Adolescent girls and young women (AGYW) face a high HIV burden, while PrEP persistence often declines post-trial. Understanding access outside research settings is key to improving study-to-clinic transitions. This study explored AGYW’s experiences accessing PrEP in public clinics after The Community PrEP Study (CPS) in Eastern Cape, South Africa, a 24-month behavioral intervention. AGYW referred to clinics post-study (June–November 2021) were interviewed on their transition experiences. Interviewers categorized participants as PrEP continuation, discontinuation, or non-presentation. The qualitative team iteratively coded transcripts, used matrix analysis and discussions to examine referral experiences, clinic access, and PrEP motivations. While most accepted the transition, many missed study support. Continuation was linked to clinic adaptation, while discontinuation stemmed from access barriers. Non-presentation resulted from logistical and privacy concerns. Recommendations included youth-friendly provider training, alternative PrEP pick-up options, and service integration. Provider engagement and training remain critical for optimizing PrEP access, even with long-acting modalities. Trial registration number NCT03977181. Date of registration: 6 June 2019 - retrospectively registered.

In Southern and Eastern Africa, initiation of daily oral pre-exposure prophylaxis (PrEP) for HIV prevention has been high among adolescent girls and young women (AGYW) offered PrEP. However, persistence and prevention-effective use of PrEP among this critical group continues to be a challenge. We conducted a qualitative sub-study of AGYW from the Community PrEP Study in Eastern Cape Province, South Africa who had high rates of pick up for monthly PrEP refills over two years, but differing levels of PrEP adherence based on tenofovir-diphosphate (TFV-DP) measurements in dried blood spots (DBS). Contrasting 22 AGYW with low versus high levels of TFV-DP in DBS, we qualitatively explored factors which influenced PrEP persistence vs. non-persistence, unique patterns of PrEP use (e.g., discarding or stockpiling), and participant recommendations for improving AGYW prevention-effective use of PrEP in the future. Results showed that PrEP misconceptions and mistrust among participants’ social networks negatively influenced adherence. In comparison, supportive families and/or partners and personal trust that PrEP works positively influenced adherence. Those with low adherence described being motivated to come to the site for other study benefits (e.g., reimbursement money, snacks, sanitary pads) and discarding PrEP to avoid stigma associated with being seen with pills. Future PrEP implementation strategies should focus on involving families and partners in PrEP support for AGYW and minimizing PrEP stigma at a community level. Trial registration NCT03977181. Retrospectively registered on June 6, 2019.

Adherence to daily oral pre-exposure prophylaxis (PrEP) for HIV prevention has been challenging for adolescent girls and young women (AGYW). As part of The Community PrEP Study (CPS), AGYW were randomised to HIV-prevention empowerment counselling (intervention) or basic medication pick-up (control). In this qualitative sub-study, we interviewed AGYW participants (n = 39) to explore PrEP use and study experiences by study arm, and study staff (n = 7) to explore study implementation, site environment, and participant engagement. Data were thematically analysed using a constant comparison approach. Comparative matrices assessed similarities and differences in study experiences and PrEP support preferences. Friendly, non-judgmental, non-stigmatizing study staff were described as central to participant's positive experiences. Participants highly valued CPS staff's holistic health support (e.g. physical and psycho-social). Intervention participants described empowerment counselling as helpful in supporting PrEP disclosure. However, control participants also described disclosing PrEP use to trusted individuals. Participants and staff recommended public-sector PrEP services provide holistic, confidential, and integrated sexual and reproductive health services, and community sensitisation. An adolescent and youth-friendly environment was the primary factor motivating AGYW's study engagement. While HIV-prevention empowerment counselling was well received, welcoming, respectful and non-judgmental staff may be the 'secret sauce' for implementing effective PrEP services to AGYW.

