Affiliation(s)
- Elzette Rousseau
- Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
| | - Kathleen J. Sikkema
- Department of Sociomedical SciencesMailman School of Public HealthColumbia UniversityNew York CityNew YorkUSA
| | - Robin F. Julies
- Department of PsychologyUniversity of the Western CapeCape TownSouth Africa
| | - Katelyn Mazer
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Gabrielle O'Malley
- Department of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Renee Heffron
- Department of MedicineHeersink School of MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Jennifer F. Morton
- Department of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Rachel Johnson
- Department of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Connie Celum
- Department of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Jared M. Baeten
- Department of Global HealthMedicine and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | | |
Collapse
|
3
|
Miller AP, Dean SS, Court L, Mvududu R, Mashele N, Wara NJ, Myer L, Shoptaw S, Davey DLJ. "So that's why I found PrEP to be safest way to protect yourself": exploring IPV experiences and impact on HIV prevention among pregnant and postpartum women in Cape Town, South Africa. BMC Public Health 2024; 24:481. [PMID: 38360616 PMCID: PMC10870618 DOI: 10.1186/s12889-024-17871-w] [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: 10/04/2023] [Accepted: 01/24/2024] [Indexed: 02/17/2024] Open
Abstract
Intimate partner violence (IPV) occurs at alarmingly high rates towards pregnant women in South Africa. Experiences of emotional, physical, and sexual IPV in pregnancy can adversely impact the health and safety of mother and fetus. Furthermore, IPV is associated with increased risk of HIV, exacerbating the public health impact of violence among pregnant women in this HIV endemic setting. In-depth understanding of cultural and contextual drivers of experiences of IPV is a critical precursor to development of interventions effectively addressing this issue among pregnant women in South Africa. The present study examines factors contributing to IPV among pregnant women to identify potential points of intervention. We conducted twenty in-depth interviews with postpartum women who used oral pre-exposure prophylaxis (PrEP) in pregnancy and reported recent experiences of IPV and/or ongoing alcohol use in a township near Cape Town, South Africa that experiences a heavy burden of both HIV and IPV. Interpretive thematic analysis was used. Several patterns of IPV during pregnancy were identified and violence was frequently described as co-occurring with male partner alcohol use. A majority of women referenced oral PrEP as their preferred method for HIV prevention, highlighting the agency and discretion it provided as beneficial attributes for women experiencing IPV. Fear of judgement from peers for remaining with an abusive partner and a lack of clear community messaging around IPV were identified as barriers to disclosure and support-seeking. Addressing the lack of social support received by women experiencing IPV during pregnancy in South Africa is essential to comprehensive IPV programming.
Collapse
Affiliation(s)
- Amanda P Miller
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, CA, USA.
| | - Sarah Schoetz Dean
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lara Court
- Division of Socio-behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rufaro Mvududu
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nyiko Mashele
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nafisa J Wara
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Steven Shoptaw
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Dvora L Joseph Davey
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
4
|
Martin CE, Cox LA, Nongena P, Butler V, Ncube S, Sawry S, Mullick S. Patterns of HIV Pre-exposure Prophylaxis use Among Adolescent Girls and Young Women Accessing Routine Sexual and Reproductive Health services in South Africa. J Adolesc Health 2023; 73:S81-S91. [PMID: 37953014 DOI: 10.1016/j.jadohealth.2023.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/30/2023] [Accepted: 08/04/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE This study describes the patterns of pre-exposure prophylaxis (PrEP) use among adolescent girls and young women (AGYW) initiated on daily oral PrEP for the prevention of HIV, within routine sexual and reproductive health services in South Africa. METHODS We analysed clinical and survey data from a nested cohort of 967 AGYW initiated on oral PrEP between January 2019 and December 2021 in four geographical clusters in South Africa. We describe the periods of PrEP use, and the proportion who discontinued and subsequently restarted PrEP. Logistic regression analyses were conducted to determine factors associated with early PrEP discontinuation, PrEP use for ≥4 months and PrEP restart. RESULTS PrEP use for ≤1 month was high (68.6%), although 27% returned and restarted PrEP; and 9% restarted more than once. Initiating PrEP at a mobile clinic (AOR 2.10, 95% CI 1.51 - 2.93) and having a partner known to be HIV negative or whose HIV status was unknown (AOR 7.11, 95% CI 1.45 - 34.23; AOR 6.90, 95% CI 1.44 - 33.09) were associated with PrEP use for ≤1 month. AGYW receiving injectable contraceptives were more likely to restart PrEP (AOR 1.61, 95% CI 1.10 - 2.35). Compared to those aged 15-17 years, participants 18 - 20 and 21 - 24 years were less likely to restart PrEP (AOR 0.51, 95% CI 0.35 - 0.74; AOR 0.60, 95%, CI 0.41 - 0.87), as were those initiating PrEP at a mobile clinic compared to a fixed facility (AOR 0.66, 95% CI 0.47 - 0.92). DISCUSSION Although early PrEP discontinuation was high, it appears that PrEP use is frequently cyclical in nature. Further research is needed to determine if these cycles of PrEP correlate to periods of perceived or actual vulnerability to HIV, which may also be cyclical. PrEP delivery presents a unique opportunity to address multiple unmet health needs of young people.
