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Krogstad Mudzingwa E, de Vos L, Atujuna M, Fynn L, Mugore M, Mabandla S, Hosek S, Celum C, Bekker LG, Daniels J, Medina-Marino A. High study participation but diverging adherence levels: qualitatively unpacking PrEP use among adolescent girls and young women over two years in Eastern Cape, South Africa. J Behav Med 2024; 47:320-333. [PMID: 38081955 PMCID: PMC10944421 DOI: 10.1007/s10865-023-00462-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 11/10/2023] [Indexed: 03/17/2024]
Abstract
In Southern and Eastern Africa, initiation of daily oral pre-exposure prophylaxis (PrEP) for HIV prevention has been high among adolescent girls and young women (AGYW) offered PrEP. However, persistence and prevention-effective use of PrEP among this critical group continues to be a challenge. We conducted a qualitative sub-study of AGYW from the Community PrEP Study in Eastern Cape Province, South Africa who had high rates of pick up for monthly PrEP refills over two years, but differing levels of PrEP adherence based on tenofovir-diphosphate (TFV-DP) measurements in dried blood spots (DBS). Contrasting 22 AGYW with low versus high levels of TFV-DP in DBS, we qualitatively explored factors which influenced PrEP persistence vs. non-persistence, unique patterns of PrEP use (e.g., discarding or stockpiling), and participant recommendations for improving AGYW prevention-effective use of PrEP in the future. Results showed that PrEP misconceptions and mistrust among participants' social networks negatively influenced adherence. In comparison, supportive families and/or partners and personal trust that PrEP works positively influenced adherence. Those with low adherence described being motivated to come to the site for other study benefits (e.g., reimbursement money, snacks, sanitary pads) and discarding PrEP to avoid stigma associated with being seen with pills. Future PrEP implementation strategies should focus on involving families and partners in PrEP support for AGYW and minimizing PrEP stigma at a community level.Trial registration NCT03977181. Retrospectively registered on June 6, 2019.
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Affiliation(s)
- Emily Krogstad Mudzingwa
- The Desmond Tutu HIV Centre, University of Cape Town, Desmond Tutu Health Foundation, 3 Woodlands Road, Woodstock, Cape Town, 7915, South Africa
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, CT, USA
| | - Lindsey de Vos
- Research Unit, Foundation for Professional Development, Buffalo City Metro, Eastern Cape Province, South Africa
| | - Millicent Atujuna
- The Desmond Tutu HIV Centre, University of Cape Town, Desmond Tutu Health Foundation, 3 Woodlands Road, Woodstock, Cape Town, 7915, South Africa
| | - Lauren Fynn
- The Desmond Tutu HIV Centre, University of Cape Town, Desmond Tutu Health Foundation, 3 Woodlands Road, Woodstock, Cape Town, 7915, South Africa
| | - Matinatsa Mugore
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Selly Mabandla
- HIV/AIDS, STIs and TB Directorate, Buffalo City Health District, Eastern Cape Provincial Department of Health, Bisho, South Africa
| | - Sybil Hosek
- Department of Psychiatry, Stroger Hospital of Cook County, Chicago, IL, USA
- Division of Infectious Diseases, Stroger Hospital of Cook County, Chicago, IL, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Desmond Tutu Health Foundation, 3 Woodlands Road, Woodstock, Cape Town, 7915, South Africa
| | - Joseph Daniels
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Andrew Medina-Marino
- The Desmond Tutu HIV Centre, University of Cape Town, Desmond Tutu Health Foundation, 3 Woodlands Road, Woodstock, Cape Town, 7915, South Africa.
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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de Vos L, Mudzingwa EK, Fynn L, Atujuna M, Mugore M, Gandhi M, Celum C, Hosek S, Bekker L, Daniels J, Medina‐Marino A. 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. J Int AIDS Soc 2023; 26:e26175. [PMID: 37758649 PMCID: PMC10533377 DOI: 10.1002/jia2.26175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
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.
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Affiliation(s)
- Lindsey de Vos
- Research UnitFoundation for Professional DevelopmentEast LondonSouth Africa
| | - Emily Krogstad Mudzingwa
- The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
- Institute for Collaboration on Health, Intervention, and PolicyUniversity of ConnecticutStorrsConnecticutUSA
| | - Lauren Fynn
- The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
| | - Millicent Atujuna
- The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
| | - Matinatsa Mugore
- Mailman School of Public HealthColumbia UniversityNew YorkNew YorkUSA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of MedicineUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Connie Celum
- Departments of Global Health, Medicine, and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Sybil Hosek
- Division of Infectious DiseasesStroger Hospital of Cook CountyChicagoIllinoisUSA
- Division of Child and Adolescent PsychiatryDepartment of PsychiatryStroger Hospital of Cook CountyChicagoIllinoisUSA
| | - Linda‐Gail Bekker
- The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
| | - Joseph Daniels
- Edson College of Nursing and Health InnovationArizona State UniversityPhoenixArizonaUSA
| | - Andrew Medina‐Marino
- The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Mudzingwa EK, de Vos L, Atujuna M, Fynn L, Mugore M, Hosek S, Celum C, Bekker LG, Daniels J, Medina-Marino A. 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. AIDS Behav 2022; 26:3726-3739. [PMID: 35653046 DOI: 10.1007/s10461-022-03702-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Emily Krogstad Mudzingwa
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, CT, USA
| | - Lindsey de Vos
- Research Unit, Foundation for Professional Development, Eastern Cape Province, Buffalo City Metro, South Africa
| | - Millicent Atujuna
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lauren Fynn
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Matinatsa Mugore
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sybil Hosek
- Department of Psychiatry, Stroger Hospital of Cook County, Chicago, IL, USA
- Division of Infectious Diseases, Stroger Hospital of Cook County, Chicago, IL, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Joseph Daniels
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Andrew Medina-Marino
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.
- Research Unit, Foundation for Professional Development, Eastern Cape Province, Buffalo City Metro, South Africa.
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Desmond Tutu Health Foundation, 10 Rochester Rd, Vincent, East London, South Africa.
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