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Contraception, HIV Services, and PrEP in South African Hair Salons: A Qualitative Study of Owner, Stylist, and Client Perspectives

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Women experience challenges engaging with the healthcare system, but frequently utilize hair salons; these are promising venues for family planning and HIV prevention services. Our objective was to assess the acceptability of nurse-offered contraceptive and PrEP services at hair salons in Durban, South Africa. We interviewed salon owners (N = 10) and clients (N = 42) and conducted focus groups with hair stylists (N = 43 stylists; 6 focus groups across five hair salons) to explore barriers and facilitators to providing contraception and PrEP in salons. After developing a codebook, we performed content analysis to identify themes within each conceptual area; 10% of transcripts were coded by two coders to ensure reliability. Content was analyzed according to the following categories: (1) facilitators of and (2) barriers to utilizing these services, and (3) factors to consider for program implementation. Participants identified convenience and female-oriented, supportive atmosphere as facilitators to offering HIV and contraceptive services in salons. Owners and stylists noted that establishing legitimacy was important for program success, including providing promotional pamphlets and employing nurses. Clients cited privacy concerns surrounding HIV testing in a public space as a significant barrier to using these services. Overall, participants were enthusiastic about the program. Convenience and a conducive environment were noted as facilitators to receiving health services in the hair salon; attention will have to be directed to establishing privacy and program legitimacy. Hair salons represent an innovative venue for reaching young women at high-risk for unintended pregnancy and HIV infection.
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Journal of Community Health (2019) 44:1150–1159
https://doi.org/10.1007/s10900-019-00698-7
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ORIGINAL PAPER
Contraception, HIV Services, andPrEP inSouth African Hair Salons:
AQualitative Study ofOwner, Stylist, andClient Perspectives
IngridV.Bassett1,2,3,4· SabinaGovere5· LuciaMillham2· SimoneC.Frank2· NosiphoDladla5· HilaryThulare5·
ChristinaPsaros3,6
Published online: 6 July 2019
© The Author(s) 2019
Abstract
Women experience challenges engaging with the healthcare system, but frequently utilize hair salons; these are promising
venues for family planning and HIV prevention services. Our objective was to assess the acceptability of nurse-offered contra-
ceptive and PrEP services at hair salons in Durban, South Africa. We interviewed salon owners (N = 10) and clients (N = 42)
and conducted focus groups with hair stylists (N = 43 stylists; 6 focus groups across five hair salons) to explore barriers and
facilitators to providing contraception and PrEP in salons. After developing a codebook, we performed content analysis to
identify themes within each conceptual area; 10% of transcripts were coded by two coders to ensure reliability. Content was
analyzed according to the following categories: (1) facilitators of and (2) barriers to utilizing these services, and (3) factors
to consider for program implementation. Participants identified convenience and female-oriented, supportive atmosphere
as facilitators to offering HIV and contraceptive services in salons. Owners and stylists noted that establishing legitimacy
was important for program success, including providing promotional pamphlets and employing nurses. Clients cited privacy
concerns surrounding HIV testing in a public space as a significant barrier to using these services. Overall, participants were
enthusiastic about the program. Convenience and a conducive environment were noted as facilitators to receiving health
services in the hair salon; attention will have to be directed to establishing privacy and program legitimacy. Hair salons
represent an innovative venue for reaching young women at high-risk for unintended pregnancy and HIV infection.
Keywords South Africa· Contraception· HIV prevention· Young women· Hair salon
Introduction
South Africa has the largest population of individuals liv-
ing with HIV in the world, with 7.2 million people infected
as of 2017, 58% of whom are women [1]. Young women in
South Africa are disproportionately affected both by the HIV
epidemic and by a high burden of unintended pregnancies.
The current annual HIV incidence rate for African women
aged 20–34 is 4.5% in South Africa, meaning that four out of
every 10 women who are 20years-old today will have HIV
by the time they are 34 [2]. Furthermore, unintended preg-
nancies account for one-third of all births in sub-Saharan
Africa, nearly half of which occur among women age 15–24.
Risk for HIV and for unintended pregnancy is driven
by underlying social and structural barriers including pov-
erty, gender inequality, and a lack of autonomous and con-
sistent healthcare access [3]. Compared to older women,
young women are more likely to both discontinue con-
traception and use HIV pre-exposure prophylaxis (PrEP)
* Ingrid V. Bassett
ibassett@partners.org
1 Division ofInfectious Diseases, Massachusetts General
Hospital, 100 Cambridge St, 16th Floor, Boston, MA02114,
USA
2 Medical Practice Evaluation Center, Massachusetts General
Hospital, Boston, MA, USA
3 Harvard Medical School, Boston, MA, USA
4 Harvard University Center forAIDS Research, Harvard
University, Boston, MA, USA
5 AIDS Healthcare Foundation, Durban, SouthAfrica
6 Behavioral Medicine Program, Department ofPsychiatry,
Massachusetts General Hospital, Boston, MA, USA
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1151Journal of Community Health (2019) 44:1150–1159
1 3
inconsistently [46]. Moreover, the number of young peo-
ple aged 15–24 in South Africa is expected to triple by
2030 [7]. Thus, in order to stem the tide of HIV among
young African women, increased focus on primary HIV
prevention and family planning efforts is needed.
The “She Conquers” campaign in South Africa focuses
on reducing new HIV infections and unwanted pregnancies
among young women [8]. The most recent national family
planning policy calls for use of non-clinical settings for
contraception provision and for incorporating HIV testing
into contraceptive services, but implementation has been
limited [9]. Expanding access to contraception and PrEP
will require a focus on service delivery systems and user
preferences to ensure maximum impact [10].
Hair salons may represent “safe” community spaces
where individuals can receive social support. They have
been used in the US to promote intimate partner violence
screening, but have not been studied for HIV service pro-
vision [11]. Given that South African women congregate
regularly in community hair salons, these salons could be
promising venues for family planning and HIV prevention
services. Our objective was to use qualitative methods to
assess the acceptability of nurse-provided contraceptive
and PrEP services in hair salons in Durban, South Africa.
Methods
Study Setting andParticipants
We conducted individual qualitative interviews with cli-
ents (N = 42) and owners (N = 10), and focus groups with
stylists (N = 43) in hair salons in and around Umlazi, an
urban township of nearly one million people outside Dur-
ban [1214]. Umlazi is the second most densely-popu-
lated township in South Africa with a single hospital in
its catchment area [14]. 80% of owners, 93% of stylists,
and 100% of clients were female and the average age of
each group was 40, 30, and 27years. Inclusion criteria
included: Age ≥ 18years, English or isiZulu speaking, and
able and willing to provide informed consent [15]. Salon
owners, stylists, and clients were recruited from a conveni-
ent sample of hair salons in Umlazi Township and neigh-
boring communities and were approached by a bilingual
(English/isiZulu), female research assistant to assess their
interest in participating in an in-depth interview or focus
group. Study procedures were approved by the University
of KwaZulu-Natal Biomedical Research Ethics Committee
(BE388/16) and the Partners (Massachusetts General Hos-
pital/Brigham and Women’s Hospital) Institutional Review
Board (Protocol 2016-P-001268, Boston, MA).
Measures
We used semi-structured interview and focus group
guides, developed using guidelines by Huberman and
Miles [16] for qualitative data collection. Our questions
were informed by domains derived from the Anderson
model of health service utilization [17], a review of recent
literature on PrEP and contraceptive services, and specific
domains believed to be of importance to the study team.
Interviews with clients focused on questions about contra-
ceptive use and preferences, knowledge about PrEP, and
opinions on offering contraceptive and PrEP services in
hair salons. Interviews with hair salon owners focused on
topics including roles of hair salons in their communities,
programmatic questions about offering these services at
hair salons (e.g. feasibility and resources needed, effects
on business, and overall comfort level). We probed styl-
ists on a range of topics, focusing on their perceived role
of hair stylist in the Umlazi community, their comfort
with intervention participation, and useful resources for
supporting a health intervention in the salon (e.g. scripts
or promotional materials). Questions were open-ended
to avoid bias and encourage generation of novel content.
Sample questions and probes for each interview and focus
group guide are provided in Table1.
