Perceptions of and interest in HIV pre-exposure prophylaxis use among adolescent girls and young women in Lilongwe, Malawi

The Effect of Stigma on Family Planning and HIV Pre-exposure Prophylaxis Decisions of Young Women Accessing Post-Abortion Care in Kenya

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.

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.

Youth-friendly services was the magic: Experiences of adolescent girls and young women in the community PrEP study, South Africa

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.

Patterns of HIV Pre-exposure Prophylaxis use Among Adolescent Girls and Young Women Accessing Routine Sexual and Reproductive Health services in South Africa

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.

Uptake of and intention to use oral pre-exposure prophylaxis for HIV among pregnant and post-natal women in Eswatini: a cross-sectional survey

Introduction

In Eswatini, HIV incidence among women of childbearing age is 1.45%. Eswatini introduced oral pre-exposure prophylaxis (PrEP) for HIV prevention in 2016 and requires that all HIV-negative pregnant and post-natal women (PPW) visiting health care facilities be offered PrEP.

Methods

Between September-November 2021, we conducted a survey among HIV-negative PPW from 16 purposively selected healthcare facilities in the Hhohho and Shiselweni regions in Eswatini. We interviewed consenting HIV-negative PPW using a structured questionnaire to collect data on PrEP knowledge, attitudes, intentions, and practices, as well as information on partner HIV status and stigma. Multivariate logistic regression was used to determine predictors of PrEP use and intention, adjusted for significant covariates.

Results

Of 1,484 PPW women approached, 1,149 consented and were interviewed, of whom 704 (61.3%) were post-partum and 445 (38.7%) pregnant. The median age was 25 years [Interquartile Range (IQR) = 21-30 years], with 533 (46.4%) 18-24 years old. Among the 1,149 women, 930 (80.7%) had ever heard about PrEP; 635 (55.3%) had knowledge about PrEP; 183 (15.9%) were currently using PrEP; and 285 (24.8%) had ever used PrEP. Increased odds of PrEP use were associated having HIV-positive male partner (aOR:7.76, 95%CI 3.53- 17.04); positive attitudes to PrEP (aOR:1.56, 95%CI: 1.02-2.40); and high self-efficacy (aOR:1.49, 95%CI:1.13-1.98). Among 864 women who never used PrEP, 569 (65.3%) intended to use PrEP in the future. Odds of intention to use PrEP were higher among women with low levels of education (aOR:2.23, 95% CI: 1.32-3.77); who ever heard about PrEP (aOR:1.69, 95%CI: 1.12-2.56); and had high self-efficacy (aOR:1.57, 95%CI: 1.31-1.87). Regarding stigma, among all women, 759 (66%) either agreed or strongly agreed that people would think they have HIV if they were to use PrEP; 658 (57.3%) reported they would be labelled as having multiple sex partners; 468 (40.7%) reported that their partner would think they are having risky sex with other people. Of 102 women who had discontinued PrEP, a majority stopped due to side effects 32 (35.2%).

Conclusion

Only about 50% of women had knowledge of PrEP, and PrEP uptake among PPW was low, though intention to use appeared high. More efforts to reduce stigma and promote PrEP use, including adequate information on side effects, are needed.

Awareness of and willingness to use oral pre-exposure prophylaxis (PrEP) for HIV prevention among sexually active adults in Malawi: results from the 2020 Malawi population-based HIV impact assessment

BACKGROUND

The World Health Organization recommends Pre-Exposure Prophylaxis (PrEP) for all populations at substantial risk of HIV infection. Understanding PrEP awareness and interest is crucial for designing PrEP programs; however, data are lacking in sub-Saharan Africa. In Malawi, oral PrEP was introduced in 2018. We analyzed data from the 2020 Malawi Population-based HIV Impact Assessment (MPHIA) to assess PrEP awareness and factors associated with PrEP interest in Malawi.

METHODS

MPHIA 2020 was a national cross-sectional household-based survey targeting adults aged 15 + years. Oral PrEP was first described to the survey participants as taking a daily pill to reduce the chance of getting HIV. To assess awareness, participants were asked if they had ever heard of PrEP and to assess interest, were asked if they would take PrEP to prevent HIV, regardless of previous PrEP knowledge. Only sexually active HIV-negative participants are included in this analysis. We used multivariable logistic regression to assess sociodemographic factors and behaviors associated with PrEP interest. All results were weighted.

RESULTS

We included 13,995 HIV-negative sexually active participants; median age was 29 years old. Overall, 15.0%, 95% confidence interval (CI): 14.2-15.9% of participants were aware of PrEP. More males (adjusted odds ratio (aOR): 1.3, 95% CI: 1.2-1.5), those with secondary (aOR: 1.5, 95% CI: 1.2-2.0) or post-secondary (aOR: 3.4, 95% CI: 2.4-4.9) education and the wealthiest (aOR: 1.6, 95% CI: 1.2-2.0) were aware of PrEP than female, those without education and least wealthy participants, respectively. Overall, 73.0% (95% CI: 71.8-74.1%) of participants were willing to use PrEP. Being male (aOR: 1.2; 95% CI: 1.1-1.3) and having more than one sexual partner (aOR: 1.7 95% CI: 1.4-1.9), were associated higher willingness to use PrEP.

CONCLUSIONS

In this survey, prior PrEP knowledge and use were low while PrEP interest was high. High risk sexual behavior was associated with willingness to use PrEP. Strategies to increase PrEP awareness and universal access, may reduce HIV transmission.

Early implementation learnings on acceptability and feasibility of "V": a multi-level PrEP intervention designed with and for adolescent girls and young women in Zimbabwe

INTRODUCTION

Adolescent girls and young women (AGYW) remain disproportionately affected by HIV in Zimbabwe. Several HIV prevention options are available, including oral tenofovir-based pre-exposure prophylaxis (PrEP), however AGYW face unique barriers to PrEP uptake and continuation and novel approaches are therefore needed to empower AGYW to use PrEP. The objective of this study was to characterize early learnings from implementing a multi-level intervention consisting of fashionable branding (including a "V Starter Kit"), service integration, and peer education and support throughout a young woman's journey using oral PrEP across four phases of implementation, from creating demand, preparing for PrEP, initiation of PrEP, and adherence to PrEP.

METHODS

A mixed methods implementation research study was undertaken, including site observations and interviews to explore the acceptability of "V" and its relevance to target users, as well as the feasibility of integrating "V" with existing service delivery models. Interviews (n = 46) were conducted with healthcare workers, Brand Ambassadors, and young women purposively sampled from four implementation sites. Interview data was analyzed thematically using the framework method for qualitative data management and analysis. Project budgets and invoices were used to compile unit cost and procurement data for all "V" materials.

RESULTS

"V" was acceptable to providers and young women due to attractive branding coupled with factual and thought-provoking messaging, establishing "a girl code" for discussing PrEP, and addressing a gap in communications materials. "V" was also feasible to integrate into routine service provision and outreach, alongside other services targeting AGYW. Cost for the "V" branded materials ranked most essential-FAQ insert, pill case, makeup bag, reminder sticker-were $7.61 per AGYW initiated on PrEP.

CONCLUSION

"V" is a novel approach that is an acceptable and feasible multi-level intervention to improve PrEP access, uptake, and continuation among AGYW, which works through empowering AGYW to take control of their HIV prevention needs. In considering "V" for scale up in Zimbabwe, higher volume procurement and a customized lighter package of "V" materials, while still retaining V's core approach, should be explored.

