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Correlates of Adherence to Oral and Vaginal Pre-exposure Prophylaxis (PrEP) Among Adolescent Girls and Young Women (AGYW) Participating in the MTN-034/REACH Trial

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Kenneth Ngure at Jomo Kenyatta University of Agriculture and Technology
Kenneth Ngure
Erica N. Browne at University of California, San Francisco
Erica N. Browne
Krishnaveni Reddy at Wits Reproductive Health and HIV Institute
Krishnaveni Reddy
Barbara Friedland at Population Council
Barbara Friedland
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We evaluated correlates of adherence to PrEP, including daily oral tenofovir disoproxil fumarate in combination emtricitabine (oral FTC/TDF) and the monthly dapivirine ring (ring)among adolescent girls and young women (AGYW) in the MTN-034/REACH study. We enrolled 247 AGYW aged 16–21 years in South Africa, Uganda and Zimbabwe (ClinicalTrials.gov: NCT03074786). Participants were randomized to the order of oral FTC/TDF or ring use for 6 months each in a crossover period, followed by a 6-month choice period. We assessed potential adherence correlates—individual, interpersonal, community, study, and product-related factors—quarterly via self-report. We measured biomarkers of adherence monthly; high adherence was defined as > 4 mg dapivirine released from returned rings or intracellular tenofovir diphosphate levels ≥ 700 fmol/punch from dried blood spots (DBS). We tested associations between correlates and objective measures of high adherence using generalized estimating equations. High adherence to oral FTC/TDF was significantly associated with having an older primary partner (p = 0.04), not having exchanged sex in the past 3 months (p = 0.02), and rating oral FTC/TDF as highly acceptable (p = 0.003). High ring adherence was significantly associated with unstable housing (p = 0.01), disclosing ring use to a male family member (p = 0.01), and noting a social benefit from study participation (p = 0.03). All associations were moderate, corresponding to about 6%–10% difference in the proportion with high adherence. In our multinational study, correlates of adherence among African AGYW differed for oral FTC/TDF and the ring, highlighting the benefit of offering multiple PrEP options.
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Vol:.(1234567890)
AIDS and Behavior (2024) 28:2990–3000
https://doi.org/10.1007/s10461-024-04382-3
ORIGINAL PAPER
Correlates ofAdherence toOral andVaginal Pre‑exposure Prophylaxis
(PrEP) Among Adolescent Girls andYoung Women (AGYW)
Participating intheMTN‑034/REACH Trial
KennethNgure1,2· EricaN.Browne3· KrishnaveniReddy4· BarbaraA.Friedland5· ArianevanderStraten6,7·
TheslaPalanee‑Phillips4· RitaNakalega8· BrendaGati8· HadijahN.Kalule8· BekezelaSiziba9· LydiaSoto‑Torres10·
GonasagrieNair11· MorganGarcia12· ConnieCelum2,13,14· SarahT.Roberts3
Accepted: 15 May 2024 / Published online: 9 June 2024
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2024
Abstract
We evaluated correlates of adherence to PrEP, including daily oral tenofovir disoproxil fumarate in combination emtricitabine
(oral FTC/TDF)and the monthly dapivirine ring (ring)among adolescent girls and young women (AGYW) in the MTN-
034/REACH study. We enrolled 247 AGYW aged 16–21years in South Africa, Uganda and Zimbabwe (ClinicalTrials.gov:
NCT03074786). Participants were randomized to the order of oral FTC/TDF or ring use for 6months each in a crossover
period, followed by a 6-month choice period. We assessed potential adherence correlates—individual, interpersonal, com-
munity, study, and product-related factors—quarterly via self-report. We measured biomarkers of adherence monthly; high
adherence was defined as > 4mg dapivirine released from returned rings or intracellular tenofovir diphosphate levels ≥ 700
fmol/punch from dried blood spots (DBS). We tested associations between correlates and objective measures of high adher-
ence using generalized estimating equations. High adherence to oral FTC/TDF was significantly associated with having
an older primary partner (p = 0.04), not having exchanged sex in the past 3months (p = 0.02), and rating oral FTC/TDF as
highly acceptable (p = 0.003). High ring adherence was significantly associated with unstable housing (p = 0.01), disclosing
ring use to a male family member (p = 0.01), and noting a social benefit from study participation (p = 0.03). All associations
were moderate, corresponding to about 6%–10% difference in the proportion with high adherence. In our multinational
study, correlates of adherence among African AGYW differed for oral FTC/TDF and the ring, highlighting the benefit of
offering multiple PrEP options.