We paid each participant ZAR 100 for their time. Inter-
views for client and owners lasted 45–60min; focus group
discussions lasted 1–2h.
Analyses
Interviews and focus groups were audio-recorded, tran-
scribed, and translated from isiZulu to English by an inde-
pendent transcriptionist. Content analyses were conducted
to uncover themes related to three category domains: (1)
facilitators of and (2) barriers to providing contraception
and PrEP in hair salons and (3) program implementation
specifics to assess the acceptability of the service and to
inform designing future interventions. The analysis was
done using an iterative multi-step process. We identified
categories and subcategories, and developed a codebook
based on those categories. The codebook was organized
according to our study question and was aimed at identi-
fying what participants viewed as barriers and facilitators
to offering contraceptive services and/or PrEP services in
hair salons in Durban, South Africa. Nvivo 12 (2018) was
used to code and organize data.
Two coders (SCF and LM) analyzed the first 10% of the
transcripts from each group (clients, stylists, and owners)
to ensure independent, consistent codebook use. The cod-
ers compared results from each phase of their analyses
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1152 Journal of Community Health (2019) 44:1150–1159
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Table 1 Sample study content areas and questions/probes
Content area Sample questions/probes
Clients
Warm-up questions • What do you think are the major health care services that young women in Durban need?
• Of the services that you mentioned, are there any that you think you would be interested in receiving at
the hair salon?
Contraceptive care/family planning • Could you describe your current contraceptive use (including you current contraceptive method, dura-
tion of use, how you chose your current method, your perceived need for contraception, and your interest
in contraception)?
• What contraceptives are most attractive to you (oral contraceptive pills, injectables, hormonal subdermal
implants, intrauterine devices)?
• Do you see hair salons as acceptable venues for contraception access and support? Why or why not?
• What are your preferences for who to hear reliable information about contraception from at the salon
(i.e. hair stylist, peer mentor, nurse)? Why?
• Do you think having adherence support for your contraception would be helpful?
HIV testing and PrEP • What have you heard about PrEP?
• How would you feel about HIV counseling and PrEP being offered to clients at the hair salon?
• How do you think this would affect salon activities?
• What strategies would help you and other clients feel more comfortable and willing to undergo testing at
the salon (i.e. park mobile tester right outside the salon, set up private testing area in a back room, etc.)?
Stylists
Warm-up questions • How do you think people perceive the role of the hair stylist in the Durban community?
• How do you perceive your role as a hair stylist?
• How would you describe the relationships you have with your clients?
Programmatic questions • Do you think discussion health topics and offering services to clients at the salon is feasible?
• How do you think this would affect logistics and flow of clients through the salon?
• What kind of support might make you feel more comfortable? For example, having a health care pro-
vider on site to answer questions
Contraceptive care/family planning • What kinds of things can make it easy for women to get access to contraception? What kinds of things
can make it hard?
• What resources might be useful to you as stylists for supporting offering contraception in the salon (i.e.
scripts, promotional materials, posters, etc.)?
• How could these be implemented?
• What do you think about offering some sort of incentive or compensation for offering and accepting
contraception at the salon?
• Do you think having adherence support for contraception would be helpful?
HIV testing and PrEP • What have you heard about PrEP?
• How would you feel about having HIV testing services offered at the hair salon?
• What suggestions would you have about the set-up for offering HIV testing services at the salon?
Owners
Rapport building questions • What do you think are the major health care services that young women in Durban need?
• How would you describe the role of hair salons in the Umlazi community?
Programmatic questions • What do you see as potential challenges to discussing health topics with or offering health services for
hair salon clients?
• Would you feel comfortable having stylists talking with your clients about a health topic?
• What resources might be useful for supporting a health intervention in the salon (i.e. scripts, promo-
tional materials, posters, etc.)? Do you have any ideas about how these could be implemented?
• What resources do you think you as a salon owner would need if the salon implemented a health inter-
vention?
• What are your ideas for these potential incentives or compensation for the salon owners? Stylists?
Clients?
Contraceptive care/family planning • How do you feel about the possibility of offering contraceptive services in the hair salon setting?
• Tell me about how you think clients would respond to the possibility of accessing contraception at the
hair salon?
HIV testing and PrEP • What have you heard about PrEP?
• How do you feel about the possibility of offering HIV prevention services such as PrEP in the salon
setting?
• Would you feel comfortable with stylists giving clients information about PrEP?
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1153Journal of Community Health (2019) 44:1150–1159
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and discussed discrepancies until a resolution was reached.
Categories and subcategories outlined in the codebook
were continually reexamined to check for applicability and
consistency in codebook interpretation. The authors also
discussed findings during analysis to ensure that interpre-
tation of the data was not being influenced by perceived
theories. An audit trail of coding templates and discus-
sions about the data and computerized coding was kept.
Oversight of the qualitative process was provided by CP
and the topic-related content was reviewed by IVB and CP.
Results
Demographic data for clients, stylists, and owners are pre-
sented in Table2. We organized data from 42 client inter-
views, 6 focus groups with 43 stylists, and 10 owner inter-
views, into our three category domains. Overall, clients,
stylists and owners, as groups, most often reported similar
views on common barriers and facilitators to providing con-
traceptive and PrEP services at hair salons.
Facilitators
Perceived Value
Participants identified the convenience of being able to
receive contraception and PrEP services at the same loca-
tion and at the same time as their hair appointment as a
major advantage to accessing these services in salons. Cli-
ents often noted that they prioritize their salon appointments
more than they prioritize clinic visits. One 23year-old (y/o)
client explained that her “biggest priority [was her] hair;”
another (35 y/o) explained that, “most women try by all
means to meet their salon appointments so it would help
if we can also receive our contraceptives [at the salon].” A
stylist agreed: “most people would rather do their hair than
go to the clinics.” One 28 y/o client explained that her salon
appointment had so much importance because attending a
salon appointment provided visible return on investment.
She explains that women understand their beauty, which can
be linked with self-esteem and/or self-worth, through the
state of their hair: “As working women we hardly get time
to go to the clinic but with the salon we don’t take chances.
We make it a must that we go to the salon… as women we
value our beauty through our hair styles.” A 29 y/o client
echoed this sentiment, explaining that while women “can’t
go to the clinic and wait for 3h for their turn … At the salon
people know they want to look beautiful, so they end up not
minding about the time.” An appointment at a hair salon
has tangible value that women can see, an appointment at a
clinic feels like long hours for little perceived benefit.
Table 2 Demographic characteristics
Variable N %
A. Clients (N = 42)
Age, years
M = 27.1 – –
SD = 6.3 – –
Cultural group
Black (South African) 41 98
Black (Other African) 1 2
Gender
Female 42 100
Is this salon mostly visited?
Yes 31 74
No 9 21
Did not answer 2 5
Time spent in salon (hour)
 < 1 6 14
1 20 48
2 11 26
3 5 12
B. Stylists (N = 43)
Age, years
M = 29.6 – –
SD = 5.1 – –
Cultural group
Black (South African) 33 77
Black (Other African) 9 21
Did not answer 1 2
Gender
Female 40 93
Male 3 7
Length of time working at salon (months)
0–12 13 30
13–24 6 14
25–48 11 26
 > 48 12 28
Did not answer 1 2
Works at multiple salons
Yes 36 84
No 6 14
Did not answer 1 2
Number of working days per week
5days/week 1 2
6days/week 20 47
7days/week 21 49
Did not answer 1 2
Number of unique clients per week
0–10 clients/week 6 14
11–25 clients/week 17 40
26–50 clients/week 15 35
> 50 clients/week 3 7
Did not answer 2 4
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1154 Journal of Community Health (2019) 44:1150–1159
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Convenience
Additionally, salons are more geographically convenient
than clinics and offer more flexible hours. Salons are often
located in commercial areas where there are fewer clinics,
but which are more convenient to day-to-day activities.
One stylist noted that this convenience could favor resi-
dents who might not normally be salon customers: “Even
if someone is not coming to the salon but works close
to the salon, they can come and get their pills from here
because they do not have time to go to the clinic.” Addi-
tionally, salons are often open on weekends and after busi-
ness hours to serve clients who work. One stylist noted that
“most people are off on weekends and clinics are closed on
weekends. So if health services are offered at the salons,
the clients would benefit a lot.”
