Background
In Africa, adolescent girls and young women (AGYW) have high risk of HIV acquisition and low engagement in prevention programs. Knowledge of HIV-negative status, paired with peer support, might motivate AGYW—who have tight social connectivity and are influenced by peers—to initiate HIV prevention services, including pre-exposure prophylaxis (PrEP).
Methods
We conducted a cluster-randomized controlled trial (CT.gov: NCT04982250) in Central Kenya where AGYW (≥16-24 years) who had used PrEP in the past 12 months (“index peers”) were randomized 1:1 to: 1) enhanced peer referral, including an in-person group training on PrEP referral strategies and HIV self-testing (HIVST); or 2) standard peer referral, including informal PrEP referral strategies ongoing among AGYW. All index peers were encouraged to identify and refer 4 peers (“referred peers”) who could benefit from PrEP and give them cards with information on clinics delivering free services; those assigned to enhanced referral were issued 8 HIVST kits for peer delivery. Index peers were followed up 3 months later and reported outcomes for referred peers: PrEP initiation (primary), PrEP continuation (any refilling), and HIV testing (following referral).
Results
From May 2023-June 2024, we screened 318 index peers and enrolled 82, who reported outcomes for 136 referred peers in the enhanced and 105 in the standard referral groups. The median age of index peers was 22 years (IQR 20-23) and of referred peers was 22 years (IQR 21-24); roughly half of referred peers had casual sexual partners (55%, 58/241). At follow up, there were no statistically significant differences in PrEP initiation among referred peers in the enhanced (29%, 40/136) and standard (40%, 42/105) referral groups (RD 11%, 95% CI -30%, 9%); nor any differences in PrEP continuation between the groups (enhanced: 13%, 17/136; standard: 11%, 11/105; RD 2%, 95% -10%, 14%). Recent HIV testing at follow up, however, was significantly higher among referred peers in the enhanced (91%, 124/136) versus standard (52%, 55/105) referral group (RD 39%, 95% CI 23%, 55%); 3 referred peers tested HIV-positive.
Conclusions
Enhancing peer referral to PrEP services with training and HIVST did not increase PrEP initiation among Kenyan AGYW. The intervention did, however, increase HIV testing, presenting an opportunity to layer other interventions with peer-delivered HIVST to potentially increase AGYW’s engagement in HIV prevention services.