Keywords Adherence· Heterosexual women· Pre-exposure prophylaxis (PrEP)· Africa
* Kenneth Ngure
kngure@jkuat.ac.ke; kngure@uw.edu
1 School ofPublic Health, Jomo Kenyatta University
ofAgriculture andTechnology, Box19704-00202, Nairobi,
Kenya
2 Department ofGlobal Health, University ofWashington,
Seattle, USA
3 Women’s Global Health Imperative (WGHI), RTI
International, Berkeley, CA, USA
4 Wits RHI, Faculty ofHealth Sciences, University
oftheWitwatersrand, Johannesburg, SouthAfrica
5 Center forBiomedical Research, Population Council,
NewYork, NY, USA
6 Department ofMedicine, Center forAIDS Prevention
Studies, University ofCalifornia, SanFrancisco, USA
7 ASTRA Consulting, Kensington, CA, USA
8 Makerere University – Johns Hopkins University Research
Collaboration, Kampala, Uganda
9 University ofZimbabwe Clinical Trials Research Centre,
Harare, Zimbabwe
10 National Institute ofAllergy andInfectious Diseases,
National Institutes ofHealth, Rockville, MD, USA
11 University ofCape Town, CapeTown, SouthAfrica
12 FHI 360, Durham, NC, USA
13 Department ofMedicine, University ofWashington, Seattle,
WA, USA
14 Department ofEpidemiology, University ofWashington,
Seattle, WA, USA
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... MTN-034/REACH (hereafter referred to as REACH) was a Phase 2a, randomized, open-label, crossover study conducted at four research sites in three countries: Zimbabwe (Harare), South Africa (Johannesburg, Cape Town), and Uganda (Kampala) between January 2019 and September 2021 (https:// clini caltr ials. gov/ study/ NCT03 593655) [19]. The primary objectives of the study were to collect safety and adherence data for two PrEP products-the monthly dapivirine vaginal ring ("vaginal ring" or "the ring") and daily oral emtricitabine/tenofovir disoproxil fumarate (FTC/ TDF) pills ("oral PrEP") in AGYW, and to assess acceptability and preference for the products. ...
... The trial enrolled 247 HIV-uninfected AGYW between the ages of 16-21 years old. The design, procedures, and primary findings have been previously reported [19]. Briefly, this was an 18-month crossover study of the vaginal ring and oral PrEP, in which participants were asked to "use and then choose." ...
... During this period, participants could switch between options after making their initial choice. Throughout the study, adherence was measured by assessing tenofovir diphosphate levels in dried blood spots after periods of oral PrEP use, and the residual amounts of dapivirine in returned vaginal rings after periods of vaginal ring use (further details reported elsewhere [19]). ...
Adolescent Girls and Young Women Overcoming Adherence Challenges with Vaginal and Oral PrEP Use: A Longitudinal Qualitative Study from a Crossover Trial in South Africa, Uganda, and Zimbabwe
Article
Full-text available
  • Sep 2024
  • AIDS BEHAV
Rates of HIV acquisition remain high among adolescent girls and young women (AGYW) in sub-Saharan Africa. We explored South African, Ugandan, and Zimbabwean AGYW’s experiences in a crossover trial of two HIV prevention products: Daily oral pre-exposure prophylaxis pills and a monthly dapivirine vaginal ring. A subset of participants (n = 25) across all sites completed up to three serial in-depth interviews (SIDIs). The SIDIs explored barriers to product use, coping strategies, and the resulting outcomes. Coded textual data were analyzed using a product acceptability conceptual framework. Participants in the SIDIs described managing the array of challenges they encountered through formal adherence support, strategic product disclosure, and personally adapted strategies. For both products, perceived discreetness of the product and decision-making around disclosure was an important component of participants’ narratives. Participants tailored their coping strategies based on available personal resources (e.g., cell phone alarms for PrEP reminders, social support through disclosure) or study provided resources (e.g., encouragement from staff, adherence groups). Notably, challenges participants encountered with each product during the crossover period helped inform product selection during the choice period. Our findings suggest that—even in a context where AGYW have access to several options for HIV prevention—challenges to consistent product use remain, but accessible support mechanisms and informed choice can help mitigate these challenges. Enacting that choice may also empower AGYW to reach their short and long-term life goals—including for HIV prevention. (NCT03593655, 20th July 2018).