Collapse
Affiliation(s)
| | | | - Pelisa Nongena
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Vusile Butler
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Sydney Ncube
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Shobna Sawry
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Saiqa Mullick
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
5
|
Roberts ST, Hartmann M, Minnis AM, Otticha SO, Browne EN, Montgomery ET, Agot K. Breaking down relationship barriers to increase PrEP uptake and adherence among adolescent girls and young women in Kenya: safety and preliminary effectiveness results from a pilot cluster-randomized trial. J Int AIDS Soc 2023; 26:e26198. [PMID: 38123866 PMCID: PMC10733161 DOI: 10.1002/jia2.26198] [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: 03/20/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa, a priority population for epidemic control. However, intimate partner violence (IPV) and low relationship power can create significant challenges to PrEP use. The Tu'Washindi intervention aimed to increase PrEP use by addressing relationship- and violence-related barriers among AGYW enrolled in the DREAMS Initiative in Siaya County, Kenya. METHODS Our multi-level, community-based intervention was piloted in a cluster-randomized controlled trial conducted at six DREAMS sites from April to December 2019 (NCT03938818). Three intervention components were delivered over 6 months: an eight-session empowerment-based support club, community sensitization targeted towards male partners and a couples' PrEP education event. Participants were ages 17-24, HIV negative and either eligible for, or already taking, PrEP. Over 6 months of follow-up, we assessed IPV (months 3 and 6) and PrEP uptake and continuation (month 6) through interviewer-administered questionnaires; PrEP adherence was assessed with Wisepill electronic monitoring devices. These outcomes were compared using adjusted Poisson and negative binomial regression models. RESULTS We enrolled 103 AGYW with median age of 22 years (IQR 20-23); one-third were currently taking PrEP and 45% reported IPV in the past 3 months. Retention was 97% at month 6. Compared to the control arm, intervention arm participants were more likely to initiate PrEP, if not already using it at enrolment (52% vs. 24%, aRR 2.28, 95% CI 1.19-4.38, p = 0.01), and those taking PrEP had more days with device openings (25% of days vs. 13%, aRR 1.94, 95% CI 1.16-3.25, p = 0.01). Twenty percent of participants reported IPV during follow-up. There were trends towards fewer IPV events (aIRR 0.66, 95% CI 0.27-1.62, p = 0.37) and fewer events resulting in injury (aIRR 0.21, 95% CI 0.04-1.02, p = 0.05) in the intervention versus control arm. CONCLUSIONS Tu'Washindi shows promise in promoting PrEP uptake and adherence among AGYW without concomitant increases in IPV; however, adherence was still suboptimal. Further research is needed to determine whether these gains translate to increases in the proportion of AGYW with protective levels of PrEP adherence and to evaluate the potential for the intervention to reduce IPV risk.