Stylists and owners agreed with clients that offering
contraceptive and PrEP services at hair salons would be
convenient, adding that they often do not have enough
time to go to the clinics themselves because of their work.
One 31 y/o female owner explained that “the problem why
[sic] we hardly go to the clinic is because … it clashes
with salon activities;” a stylist felt similarly: “even as an
employee of the salon I do not get the time to go to the
clinic so I can [get services] from the salon.”
Salon Atmosphere
Clients, stylists, and owners also identified the uniquely
supportive and peaceful atmosphere found at salons as a
facilitator to using these services. Women feel that there is
a mutual understanding and support at a salon that may not
be present elsewhere. One 25 y/o client explained that, “at
the salon even when you are waiting you are with people
that you know … [this tends] to make you not worry about
the time that you spending [sic] at the salon.” In addition,
offering PrEP and contraceptives in this environment is
not incongruous with topics already discussed at salons.
One 20 y/o client explained that “the topics at the salon
amongst women always related to [HIV and contracep-
tion],” and a 22 y/o client noted that at the salon, “we
all have similar interests when it comes to female health
issues.”
Many clients, stylists, and owners focused on how the
atmosphere at the salon existed because it was a female-
dominated space “where women come together,” “feel safe
with other women,” and where “the privacy in the salon is
between us women. You hardly ever see guys in the salon.
In addition, clients noted a mutual respect for privacy
between women that might be lacking in a more heteroge-
neous environment:
I think I would be comfortable to receive [these ser-
vices] because there are few men at the salon… if we
go to clinics and you see someone who knows you they
might think that you are there for HIV. (22 y/o)
In addition, women talked about the mutual understand-
ing that they, as women, have for the health problems that
they face that again, might not be present outside of this
female-dominated space: “I can get my contraceptives at the
salon because we all women … and we all understand that
this is a normal thing (28 y/o).
Table 2 (continued)
Variable N %
C. Owners (N = 10)
Age, y
M = 40.3 – –
SD = 7.6 – –
Cultural group
Black (South African) 6 60
Black (Other African) 4 40
Gender
Female 8 80
Male 2 20
Length of time owning salon (years)
0–5years 4 40
6–10years 3 30
 > 10years 3 30
Length of stylist employment
< 1year 2 20
1–2years 3 30
3–5years 3 30
> 5years 1 10
Did not answer 1 10
Number of new clients per week
20–75 6 60
76–150 2 20
> 150 1 10
Did not answer 1 10
Number of salon chairs
1–5 2 20
6–10 7 70
> 10 1 10
Number of stylists
1–5 8 80
6–10 – –
> 10 1 10
Did not answer 1 10
Owner owns multiple salons
No 8 80
Yes 2 20
M mean, SD standard deviation
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1155Journal of Community Health (2019) 44:1150–1159
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Clients’ focused on salons as good places for women’s
health services because of the dearth of men and because
as women they understand the importance of these services.
The salon atmosphere was enhanced by salon personnel.
Clients and stylists both noted a supportive client-stylist
relationship that can foster meaningful conversations. One
28 y/o client explained that she would prefer to get informa-
tion about contraceptive and PrEP services from her stylist
because “we have developed a relationship with the styl-
ist.” The stylists feel similarly, describing clients as friends
or family, suggesting that these relationships are not only
professional, but personal—built on trust and respect: “My
clients are my friends… and my sisters,” “we take them as
family,” and “we become counsellors to [clients]…when
you are with a client for so many hours, even the problems
or situations they have in their lives you can talk to them
and advise them.” Overall, the stylists see clients as friends
and family; clients divulge personal information and stylists
often try to offer advice and assistance on matters outside
of hair care.
This supportive and safe atmosphere was contrasted with
clinic experiences. A 35 y/o client would rather talk to her
stylist because “I am comfortable around my stylist. The
nurses are always intimidating and rude.” A stylist also saw
this dichotomy, “we would have to be different [than the
nurses] … we do everything that the nurses do not do. We
have to be kind to the clients and patients.
One stylist also noted there may be an added challenge to
maintaining a comfortable and supportive atmosphere while
instituting these services at the salon. The stylist expressed
concern that “there are those people who will no longer
want to come to [the salon]… some will [talk] negatively
about us to other people saying that the salon no longer does
hair but now they teaching about HIV.” Given that partici-
pants indicated the clinics’ unfavorable atmosphere contrib-
uted to their reluctance to go, maintaining an atmosphere
at the salon that is different from the clinic is particularly
important.
Barriers
Establishing Legitimacy
Clients, stylists, and owners noted that establishing legiti-
macy is paramount to program success. One 27 y/o client
indicated that people are prone to question the legitimacy
of the program, “people would think, how do they trust the
needles used for injections?.” Participants used words like
“joke” or “scam” to describe how the program could be per-
ceived if it was not done in a way that proved to people that
it was “genuine,” “serious,” “legit,” or “well thought of.
Solutions to overcome this barrier included education
materials, in the form of posters, pamphlets, and trainings
for the stylists. A stylist suggested that posters and pam-
phlets will “show clients that this is a genuine initiative.
A 42 y/o male owner argued that these materials were nec-
essary for program legitimacy, “If we run the programme
without poster or pamphlets, people would think this is a
joke or a scam.” A 34 y/o client indicated that “offering a
voucher would make people think what you are offering is
serious.” Overall, participants suggested that having tan-
gible aspects to the program to “show” people what the
program entails would establish legitimacy.
It was also important that clients understood partici-
pation was voluntary. One stylist viewed this as a major
barrier: “the biggest challenge would be in convincing
people…that they are not forced to use this programme.”.
Moreover, there may be some hesitation about a program
that is offering healthcare services that include prescrib-
ing medication outside of a clinic: “people would have to
understand that no one is forced to get tested or use the
medication” (24 y/o).
A stylist noted that having resources to educate clients
about the program would help:
I think there should be trainings and counselling that
educates people on the benefits of this programme,
this way… they will understand that this programme
is aimed at helping them.
Stylists felt they needed training to perform their role in
a way that would engender trust in the clients. One 22 y/o
client noted that people may be remiss to trust stylists, “a
stylist is just a stylist and has no knowledge of health issues.”
Clients can often view them as uneducated: “some of the
clients have very low regard for us… since we do hair, we
are uneducated,” and another, “some people think we just
remove dandruff.” Thus, ensuring that stylists are knowl-
edgeable and have proper training is important; one stylist
explained, “I think certificates will [assure] clients… that as
stylists we know what we are talking about.”
Lastly, while stylists were interested in offering and
explaining these services to their clients, participants
across groups felt that having a nurse deliver the services
would be the best way to promote trust and to maintain
some separation between salon and healthcare-oriented
activities. One 25 y/o client suggested that, “maybe [the
stylists] can just prep us up for it… but when we have to
do the actual test it can be the peer advisor or nurse so that
your test results can be private and confidential.” Clients
explained that there is an assumption that nurses will be
“knowledgeable in health-related matters” and have more
“experience with health issues,” and that this would garner
more trust. One 29 y/o client explained: “People would see
it’s a nurse and assume the nurse would do the right thing.”
Stylists also mentioned uniforms as a way of establishing
legitimacy both for themselves (e.g. caps and T-shirts),
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1156 Journal of Community Health (2019) 44:1150–1159
1 3
and also for the nurses: “if there is someone in uniform…
even clients would take the programme seriously.”
Privacy Concerns
Clients were most concerned about privacy as a barrier
to implementing contraceptive and PrEP services in hair
salons, specifically regarding HIV testing. Stigma was at
the forefront of participants concerns. Clients explained
that they would be worried about someone they know
learning private information about their sexual activity
because they saw them at the salon:
Some people would just not want to be seen using
this service of contraception because they think peo-
ple would know that they are having sex. (29 y/o)
Imagine you are here to get your prevention pills
from the salon and you bump into someone that you
know… everyone would know that you [sic] getting
contraception from the salon. (24 y/o)
Multiple clients also worried that it might be difficult to
keep the results of an HIV test private in a salon setting:
If someone gets tested and they find that they are
HIV positive and then now come out of the testing
room crying… people notice that. (24y/o)
In addition, some clients worried that stylists might
gossip. One 25 y/o client explained, “hair stylists are not
known for their ability to keep secrets. Stylists are always
talking.” Overall, participants worried about losing con-
trol of how information about them is shared by using
services at a salon where others might know and observe
them. These participants were outliers compared to the
larger portion of participants who felt that offering ser-
vices amongst women and supportive stylists would be a
positive intervention.