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... Method adherence remained relatively high during the choice period. Correlates of high adherence varied between methods, suggesting the person-centered benefits of offering method choice [61]. While not in a real-world setting, these results offer an example of choice and potential switching patterns among young women when offered two biomedical prevention options. ...
PrEP Method Switching: Will it Yield Greater Coverage of HIV Protection? Applying Lessons Learned from Family Planning to Guide Future Research in the Context of PrEP Choice
Article
Full-text available
  • Jul 2024
  • Curr HIV AIDS Rep
Purpose of Review Despite the growing availability of oral PrEP, coverage remains suboptimal. Through the introduction of additional PrEP methods, including vaginal rings and long-acting injectable formulations, health systems globally are on the cusp of offering PrEP methods that vary by route of administration, efficacy, and frequency of use. With PrEP choice, it will be important to explore PrEP use patterns to better understand how the ability to choose and switch products affects coverage and continuation. In this review, we draw parallels with family planning (FP) by summarizing how method choice and product switching affected contraceptive coverage globally, synthesize what is known about PrEP product switching, and outline evidence gaps to help guide future research on PrEP switching in the context of choice. Recent Findings Decades of research in FP has demonstrated that product switching is common and can lead to more satisfaction and increases in contraceptive use. While research on PrEP product switching is nascent, findings suggest switching is common, and that providing more than one PrEP option can increase coverage. Key evidence gaps include understanding product switching in the context of full versus constrained choice, switching in the context of temporary need, and developing interventions that promote product switching for those who could benefit. Summary Providing choice and allowing people to start, stop, and switch products according to their needs and desires is a core component of a rights-based approach to HIV prevention. More research is needed to better understand what drives use patterns, including switching, and how to leverage choice to improve coverage. Standard definitions —some of which have been proposed in this review—are needed to inform comparable measurement. Finally, there is a need to holistically frame PrEP use to acknowledge changes in need over the life course, thus making method switching a standard part of HIV prevention.
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Transforming HIV prevention: the promise of long-acting preexposure prophylaxis in high HIV burden settings
Article
  • Nov 2024
  • Curr Opin HIV AIDS
Purpose of review Recent research on efficacy and safety of long-acting preexposure prophylaxis (PrEP) holds the promise to transform HIV prevention in high HIV burden settings. We review emerging findings regarding early end-user acceptability of long-acting PrEP modalities, feasibility of integrating long-acting PrEP into health systems, and considerations regarding drug resistance and cost. Recent findings Long-acting PrEP, particularly injectables, was found to be highly acceptable among individuals across key populations in high HIV burden settings. Concerns around use of long-acting PrEP highlight the importance of choice and ability to switch methods. Existing provider-level barriers to oral PrEP implementation (e.g., overburdened staff, training gaps) may impact long-acting PrEP rollout – however, utilization of PrEP implementation strategies such as task-shifting, timely PrEP training for all providers, differentiated service delivery, and integration with sexual health services, may mitigate barriers. Studies modeling injectable PrEP scale-up demonstrate substantial benefits in HIV mortality reduction, outweighing risks of increased integrase inhibitor resistance, but also highlight the urgency of pricing long-acting PrEP to ensure access and affordability. Summary Long-acting PrEP could be a game changer in HIV prevention in high burden settings. There is an urgent need for rapid scale production and price reductions to ensure access in high HIV burden settings. Implementation strategies are needed to address individual and provider-level barriers.