Motivators for oral PrEP uptake and adherence in the eThekwini municipality, KwaZulu-Natal

Pre-exposure prophylaxis (PrEP) is a single daily pill that prevents a seropositive HIV status. Since 2016, South Africa has staggered PrEP roll-out, with uptake levels not reaching optimal goals. The aim of this study was to determine motivation behind PrEP initiation and adherence among South African users. A phenomenological qualitative study (n = 15) was used. Participants were purposively recruited from two primary healthcare clinics in eThekwini, KwaZulu-Natal. Thematic analysis was used to analyse the data. Three themes were identified: motivation for PrEP uptake, PrEP adherence and PrEP awareness. Initiation was influenced by healthcare professionals. Responsibility for one's well-being, serodiscordant relationships and sexual partner's behavioural patterns contributed toward initiation. Most were fully compliant, using reminders to negate medication forgetfulness. The internet and healthcare professionals served as information sources, however, few were aware of PrEP prior to this. Innovative ways are required to increase awareness levels and increase uptake.

Service delivery models that promote linkages to PrEP for adolescent girls and young women and men in sub-Saharan Africa: a scoping review

BACKGROUND

Pre-exposure prophylaxis (PrEP) is an emerging biomedical prevention intervention. Documenting PrEP service delivery models (SDMs) that promote linkage to and continuation of PrEP will inform guidelines and maximise roll-out.

OBJECTIVES

To synthesise and appraise the effectiveness and feasibility of PrEP SDMs designed to promote linkage to PrEP care among adolescent girls and young women (AGYW) and men in sub-Saharan Africa (SSA).

ELIGIBILITY CRITERIA

Primary quantitative and qualitative studies published in English and conducted in SSA were included. No restrictions on the date of publication were applied.

SOURCES OF EVIDENCE

Methodology outlined in the Joanna Briggs Institute reviewers' manual was followed. PubMed, Cochrane library, Scopus, Web of Science and online-conference abstract archives were searched.

CHARTING METHODS

Data on article, population, intervention characteristics and key outcomes was charted in REDCap.

RESULTS AND CONCLUSION

Of the 1204 identified records, 37 (met the inclusion criteria. Health facility-based integrated models of PrEP delivery with family planning, maternal and child health or sexual and reproductive services to AGYW resulted in PrEP initiation of 16%-90%. Community-based drop-in centres (66%) was the preferred PrEP outlet for AGYW compared with public clinics (25%) and private clinics (9%). Most men preferred community-based delivery models. Among individuals who initiated PrEP, 50% were men, 62% were <35 years old and 97% were tested at health fairs compared with home testing. Integrated antiretroviral therapy (ART)-PrEP delivery was favoured among serodiscordant couples with 82.9% of couples using PrEP or ART with no HIV seroconversions. PrEP initiation within healthcare facilities was increased by perceived client-friendly services and non-judgemental healthcare workers. Barriers to PrEP initiation included distance to travel to and time spent at health facilities and perceived community stigma. PrEP SDMs for AGYW and men need to be tailored to the needs and preferences for each group. Programme implementers should promote community-based SDMs to increase PrEP initiation among AGYW and men.

Uptake and continuation of HIV pre-exposure prophylaxis among women of reproductive age in two health facilities in Kisumu County, Kenya

INTRODUCTION

In 2020, Kenya had 19,000 new HIV infections among women aged 15+ years. Studies have shown sub-optimal oral pre-exposure prophylaxis (PrEP) use among sub-populations of women. We assessed the uptake and continuation of oral PrEP among women 15-49 years in two health facilities in Kisumu County, Kenya.

METHODS

A retrospective cohort of 262 women aged 15-49 years, initiated into oral PrEP between 12 November 2019 and 31 March 2021, was identified from two health facilities in the urban setting of Kisumu County, Kenya. Data on baseline characteristics and oral PrEP continuation at months 1, 3 and 6 were abstracted from patient records and summarized using descriptive statistics. Missing data in the predictor variables were imputed within the joint modelling multiple imputation framework. Using logistic regression, we evaluated factors associated with the discontinuation of oral PrEP at month 1.

RESULTS

Of the 66,054 women screened, 320 (0.5%) were eligible and 262 (82%) were initiated on oral PrEP. Uptake was higher among women 25-29 years as compared to those 15-24 years (77% vs. 33%). Oral PrEP continuation declined significantly with increasing duration of follow-up; 37% at month 1, 21% at month 3 and 12% at month 6 (p<0.05). In the adjusted analysis, women 15-24 years had lower adjusted odds of continuing at month 1 than women ≥25 years (adjusted odds ratio [aOR]: 0.41, 95% CI: 0.21-0.82). There was no association between being sero-discordant and continuation of oral PrEP at month 1 (aOR; 1.21, 95% CI 0.59-2.50). Women from the sub-county hospital were more likely to continue at month 1 of follow-up compared to women enrolled in the county referral hospital (aOR 5.11; 95% CI 2.24-11.70).

CONCLUSIONS

The low eligibility for oral PrEP observed among women 15-49 years in an urban setting with high HIV prevalence calls for a review of the screening process to validate the sensitivity of the screening tool and its proper application. The low uptake and continuation among adolescent girls and young women underscores the need to identify and address specific patient- and facility-level barriers affecting different sub-populations at risk for HIV acquisition.

Development of a tool to assess HIV prevention readiness of adolescent girls and young women in HPTN 082 study

BACKGROUND

African adolescent girls and young women (AGYW) represent a large proportion of new HIV infections, a priority population for pre-exposure prophylaxis (PrEP), but adherence remains a challenge. A reliable, valid readiness tool would help identify AGYW motivated to take PrEP who need adherence support.

METHODS

In the HPTN 082 open-label PrEP study (2016-2019), South African and Zimbabwean women ages 16-25 were administered an HIV prevention readiness measure (HPRM). The 25 items in the HPRM included medication beliefs, connection with care, disclosure of PrEP use, social support, and housing stability using a 5-point Likert scale. Exploratory factor analysis (EFA) using polychoric correlations, scale reliability, and predictive validity were performed on data from 315 participants who responded to all items. We assessed the predictive value of HPRM scores with PrEP adherence, defined as tenofovir-diphosphate (TFV-DP) concentrations in dried blood spots, as a continuous measure and dichotomized as high PrEP adherence (≥700 fmol/punch).

RESULTS

EFA yielded 23 items with three subscales: self-efficacy (16 items), PrEP disclosure (4 items), and social support (3 items). Cronbach's α ranged from 0.71 to 0.92 for the overall scale and the subscales. The average overall scale and the subscales were predictive of 3-month PrEP adherence for TFV-DP concentrations: for each unit increase of the HPRM score, TFV-DP concentration increased by 103 fmol/punch (95% CI: 16, 189, p = 0.02); the highest HPRM score equated with 608 fmol/punch on average. For the self-efficacy subscale, TFV-DP increased by 90 fmol/punch (95% CI: 7, 172, p = 0.03); PrEP disclosure, 68 fmol/punch (95% CI: 19, 117 p = 0.01); and social support, 58fmol/punch (95% CI: 2, 113, p = 0.04). Higher PrEP disclosure suggests high adherence (OR 1.36, 95% CI: 1.00, 1.86, p = 0.05) and predicted persistent high adherence at both months three and six (OR: 1.50, 95% CI: 1.03, 2.21, p = 0.04).

CONCLUSIONS

The HPRM scale overall and the subscales individually demonstrated good internal consistency among African young women. PrEP disclosure subscale exhibiting significant association with persistent high PrEP adherence is an important finding for PrEP adherence support programs. Future work will assess replicability and expand self-efficacy and social-support subscales after item revision.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02732730.

"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.

Planning for decentralized, simplified prEP: Learnings from potential end users in Ga-Rankuwa, gauteng, South Africa

Background

In South Africa, youth experience challenges with oral Pre-Exposure Prophylaxis (PrEP) access and uptake. Taking services out of healthcare settings has the potential to increase reach and overcome these challenges. This paper presents young and older people's preferences for decentralized, simplified PrEP service delivery and new long-acting HIV prevention methods, in Ga-Rankuwa, South Africa.

