How gender norms and 'good girl' notions prevent adolescent girls and young women from engaging with PrEP: qualitative insights from Zimbabwe

Appraising the HIV Prevention Cascade methodology to improve HIV prevention targets: Lessons learned from a general population pilot study in east Zimbabwe

Introduction

Multiple HIV Prevention Cascades (HPC) formulations have been proposed to assist advocacy, monitoring of progress of HIV prevention implementation and research to identify ways to increase use of HIV prevention methods. Schaefer and colleagues proposed a unifying formulation suitable for widespread use across different populations which could be used for routine monitoring or advocacy. Robust methods for defining and interpreting this HPC formulation using real world data is required.

Methods

Data collected as part of the Manicaland Pilot HIV Prevention Cascades Study, east Zimbabwe, in 2018-19, was used to validate the HPC framework for PrEP, VMMC, male condom and combination prevention method use. Validation measures included feasibility of populating the HPC, contrasting simple vs complex measures of the HPC (using 2-sample proportion test), and testing ability of main bars to predict prevention use and testing whether sub-bars explained why people were lost from the HPC using logistic regression.

Results

It was possible to populate the HPC for both individual and combined prevention methods using pilot survey data. Most steps were associated with prevention method usage outcomes, except for VMMC. There were significant overlaps between individuals reporting positive responses for the main bar and those citing barriers to motivation. To refine the HPC's access bar definition, it is suggested to also consider individuals who report access barriers. While the HPC framework identifies barriers to individual prevention methods, challenges arise in identifying those for combined prevention.

Discussion

Our study successfully utilised questionnaires from the Manicaland HPC pilot survey to measure the HPC for individual and combined prevention methods. This demonstrates the feasibility of populating this framework using general population survey data and designated questionnaire modules. We propose a final formulation of the HPC, questionnaire modules and methods to create it. With proper evaluation and promotion, the HPC can enhance prevention services, aiding in the crucial reduction of HIV incidence.

The development of a conceptual framework on PrEP stigma among adolescent girls and young women in sub-Saharan Africa

INTRODUCTION

Stigma is a well-known barrier to HIV testing and treatment and is an emerging barrier to pre-exposure prophylaxis (PrEP) use. To guide future research, measurement and interventions, we developed a conceptual framework for PrEP stigma among adolescent girls and young women (AGYW) in sub-Saharan Africa, a priority population for PrEP.

METHODS

A literature review, expert consultations and focus group discussions (FGDs) were conducted to adapt the Health Stigma and Discrimination Framework, describing the stigmatization process nested within the socio-ecological framework. We reviewed all articles on PrEP stigma and on HIV, contraceptive or sexuality stigma among AGYW from 2009 to 2019. Expert consultations were conducted with 10 stigma or PrEP researchers and two Kenyan youth advisory boards to revise the framework. Finally, FGDs were conducted with AGYW PrEP users (4 FGDs; n = 20) and key influencers (14 FGDs; n = 72) in Kenya with the help of a Youth Research Team who aided in FGD conduct and results interpretation. Results from each phase were reviewed and the framework was updated to incorporate new and divergent findings. This was validated against an updated literature search from 2020 to 2023.

RESULTS

The conceptual framework identifies potential drivers, facilitators and manifestations of PrEP stigma, its outcomes and health impacts, and relevant intersecting stigmas. The main findings include: (1) PrEP stigma is driven by HIV, gender and sexuality stigmas, and low PrEP community awareness. (2) Stigma is facilitated by factors at multiple levels: policy (e.g. targeting of PrEP to high-risk populations), health systems (e.g. youth-friendly service availability), community (e.g. social capital) and individual (e.g. empowerment). (3) Similar to other stigmas, manifestations include labelling, violence and shame. (4) PrEP stigma results in decreased access to and acceptability of PrEP, limited social support and community resistance, which can impact mental health and decrease PrEP uptake and adherence. (5) Stigma may engender resilience by motivating AGYW to think of PrEP as an exercise in personal agency.

CONCLUSIONS

Our PrEP stigma conceptual framework highlights potential intervention targets at multiple levels in the stigmatization process. Its adoption would enable researchers to develop standardized measures and compare stigma across timepoints and populations as well as design and evaluate interventions.

Brief Report: HIV Pre-Exposure Prophylaxis Awareness and Use Among Adolescents in Kenya

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is an effective prevention tool; however, use among adolescents is thought to be low. To determine the unmet need and opportunity to expand use, we assessed awareness, prior use, and willingness to take PrEP among Kenyan adolescents.

METHODS

The Maneno Yetu study recruited a community-based sample of adolescents aged 15-19 years (N = 3061) in Kisumu for a survey using respondent-driven sampling.