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Effective preexposure prophylaxis in young women and girls, a key population for HIV prevention
Article
  • Aug 2024
Purpose of review Although there is substantial momentum to scale up preexposure prophylaxis (PrEP) for HIV prevention in adolescent girls and young women (AGYW) at risk of HIV acquisition, this key population has demonstrated difficulty in sustained PrEP use. Despite being a user-controlled and discreet prevention option, effective oral PrEP use requires a series of complex daily decisions in the life of the PrEP user. In this review, we describe how the number of decisions AGYW have to execute for effective and continued PrEP use may potentially be reduced by providing simplified, integrated, differentiated sexual and reproductive health services that include PrEP, and introducing a choice of PrEP products, including less frequently dosed, longer acting and/or multipurpose prevention technology (MPT) products. Recent findings PrEP uptake and effective use are enhanced when AGYW experience PrEP service delivery channels as convenient, integrated with their other sexual and reproductive health needs and matching their experiences (including limited autonomy) and lifestyle. Longer acting or less frequently dosed PrEP products or MPTs may reduce the cognitive burden associated with prevention decision-making and is, therefore, likely more suitable for the majority of AGYW who struggle with daily pill adherence. Summary In the scaling up of HIV prevention for AGYW, implementers are encouraged to consider both PrEP products and PrEP delivery outlet preferences. Understanding and responding to AGYW's different needs will allow for preferred PrEP delivery outlets and choice in PrEP products, leading to a greater likelihood of effective PrEP use in this key population.
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Latent Class Analysis of Online Platforms for Partner-Seeking and Sexual Behaviors Among Men Who Have Sex with Men from Central Kentucky
Article
Full-text available
  • Oct 2023
  • AIDS BEHAV
Little is known whether engagement in sexual behaviors associated with potential HIV risks differs by subgroups of men who have sex with men (MSM), who are distinct regarding patterns of use of online tools for partner-seeking. Using latent class analysis, we revealed four classes of app-using MSM (n = 181, 18–34 y.o., 82.4% identified as White and non-Hispanic) residing in Central Kentucky: the Grindr/Tinder class; the Poly App Use class of MSM-oriented apps; the General Social Media class, and the Bumble class. Unadjusted penalized logistic regressions showed associations of the Poly App Use class with increased numbers of receptive anal sex partners and reporting condomless receptive anal sex. Adjusting for other covariates, poly app users versus others were more likely to be older (25–34 vs. 18–24, AOR = 3.81, 95%CI = 1.70–9.03), to report past six-month illicit drug use (AOR = 2.93, 95%CI = 1.25–7.43) and to have ever used pre-exposure prophylaxis (AOR = 2.79, 95%CI = 1.10–7.12). Poly app users had behavior profiles associated with an elevated HIV risk and also reported HIV-related protective behaviors likely indicating increased risk awareness among this class. Our findings warrant differentiation of behavior profiles by patterns of app use and suggest not to generalize sexual behaviors associated with potential HIV risks to all app-using MSM
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Adolescent Girls and Young Women’s Experiences with Disclosing Oral PrEP or Dapivirine Vaginal Ring Use: a Multi-Country Qualitative Analysis
Article
Full-text available
  • Jul 2023
  • AIDS BEHAV
Effective use of oral pre-exposure prophylaxis (PrEP) has been low among adolescent girls and young women (AGYW) in Eastern and Southern Africa, partly due to stigma and opposition from key influencers. Understanding AGYW’s experiences of disclosure of different PrEP modalities to key influencers may inform strategies to motivate uptake and adherence. We analyzed qualitative in-depth interviews and focus group discussions data from 119 participants in the MTN-034/REACH (Reversing the Epidemic in Africa with Choices in HIV Prevention) study of oral PrEP and the dapivirine vaginal ring (ring) to explore AGYW’s disclosure experiences. We found that AGYW disclosure experiences varied across influencers and product type. The ring was disclosed less often to most influencers, except partners, because it was discreet. Oral PrEP was disclosed more often, because pills were more common and to avoid HIV stigma given that oral PrEP resembled HIV treatment. Ultimately, disclosure typically led most key influencers to support product use through reminders and encouragement. While disclosure yielded positive support from influencers, further community awareness of both PrEP products is essential to reduce potential opposition and perceived stigma. Clinical Trial Number: NCT03593655.