Collapse
Affiliation(s)
- Sarah T. Roberts
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
| | - Miriam Hartmann
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
| | | | | | - Erica N. Browne
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
| | | | - Kawango Agot
- Impact Research and Development OrganizationKisumuKenya
| |
Collapse
|
6
|
Thurman AR, Ouattara LA, Yousefieh N, Anderson PL, Bushman LR, Fang X, Hanif H, Clark M, Singh O, Doncel GF. A phase I study to assess safety, pharmacokinetics, and pharmacodynamics of a vaginal insert containing tenofovir alafenamide and elvitegravir. Front Cell Infect Microbiol 2023; 13:1130101. [PMID: 37153145 PMCID: PMC10154607 DOI: 10.3389/fcimb.2023.1130101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
Background New multi-purpose prevention technology (MPT) products are needed to prevent human immunodeficiency virus (HIV) and herpes simplex virus type 2 (HSV2). In this study, we evaluated a fast-dissolve insert that may be used vaginally or rectally for prevention of infection. Objective To describe the safety, acceptability, multi-compartment pharmacokinetics (PK), and in vitro modeled pharmacodynamics (PD) after a single vaginal dose of an insert containing tenofovir alafenamide (TAF) and elvitegravir (EVG) in healthy women. Methods This was a Phase I, open-label, study. Women (n=16) applied one TAF (20mg)/EVG (16mg) vaginal insert and were randomized (1:1) to sample collection time groups for up to 7 days post dosing. Safety was assessed by treatment-emergent adverse events (TEAEs). EVG, TAF and tenofovir (TFV) concentrations were measured in plasma, vaginal fluid and tissue, and TFV-diphosphate (TFV-DP) concentration in vaginal tissue. PD was modeled in vitro by quantifying the change in inhibitory activity of vaginal fluid and vaginal tissue against HIV and HSV2 from baseline to after treatment. Acceptability data was collected by a quantitative survey at baseline and post treatment. Results The TAF/EVG insert was safe, with all TEAEs graded as mild, and acceptable to participants. Systemic plasma exposure was low, consistent with topical delivery, while high mucosal levels were detected, with median TFV vaginal fluid concentrations exceeding 200,000 ng/mL and 1,000 ng/mL for up to 24 hours and 7 days post dosing, respectively. All participants had vaginal tissue EVG concentrations of > 1 ng/mg at 4 and 24 hours post dosing. The majority had tissue TFV-DP concentrations exceeding 1000 fmol/mg by 24 - 72 hours post dosing. Vaginal fluid inhibition of HIV-1 and HSV-2 in vitro significantly increased from baseline and was similarly high at 4 and 24 hours post dosing. Consistent with high tissue TFV-DP concentrations, p24 HIV antigen production from ectocervical tissues infected ex vivo with HIV-1 significantly decreased from baseline at 4 hours post dosing. HSV-2 production from tissue also decreased post treatment. Conclusions A single dose of TAF/EVG inserts met PK benchmarks, with PK data supporting an extended window of high mucosal protection. PD modeling supports mucosal protection against both HIV-1 and HSV-2. The inserts were safe and highly acceptable. Clinical trial registration ClinicalTrials.gov, identifier NCT03762772.
Collapse
Affiliation(s)
- Andrea R. Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
- *Correspondence: Andrea R. Thurman,
| | - Louise A. Ouattara
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Nazita Yousefieh
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Peter L. Anderson
- University of Colorado, Colorado Antiviral Pharmacology Lab, School of Pharmacy, Anschutz Medical Campus, Aurora, CO, United States
| | - Lane R. Bushman
- University of Colorado, Colorado Antiviral Pharmacology Lab, School of Pharmacy, Anschutz Medical Campus, Aurora, CO, United States
| | - Xi Fang
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Homaira Hanif
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Meredith Clark
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Onkar Singh
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| |
Collapse
|
7
|
Drug-level feedback counselling: modest support to PrEP adherence. THE LANCET HIV 2022; 9:e668-e669. [DOI: 10.1016/s2352-3018(22)00250-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022]
|
8
|
Partner violence as conversation opener for preexposure prophylaxis use among younger women. AIDS 2022; 36:1195-1196. [DOI: 10.1097/qad.0000000000003241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|