Participants referenced two main solutions to address the
issue of privacy in the salon: a private room within the salon
or an outside space outside, adjacent to the salon (like a
mobile van). Clients who advocated for a private room inside
the salon thought it would help ensure utilization:
It would be better if it is inside because people would
know while they wait they can go to the nurse and get
tested… outside it would take too much time. (29 y/o)
As this participant suggests, offering these services even
just outside the salon could be less convenient because it
adds an additional step in a different location, which may
be problematic because participants saw convenience as a
major facilitator of program success. Private rooms do pose
a logistical issue; some salons do not have existing spaces
that could be used as a private room for this purpose.
Clients who advocated for a mobile van liked the option
of going to the mobile van without anyone from the salon
observing them:
I would prefer it if there was a mobile van because if I
get tested and find out that I am HIV positive you can
just put me in the van and give me proper counsel-
ling… if they had a private room here in the salon, I
would just come out of that room crying so everyone
would know what happened. (22 y/o)
Owners also noted that the mobile van would be good
solution to address the lack of extra space in many salons.
At the same time, a mobile van would be more visible to
the public:
If I tell a client to go to the tent and get tested, when
the client comes back from the tent I will be able to
see if everything is not well…everyone outside will
see that this person received bad news. However, if a
client tests inside the salon, not many people will see
that this person has received bad news. (stylist)
Overall, participants are interested in incorporating this
service as discreetly as possible and ensuring privacy for
each participant.
Program Implementation
Incentives
Participants felt that incentives would be beneficial to pro-
gram enrollment, if not necessary, to garner interest among
clients. One client noted that incentives have become an
expected part of research:
People, patients, or clients expect to get something
[from research] because most of the time research has
something to offer. (24 y/o)
Others indicated that incentives would help overcome the
barrier of legitimacy, “[incentives] would make people think
what you are offering is serious” (34 y/o client) and would
be an effective way to motivate participants, “free things
give better motivations” (24 y/o client).
On the other hand, stylists in particular did not feel that
incentives were necessary—clients should want to partici-
pate in this program because it is aimed at improving their
health and wellbeing. As one stylist explained, “At the end
of the day, this is your life, you need to do what is best for
yourself, not because there is [sic] incentives offered.” A
22 y/o client echoed that she did not think that incentives
would help to accomplish the programs goals, “you cannot
buy people to take better care of themselves.
Participants offered a variety of ideas for incentives,
beyond money. Many suggested vouchers for airtime or
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1157Journal of Community Health (2019) 44:1150–1159
1 3
food; others offered ideas more tailored to the program,
like sanitary products or hair styling vouchers. Some cli-
ents thought that offering sanitary products could both offer
something free while simultaneously align with the pro-
gram’s intentions to promote women’s health—“instead of
bring [sic] us stuff just to make us happy, you can bring us
feminine stuff that would also educate us” (25 y/o). One styl-
ist noted that: “Every girl has a desire to go to the salon but
some cannot afford” (24 y/o). Vouchers for salon services of
products would help women overcome financial barriers to
going to the salon and could simultaneously promote easier
access to the health services offered. Owners mentioned that
they would want reimbursement for use of the salon space
and stylists indicated that they would want extra pay and/
or T-shirts and caps to identify themselves as part of the
program.
Adherence Support
Overall, participants liked the idea of receiving personal
SMS messages and having WhatsApp groups as adherence
supports. Clients preferred SMS messages for direct adher-
ence motivation because they are more private. One client
felt that an SMS could also serve as an automated daily
reminder for women on PrEP to take their medication. A few
participants also noted that SMS would be more accessible
than WhatsApp given data constraints; “WhatsApp will be
a problem because I sometimes run out of data. I can receive
an SMS even if I do not have data” (35 y/o client).
WhatsApp groups were viewed as a tool that could foster
community and provide support. This support could come
in the form of “sharing [their] programmes and life experi-
ences” (18 y/o client) or as a place for women to help one
another problem solve, “if a participant is having problems
with the injection or pills, we can use the WhatsApp group
to share ideas on what can be done” (stylist). Overall, partic-
ipants expressed interest in both personalized SMS remind-
ers and WhatsApp support groups as options for adherence
support.
Discussion
This study explored barriers to and facilitators of offering
contraceptive and PrEP services in hair salons in Durban,
South Africa. Overall, clients, stylists, and owners were
interested in bringing contraceptive and PrEP services to
hair salons and believed that it would be possible to suc-
cessfully implement this intervention. Participants indicated
that they saw potential for hair salons to be innovative ven-
ues for delivering important healthcare services to women,
citing their convenience and supportive, female-dominated
environment. Participants did foresee challenges with the
program, especially establishing legitimacy to garner trust
and ensuring client privacy.
Community interventions can be attractive alternatives to
clinic-based care, especially in South Africa where clinics
are often overcrowded and inconveniently located. Our pro-
posed intervention aims to use hair salons as “safe” spaces
within communities where women can access contracep-
tive and PrEP services. In the US, hair salons have been
successfully used as venues for a variety of health-related
interventions. One 2004 study found that clients often dis-
cuss sensitive health-related topics with stylists and found
that hair salons offered a feasible venue to discuss healthcare
matters [11]. A recent study showed the women would dis-
close experiences of intimate partners violence to stylists in
hair salons [18]. Hair salon-based health interventions have
yet to be implemented or studied in Sub-Saharan Africa,
although our findings suggest that there may be a similar cul-
ture around discussing personal topics. A meta-analysis of
health promotion and education interventions in hair salons
and barbershops in the US found that 73% of them showed
significant results [19]. In these interventions, stylists and
barbers were often trained to deliver healthcare education to
clients, an approach that showed success across health topics
(including cancer, hypertension, diabetes, and general well-
ness). Most of the outcomes, however, were about increased
knowledge on health topics, and did not include interven-
tions in which clients participated in an ongoing program or
service. However, one barbershop-based intervention aimed
at reducing systolic blood pressure in non-Hispanic black
men in the United States found that a barber-promoted and
pharmacist-led drug therapy led to significantly larger blood
pressure reduction than when barbers encouraged patients
to make lifestyle modifications and a doctor’s appointment
[20]. This suggests that service-oriented interventions in
haircare settings can be successful. While service-oriented
hair salon interventions have yet to be studied, our research
suggests that they are feasible.
A hair salon-based intervention may ameliorate common
barriers to PrEP uptake and adherence among young women
in South Africa. Women often worry about the stigma asso-
ciated with taking PrEP. They worry that they might be
falsely identified as HIV positive [21] and/or that they will
be perceived by others as sexually active [22]. In addition, a
dearth of resources and access to reproductive services for
women and a lack of social support have added additional
barriers to uptake and adherence [22]. Women also cite con-
cerns about PrEP’s side effects as a reason for non-adherence
[21]. Through our planned intervention, we seek to address
many of these barriers by increasing accessibility to services
at a community-level and by offering services in a “safe,”
comfortable environment where women receive social sup-
port and education on the services provided by people with
whom they already have close relationships. Additionally,
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1158 Journal of Community Health (2019) 44:1150–1159
1 3
the female-dominated atmosphere, where participants felt
there was acceptance and understanding of the importance
of these services, suggests that offering contraception and
PrEP in hair salons could be a helpful way to reduce stigma
and focus on prevention as part of wellness. Participants
worried about the potential side effects of PrEP and indi-
cated that having pamphlets and posters to properly educate
clients would help establish program legitimacy and assuage
these concerns.