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PrEP uptake and persistence amongst HIV-negative women who exchange sex for money or commodities in Kampala, Uganda: A qualitative inquiry assessing the influence of pregnancy
Article
Full-text available
  • Jun 2023
Pregnant young women who exchange sex for money or commodities are at elevated biological and social risk for HIV acquisition. PrEP serves as an effective means of HIV prevention, including during pregnancy. This study aimed to explore attitudes, experiences and challenges with PrEP to understand what motivates or limits PrEP uptake and adherence specifically during pregnancy among this population of young women. Semi-structured interviews were conducted with 23 participants, recruited from the Prevention on PrEP (POPPi) study in the Good Health for Women Project clinic in Kampala, Uganda. POPPi’s inclusion criteria comprised of HIV-uninfected women, aged 15–24, who exchange sex for money or commodities. Interviews focused on experience with PrEP and pregnancy. Data were analyzed utilizing a framework analysis approach. Key themes were comprised of participant barriers to and facilitators of PrEP uptake and adherence. Reasons for PrEP initiation included desire for autonomy and agency, mistrust of partners, and social support. Participants expressed challenges with initiating or sustaining their use of PrEP, including pregnancy, PrEP access and perceived or felt stigma. During pregnancy, participants’ primary motivators for altering PrEP use were either understanding of PrEP safety for their baby or changes in perceptions of their HIV risk. Many of these factors were similar across participants who had experience with pregnancy and those who did not. This study highlights the importance of addressing barriers to and facilitators of PrEP uptake and persistence, especially during pregnancy where risk is elevated, with a multi-level approach. Community-oriented education, stigma reduction activities alongside access to PrEP, can serve as means for adherence. The development of robust PrEP support services and guidelines regarding PrEP use during pregnancy among high-risk women, and strategies for their implementation, are of utmost importance for the control of HIV in key populations and the elimination of mother-to-child transmission of HIV.
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Baseline preferences for oral pre-exposure prophylaxis (PrEP) or dapivirine intravaginal ring for HIV prevention among adolescent girls and young women in South Africa, Uganda and Zimbabwe (MTN-034/IPM-045 study)
Article
Full-text available
Introduction Adolescent girls and young women (AGYW) in sub-Saharan Africa are disproportionately affected by the HIV epidemic and face an array of challenges using proven behavioral and biomedical prevention methods. To address the urgent need for expanding prevention options, we evaluated the baseline preferences of HIV prevention methods among participants enrolled in the MTN-034/REACH crossover trial along with their stated product preference prior to product initiation. Methods AGYW aged 16–21 years were enrolled at 4 study sites: Cape Town and Johannesburg, South Africa; Kampala, Uganda; and Harare, Zimbabwe and randomly assigned to the sequence of using oral PrEP and the dapivirine ring for 6 months each, followed by a choice period in which they could choose either product (or neither) for an additional six months. Eligible AGYW were HIV-negative, not pregnant and using effective contraception for at least two months prior to enrollment. Descriptive statistics were used to summarize demographic and behavioral data while multinomial analysis was used to determine predictors of stated product preference (ring or oral PrEP). Results Of the 247 AGYW enrolled in REACH, 34% were aged 16–17 and 89% had a primary partner.The median age of sexual debut was 16 years and 40% had ever been pregnant. At screening, 35% of participants were diagnosed with a sexually transmitted infection (STI), 39% had an AUDIT-C score associated with harmful drinking and 11% reported intimate partner violence in the past 6 months. Overall, 28% of participants, had CESD-10 scores suggestive of depressive symptoms (≥12) in the past week. At baseline, similar proportions stated a preference for the ring and oral PrEP (38.1% and 40.5% respectively), with 19% of participants stating they preferred both products equally. Only study site was significantly associated with product preference (P<0.05) with AGYW from Johannesburg having higher odds of preferring the ring and those from Kampala having higher odds of preferring both options equally. Conclusions We successfully enrolled African AGYW with a clear unmet need for HIV prevention. The balanced preference between the two products suggests that multiple biomedical prevention options may be appealing to this age group and could address their prevention needs.