Methods

Between May and August 2021, both PrEP user and non-user adolescent girls and young women (AGYW), pregnant AGYW, female sex workers, adolescent boys and young men (ABYM), and men who have sex with men (MSM) were recruited to participate in focus group discussions (FDGs) in Ga-Rankuwa, Gauteng. Twenty-two FGDs were conducted. Participants were asked about PrEP uptake, potential acceptability of long-acting HIV prevention products, provision of integrated, simplified, and decentralized services, and digital tools to facilitate access to PrEP and other SRH services. A qualitative approach using inductive thematic analysis was carried out to explore emerging themes on decentralized, simplified delivery and the acceptability of long-acting methods.

Results

Of the 109 participants included in the study approximately 45% (n = 50) were female, the median age was 23 years ± 5.3. A third (n = 37) were current or previous PrEP users, of which, 59.5% (n = 22) collected PrEP refills from the clinic. Decentralized, simplified service delivery was appealing; health facilities, pharmacies and institutions of learning were preferred as service points for PrEP and SRH services, and recreational spaces preferred for dissemination of health information and engagement. ABYM were more open to having recreational spaces as service points. Long-acting Cabotegravir was preferred over the Dapivirine Vaginal Ring due to concerns around perceived side-effects, efficacy, and comfort.

Conclusion

Providing long-acting PrEP methods through decentralized, simplified service delivery was appealing to this population. They provided practical locations for decentralized service provision to potentially increase their engagement with and uptake of HIV prevention and SRH services.

Feasibility and preliminary effectiveness of integrating HIV prevention into an adolescent empowerment and livelihood intervention at youth clubs in rural Uganda

The uptake of HIV prevention services is lower among youth than adults in sub-Saharan Africa. Existing youth livelihood trainings offer a potential entry point to HIV prevention services. We determined feasibility and preliminary effectiveness of integrating HIV prevention into youth clubs implementing an empowerment and livelihood for adolescents (ELA) intervention in rural Uganda. Staff conducted community mobilization for youth (15-24 years) over one month. Clubs met (3×/week) over six months, with local peer mentors trained to teach life-skills and sexual/reproductive health education. We integrated mentor-led education on HIV prevention, including pre- and post-exposure prophylaxis (PrEP/PEP). Clubs offered on-site HIV testing, a field trip to a local clinic and PrEP referrals after one month and six months. Surveys were conducted at baseline and six months. Forty-two participants (24 adolescent girls/young women (AGYW) and 18 adolescent boys/young men (ABYM)) joined the clubs. At baseline, no participants accepted referral for PrEP, whereas 5/18 (28%) sexually active, HIV-negative AGYW requested PrEP referral at follow-up. One ABYM requested PEP referral. Integration of HIV prevention services into an established ELA curriculum at mentor-led youth clubs in rural Uganda was feasible. PrEP uptake increased among sexually active AGYW. Evaluation of this approach for HIV prevention among youth merits further study.

PrEP risk perception and adherence among men who have sex with men: a prospective cohort study based on growth mixture model

BACKGROUND

It can be considered that pre-exposure prophylaxis (PrEP) risk perception is the negative experiences or concerns about taking PrEP. The aim of this study is to explore the longitudinal trajectory of PrEP risk perception among men who have sex with men (MSM) and its impact on adherence.

METHODS

Data related to PrEP risk perception and adherence were derived from a prospective cohort study in Western China from 2013 to 2015. Subjects were categorized into the time-driven, event-driven and blank control groups. Tenofovir disoproxil fumarate (TDF) was administered to subjects in the time-driven and event-driven groups, and all subjects were followed up every 12 weeks. The PrEP risk perception scale was constructed, and the growth mixture model (GMM) was used to classify longitudinal PrEP risk perception. The effect of different levels of PrEP risk perception on drug adherence was explored using generalized estimating equations (GEE) with relative risk (RR) and 95% confidence interval (CI).

RESULTS

The PrEP risk perception scale consists of 4 dimensions and 16 items with Cronbach's alpha = 0.828 and a good model fit. According to the GMM analysis, the subjects' PrEP risk perceptions were separated into two groups: a "high-risk perception group" (n = 133) and a "low-risk perception group" (n = 493), where the proportion of high levels of drug adherence were 57.89% and 68.35%, respectively (p = 0.024). High levels of PrEP risk perception in the MSM population hinder drug adherence (RR = 0.71, 95% CI 0.50 to 0.99, p = 0.046). The results of this study were validated in the subsequent PrEP projects conducted in 2019 to 2021.

CONCLUSION

This study demonstrates that high levels of PrEP risk perception in the MSM population are an obstacle to drug adherence, emphasizing the necessity of focusing on PrEP risk perception in this population and the value of its application in the current context.

Structural Interventions to Enable Adolescent Contraceptive Use in LMICs: A Mid-Range Theory to Support Intervention Development and Evaluation

Enabling contraceptive use is critical for addressing high adolescent pregnancy rates in low- and middle-income countries (LMICs). Broader or 'upstream' determinants, such as poverty, education, and social norms, can affect the knowledge, attitudes, motivation, and ability to access and use contraception. Structural interventions aim to address these broader determinants, e.g., through poverty alleviation from livelihood training or cash transfers, increasing school participation, or changing social norms. We conducted an evidence synthesis using intervention component analysis, a case-based approach, following a systematic mapping of the evidence base. We identified 17 studies with 29 structural intervention arms, which reported adolescent contraceptive use outcomes compared to a control group or baseline. It was not possible to identify with certainty which interventions were 'likely effective' or 'likely ineffective' due to the high heterogeneity of the methods. We built on an existing framework of family planning use to propose three steps to designing interventions: (1) tailor interventions to adolescents' life stages; (2) assess the baseline situation; and (3) select appropriate activities to match the gaps. These steps will aid developers and evaluators of structural adolescent contraceptive interventions to develop an evidence base that is of use across a wide range of settings and use scenarios.

Factors influencing adolescent girls and young women's uptake of community-based PrEP services following home-based HIV testing in Eastern Cape, South Africa: a qualitative study

Home-based service delivery has been used to improve access to HIV testing and antiretroviral initiation across sub-Saharan Africa, but it has yet to be leveraged to improve pre-exposure prophylaxis (PrEP) uptake. We interviewed 37 adolescent girls and young women (AGYW) in Eastern Cape, South Africa to explore why they chose to initiate PrEP or not following home-based HIV testing and referral for PrEP, and what influenced time to PrEP initiation. Participants reported that home visits provided a source of trusted information and a way to involve family members in their PrEP initiation decisions, motivating some to start PrEP. AGYW who initiated PrEP were more likely to qualitatively perceive themselves to be at high risk for HIV compared with those who never initiated PrEP. Integrating home-based HIV testing with PrEP education and referral may be a valuable way to reduce familial barriers and boost PrEP uptake among AGYW in South Africa. Trial registration: NCT03977181. Retrospectively registered on June 6, 2019.

Providers' Attitudes and Experiences with Pre-Exposure Prophylaxis Implementation in a Population-Based Study in Kenya and Uganda

Pre-exposure prophylaxis (PrEP) implementation is underway across sub-Saharan Africa. However, little is known about health care providers' experiences with PrEP provision in generalized epidemic settings, particularly outside of selected risk groups. In this study (NCT01864603), universal access to PrEP was offered to adolescents and adults at elevated risk during population-level HIV testing in rural Kenya and Uganda. Providers received training on PrEP prescribing and support from local senior clinicians. We conducted in-depth interviews with providers (n = 19) in four communities in Kenya and Uganda to explore the attitudes and experiences with implementation. Transcripts were coded and analyzed using interpretivist methods. Providers had heterogenous attitudes toward PrEP in its early implementation: some expressed enthusiasm, while others feared being blamed for "failures" (HIV seroconversions) if participants were nonadherent, or that offering PrEP would increase "immorality." Providers supported PrEP usage among HIV-serodifferent couples, whose mutual support for daily pill-taking facilitated harmony and protection from HIV. Providers reported challenges with counseling on "seasons of risk," and safely stopping and restarting PrEP. They felt uptake was hampered for women by difficulties negotiating with partners, and for youth by parental consent requirements. They believed PrEP continuation was hindered by transportation costs, stigma, pill burden, and side effects, and was facilitated by counseling, proactive management of side effects, and home/community-based provision. Providers are critical "implementation actors" in interventions to promote adoption of new technologies such as PrEP. Dedicated training and ongoing support for providers may facilitate successful scale-up.