We present a novel and viable approach to address some
of the most pressing public health concerns facing women
in South Africa through assessing the feasibility of offering
PrEP and contraceptive services in hair salons. These quali-
tative data can directly inform implementation of this inter-
vention. Such an intervention needs to emphasize privacy,
convenience and support for participants and be perceived
as legitimate and trustworthy. Privacy can be prioritized
through creating a separate space for health-related services,
while remaining associated with the salon and maintaining
the salon environment. Clients were open to both private
rooms and mobile vans as potential spaces for services;
owners were concerned about space issues associated with
private rooms while clients did generally prefer the idea of
a mobile van. Posters displayed in salons and pamphlets dis-
tributed to interested clients can establish legitimacy and
incorporating positive messaging and destigmatizing cam-
paigns into these materials could encourage and maintain
an atmosphere distinct from those at clinics. While clients
often cited nurses as mean and rude, they were important
to involve for legitimacy. It may help to provide additional
training to nurses to mitigate this dichotomy. We can also
provide training for stylists and maintain a nurse on site to
deliver injections, perform HIV testing, and dispense PrEP.
Participants felt mixed about offering incentives to program
participants, which will need to be considered as something
that may impact implementation.
This study should be considered in the context of its
strengths and limitations. We sampled participants with
a variety of perspectives and roles (clients, stylists, and
owners) from multiple different hair salons in Umlazi. We
asked open-ended questions in a semi-structured format that
allowed participants to explore subjects more in depth if they
wished, but also created a baseline level of comparability
between participant responses. We did not ask participants
to report their HIV status, which may have influenced their
views on HIV testing and PrEP services. Questions about
willingness and interest in PrEP services may have been
influenced by the participants current HIV status. Pre-exist-
ing knowledge of PrEP was limited. Therefore, study staff
had to explain what PrEP was, and the centrality of HIV
testing to PrEP provision. While women under 18years are
at also high risk for unintended pregnancy and HIV and may
have their own unique set of barriers and facilitators to hair
salon-based services, they were not included in our sample.
Despite these limitations, this study conveys an overall will-
ingness of clients to participate in receiving contraceptive
and PrEP services in hair salons and eagerness of owners
and stylists to offer such services to women in Umlazi. In
this qualitative study of hair salon owners, stylists, and cli-
ents in Umlazi Township, South Africa, convenience and a
conducive environment were noted as facilitators to receiv-
ing health services in hair salons. Establishing privacy for
HIV testing and program legitimacy through advertising will
be paramount. Hair salons represent an innovative venue for
reaching young women at high-risk for unintended preg-
nancy and HIV infection by capitalizing on the focus on
convenience and comfort that salons provide.
Acknowledgements We would like to acknowledge our study par-
ticipants, particularly the salon owners who opened their doors and
hearts to this idea. This study was funded by the US National Institute
of Allergy and Infectious Disease (K24AI141036), the Graham Fam-
ily, and the Weissman Family MGH Research Scholar Award. The
contents of this publication are solely the responsibility of the authors
and do not necessarily represent the official views of the US National
Institutes of Health.
Funding This study was funded by the US National Institute of Allergy
and Infectious Disease (K24AI141036) (IVB), the Graham Family,
and the Weissman Family MGH Research Scholar Award (IVB). The
contents of this publication are solely the responsibility of the authors
and do not necessarily represent the official views of the US National
Institutes of Health.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical Approval All procedures performed this study involving human
participants were in accordance with the ethical standards of the insti-
tutional and national research committee (Partners Human Research
Committee, Protocol #2016P001268 and Biomedical Research Ethics
Committee (University of Kwazulu-Natal), Reference No. BE388/16)
and with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creativecom-
mons.org/licenses/by/4.0/), which permits unrestricted use, distribu-
tion, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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... Women in sub-Saharan Africa are disproportionately impacted, with an annual rate of 91 unintended pregnancies per 1000 women aged 15-49 years, 30% higher than the global rate. Of these, nearly half occur among adolescent girls and young women (AGYW) ages 15-24 [2]. ...
... Keywords: South Africa, Contraception, Adolescent girls and young women, Hair salon, Community delivery for delivery of contraceptives and HIV pre-exposure prophylaxis by salon owners, stylists, and clients due to their convenience and accessibility [2,25]. We have previously assessed the feasibility and acceptability of providing health services in salons using cross-sectional descriptive data and qualitative analyses in the service of intervention design [2,25]. ...
... Keywords: South Africa, Contraception, Adolescent girls and young women, Hair salon, Community delivery for delivery of contraceptives and HIV pre-exposure prophylaxis by salon owners, stylists, and clients due to their convenience and accessibility [2,25]. We have previously assessed the feasibility and acceptability of providing health services in salons using cross-sectional descriptive data and qualitative analyses in the service of intervention design [2,25]. While convenience and accessibility of salons may address structural barriers to contraceptive access, the social environment of salons may additionally impact contraceptive decision-making. ...
Article
Full-text available
Background: South Africa faces a high burden of unmet contraceptive need, particularly among adolescent girls and young women. Providing contraception in community-based venues may overcome barriers to contraceptive access. Our objective was to explore the potential impact of the social environment and stylist-client interactions on perceived accessibility of contraceptives within hair salons. Methods: We conducted 42 semi-structured, in-depth interviews with salon clients (100% identified as female, 100% identified as Black, median age 27.1 years) and 6 focus groups with 43 stylists (95% identified as female, 98% identified as Black, median age 29.6 years) in and around Umlazi Township, Durban, KwaZulu-Natal to explore perspectives on offering contraceptive services in hair salons. We used an inductive and deductive approach to generate the codebook, identified themes in the data, and then organized findings according to Rogers' Individual Adoption Model as applied to community-based health prevention programs. Twenty-five percent of transcripts were coded by two independent coders to ensure reliability. Results: We identified elements of the salon environment and stylist-client relationships as facilitators of and barriers to acceptability of salon-based contraceptive care. Factors that may facilitate perceived contraceptive accessibility in salons include: the anonymous, young, female-centered nature of salons; high trust and kinship within stylist-client interactions; and mutual investment of time. Stylists may further help clients build comprehension about contraceptives through training. Stylists and clients believe salon-based contraceptive delivery may be more accessible due to contraceptive need facilitating client buy-in for the program, as well as a salon environment in which clients may encourage other clients by voluntarily sharing their own contraceptive decisions. The non-judgmental nature of stylist-client relationships can empower clients to make contraceptive decisions, and stylists seek to support clients' continued use of contraceptives through various adherence and support strategies. Some stylists and clients identified existing social barriers (e.g. confidentiality concerns) and made recommendations to strengthen potential contraceptive delivery in salons. Conclusion: Stylists and clients were highly receptive to contraceptive delivery in salons and identified several social facilitators as well as barriers within this setting. Hair salons are community venues with a social environment that may uniquely mitigate barriers to contraceptive access in South Africa.
... An in-depth discussion of potential complications is beyond the scope of this paper, but includes potential drug interactions, the need to switch back to oral medications should the injections be delayed from their regular schedule (called "bridging"), and the risk of viral resistance should treatment delays become too long or frequent. Some infrastructural considerations moving forward include developing the capacity for home-based or point-of-care delivery (e.g., pharmacies or other businesses) of LAI treatments [15]. Also important is the harmonization of tracking records to ease implementation across multiple access sites. ...
Article
Full-text available
Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.
... The authors have previously shown that a salon-based intervention to promote awareness and uptake of PrEP would be feasible and acceptable among Black female salon customers (n=44), salon owners (n=6), and hair stylists (n=25) [16,17]. Salon-based research interventions have shown promise for promoting health broadly in Black communities, because stylists can share health information in the salon with Black women, who view them as trusted confidantes [16][17][18][19][20][21]. There is evidence that stylist and customer confidence is increased when stylists undertake training in preparation for sharing information [18], but only a single study conducted in Brazil has evaluated such a training program for beauty salon professionals [19]. ...