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Qualitative Analysis Using Social Maps to Explore Young Women's Experiences With Social Support of their Oral PrEP Use in Kenya and South Africa
Article
Full-text available
  • Sep 2022
  • J ASSOC NURSE AIDS C
Daily oral pre-exposure prophylaxis (PrEP) adherence is challenging. We explored African adolescent girls and young women's (AGYW) perceptions of the social influencers of their PrEP use and the social influencers' PrEP knowledge and support (six focus group discussions; 33 South African and Kenyan AGYW) in the Prevention Options for Women Evaluation Research demonstration project. Participants completed a social mapping exercise indicating strength and direction of influence of members in their social networks. Mothers and counselors were identified as positive influencers and most influential by >50% of participants, sex partners were labeled negative influencers or both positive and negative, and best friends were mostly positive influencers. HIV- and PrEP-related stigma were the major reasons influencers were identified as negative. Participants wanted their social networks to be better educated about PrEP by someone other than the AGYW themselves (e.g., clinic staff) and to support their PrEP use. To improve PrEP adherence, community- and peer-based PrEP sensitization and delivery interventions should be evaluated.
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Continued attendance in a PrEP program despite low adherence and non-protective drug levels among adolescent girls and young women in Kenya: Results from a prospective cohort study
Article
Full-text available
Background In sub-Saharan Africa (SSA), adolescent girls and young women (AGYW) ages 15 to 24 years represent <10% of the population yet account for 1 in 5 new HIV infections. Although oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) can be highly effective, low persistence in PrEP programs and poor adherence have limited its ability to reduce HIV incidence among women. Methods and findings A total of 336 AGYW participating in the PEPFAR-funded DREAMS PrEP program in western Kenya were enrolled into a study of PrEP use conducted between 6/2019 to 1/2020. AGYW, who used daily oral TDF/FTC, completed interviews and provided dried blood spots (DBS) for measurement of tenofovir-diphosphate (TFV-DP) concentrations at enrollment and 3 months later, and 176/302 (58.3%, 95% confidence interval [95% CI 52.3 to 63.8]) met our definition of PrEP persistence: having expressed intention to use PrEP and attended both the second interview and an interim refill visit. Among AGYW with DBS taken at the second interview, only 9/197 (4.6%, [95% CI 1.6 to 7.5]) had protective TFV-DP levels (≥700 fmol/punch) and 163/197 (82.7%, [95% CI 77.5 to 88]) had levels consistent with no recent PrEP use (<10 fmol/punch). Perception of being at moderate-to-high risk for HIV if not taking PrEP was associated with persistence (adjusted odds ratio, 10.17 [95% CI 5.14 to 20.13], p < 0.001) in a model accounting for county of residence and variables that had p-value <0.1 in unadjusted analysis (age, being in school, initiated PrEP 2 to 3 months before the first interview, still active in DREAMS, having children, having multiple sex partners, partner aware of PrEP use, partner very supportive of PrEP use, partner has other partners, AGYW believes that a partner puts her at risk, male condom use, injectable contraceptive use, and implant contraceptive use). Among AGYW who reported continuing PrEP, >90% indicated they were using PrEP to prevent HIV, although almost all had non-protective TFV-DP levels. Limitations included short study duration and inclusion of only DREAMS participants. Conclusions Many AGYW persisted in the PrEP program without taking PrEP frequently enough to receive benefit. Notably, AGYW who persisted had a higher self-perceived risk of HIV infection. These AGYW may be optimal candidates for long-acting PrEP.