Which Structural Interventions for Adolescent Contraceptive Use Have Been Evaluated in Low- and Middle-Income Countries?

Reducing adolescent childbearing is a global priority, and enabling contraceptive use is one means of achieving this. Upstream factors, e.g., gender inequalities, fertility norms, poverty, empowerment and schooling, can be major factors affecting contraceptive use. We conducted a systematic map to understand which structural adolescent contraception interventions targeting these upstream factors have been evaluated in LMICs. We searched eight academic databases plus relevant websites and a 2016 evidence gap map and screened references based on set inclusion criteria. We screened 6993 references and included 40 unique intervention evaluations, reported in 138 papers. Seventeen evaluations were reported only in grey literature. Poverty reduction/economic empowerment interventions were the most common structural intervention, followed by interventions to increase schooling (e.g., through legislation or cash transfers) and those aiming to change social norms. Half of the evaluations were RCTs. There was variation in the timing of endline outcome data collection and the outcome measures used. A range of structural interventions have been evaluated for their effect on adolescent contraceptive use/pregnancy. These interventions, and their evaluations, are heterogenous in numerous ways. Improved understandings of how structural interventions work, as well as addressing evaluation challenges, are needed to facilitate progress in enabling adolescent contraceptive use in LMICs.

HIV Risk Factors and Risk Perception Among Adolescent Girls and Young Women: Results From a Population-Based Survey in Western Kenya, 2018

BACKGROUND

In sub-Saharan Africa, HIV prevalence in adolescent girls and young women (AGYW) is 2-fold to 3-fold higher than that in adolescent boys and young men. Understanding AGYW's perception of HIV risk is essential for HIV prevention efforts.

METHODS

We analyzed data from a HIV biobehavioral survey conducted in western Kenya in 2018. Data from AGYW aged 15-24 years who had a documented HIV status were included. We calculated weighted prevalence and evaluated factors associated with outcomes of interest (HIV infection and high risk perception) using generalized linear models to calculate prevalence ratios.

RESULTS

A total of 3828 AGYW were included; 63% were aged 15-19 years. HIV prevalence was 4.5% and 14.5% of sexually active AGYW had high risk perception. Over 70% of participants had accessed HIV testing and counseling in the past 12 months. Factors associated with both HIV infection and high risk perception included having an HIV-positive partner or partner with unknown status and having a sexually transmitted infection in the past 12 months. Having an older (by ≥10 years) partner was associated with HIV infection, but not high risk perception. Less than 30% of sexually active AGYW with 3 or more HIV risk factors had high perception of HIV risk.

CONCLUSION

Gaps in perceived HIV risk persist among AGYW in Kenya. High access to HIV testing and prevention services in this population highlights platforms through which AGYW may be reached with improved risk counseling, and to increase uptake of HIV prevention strategies.

Understanding PrEP decision making among pregnant women in Lilongwe, Malawi: A mixed-methods study

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is a promising tool for HIV prevention during pregnancy. With increasing rollout in antenatal settings, counselling strategies to help pregnant women make appropriate decisions about PrEP use are needed. Understanding women's motivations and concerns for PrEP use-and how these inform their decision making and feelings about the decision to start PrEP-are critical to inform these strategies.

METHODS

We conducted a convergent mixed-methods study from June 2020 to June 2021 in the context of a PrEP adherence support trial among HIV-negative pregnant women in Lilongwe, Malawi. Two hundred women completed a survey reporting their motivations and concerns about PrEP use, and their feelings about the decision to start PrEP (Decisional Regret Scale). Thirty women completed in-depth interviews to better understand the decision-making process, including motivations and concerns weighed in women's decision to use PrEP. Analyses comprised descriptive and bivariate statistics, thematic qualitative analysis, and integration of quantitative and qualitative results.

RESULTS

Women initiating PrEP during pregnancy were highly motivated to obtain HIV protection for themselves and their unborn child, often due to perceived HIV risk connoted by a recent sexually transmitted infection and/or concerns about partner non-monogamy. These motivations prevailed despite some concerns about safety and side effects, anticipated stigmatization, and concerns about adherence burden and pill attributes. Many women had informed their partner of their decision to use PrEP yet few felt their decision was contingent upon partner approval. Most women felt positively about the decision to start PrEP (mean decisional regret = 1.2 out of 5), but those with a greater number of concerns reported greater decisional regret (B = 0.036; p = 0.005). Furthermore, women who were specifically concerned about partner disclosure, who disliked pills or who had no perceived HIV risk reported greater decisional regret.

CONCLUSIONS

Pregnant women were strongly motivated by the promise of HIV protection offered by PrEP and accepted it despite diverse concerns. A shared decision-making approach that centres pregnant women and offers partner involvement may help identify and address initial concerns about PrEP use and support prevention-effective use of PrEP during this important period.

Women's Perceptions of HIV- and Sexuality-Related Stigma in Relation to PrEP: Qualitative Findings from the Masibambane Study, Durban, South Africa

Daily oral pre-exposure prophylaxis (PrEP) offers effective HIV prevention. In South Africa, PrEP is publicly available, but use among young women remains low. We explored young women's perceptions of PrEP to inform a gender-focused intervention to promote PrEP uptake. Six focus group discussions and eight in-depth interviews exploring perceptions of PrEP were conducted with forty-six women not using PrEP, ages 18-25, from central Durban. Data were thematically analyzed using a team-based consensus approach. The study was conducted among likely PrEP users: women were highly-educated, with 84.8% enrolled in post-secondary education. Qualitative data revealed intersecting social stigmas related to HIV and women's sexuality. Women feared that daily PrEP pills would be confused with anti-retroviral treatment, creating vulnerability to misplaced HIV stigma. Women also anticipated that taking PrEP could expose them to assumptions of promiscuity from the community. To address these anticipated community-level reactions, women suggested community-facing interventions to reduce the burden on young women considering PrEP. Concerns around PrEP use in this group of urban, educated women reflects layered stigmas that may inhibit future PrEP use. Stigma-reducing strategies, such as media campaigns and educational interventions directed at communities who could benefit from PrEP, should re-frame PrEP as an empowering and responsible choice for young women.

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

BACKGROUND

Pre-exposure prophylaxis, or PrEP, has been hailed for its promise to provide women with user-control. However, gender-specific challenges undermining PrEP use are beginning to emerge. We explore the role of gender norms in shaping adolescent girls and young women's (AGYW) engagement with PrEP.

METHODS

We draw on qualitative data from 12 individual interviews and three focus group discussions with AGYW from eastern Zimbabwe. Interviews were transcribed and thematically coded in NVivo 12. Emerging themes were further investigated using Connell's notion of 'emphasised femininity'.

RESULTS

Participants alluded to the patriarchal society they are part of, with 'good girl' notions subjecting them to direct and indirect social control. These controls manifest themselves through the anticipation of intersecting sexuality- and PrEP-related stigmas, discouraging AGYW from engaging with PrEP. AGYW recounted the need for permission to engage with PrEP, forcing them to consider engaging with PrEP in secrecy. In addition, limited privacy at home, and fear of disclosure of their health clinic visits, further heightened their fear of engaging with PrEP. PrEP is not simply a user-controlled HIV prevention method, but deeply entrenched within public gender orders.

