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.

Structural influences on delivery and use of oral HIV PrEP among adolescent girls and young women seeking post abortion care in Kenya

Background

Adolescent girls and young women (AGYW) in East and southern Africa experience a disproportionate burden of HIV incidence. Integrating HIV pre-exposure prophylaxis (PrEP) within existing programs is a key component of addressing this disparity.

Methods

We evaluated an oral PrEP program integrated into post-abortion care (PAC) in Kenya from March 2021 to November 2022. Technical advisors trained staff at PAC clinics on PrEP delivery, abstracted program data from each clinic, and collected data on structural characteristics. Utilizing a modified Poisson regression, we estimated the effect of structural factors on the probability of PrEP offer and uptake.

Findings

We abstracted data on 6877 AGYW, aged 15-30 years, across 14 PAC clinics. PrEP offers were made to 57.4% of PAC clients and 14.1% initiated PrEP. Offers were associated with an increased probability at clinics that had consistent supply of PrEP (relative risk (RR):1.81, 95% CI: 1.1-2.95), inconsistent HIV testing commodities (RR: 1.89, 95% CI: 1.29-2.78), had all providers trained (RR: 1.65, 95% CI: 1.01, 2.68), and were public (RR: 1.89, 95% CI: 1.29-2.78). These same factors were associated with PrEP uptake: consistent supply of PrEP (RR: 2.71, 95% CI: 1.44-5.09), inconsistent HIV testing commodities (RR: 2.55, 95% CI: 1.39-4.67), all providers trained (RR: 2.61, 95% CI: 1.38-4.92), and were public (RR: 2.55, 95% CI: 1.39-4.67).

Interpretation

Greater success with integration of HIV prevention into reproductive health services will likely require investments in systems, such as human resources and PrEP and HIV testing commodities, to create stable availability and ensure consistent access.

Funding

PrEDIRA 2 was supported by funding from Children's Investment Fund Foundation (R-2001-04433). Ms. Zia was funded by the NIH Ruth L. Kirchstein pre-doctoral award (5F31HD105494-02) and Dr. Heffron was funded by National Institute of Mental Health (K24MH123371).

Management intensity controls soil N2O fluxes in an Afromontane ecosystem

Studies that quantify nitrous oxide (N₂O) fluxes from African tropical forests and adjacent managed land uses are scarce. The expansion of smallholder agriculture and commercial agriculture into the Mau forest, the largest montane forest in Kenya, has caused large-scale land use change over the last decades. We measured annual soil N₂O fluxes between August 2015 and July 2016 from natural forests and compared them to the N₂O fluxes from land either managed by smallholder farmers for grazing and tea production, or commercial tea and eucalyptus plantations (n=18). Air samples from 5 pooled static chambers were collected between 8:00am and 11:30am and used within each plot to calculate the gas flux rates. Annual soil N₂O fluxes ranged between 0.2 and 2.9kgNha^-1yr^-1 at smallholder sites and 0.6-1.7kgNha^-1yr^-1 at the commercial agriculture sites, with no difference between land uses (p=0.98 and p=0.18, respectively). There was marked variation within land uses and, in particular, within those managed by smallholder farmers where management was also highly variable. Plots receiving fertilizer applications and those with high densities of livestock showed the highest N₂O fluxes (1.6±0.3kgN₂O-Nha^-1yr^-1, n=7) followed by natural forests (1.1±0.1kgN₂O-Nha^-1yr^-1, n=6); although these were not significantly different (p=0.19). Significantly lower fluxes (0.5±0.1kgNha^-1yr^-1, p<0.01, n=5) were found on plots that received little or no inputs. Daily soil N₂O flux rates were not correlated with concurrent measurements of water filled pore space (WFPS), soil temperature or inorganic nitrogen (IN) concentrations. However, IN intensity, a measure of exposure of soil microbes (in both time and magnitude) to IN concentrations was strongly correlated with annual soil N₂O fluxes.