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PrEP use and HIV seroconversion rates in adolescent girls and young women from Kenya and South Africa: the POWER demonstration project
Article
Full-text available
  • Jul 2022
Introduction: HIV incidence remains high among African adolescent girls and young women (AGYW). The primary objective of this study is to assess pre-exposure prophylaxis (PrEP) initiation, use, persistence and HIV acquisition among African AGYW offered PrEP in order to inform PrEP scale-up. Methods: POWER was a prospective implementation science evaluation of PrEP delivery for sexually active HIV-negative AGYW ages 16-25 in family planning clinics in Kisumu, Kenya and youth and primary healthcare clinics in Cape Town and Johannesburg, South Africa. Follow-up visits occurred at month 1 and quarterly for up to 36 months. PrEP users were defined based on the month 1 refill. PrEP persistence through month 6 was assessed using Kaplan-Meier survival analysis among AGYW with a month 1 visit, defining non-persistence as an ≥15 day gap in PrEP availability for daily dosing. PrEP execution was evaluated in a subset with PrEP supply from the prior visit sufficient for daily dosing by measuring blood tenofovir diphosphate (TFV-DP) levels. Results: From June 2017 to September 2020, 2550 AGYW were enrolled (1000 in Kisumu, 787 in Cape Town and 763 in Johannesburg). Median age was 21 years, 66% had a sexual partner of unknown HIV status, and 29% had chlamydia and 10% gonorrhoea. Overall, 2397 (94%) initiated PrEP and 749 (31%) had a refill at 1 month. Of AGYW who could reach 6 months of post-PrEP initiation follow-up, 128/646 (20%) persisted with PrEP for 6 months and an additional 92/646 (14%) had a gap and restarted PrEP. TFV-DP levels indicated that 47% (91/193) took an average of ≥4 doses/week. Sixteen HIV seroconversions were observed (incidence 2.2 per 100 person-years, 95% CI 1.2, 3.5); 13 (81%) seroconverters either did not have PrEP dispensed in the study interval prior to seroconversion or TFV-DP levels indicated <4 doses/week in the prior 6 weeks. Conclusions: In this study of PrEP integration with primary care and reproductive health services for African AGYW, demand for PrEP was high. Although PrEP use decreased in the first months, an important fraction used PrEP through 6 months. Strategies are needed to simplify PrEP delivery, support adherence and offer long-acting PrEP options to improve persistence and HIV protection.
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The future of HIV pre-exposure prophylaxis adherence: reducing barriers and increasing opportunities
Article
  • May 2023
The effectiveness of HIV pre-exposure prophylaxis (PrEP) hinges on adherence, which has been restricted by multifaceted barriers. Uptake of PrEP has been impeded by poor access resulting from high costs, provider uncertainty, discrimination, stigma, and poor understanding within the health-care community and the public of who can benefit from PrEP. Other important barriers to adherence and persistence over time relate to individuals (eg, depression) and their community, partners, and family (eg, poor support), and their effects vary substantially with each person, population, and setting. Despite these challenges, key opportunities for improving PrEP adherence exist, including novel delivery systems, tailored individual interventions, mobile health and digital health interventions, and long-acting formulations. Objective monitoring strategies will help to improve adherence interventions and alignment of PrEP use with the need for HIV prevention (ie, prevention-effective adherence). The future of PrEP adherence lies in person-centred approaches to service delivery that meet the needs of individuals while creating supportive environments and facilitating health-care access and delivery.
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HIV Risk Factors and Risk Perception Among Adolescent Girls and Young Women: Results From a Population-Based Survey in Western Kenya, 2018
Article
  • Jun 2022
  • JAIDS-J ACQ IMM DEF
Background: In sub-Saharan Africa, HIV prevalence in adolescent girls and young women (AGYW) is 2-fold to 3-fold higher than that in adolescent boys and young men. Understanding AGYW's perception of HIV risk is essential for HIV prevention efforts. Methods: We analyzed data from a HIV biobehavioral survey conducted in western Kenya in 2018. Data from AGYW aged 15-24 years who had a documented HIV status were included. We calculated weighted prevalence and evaluated factors associated with outcomes of interest (HIV infection and high risk perception) using generalized linear models to calculate prevalence ratios. Results: A total of 3828 AGYW were included; 63% were aged 15-19 years. HIV prevalence was 4.5% and 14.5% of sexually active AGYW had high risk perception. Over 70% of participants had accessed HIV testing and counseling in the past 12 months. Factors associated with both HIV infection and high risk perception included having an HIV-positive partner or partner with unknown status and having a sexually transmitted infection in the past 12 months. Having an older (by ≥10 years) partner was associated with HIV infection, but not high risk perception. Less than 30% of sexually active AGYW with 3 or more HIV risk factors had high perception of HIV risk. Conclusion: Gaps in perceived HIV risk persist among AGYW in Kenya. High access to HIV testing and prevention services in this population highlights platforms through which AGYW may be reached with improved risk counseling, and to increase uptake of HIV prevention strategies.
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