CONCLUSION

AGYW face significant limitations in their autonomy to initiate and engage with PrEP. Those considering PrEP face the dilemma of Scylla and Charybdis: The social risks of stigmatisation or risks of HIV acquisition. Efforts to make PrEP available must form part of a combination of social and structural interventions that challenge harmful gender norms.

From policy to practice: uptake of pre-exposure prophylaxis among adolescent girls and young women in United States President's Emergency Plan for AIDS Relief-supported countries, 2017-2020

BACKGROUND

The US President's Emergency Plan for AIDS Relief's (PEPFAR) first implemented pre-exposure prophylaxis (PrEP) for HIV prevention through the Determined, Resilient, Empowered, AIDS-Free, Mentored and Safe (DREAMS) partnership in 2016. PrEP is a critical intervention to achieve the main objective of DREAMS, reducing new HIV infections among 15-14 year old adolescent girls and young women (AGYW) in 15 high HIV burdened countries.

METHODS

We describe uptake of PrEP among AGYW in PEPFAR. Most PrEP programs screened persons who tested HIV-negative for eligibility and offered PrEP as part of combination prevention with follow-up, including repeat HIV testing and counseling, at 3-month intervals. Platforms providing comprehensive services for AGYW were also leveraged. We examined two PEPFAR monitoring indicators, using the FY20Q4 Monitoring, Evaluation, Reporting (MER) indicator dataset to assess progress in PrEP uptake, and descriptive narratives to understand successes and challenges from fiscal year 2017 to 2020. To assess coverage, we calculated the PrEP to Need ratio (PnR) using a published methodology.

RESULTS

From FY2017 to FY2020, 576570 total clients initiated PrEP and the number of PEPFAR countries offering PrEP doubled from 12 to 24. Of 360073 (62% of total) initiations among women, 52% were among AGYW with steady increases from year to year. Among all AGYW, 20-24-year-old women represented a significantly higher proportion of PrEP initiators than adolescents (15-19years) (64 versus 36%, P  < 0.05). Of all 186985 PrEP initiations among AGYW, 99% were in DREAMS countries. Barriers, such as low demand and adherence, were addressed through outreach efforts, including mobile sites, use of technology to educate and support AGYW, media campaigns, and engaging peers in program implementation. We saw a 2.5-fold increase in PrEP uptake among AGYW from 2018 to 2019; by 2020, all DREAMS countries were implementing PrEP. However, PrEP coverage among AGYW in DREAMS countries remains low (PnR range: 0-4.1); only two have a PnR greater than 1 where there were more PrEP users than new HIV diagnoses.

CONCLUSION

PrEP uptake among AGYW has grown since 2016; however, challenges remain. Tools to improve adherence are needed to improve PrEP persistence among AGYW. National policies to facilitate greater PrEP uptake among adolescents would be beneficial. A greater need for PrEP in DREAMS countries is evident and if realized, will contribute to epidemic control.

Low awareness of oral and injectable PrEP among high-risk adolescent girls and young women in Kampala, Uganda

BACKGROUND

Adolescent girls and young women (AGYW) account for a disproportionate number of new HIV infections worldwide. HIV prevalence among young sex workers in Uganda is 22.5%. Although pre-exposure prophylaxis (PrEP) is a highly effective biomedical HIV prevention method, awareness of PrEP among AGYW in Uganda has not been studied systematically. We aimed to assess awareness of PrEP and factors associated with awareness of PrEP among AGYW who frequently reported paid sex.

METHODS

We conducted a cross-sectional study among 14-24-year old AGYW at high risk of HIV infection in Kampala, Uganda from January to October 2019. Participants were screened for PrEP eligibility using a national screening tool of whom 82.3% were eligible. Data on socio-demographics, behavioral and sexual risks were collected by interview. Awareness of oral or injectable PrEP, the latter of which is currently in late-stage trials, was defined as whether an individual had heard about PrEP as an HIV prevention method. Multivariable robust poisson regression model was used to assess factors associated with oral PrEP awareness.

RESULTS

We enrolled 285 participants of whom 39.3% were under 20 years old, 54.7% had completed secondary education, 68.8% had multiple sex partners in the past 3 months, 8.8% were screened as high risk drinkers'/ alcohol dependent (AUDIT tool) and 21.0% reported sex work as main occupation. Only 23.2% were aware of oral PrEP and 3.9% had heard about injectable PrEP. The prevalence of oral PrEP awareness was significantly higher among volunteers screened as alcohol dependents (aPR 1.89, 95% CI 1.08-3.29) and those with multiple sexual partners (aPR 1.84, 95% CI 1.01-3.35), but was lower among those who reported consistent condom use with recent sexual partners (aPR 0.58, 95% CI 0.37-0.91).

CONCLUSIONS

Majority of AGYW were not aware of any kind of PrEP. Those with higher risk behavior, i.e. alcohol dependents or multiple sexual partners, were more aware of oral PrEP. Interventions to increase awareness among female youth are needed. Improving PrEP awareness is critical to increasing PrEP uptake among high-risk AGYW in Uganda.

Oral pre-exposure prophylaxis preference, uptake, adherence and continuation among adolescent girls and young women in Kampala, Uganda: a prospective cohort study

Introduction

Oral pre‐exposure prophylaxis (PrEP) has been scaled up; however, data from real‐world settings are limited. We studied oral PrEP preference, uptake, adherence and continuation among adolescent girls and young women (AGYW) vulnerable to HIV in sub‐Saharan Africa.

Methods

We conducted a prospective cohort study among 14‐ to 24‐year‐old AGYW without HIV who were followed for 12 months in Kampala, Uganda. Within at least 14 days of enrolment, they received two education sessions, including demonstrations on five biomedical interventions that are; available (oral PrEP), will be available soon (long‐acting injectable PrEP and anti‐retroviral vaginal ring) and in development (PrEP implant and HIV vaccine). Information included mode and frequency of delivery, potential side effects and method availability. Volunteers ranked interventions, 1 = most preferred to 5 = least preferred. Oral PrEP was “preferred” if ranked among the top two choices. All were offered oral PrEP, and determinants of uptake assessed using Poisson regression with robust error variance. Adherence was assessed using plasma tenofovir levels and self‐reports.

Results

Between January and October 2019, 532 volunteers were screened; 285 enrolled of whom 265 received two education sessions. Mean age was 20 years (SD±2.2), 92.8% reported paid sex, 20.4% reported ≥10 sexual partners in the past 3 months, 38.5% used hormonal contraceptives, 26.9% had chlamydia, gonorrhoea and/or active syphilis. Of 265 volunteers, 47.6% preferred oral PrEP. Willingness to take PrEP was 90.2%; however, uptake was 30.6% (n = 81). Following enrolment, 51.9% started PrEP on day 14 (same day PrEP offered), 20.9% within 30 days and 27.2% after 30 days. PrEP uptake was associated with more sexual partners in the past 3 months: 2–9 partners (aRR = 2.36, 95% CI: 1.20–4.63) and ≥10 partners (aRR 4.70, 95% CI 2.41–9.17); oral PrEP preference (aRR 1.53, 95% CI 1.08–2.19) and being separated (aRR 1.55, 95% CI 1.04–2.33). Of 100 samples from 49 volunteers during follow up, 19 had quantifiable tenofovir levels (>10 μg/L) of which only three were protective (>40 μg/L).

Conclusions

Half of AGYW preferred oral PrEP, uptake and adherence were low, uptake was associated with sexual behavioural risk and oral PrEP preference. Development of alternative biomedical products should be expedited to meet end‐user preferences and, community delivery promoted during restricted movement.

"We just do it … we are dead already": Exploring the sexual behaviors of youth living with HIV

INTRODUCTION

This study aims to describe the sexual behaviors of youth living with human immunodeficiency virus (HIV) in Malawi. As a high-risk population, understanding the contextual factors that shape their sexual behaviors is of particular interest when designing strategies to reduce HIV transmission.