Article
Background Multilevel interventions are necessary to address the complex social contributors to health that limit pre-exposure prophylaxis use among Black women, including medical distrust, pre-exposure prophylaxis stigma, and access to equitable health care. Strategies to improve knowledge, awareness, and uptake of pre-exposure prophylaxis among Black women will be more successful if information-sharing and implementation take place within trusted environments. Providing women with information through trusted cultural and social channels can effectively support informed decision-making about pre-exposure prophylaxis for themselves and members of their social networks who are eligible for pre-exposure prophylaxis. Objective The goal of this project is to improve knowledge, awareness, uptake, and trust of pre-exposure prophylaxis, as well as reduce pre-exposure prophylaxis stigma, among Black women living in the US South. Methods This multilevel, mixed methods study uses a community-engagement approach to develop and pilot test a salon-based intervention. There are three components of this intervention: (1) stylist training, (2) women-focused entertainment videos and modules, and (3) engagement of a pre-exposure prophylaxis navigator. First, stylist training will be provided through two 2-hour training sessions delivered over 2 consecutive weeks. We will use a pre- and posttest design to examine knowledge and awareness improvement of pre-exposure prophylaxis among the stylists. Upon full completion of training, the stylists will receive a certificate of completion and “Ask Me about PrEP” signage for their beauty salons. Second, together with the community, we have codeveloped a 4-part entertainment series (The Wright Place) that uses culturally and socially relevant stories to highlight key messages about (1) HIV, (2) pre-exposure prophylaxis, and (3) Black women’s social contributors to health. Quantitative and qualitative measures will be used in a pre- and posttest design to examine pre-exposure prophylaxis knowledge, awareness, risk, stigma, trust, intentions, and women’s perceptions of the usability and acceptability of the overall intervention and its implementation strategies. A video blog will be provided after each video. Third, participants will have access through an email or text message link to a pre-exposure prophylaxis navigator, who will respond to them privately to answer questions or make referrals for pre-exposure prophylaxis as requested. Results This project was funded in October 2020 by Gilead Sciences and was approved by the Duke University School of Nursing institutional review board in April 2021 (Pro00106307). Intervention components were developed in partnership with community partners in the first year. Data collection for phase 1 began in April 2022. Data collection for phase 2 began in May 2022. The study will be complete by October 2022. Conclusions Multilevel interventions that consider the assets of the community have promise for promoting health among Black women who have influence within their social networks. The findings of this study have the potential to be generalizable to other populations. International Registered Report Identifier (IRRID) PRR1-10.2196/34556
... To address continued high HIV incidence among AGYW and adolescent boys and young men (ABYM), and the factors that increase their vulnerability to infection, various differentiated care models-tailored and streamlined client-catered HIV services-have been implemented throughout South Africa, including the Determined, Resilient, Empowered, AIDSfree, Mentored and Safe (DREAMS) initiative [25]. These services comprise of adolescent and youth-friendly clinics [26], mobile clinics for reproductive health services for youth [26,27] and community-based services [28], of which there is a high willingness among AGYW to initiate PrEP when delivered through an integrated approach within youth-friendly settings [26]. AGYW who used contraception were significantly more likely to initiate PrEP on the same day compared to those who declined contraception [27]. ...
Article
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Introduction Pre-exposure prophylaxis (PrEP) is an effective prevention intervention that can be used to control HIV incidence especially among people who are at increased risk for HIV such as adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM). In South Africa, various approaches of delivering PrEP have been adopted at different service delivery points (facility-based only, school-based only, community-based only and hybrid school-facility and community-facility models) to overcome challenges associated with individual, structural, and health systems related barriers that may hinder access to and uptake of PrEP among these populations. However, little is known about how to optimize PrEP implementation and operational strategies to achieve high sustained uptake of good quality services for AGYW and ABYM. This study aims to identify effective and feasible PrEP models of care for improving PrEP uptake, continuation, and adherence among AGYW and ABYM. Methods and analysis A sequential explanatory mixed-methods study will be conducted in 22 service delivery points (SDPs) in uMgungundlovu district, KwaZulu-Natal, South Africa. We will recruit 600 HIV negative, sexually active, high risk, AGYW (aged 15–24 years) and ABYM (aged 15–35 years). Enrolled participants will be followed up at 1-, 4- and 7-months to determine continuation and adherence to PrEP. We will conduct two focus group discussions (with 8 participants in each group) across four groups (i. Initiated PrEP within 1 month, ii. Did not initiate PrEP within 1 month, iii. Continued PrEP at 4/7 months and iv. Did not continue PrEP at 4/7 months) and 48 in-depth interviews from each of the four groups (12 per group). Twelve key informant interviews with stakeholders working in HIV programs will also be conducted. Associations between demographic characteristics stratified by PrEP initiation and by various service-delivery models will be assessed using Chi-square/Fishers exact tests or t-test/Mann Whitney test. A general inductive approach will be used to analyze the qualitative data. Ethics and dissemination The protocol was approved by the South African Medical Research Council Health Research Ethics Committee (EC051-11/2020). Findings from the study will be communicated to the study population and results will be presented to stakeholders and at appropriate local and international conferences. Outputs will also include a policy brief, peer-reviewed journal articles and research capacity building through research degrees.
... The availability of different options for PrEP, similar to contraceptive methods, can enhance women's agency to choose the form that best fits their preferences. In whatever form PrEP is available, women in our study reaffirm that interventions should make it accessible in everyday locations [49][50][51], garner support from peers, partners, and families [26,52], and recognize the reality of sociocultural gender norms [53][54][55][56]. ...
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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.
... To address continued high HIV incidence among AGYW and adolescent boys and young men (ABYM), and the factors that increase their vulnerability to infection, various differentiated care models -tailored and streamlined client-catered HIV services -have been implemented throughout South Africa, including the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) initiative (25). These services comprise of adolescent and youth-friendly clinics (26), mobile clinics for reproductive health services for youth (26,27) and community-based services (28), of which there is a high willingness among AGYW to initiate PrEP when delivered through an integrated approach within youth-friendly settings (26). AGYW who used contraception were significantly more likely to initiate PrEP on the same day compared to those who declined contraception (27). ...
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Introduction Pre-exposure prophylaxis (PrEP) is an effective prevention intervention that can be used to control HIV incidence especially among people who are at increased risk for HIV such as adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM). In South Africa, various approaches of delivering PrEP have been adopted at different service delivery points (facility-based only, school-based only, community-based only and hybrid school-facility and community-facility models) to overcome challenges associated with individual, structural, and health systems related barriers that may hinder access to and uptake of PrEP among these populations. However, little is known about how to optimize PrEP implementation and operational strategies to achieve high sustained uptake of good quality services for AGYW and ABYM. This study aims to identify effective and feasible PrEP models of care for improving PrEP uptake, continuation, and adherence among AGYW and ABYM. Methods and analysis A sequential explanatory mixed-methods study will be conducted in 22 service delivery points (SDPs) in uMgungundlovu district, KwaZulu-Natal, South Africa. We will recruit 600 HIV negative, sexually active, high risk, AGYW (aged 15-24 years) and ABYM (aged 15-35 years). Enrolled participants will be followed up at 1-, 4- and 7-months to determine continuation and adherence to PrEP. We will conduct two focus group discussions (with 8 participants in each group) across four groups (i. Initiated PrEP within 1 month, ii. Did not initiate PrEP within 1 month, iii. Continued PrEP at 4/7 months and iv. Did not continue PrEP at 4/7 months) and 48 in-depth interviews from each of the four groups (12 per group). Twelve key informant interviews with stakeholders working in HIV programs will also be conducted. Associations between demographic characteristics stratified by PrEP initiation and by various service-delivery models will be assessed using Chi-square/Fishers exact tests or t-test/Mann Whitney test. A general inductive approach will be used to analyze the qualitative data. Ethics and dissemination The protocol was approved by the South African Medical Research Council Health Research Ethics Committee (EC051-11/2020). This project was reviewed by the U.S. Centers for Disease Control and Prevention (Atlanta, GA), Centers for Global Health Associate Director for Science in accordance with CDC human research protection procedures and was determined to be research, but CDC investigators did not interact with human subjects or have access to identifiable data or specimens for research purposes. Provincial and district level approval has been granted. Findings from the study will be communicated to the study population and results will be presented to stakeholders and at appropriate local and international conferences. Outputs will also include a policy brief, peer-reviewed journal articles and research capacity building through research degrees.