INTRODUCTION:Adolescent girls and young women (AGYW) face barriers that jeopardize their prevention-effective use of daily oral pre-exposure prophylaxis (PrEP). We sought to understand factors that influence AGYW's prolonged breaks in PrEP use, and their decisions to re-initiate or discontinue using PrEP in the context of a community-based adherence support intervention. METHODS:In-depth interviews (IDIs) were conducted between December 2019 and April 2021 with purposively selected AGYW (aged 16-25) enrolled in the Community PrEP Study (CPS) in Buffalo City Metro Health District, Eastern Cape Province, South Africa. AGYW were offered monthly PrEP for 24 months at two community-based study sites. Interview guides were informed by the Information-Motivation-Behavioural Skills Model, and data were analysed using illustrative code reports and a case analysis. RESULTS:A total of 603 participants were enrolled and initiated on PrEP in the parent study. Fifty-three IDIs were conducted with 50 CPS participants. Findings revealed that external factors (e.g. local movement, school holidays and medication side-effects) and social conflicts (e.g. discretion and partner mistrust) directly influenced breaks in PrEP usage. A decrease in one's self-perception of HIV risk prolonged the duration of these "PrEP breaks." Once PrEP refill visits were missed, some AGYW delayed returning for refills out of fear of being scolded by study staff. The differences between those participants who eventually re-initiated PrEP and those who disengaged from PrEP use can be attributed to social support and encouragement, level of familiarity with PrEP, risk perceptions, self-initiated discussions with staff and diminishing side effects. CONCLUSIONS:Despite implementing a community-based PrEP delivery platform and behavioural intervention that included support for daily oral PrEP adherence and disclosure, participants struggled with consistent daily oral PrEP use. Unpredictable life events, including local movement and schooling schedules, in addition to being judged for their perceived behaviours, pose a challenge for consistent pill pick-up for AGYW and habit formation. Long-acting injectable PrEP may mitigate a number of these external barriers. Interventions that integrate long-term planning skills, how to navigate existing social judgements and how to access sources of social support may further improve habit formation for PrEP use, regardless of its formulation.

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

Women in sub-Saharan Africa are one of the groups at highest risk of HIV in the world, encompassing 38% of new cases globally. 1 Joint United Nations Programme on HIV/AIDS (UNAIDS)UNAIDS data 2021. https://www.unaids.org/sites/default/files/media_asset/JC3032_AIDS_Data_book_2021_En.pdfDate: Nov 29, 2021 Date accessed: March 16, 2022 Google Scholar Multiple HIV prevention modalities have been developed and trialled in women in sub-Saharan Africa with limited success. Tenofovir vaginal gels showed initial promise with a 39% overall reduction in HIV infection, 2 Karim Q Karim SSA Frohlich JA Grobler AC Baxter C Mansoor LE Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science. 2010; 3291168 Google Scholar but later trials showed no evidence of protection. 3 Marrazzo JM Ramjee G Richardson BA et al. Tenofovir-based preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2015; 372: 509-518 Crossref PubMed Scopus (846) Google Scholar Two clinical trials of dapivirine vaginal rings showed an overall 27–31% risk reduction. 4 Baeten JM Palanee-Phillips T Brown ER et al. Use of a vaginal ring containing dapivirine for HIV-1 prevention in women. N Engl J Med. 2016; 375: 2121-2132 Crossref PubMed Scopus (511) Google Scholar , 5 Nel A van Niekerk N Kapiga S et al. Safety and efficacy of a dapivirine vaginal ring for HIV prevention in women. N Engl J Med. 2016; 375: 2133-2143 Crossref PubMed Scopus (276) Google Scholar Daily oral pills containing tenofovir disoproxil fumarate are currently the standard for pre-exposure prophylaxis (PrEP). 6 WHOConsolidated guidelines on HIV prevention, testing, treatment, service delivery, and monitoring: recommendations for a public health approach. https://www.who.int/publications/i/item/9789240031593Date: July 16, 2021 Date accessed: March 16, 2022 Google Scholar Although oral PrEP is effective if taken regularly, 7 Fonner VA Dalglish SL Kennedy CE et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS. 2016; 30: 1973-1983 Crossref PubMed Scopus (505) Google Scholar clinical trials in women in sub-Saharan Africa show variable protection ranging from 0% to 75%. 8 Van Damme L Corneli A Ahmed K et al. Preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2012; 367: 411-422 Crossref PubMed Scopus (1155) Google Scholar , 9 Baeten JM Donnell D Ndase P et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012; 367: 399-410 Crossref PubMed Scopus (2181) Google Scholar All of these studies highlight poor adherence as a primary driver of low protection, supported by clear adherence–efficacy associations. Cabotegravir for the prevention of HIV-1 in women: results from HPTN 084, a phase 3, randomised clinical trialAlthough both products for HIV prevention were generally safe, well tolerated, and effective, cabotegravir was superior to TDF-FTC in preventing HIV infection in women. Full-Text PDF Open Access