METHODS

Semi-structured qualitative interviews were used to collect information about sexual behaviors from 22 youth (12 females and 10 males) living with HIV aged from 15 to 24 years. All participants were recruited from a specialized HIV clinic in Malawi. Thematic analysis was applied to identify current themes.

RESULTS

The majority of participants were sexually active. Engaging in sexual behaviors was largely related to social processes identified in three main themes: (1) Risk-taking in pursuit of confidence and maturity; (2) A lack of voice in decision making concerning practising safe sex; (3) Perceived barriers to safe sex practice such as poverty, dropping out of school, and personal perspectives about transmitting HIV to others.

CONCLUSION

Our results suggest that prevention strategies targeting youth social and economic vulnerabilities to social influences are needed to enhance their personal and social skills. We suggest nurturing cultural and religious ceremonies and involving elders to equip youth with skills and knowledge for the prevention of HIV transmission.

Implementation strategies for integrating pre-exposure prophylaxis for HIV prevention and family planning services for adolescent girls and young women in Kenya: a qualitative study

INTRODUCTION

Across sub-Saharan Africa, ministries of health have proposed integrating pre-exposure prophylaxis (PrEP) for HIV prevention into family planning (FP) services to reach adolescent girls and young women (AGYW); however, evidence on effective implementation strategies is still limited. We conducted a qualitative study of integrated PrEP-FP service implementation at two FP clinics in Kisumu, Kenya.

METHODS

From June 2017 to May 2020, the Prevention Options for Women Evaluation Research (POWER) study enrolled 1000 sexually active, HIV-negative AGYW age 16 to 25. Actions taken to implement PrEP were captured prospectively in 214 monitoring and evaluation documents and 15 interviews with PrEP implementers. We analysed data using conventional and directed content analysis, with the latter informed by the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change (ERIC) compilation.

RESULTS

POWER deployed a variety of implementation strategies to train and educate stakeholders (e.g., having new providers shadow PrEP providers); develop stakeholder interrelationships (e.g., organizing support teams with protected time to reflect on implementation progress and make refinements); provide technical assistance; and change physical infrastructure and workflow. Although these strategies reportedly influenced contextual factors across four of the five CFIR domains, they primarily interacted with contextual factors relevant to inner setting, especially implementation climate and readiness for implementation. Overall, implementing PrEP proved easier and less labor-intensive at a private, youth-friendly clinic than a public FP clinic, largely because the baseline structural characteristics (e.g., space, workflow) and organizational mission of the former were more conducive to offering AGYW-centered care. Nevertheless, adoption of PrEP delivery among non-study staff at both sites was low, likely due to the widespread perception that PrEP was not within their scope of work.

CONCLUSIONS

Some FP clinics may be "lower-hanging fruit" than others for PrEP implementation. Approaching PrEP implementation as a behavioral intervention for FP providers may help ensure that providers have the requisite capability, opportunity, and motivation to adopt the clinical innovation. In particular, PrEP implementers should assess the need for implementation strategies that support providers' clinical decision-making, establish worker expectations and accountability, and address workload constraints.

TRIAL REGISTRATION

Clinical Trial Number: NCT03490058 .

Women's preferences and acceptance for different drug delivery routes and products

To use or not to use, that is the first decision to take regarding a drug product. This mandatory step for adherence dictates product efficacy. The determinants for such decision do not only rely on the priority of the therapeutic or preventive strategy, but are related to a complex network of perceptions, preferences, personal and cultural backgrounds, and results from previous experiences. Women's preferences for dosage forms and even for drug delivery routes have been mainly studied in the fields of contraception and HIV prevention (and their related multipurpose approaches). Much less attention has been devoted to other therapeutic or preventive strategies. In a time when patient-centred approaches and shared decisions are increasingly valued, considering women's preferences and their main determinants is essential for product development and selection. Such products will be more likely to be chosen and used as intended, increasing efficacy, and reducing the overall costs related with these treatments. This knowledge shall be integrated in early stages of product development. This article reviews the state of the art related with women's preferences and acceptance for different dosage forms and drug delivery routes involved in women's health. The methodologies used for collecting these data and their major drawbacks are discussed. Results obtained from acceptability studies and the main determinants for selection of preventive and treatment drug products are discussed as tools for new developments in the field.

"I prefer to take pills when I plan to have sex": Perceptions of on-demand versus daily oral pre-exposure prophylaxis among adolescents in Kampala, Uganda

There is limited information about the use of on-demand and daily pre-exposure prophylaxis (PrEP) among adolescents and young people (AYP) in sub-Saharan Africa. We explored perceptions of both regimens among 14- to 19-year-olds perceived to be at high risk of HIV infection in Kampala, Uganda, using qualitative data collection methods. Data were analysed by theme and interpreted based on constructs from the framework of acceptability. Although there were no noticeable gender differences in preferences for a particular regimen, acceptability of PrEP depended on individual AYP sexual behaviour at the time of the study. Those who perceived themselves to be at increased risk of acquiring HIV preferred using daily PrEP, citing the consistency that comes from taking a pill daily and which they considered to be efficacious and safe. AYP who had less frequent sex preferred on-demand PrEP because it would enable them to "plan for sex". However, both groups perceived taking daily PrEP to be a burden, which was an impediment to acceptance of this form of PrEP. AYP anticipated that daily pill taking would be very stressful, requiring a lot of effort and would interrupt their daily routine. Therefore, while both on-demand and daily PrEP were acceptable and beneficial to these AYP, preferences for either regimen depended on self-perceived risk. Thus, oral PrEP use should be tailored to end-user preferences and risk profiles.

Oral PrEP Consultations Among Adolescent Girls and Young Women in Kisumu County, Kenya: Insights from the DREAMS Program

Although Kenya nationally scaled up oral pre-exposure prophylaxis (PrEP) in May 2017, adolescent girls' (AG, aged 15-19 years) and young women's (YW, aged 20-24 years) PrEP use remains suboptimal. Thus, we analyzed PrEP consultations-interactions with a healthcare provider about PrEP-among Kenyan AGYW. In April-June 2018, AGYW enrolled in DREAMS in Kisumu County, Kenya self-reported their HIV-related knowledge, behaviors, and service use. Among HIV negative, sexually active AG (n = 154) and YW (n = 289), we examined associations between PrEP eligibility and PrEP consultations using prevalence ratios (PR, adjusted: aPR). Most AG (90.26%) and YW (94.12%) were PrEP-eligible due to inconsistent/no condom use, violence survivorship, or recent sexually transmitted infection symptoms. Between PrEP-eligible AG and YW, more YW were ever-orphaned (58.09%), ever-married (54.41%), ever-pregnant (80.88%), and out of school (78.31%); more PrEP-eligible YW reported PrEP consultations (41.18% vs. 24.46%, aPR = 1.51 [1.01-2.27]). AG who used PEP (post-exposure prophylaxis) reported more consultations (aPR = 5.63 [3.53-8.97]). Among YW, transactional sex engagers reported more consultations (58.62% vs. 39.09%, PR = 1.50 [1.06-2.12]), but only PEP use (aPR = 2.81 [2.30-3.43]) and multiple partnerships (aPR = 1.39 [1.06-1.82]) were independently associated with consultations. Consultations were lowest among those with 1 eligibility criterion (AG = 11.11%/YW = 27.18%). Comparatively, consultations were higher among AG and YW with 2 (aPR = 3.71 [1.64-8.39], PR = 1.60 [1.07-2.38], respectively) or ≥ 3 (aPR = 2.51 [1.09-5.78], PR = 2.05 [1.42-2.97], respectively) eligibility criteria. Though most AGYW were PrEP-eligible, PrEP consultations were rare and differed by age and vulnerability. In high-incidence settings, PrEP consultations should be conducted with all AGYW. PrEP provision guidelines must be re-assessed to accelerate AGYW's PrEP access.

