Background
Providing oral pre-exposure prophylaxis (PrEP) has not achieved population-level impact in southern Africa due to challenges reaching those with the highest risk of HIV-acquisition. We hypothesise that peer-led mobilisation into mobile sexual reproductive health (SRH) clinics will promote oral PrEP use amongst adolescents and young adults (AYA) at higher risk of HIV acquisition in rural KwaZulu-Natal, South Africa.
Methods
We analysed data from a clinical cohort of 2515 AYA aged 15-30 years within the first period of “Thetha Nami ngithethe nawe” stepped wedge trial (NCT05405582), in 20 communities randomised to early rollout of the intervention. In intervention communities, trained peer-navigators conduct needs assessments with AYA and tailor referrals to mobile SRH clinics that visit monthly. HIV high-risk was defined as reporting ≥1 of following: condom-less sex with >1 partner or partner of unknown HIV status; buying or selling sex; sex under the influence of alcohol/drugs. PrEP uptake and retention were defined as initiating oral PrEP within 1 month of attending the clinic, and returning for at least 2 PrEP refills, respectively. GEE logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association between HIV high-risk and PrEP uptake and retention.
Results
June 2022-April 2024, peer navigators reached 11,921 AYA and 3046 [25.6%; 1143 (45.4%) men] attended the SRH clinics. N=240 were living with HIV and were started/continued on antiretroviral therapy. 1950 (77.5%) of 2515 AYA who agreed to point of care HIV testing and tested negative were at HIV high-risk. 863/2515 (34.3%) AYA initiated oral PrEP (805 HIV high-risk) and 151/863 (17.5%) continued PrEP (142 HIV high-risk). PrEP uptake was higher among high-risk than low-risk AYA (adjusted (a)OR 5.38, 95%CI=3.61-8.02, p<0.001). Women and AYA in urban/peri-urban areas had lower odds of PrEP uptake (aOR 0.76, 95%CI=0.61–0.95, p=0.015; aOR 0.84, 95%CI=0.72-0.98, p=0.027, respectively). PrEP retention did not differ between high-risk and low-risk AYA (aOR 1.45, 95%CI=0.62-3.38).
Conclusions
Peer-led mobilisation into mobile SRH services promoted PrEP uptake amongst AYA at highest HIV risk. However, initiation and continuation of daily oral PrEP remains suboptimal. Long-acting injectable PrEP may overcome barriers to oral PrEP.