RESULTS

Overall, 50% of adolescents had heard of PrEP and 2% had used PrEP. Girls were more likely than boys to have heard of PrEP (53.4% vs. 45.1%; P < 0.001) and used PrEP (3.6% vs. 0.3%; P < 0.001). Among participants, 14% engaged in transactional sex and 21% experienced forced sexual contact. PrEP use was higher among adolescents who engaged in transactional sex (4.8% vs. 0.6%; P < 0.001) and experienced forced sexual contact (2.7% vs. 0.7%; P < 0.001) compared with those who did not. Among adolescents with no prior use, 53% were willing to consider using PrEP, although girls were less willing than boys (49.7% vs. 55.9%; P = 0.001).

CONCLUSIONS

PrEP is an important prevention tool, especially for adolescents whose circumstances potentially expose them to HIV-positive or unknown status sexual partners, yet remains underused, particularly in resource-limited settings. Although many expressed willingness to use PrEP, low awareness and use highlight the need to expand HIV prevention education and services tailored for adolescents. Our finding that boys were more willing to use PrEP suggests campaigns should also be designed to reach male youth to narrow the gender gap and expand uptake in the adolescent population.

Creating allies: qualitative exploration of young women's preferences for PrEP methods and parents' role in PrEP uptake and user support in urban and rural Zambia

BACKGROUND

Zambian adolescent girls and young women (AGYW) have high HIV incidence and face barriers to the use of pre-exposure prophylaxis (PrEP). Parental support improves PrEP use and adherence in some settings, but negative parental attitudes toward HIV prevention may inhibit engagement with AGYW. We explored perceptions of future PrEP methods among AGYW and parents and parent-youth engagement on HIV prevention and PrEP use.

METHODS

We conducted a qualitative descriptive study among AGYW and parents of AGYW in five provinces in Zambia in September-October 2021. We conducted 10 focus group discussions (FGDs) and four in-depth interviews (IDIs) with AGYW participants (n = 87) and seven FGDs and four IDIs among parents of AGYW (n = 62). All FGDs and IDIs were audio-recorded, transcribed verbatim, and analyzed to identify qualitative themes.

RESULTS

Most AGYW participants preferred the discreet nature and longer duration of injectable PrEP compared to the PrEP ring and oral PrEP. Many AGYWs reported inability to disclose PrEP use to their parents due to lack of parental support based on cultural taboos against premarital sex. Nevertheless, AGYW participants said they would like to talk to their parents about PrEP so their parents could support their use. Many parents also described difficulties discussing PrEP with their daughters because of cultural and religious beliefs about abstinence from sex before marriage. However, parents acknowledged that the threat of HIV is real and said they need PrEP knowledge and guidance on speaking with their children about HIV prevention and PrEP.

CONCLUSIONS

Although many parents are currently not playing a role in daughters' decisions about PrEP use, both parents and AGYW are willing to engage with each other on HIV prevention issues. To foster parent-child engagement, HIV prevention programs should not only provide information about PrEP but also address social norms that impede discussion of HIV prevention and equip both parents and AGYW with skills and support for such conversations. Community sensitization is also needed as new PrEP products are introduced, to create an enabling environment for parent-child engagement by increasing awareness, countering misconceptions, and reducing stigma.

Factors that influence adolescent girls and young women's re-initiation or complete discontinuation from daily oral PrEP use: a qualitative study from Eastern Cape Province, South Africa

INTRODUCTION

Adolescent girls and young women (AGYW) face barriers that jeopardize their prevention-effective use of daily oral pre-exposure prophylaxis (PrEP). We sought to understand factors that influence AGYW's prolonged breaks in PrEP use, and their decisions to re-initiate or discontinue using PrEP in the context of a community-based adherence support intervention.

METHODS

In-depth interviews (IDIs) were conducted between December 2019 and April 2021 with purposively selected AGYW (aged 16-25) enrolled in the Community PrEP Study (CPS) in Buffalo City Metro Health District, Eastern Cape Province, South Africa. AGYW were offered monthly PrEP for 24 months at two community-based study sites. Interview guides were informed by the Information-Motivation-Behavioural Skills Model, and data were analysed using illustrative code reports and a case analysis.

RESULTS

A total of 603 participants were enrolled and initiated on PrEP in the parent study. Fifty-three IDIs were conducted with 50 CPS participants. Findings revealed that external factors (e.g. local movement, school holidays and medication side-effects) and social conflicts (e.g. discretion and partner mistrust) directly influenced breaks in PrEP usage. A decrease in one's self-perception of HIV risk prolonged the duration of these "PrEP breaks." Once PrEP refill visits were missed, some AGYW delayed returning for refills out of fear of being scolded by study staff. The differences between those participants who eventually re-initiated PrEP and those who disengaged from PrEP use can be attributed to social support and encouragement, level of familiarity with PrEP, risk perceptions, self-initiated discussions with staff and diminishing side effects.