Multi-level Interventions to Promote Oral Pre-exposure Prophylaxis Use Among Adolescent Girls and Young Women: a Review of Recent Research

Purpose of review

This review summarizes interventions to promote HIV pre-exposure prophylaxis (PrEP) use among adolescent girls and young women (AGYW) in HIV endemic settings, while also highlighting gaps in our current measures of PrEP intervention success.

Recent findings

AGYW report challenges with PrEP use, although the field is currently grappling with defining metrics of optimal PrEP use applicable for AGYW with dynamic HIV prevention needs. Ongoing studies are exploring multilevel interventions to address barriers to PrEP use for AGYW. At the individual and interpersonal levels, mHealth, drug-level feedback, adherence counseling, peer groups, and PrEP decision-support interventions are acceptable and feasible for AGYW although limited effectiveness data are available. At the health facility and community levels, PrEP demand creation, modified PrEP refill schedules, and integrated PrEP and reproductive health services are also promising options to support PrEP use for AGYW.

Summary

As PrEP delivery continues to expand, improved metrics of success and evidence on the effectiveness of multi-level adherence support interventions are needed to maximize the impact of PrEP for AGYW in HIV endemic settings. We present case studies of these intervention approaches but limited data are currently available on the effectiveness of these approaches. We will look toward forthcoming study results on the impact of PrEP interventions, including mHealth, drug-level feedback and other enhanced counseling, peer support, decision-support tools, PrEP demand creation, modified refills, and integrated service delivery, to determine the ideal package of PrEP support approaches for AGYW.

The impact of the DREAMS partnership on HIV incidence among young women who sell sex in two Zimbabwean cities: results of a non-randomised study

INTRODUCTION

Young women who sell sex (YWSS) in Zimbabwe remain at high risk of HIV infection. Effective HIV prevention strategies are needed. Through support to access a combination of evidence-based interventions, including oral pre-exposure prophylaxis (PrEP), the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) partnership aimed to reduce new HIV infections among adolescent girls and young women by 40% over 24 months.

METHODS

Non-randomised 'plausibility' evaluation, powered to detect a 40% HIV incidence difference between DREAMS and non-DREAMS sites. Two large cities with DREAMS funding were included, and four smaller non-DREAMS towns for comparison. In all sites, YWSS were enrolled to a cohort through peer-referral. Women were followed up for 24 months. HIV seroconversion was the primary outcome, with secondary outcomes identified through a theory of change. Outcomes were compared between YWSS recruited in DREAMS cities and non-DREAMS towns, adjusting for individual-level confounders and HIV prevalence at enrolment.

RESULTS

From April to July 2017, 2431 women were enrolled, 1859 of whom were HIV negative at enrolment; 1019 of these women (54.8%) were followed up from March to May 2019 and included in endline analysis. Access to clinical services increased, but access to socioeconomic interventions promoted by DREAMS was limited. A total of 79 YWSS HIV seroconverted, with HIV incidence among YWSS in DREAMS cities lower (3.1/100 person-years) than in non-DREAMS towns (5.3/100 person-years). In prespecified adjusted analysis, HIV incidence was lower in DREAMS cities but with weak statistical evidence (adjusted rate ratio (RR)=0.68; 95% CI 0.40 to 1.19; p=0.18). Women in DREAMS cities were more likely to report ever and ongoing PrEP use, consistent condom use, fewer sexual partners and less intimate partner violence.

CONCLUSION

It is plausible that DREAMS lowered HIV incidence among YWSS in two Zimbabwean cities, but our evaluation provides weak statistical evidence for impact and suggests any reduction in incidence was lower than the anticipated 40% decline. We identified changes to some important 'pathways to impact' variables, including condom use.

Integrating Oral PrEP Into Family Planning Services for Women in Sub-saharan Africa: Findings From a Multi-Country Landscape Analysis

Integration of HIV and family planning (FP) services is a renewed focus area for national policymakers, donors, and implementers in sub-Saharan Africa as a result of high HIV incidence among general-population women, especially adolescent girls and young women (AGYW), and the perception that integrating HIV pre-exposure prophylaxis (PrEP) into FP services may be an effective way to provide comprehensive HIV and FP services to this population. We conducted a focused desk review to develop a PrEP-FP integration framework across five key categories: plans and policies, resource management, service delivery, PrEP use, and monitoring and reporting. The framework was refined via interviews with 30 stakeholders across seven countries at varying stages of oral PrEP rollout: Kenya, Lesotho, Malawi, South Africa, Uganda, Zambia, and Zimbabwe. After refining the framework, we developed a PrEP-FP integration matrix and assessed country-specific progress to identify common enablers of and barriers to PrEP-FP integration. None of the countries included in our analysis had made substantial progress toward integrated PrEP-FP service delivery. Although the countries made progress in one or two categories, integration was often impeded by lack of advancement in other areas. Our framework offers policymakers, program implementers, and health care providers a road map for strategically assessing and monitoring progress toward PrEP-FP integration in their contexts.

Women's perspectives on relationship dynamics with their partners and their role in HIV acquisition, HIV disclosure, hormonal contraceptive uptake, and condom use

Background: Limited information exists about relationship dynamics and their role in HIV acquisition, HIV disclosure, hormonal contraceptive uptake, and condom use among women in Malawi.Methods: Ninety-seven women aged 18-45 years were randomly assigned to initiate the depot medroxyprogesterone acetate injectable or levonorgestrel implant from May 2014 to April 2015 in Lilongwe, Malawi. Women were recruited after randomisation to participate in semi-structured interviews about HIV and family planning using purposive sampling. Interviews were thematically analysed using within and between group comparisons.Results: We conducted individual interviews and/or focus group discussions with 41 women: 30 (73%) women living with HIV and 11 (27%) women not living with HIV. Most women living with HIV who participated in in-depth interviews disclosed their status to their partners, and most partners agreed to get HIV tested only after disclosure. Nearly all women said their partners agreed to use condoms, but few used them consistently. Nearly all women believed their current and former partners had outside partners. Most women living with HIV who participated in in-depth interviews believed their current or other serious partners were the source of their infection. Some women thought their partner's infidelity was due to their partner's disinterest in sex with them during menstrual/ breakthrough bleeding. Some women included their partners in contraceptive decision-making when the partner was supportive.Discussion: Relationship dynamics affected decision-making for contraceptive and condom use, as well as serodisclosure for the women living with HIV in the study. All women reported challenges with consistent condom use with their male partners, although contraceptive use was generally more acceptable. Women included their partners in their decision-making concerning contraceptive use when they were supportive.

Awareness of and willingness to use HIV pre-exposure prophylaxis among community residents

INTRODUCTION

Human Immunodeficiency Virus (HIV) Pre-exposure prophylaxis (PrEP) helps to decrease HIV acquisition and transmission rates. The purpose of this study was to assess awareness of HIV PrEP and willingness to use it, if available, among individuals residing in Buea, Cameroon.

METHODS

Residents in different communities throughout Buea, Cameroon participated in the study through survey completion with their responses assessed by age, marital status, highest level of education completed, profession, and health area (urban or rural).

RESULTS

421 participants completed the survey with the majority being 20-29 years of age, single, having secondary or tertiary education, residing in rural Cameroonian areas. Eighty percent of respondents had not previously heard of HIV PrEP. Ninety-five percent of the study sample expressed willingness to use HIV PrEP, if available. Participants ages 40 years old and above were less aware of HIV PrEP than those 39 years old and younger. Primary education, serving in the role of a nurse, doctor, or scientist, along with hospital affiliations were characteristics closely associated with HIV PrEP awareness. Participants younger than 20 years old were less likely to report willingness to use HIV PrEP whereas married participants found HIV PrEP to be a more favorable option.

CONCLUSIONS

Awareness of HIV PrEP was minimal with healthcare personnel having more familiarity. Willingness to use HIV PrEP decreased by age but higher among married participants. Further promotion of HIV PrEP and facilitating its accessibility can lead to less transmissions of HIV worldwide.

