Background
HIV prevalence among South African AGYW increases by 10% as young women reach ages 20 to 24, highlighting the need to intervene during adolescence and emerging adulthood. PrEP for HIV prevention promises to reduce HIV incidence. However, its impact may be tempered by structural barriers and individual-level barriers. Few evaluations of multilevel interventions to support AGYW to initiate and use PrEP exist. To this end, we adapted The Health Policy Project Health Facility HIV Stigma and Discrimination Reduction Training curriculum to address stigma and discrimination (S&D) toward AGYW in public clinics. We also adapted an evidence-based, young woman–focused (YW) HIV prevention intervention to support AGYW to initiate and persist on PrEP.
Methods
We conducted a cluster-randomized trial across 12 clinics to assess the impact of S&D reduction training and the YW intervention. There were four study conditions: PrEP/SRH only (Control); S&D + PrEP/SRH; PrEP/SRH + YW; and S&D + PrEP/SRH + YW. 802 AGYW were recruited, provided consent or assent, and completed a questionnaire in English or Setswana. At follow-up, those who reported initiating PrEP provided blood samples (finger prick) for dried blood spots (DBS) to assess PrEP adherence and persistence. PrEP readiness was measured via self-report and PrEP uptake was assessed via medical record data.
Results
A repeated-measures mixed model indicated a significant effect of treatment-by-time interaction on PrEP readiness, χ²(3, 9) = 30.08, p = 0.004. Logistic regressions, accounting for clustering, revealed that there was not a statistically significant effect of the treatment on PrEP uptake – although those in the S&D + PrEP/SRH (OR = 2.50; CI = 1.47, 4.25) and S&D + PrEP/SRH + YW (OR = 2.94; CI 1.75, 4.95) arms were more likely to initiate PrEP than those in the control arm. AGYW in the PrEP/SRH + YW arm (OR = 2.74, CI = 1.26, 5.94) were more likely than those in the control arm to be adherent. AGYW in the S&D + PrEP/SRH (OR = 1.89, CI = 1.09, 3.22), PrEP/SRH + YW (OR = 2.32, CI = 1.99, 2.71) and the S&D + PrEP/SRH + YW (OR = 1.82, CI = 1.31, 2.52) arms were more likely to persist on PrEP than those in the control arm.
Conclusions
Our study and its findings offers some important evidence of the impact of a stigma reduction training and woman-focused intervention that can improve PrEP uptake, adherence, and persistence among AGYW.