CONCLUSIONS

Despite implementing a community-based PrEP delivery platform and behavioural intervention that included support for daily oral PrEP adherence and disclosure, participants struggled with consistent daily oral PrEP use. Unpredictable life events, including local movement and schooling schedules, in addition to being judged for their perceived behaviours, pose a challenge for consistent pill pick-up for AGYW and habit formation. Long-acting injectable PrEP may mitigate a number of these external barriers. Interventions that integrate long-term planning skills, how to navigate existing social judgements and how to access sources of social support may further improve habit formation for PrEP use, regardless of its formulation.

The experience of healthcare workers to HIV pre-exposure prophylaxis (PrEP) implementation in low- and middle-income countries: a systematic review and qualitative meta-synthesis

Background

The effectiveness of pre-exposure prophylaxis has been extensively documented. However, there are substantial gaps between the actual implementation of pre-exposure prophylaxis and the ideal goal, especially in low-and middle-income countries. Healthcare workers play critical roles in the pre-exposure prophylaxis implementation, and they have more multi-level experiences about the barriers of pre-exposure prophylaxis implementation and how to facilitate it. However, the evidence aiming to synthesize their experiences is limited.

Objective

This study aims to aggregate the healthcare workers' experiences of providing pre-exposure prophylaxis in low-and middle-income countries, and find the barriers, facilitators, and recommendations of pre-exposure prophylaxis implementation.

Methods

The ENTREQ (Enhancing transparency in reporting the synthesis of qualitative research) statement was used to guide the design and reporting of this qualitative meta-synthesis. A comprehensive search was conducted from inception of databases to 16th March 2023 in four databases: PubMed, CINAHL Plus with Full Text, Embase, Web of Science. The quality appraisal was conducted using the Joanna Briggs Institute Critical Appraisal Checklist. JBI's meta-aggregation approach was used to guide the data extraction and synthesis, and the JBI ConQual approach was used to evaluate the evidence level of the synthesized findings.

Results

Fourteen articles with good methodological quality were included in this review. A total of 122 findings were extracted and 117 findings with credibility ratings of "unequivocal" or "equivocal" were included in this meta-synthesis. The eligible findings were aggregated into 13 new categories and subsequently developed into 3 synthesized findings: the barriers, facilitators, and recommendations of pre-exposure prophylaxis implementation in low-and middle-income countries. The overall ConQual score of all three synthesized findings was rated as "low."

Conclusion

This review aggregated the experience of health care workers implementing pre-exposure prophylaxis in low-and middle-income countries and we could focus on the following key points to promote the uptake of pre-exposure prophylaxis: improve knowledge about pre-exposure prophylaxis, create a supportive environment, address medication-related barriers, increase the human resources and financial investments, and diversify the providing models.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/. The protocol of this review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023411604).

"It will not be easy to accept": Parents conflicting attitudes towards pre-exposure prophylaxis for HIV prevention amongst adolescent girls and young women

BACKGROUND

Pre-exposure prophylaxis, or PrEP, is a pill that has been hailed as a 'game changer' for HIV prevention, based on the belief it provides adolescent girls and young women (AGYW) with a level of user-control. However, engagement with PrEP is often dependent on societal factors, such as social attitudes towards gender, sexuality, and PrEP. As parents' communication on sexual and reproductive health issues with AGYW are central to HIV prevention, it is critical to explore how parents talk and think about PrEP.

OBJECTIVE

To examine parental attitudes towards PrEP for HIV prevention amongst adolescent girls and young women in eastern Zimbabwe.

METHOD

A qualitative interview study with 14 parents from two districts in Manicaland, eastern Zimbabwe. Interviews were transcribed, translated, and subjected to thematic network analysis. The concept of 'attitudes' steered the analytical work.

RESULTS

Parents' attitudes towards PrEP are conflictual, multi-layered, and contingent on the context in which they reflect and talk about PrEP. While parents aspired to be supportive of innovative HIV prevention methods and wanted to see girl-children protected from HIV, they struggled to reconcile this positive and accepting attitude towards PrEP with traditional 'good girl' notions, which stigmatize pre-marital sex. Although a few parents articulated an acceptance of PrEP use amongst their daughters, for many this was simply not possible. Many parents thus co-produce public gender orders that prevent adolescent girls and young women from engaging with PrEP.

CONCLUSIONS

While parents' conflicting attitudes towards PrEP may provide spaces and opportunities for change, harmful gender norms and negative attitudes towards PrEP must be addressed at a community and cultural level. Only then can parents and their children have productive conversations about sexual health.