Effect of SMS reminders on PrEP adherence in young Kenyan women (MPYA study): a randomised controlled trial

BACKGROUND

Pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV acquisition. However, adherence among young women (aged 18-24 years) has been challenging. SMS reminders have been shown to improve adherence to antiretroviral therapy in some contexts, including in combination with real-time adherence monitoring. We aimed to determine the effect of SMS reminders on PrEP adherence among young women in Kenya over a 2-year period.

METHODS

The monitoring PrEP among young adult women (MPYA) study was an open label randomised controlled trial involving young adult women at high risk of HIV in Thika and Kisumu, Kenya. Participants were recruited from colleges, vocational institutions, informal settlements, and community-based organisations supporting young women. Women had to be aged 18-24 years and at high risk of HIV acquisition (defined as a VOICE risk score of 5 or higher, or being in a serodiscordant relationship). Study staff randomly assigned participants (1:1) to receive either SMS reminders (SMS reminder group) or no reminders (no SMS reminder group). Study group assignment was known to trial staff but masked to investigators. Reminders were initially sent daily and participants could switch to as-needed reminders (ie, sent only if they missed opening the monitor as expected) after 1 month. Study visits occurred at 1 month, 3 months, and then quarterly (ie, every 3 months). The primary outcome was PrEP adherence over 24 months measured with a real-time electronic monitor and assessed by negative binomial models adjusted for the study site and quarter among participants who collected PrEP. This trial is registered with ClinicalTrials.gov, NCT02915367.

FINDINGS

Of 642 women initially approached, 348 eligible women were enrolled between Dec 21, 2016, and Feb 5, 2018. Participants were randomly assigned to either the SMS reminder group (n=173) or the no SMS reminder group (n=175). The median age was 21 years (IQR 19-22) and 228 (66%) of the 348 participants reported condomless sex in the month before baseline. 24 (14%) of the 173 participants assigned to receive daily SMS reminders later opted for as-needed reminders. 69 291 (97%) of 71 791 SMS reminders were sent as planned. Among participants collecting PrEP (thus potentially suggesting a desire for HIV protection), electronically monitored adherence averaged 26·8% over 24 months and was similar by study group (27·0% with SMS, 26·6% without SMS, adjusted incidence rate ratio 1·16 [95% CI 0·93-1·45], p=0·19). There were no serious adverse events related to trial participation; five social harms occurred in each study group, primarily related to PrEP use.

INTERPRETATION

SMS reminders were ineffective in promoting PrEP adherence among young Kenyan women. Given the overall low adherence in the trial, additional interventions are needed to support PrEP use in this population.

FUNDING

US National Institute of Mental Health.

Protection at First Sexual Intercourse Among Adolescent Girls and Young Women in Kenya

Adolescent girls and young women (AGYW) are at high risk of HIV and other sexually transmitted infections (STIs), including at first sexual intercourse. The literature is scarce on factors influencing use of protective strategies at this critical time. We conducted 20 in-depth interviews and five focus group discussions with purposively sampled AGYW aged 16-20 years who reported first sex while enrolled in a larger cohort study and willing to participate. All AGYW were counseled on HIV prevention and had access to reproductive health information and services. Data collected were transcribed, translated and analyzed thematically. We identified two approaches to first sex. In one approach, the AGYW facilitated protection use, and those AGYW reported intention and preparation to initiate sexual activity and ability to request condom use, as well as their male partner's willingness to use and provide condoms. In another approach, AGYW experienced first sexual intercourse without agency (the feeling of control over actions and their consequences [Moore, 2016]) and described lack of prior intentions and planning, discomfort with discussions about sex and condom use, and desire to experience sexual pleasure as reported by peers. No AGYW mentioned parents/adults as playing any role as facilitators of protection use at first sex, highlighting the need for further research on the missing gap. The AGYW were trusting of verbal reports by male partners describing themselves as having never engaged in sex, HIV negative, and free of STIs. We found that some AGYW were empowered to plan, discuss, and request protection at first sex, and others did not take agency. First sex is a time of vulnerability where innovative strategies are needed to strengthen AGYW's agency and promote condom use and other HIV/STI prevention methods.

Risk of HIV infection among adolescent girls and young women in age-disparate relationships in sub-Saharan Africa

OBJECTIVE

To determine the association between age-disparate relationships and risk of HIV infection among adolescent girls and young women (AGYW) aged 15-24 years.

DESIGN

Systematic review and meta-analysis of published studies until January 5, 2020 in sub Saharan Africa (SSA).

METHODS

We searched several electronic databases, grey literature, and hand searched reference list of included studies to identify eligible studies for data abstraction. We assessed the quality of included studies using Newcastle-Ottawa Scale for nonrandomized studies. The DerSimonian-Laird random effects model was used to pool the overall results using risk ratios (RR), presented in a forest plot with 95% confidence interval (CI) and predictive interval. Heterogeneity was assessed with Cochrane's Q-test and quantified with I values. Publication bias was checked with funnel plots and Egger's test.

RESULTS

We included 24 studies with an overall sample size of 33 390. Data show that age-disparate relationships were significantly associated with unprotected sexual intercourse (pooled RR, 1.57; 95% CI, 1.34-1.83; 95% predictive interval, 1.22-2.02), and higher risk for HIV infection (pooled RR, 1.39; 95 CI, 1.21-1.60; 95% predictive interval, 0.80-2.42). Studies included in pooling risk of unprotected sexual intercourse were largely homogeneous (I-value= 0.0, P = 0.79) whereas those for HIV infection were heterogeneous (I- value = 89.0%, P < 0.01). We found no publication bias and no study influenced the meta-analytic results.

CONCLUSION

Age-disparate relationships among AGYW are associated with increased risk of unprotected sexual intercourse and HIV infection in SSA. HIV prevention interventions should target this sub-population.

HIV risk, risk perception, and PrEP interest among adolescent girls and young women in Lilongwe, Malawi: operationalizing the PrEP cascade

INTRODUCTION

As a user-controlled HIV prevention method, oral pre-exposure prophylaxis (PrEP) holds particular promise for adolescent girls and young women (AGYW). HIV prevention cascades, critical frameworks for the design and evaluation of PrEP programmes, outline the priorities of identifying individuals at greatest HIV risk and motivating them to initiate PrEP through perceived HIV risk. To inform future iterations of these cascades and PrEP delivery for AGYW, the objective of this study was to understand the level of interest in PrEP among AGYW at highest HIV risk, and the potential role of perceived risk in motivating PrEP interest.

METHODS

Using data from a cohort study of HIV-negative AGYW in Lilongwe, Malawi (February 2016 to August 2017), we assessed the relationship between epidemiologic HIV risk (risk index developed in a previous analysis) and PrEP interest, and the extent to which perceived risk explains the relationship between HIV risk and PrEP interest. We further aimed to operationalize the pre-initiation steps of the HIV prevention cascade in the study population.

RESULTS

In total, 825 AGYW were included in analyses, of which 43% met the criterion for high epidemiologic HIV risk. While epidemiologic risk scores were positively associated with PrEP interest, high numbers of AGYW both above and below the high-risk cutoff were very interested in PrEP (68% vs. 63%). Perceived risk partially explained the relationship between HIV risk and PrEP interest; greater epidemiologic HIV risk was associated with high perceived risk, which was in turn associated with PrEP interest. Many more high-risk AGYW were interested in PrEP (68%) than expressed a high level of perceived HIV risk (26%).

CONCLUSIONS

These results highlight key relationships between epidemiologic HIV risk, risk perception and interest in PrEP. While risk perception did partially explain the relationship between epidemiologic risk and PrEP interest, there may be other important motivational mechanisms that are not captured in many HIV prevention cascades. The high number of participants with risk scores below the high-risk cutoff who both expressed high perceived risk and interest in PrEP suggests that demand for PrEP among AGYW may not be well aligned with epidemiologic risk.