Article
Aims and objectives To understand Black women's perspectives on a pre‐exposure prophylaxis (PrEP) education intervention in a salon setting. Background Black women have a significant lifetime risk of acquiring HIV. Pre‐exposure prophylaxis (PrEP) is an effective prevention approach in reducing that risk. Despite this, Black women are least likely to use PrEP. Design This was a qualitative study to identify Black women's perspectives on acceptability of a PrEP education intervention in a salon setting using hair stylists. The paper adhered to the COREQ checklist in reporting. Methods Seven focus groups among Black women (n = 44) living in north‐central North Carolina were conducted. Ethical approval was obtained. The interview guide included questions on knowledge of PrEP and barriers and facilitators to a PrEP promotion programme in a salon setting. Results Conventional content analysis considered content in relation to themes of facilitators, barriers and women's preferences for intervention delivery. Facilitators included the salon characteristics, social culture and relationship with the stylist. Women noted concerns of accuracy of content from stylists and privacy as barriers. Conclusions Participants’ trust with their stylists make a PrEP education salon‐based intervention feasible. Salon‐based interventions are not one‐size‐fits‐all and researchers interested in this setting should tailor interventions to the individual salon. Interventions for PrEP in a salon setting should be culturally appropriate, confidential and consider the potential reach to the social networks of Black women in the salon. Relevance to clinical practice The insights shared by Black women can contribute to developing a PrEP uptake intervention as a way of reducing new cases of HIV.
Article
Following recommendations by the World Health Organization in 2015, and key clinical trials, countries in sub-Saharan Africa, the region with the highest burden of human immunodeficiency virus (HIV), developed policies that incorporate pre-exposure prophylaxis (PrEP) into national HIV-prevention strategies. By the end of 2019, more than one third of people receiving PrEP globally were in Africa. Crucial understandings gained from early rollout among at-risk populations, such as HIV-serodiscordant couples, adolescent girls and young women, female sex workers, and men who have sex with men, include the importance of strategies for maintaining persistent adherence to PrEP and novel approaches to making PrEP services accessible, simplified and efficient. This Perspective will discuss the current status of these programs and how to further widen their implementation.
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Placebo-controlled trials of pre-exposure prophylaxis (PrEP) have reported challenges with study-product uptake and use, with the greatest challenges reported in studies with young women in sub-Saharan Africa. We conducted a qualitative sub-study to explore experiences with open-label PrEP among young women in Cape Town, South Africa participating in HTPN 067/Alternative Dosing to Augment Pre-Exposure Prophylaxis Pill Taking (ADAPT). HPTN 067/ADAPT provided open label oral FTC/TDF PrEP to young women in Cape Town, South Africa who were randomized to daily and non-daily PrEP regimens. Following completion of study participation, women were invited into a qualitative sub-study including focus groups and in-depth interviews. Interviews and groups followed a semi-structured guide, were recorded, transcribed, and translated to English from isiXhosa, and coded using framework analysis. Sixty of the 179 women enrolled in HPTN 067/ADAPT participated in either a focus group (six groups for a total of 42 participants) or an in-depth interview (n = 18). This sample of mostly young, unmarried women identified facilitators of and barriers to PrEP use, as well as factors influencing study participation. Cross-cutting themes characterizing discourse suggested that women placed high value on contributing to the well-being of one's community (Ubuntu), experienced a degree of skepticism towards PrEP and the study more generally, and reported a wide range of approaches towards PrEP (ranging from active avoidance to high levels of persistence and adherence). A Mutuality Framework is proposed that identifies four dynamics (distrust, uncertainty, alignment, and mutuality) that represent distinct interactions between self, community and study and serve to contextualize women's experiences. Implications for better understanding PrEP use, and non-use, and intervention opportunities are discussed. In this sample of women, PrEP use in the context of an open-label research trial was heavily influenced by underlying beliefs about safety, reciprocity of contributions to community, and trust in transparency and integrity of the research. Greater attention to factors positioning women in the different dynamics of the proposed Mutuality Framework could direct intervention approaches in clinical trials, as well as open-label PrEP scale-up.
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Introduction: HIV incidence remains high among young women in sub-Saharan Africa in spite of scale-up of HIV testing, behavioural interventions, antiretroviral treatment and medical male circumcision. There is a critical need to critique past approaches and learn about the most effective implementation of evidence-based HIV prevention strategies, particularly emerging interventions such as pre-exposure prophylaxis (PrEP). Discussion: Women in sub-Saharan Africa are at increased risk of HIV during adolescence and into their 20s, in part due to contextual factors including gender norms and relationship dynamics, and limited access to reproductive and sexual health services. We reviewed behavioural, behavioural economic and biomedical approaches to HIV prevention for young African women, with a particular focus on the barriers, opportunities and implications for implementing PrEP in this group. Behavioural interventions have had limited impact in part due to not effectively addressing the context, broader sexual norms and expectations, and structural factors that increase risk and vulnerability. Of biomedical HIV prevention strategies that have been tested, daily oral PrEP has the greatest evidence for protection, although adherence was low in two placebo-controlled trials in young African women. Given high efficacy and effectiveness in other populations, demonstration projects of open-label PrEP in young African women are needed to determine the most effective delivery models and whether women at substantial risk are motivated and able to use oral PrEP with sufficient adherence to achieve HIV prevention benefits. Conclusions: Social marketing, adherence support and behavioural economic interventions should be evaluated as part of PrEP demonstration projects among young African women in terms of their effectiveness in increasing demand and optimizing uptake and effective use of PrEP. Lessons learned through evaluations of implementation strategies for delivering oral PrEP, a first-generation biomedical HIV prevention product, will inform development of new and less user-dependent PrEP formulations and delivery of an expanding choice of prevention options in HIV prevention programmes for young African women.
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Reproductive-age women need effective interventions to prevent the acquisition of human immunodeficiency virus type 1 (HIV-1) infection. We conducted a randomized, placebo-controlled trial to assess daily treatment with oral tenofovir disoproxil fumarate (TDF), oral tenofovir-emtricitabine (TDF-FTC), or 1% tenofovir (TFV) vaginal gel as preexposure prophylaxis against HIV-1 infection in women in South Africa, Uganda, and Zimbabwe. HIV-1 testing was performed monthly, and plasma TFV levels were assessed quarterly. Of 12,320 women who were screened, 5029 were enrolled in the study. The rate of retention in the study was 91% during 5509 person-years of follow-up. A total of 312 HIV-1 infections occurred; the incidence of HIV-1 infection was 5.7 per 100 person-years. In the modified intention-to-treat analysis, the effectiveness was -49.0% with TDF (hazard ratio for infection, 1.49; 95% confidence interval [CI], 0.97 to 2.29), -4.4% with TDF-FTC (hazard ratio, 1.04; 95% CI, 0.73 to 1.49), and 14.5% with TFV gel (hazard ratio, 0.85; 95% CI, 0.61 to 1.21). In a random sample, TFV was detected in 30%, 29%, and 25% of available plasma samples from participants randomly assigned to receive TDF, TDF-FTC, and TFV gel, respectively. Independent predictors of TFV detection included being married, being older than 25 years of age, and being multiparous. Detection of TFV in plasma was negatively associated with characteristics predictive of HIV-1 acquisition. Elevations of serum creatinine levels were seen more frequently among participants randomly assigned to receive oral TDF-FTC than among those assigned to receive oral placebo (1.3% vs. 0.2%, P=0.004). We observed no significant differences in the frequencies of other adverse events. None of the drug regimens we evaluated reduced the rates of HIV-1 acquisition in an intention-to-treat analysis. Adherence to study drugs was low. (Funded by the National Institutes of Health; VOICE ClinicalTrials.gov number, NCT00705679.).
Article
Background Uncontrolled hypertension is a major problem among non-Hispanic black men, who are underrepresented in pharmacist intervention trials in traditional health care settings. Methods We enrolled a cohort of 319 black male patrons with systolic blood pressure of 140 mm Hg or more from 52 black-owned barbershops (nontraditional health care setting) in a cluster-randomized trial in which barbershops were assigned to a pharmacist-led intervention (in which barbers encouraged meetings in barbershops with specialty-trained pharmacists who prescribed drug therapy under a collaborative practice agreement with the participants’ doctors) or to an active control approach (in which barbers encouraged lifestyle modification and doctor appointments). The primary outcome was reduction in systolic blood pressure at 6 months. Results At baseline, the mean systolic blood pressure was 152.8 mm Hg in the intervention group and 154.6 mm Hg in the control group. At 6 months, the mean systolic blood pressure fell by 27.0 mm Hg (to 125.8 mm Hg) in the intervention group and by 9.3 mm Hg (to 145.4 mm Hg) in the control group; the mean reduction was 21.6 mm Hg greater with the intervention (95% confidence interval, 14.7 to 28.4; P<0.001). A blood-pressure level of less than 130/80 mm Hg was achieved among 63.6% of the participants in the intervention group versus 11.7% of the participants in the control group (P<0.001). In the intervention group, the rate of cohort retention was 95%, and there were few adverse events (three cases of acute kidney injury). Conclusions Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in larger blood-pressure reduction when coupled with medication management in barbershops by specialty-trained pharmacists. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT02321618.)
Article
Over the past decade, the global response to the HIV epidemic has been unprecedented, and enormous progress has been made. Significant investment in the roll out of antiretroviral treatment (ART) and efforts to increase treatment coverage have greatly reduced the number of AIDS-related deaths worldwide. There are a growing number of promising innovations to expand the HIV prevention mix. However, the reach of these interventions is still very limited in adolescent girls and young women (15-24 years) and the full realisation of the intervention mandates has not yet been achieved. The HIV prevention field has been criticised for the tendency to adopt a narrow focus. The Fast-Track Strategy offers a unique opportunity for the HIV prevention field to broaden its gaze and to begin to identify synergies (and efficiencies) with prevention approaches from other global development priorities, namely sexual and reproductive health and rights (SRHR). This paper applies a SRHR lens to HIV prevention by highlighting the critical relationship between unintended pregnancy and HIV, and seeks to expand on earlier debates that prevention of HIV and prevention of unintended pregnancy are inextricably linked, complementary activities with interrelated and common goals. We call for the prioritisation of prevention of unintended pregnancy amongst two overlapping population groups - girls and young women (15-24 years old) and women living with HIV - as a key tactic to accomplish the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track Strategy and as a way to fully realise existing HIV prevention efforts. We discuss the intersecting pathways between HIV prevention and unintended pregnancy prevention and build a case for contraception to be placed at the centre of the HIV prevention agenda.
Article
Background Antiretroviral medications that are used as prophylaxis can prevent acquisition of human immunodeficiency virus type 1 (HIV-1) infection. However, in clinical trials among African women, the incidence of HIV-1 infection was not reduced, probably because of low adherence. Longer-acting methods of drug delivery, such as vaginal rings, may simplify use of antiretroviral medications and provide HIV-1 protection. Methods We conducted a phase 3, randomized, double-blind, placebo-controlled trial of a monthly vaginal ring containing dapivirine, a non-nucleoside HIV-1 reverse-transcriptase inhibitor, involving women between the ages of 18 and 45 years in Malawi, South Africa, Uganda, and Zimbabwe. Results Among the 2629 women who were enrolled, 168 HIV-1 infections occurred: 71 in the dapivirine group and 97 in the placebo group (incidence, 3.3 and 4.5 per 100 person-years, respectively). The incidence of HIV-1 infection in the dapivirine group was lower by 27% (95% confidence interval [CI], 1 to 46; P=0.05) than that in the placebo group. In an analysis that excluded data from two sites that had reduced rates of retention and adherence, the incidence of HIV-1 infection in the dapivirine group was lower by 37% (95% CI, 12 to 56; P=0.007) than that in the placebo group. In a post hoc analysis, higher rates of HIV-1 protection were observed among women over the age of 21 years (56%; 95% CI, 31 to 71; P<0.001) but not among those 21 years of age or younger (−27%; 95% CI, −133 to 31; P=0.45), a difference that was correlated with reduced adherence. The rates of adverse medical events and antiretroviral resistance among women who acquired HIV-1 infection were similar in the two groups. Conclusions A monthly vaginal ring containing dapivirine reduced the risk of HIV-1 infection among African women, with increased efficacy in subgroups with evidence of increased adherence. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01617096.)
Article
BACKGROUND: Intimate partner violence (IPV) is a source of severe health consequences, and therefore, health care organizations have recommended routine IPV screening. Implementing health-related screenings outside of health care facilities is common public health practice, but to date, IPV screening in hair salons has not been reported. The objective of this study was to determine the prevalence of IPV among women at hair salons. We hypothesized that women would disclose IPV in this setting and that rates of abuse would reflect national averages. METHODS: We recruited a convenience sample of hair salons in Connecticut in 2014. Hair stylists were trained on how to recognize and refer IPV victims. Self-reported IPV of salon clients was measured by a tablet-based validated screening tool, the Patient Satisfaction and Safety Survey. RESULTS: Overall, reported past-year prevalence of physical abuse was 3.6%, past-year prevalence of sexual abuse was 2.7%, lifetime prevalence of emotional or physical abuse was 34.2%, and 5.3% of the sample reported that they had been hurt that day by their current or former partner. Past-year physical abuse was more common among women 30 years to 39 years old (9.1%), black (9%), and single women (7.5%). Past-year sexual abuse was more common among women 20 years to 29 years old (13.8%), other races (6.7%), and single women (5.4%). Lifetime abuse was more common among women 50 years to 59 years old (13.8%), black (36.1%), and divorced women (69.7%). Hurt-today abuse was more common among women younger than 20 years (12.5%), other races (13.3%), and women in common law relationships (25%). CONCLUSION: Women in our study reported IPV prevalence rates consistent with national data. Documentation of IPV prevalence in hair salons will provide much-needed support for novel interventions such as CUT IT OUT, a national program designed to train hair stylists on how to recognize and refer IPV victims.
Article
Purpose of review: We summarize key lessons learned from contraceptive development and introduction, and implications for preexposure prophylaxis (PrEP). Recent findings: New approaches to HIV prevention are urgently needed. PrEP is a new technology for HIV prevention. Uncertainty remains about its acceptance, use and potential to have an impact on the HIV epidemic. Despite imperfect use and implementation of programs, the use of modern contraception has led to significant reproductive health and social gains, making it one of the public health's major achievements. Guided by the WHO strategic approach to contraception introduction, we identified the following lessons for PrEP introduction from contraception: the importance of a broader focus on the method mix rather than promotion of a single technology, new technologies alone do not increase choice - service delivery systems and providers are equally important to success, and that failure to account for user preferences and social context can undermine the potential of new methods to provide benefit. Summary: Taking a strategic approach to PrEP introduction that includes a broader focus on the technology/user interface, the method mix, delivery strategies, and the context in which methods are introduced will benefit HIV prevention programs, and will ensure greater success.
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Barbershops and beauty salons are located in all communities and frequented by diverse groups of people, making them key settings for addressing health disparities. No studies have reviewed the growing body of literature describing studies promoting health in these settings. This review summarized the literature related to promoting health within barbershops and beauty salons to inform future approaches that target diverse populations in similar settings. We identified and reviewed published research articles describing formative research, recruitment, and health-related interventions set in beauty salons and barbershops. PubMed and other secondary search engines were searched in 2010 and again in 2013 for English-language papers indexed from 1990 through August 2013. The search yielded 113 articles, 71 of which were formerly reviewed, and 54 were eligible for inclusion. Included articles were categorized as formative research (n=27); recruitment (n=7); or intervention (n=20). Formative research studies showed that owners, barbers/stylists, and their customers were willing participants, clarifying the feasibility of promoting health in these settings. Recruitment studies demonstrated that salon/shop owners will join research studies and can enroll customers. Among intervention studies, level of stylist/barber involvement was categorized. More than 73.3% of intervention studies demonstrated statistically significant results, targeted mostly racial/ethnic minority groups and focused on a variety of health topics. Barbershops and beauty salons are promising settings for reaching populations most at risk for health disparities. Although these results are encouraging, more rigorous research and evaluation of future salon- and barbershop-based interventions are needed.