Successful scale-up of PrEP for HIV prevention in African adolescent girls and young women (AGYW) requires integration of PrEP into young women’s everyday lives. We conducted interviews and focus group discussions with 137 AGYW PrEP users aged 16–25 from South Africa and Kenya. Individual and relational enablers and disablers were explored at key moments during their PrEP-user journey from awareness, initiation and early use through persistence, including PrEP pauses, restarts, and discontinuation. PrEP uptake was facilitated when offered as part of an integrated sexual reproductive health service, but hampered by low awareness, stigma and misconceptions about PrEP in the community. Daily pill-taking was challenging for AGYW due to individual, relational and structural factors and PrEP interruptions (intended or unintended) were described as part of AGYW’s PrEP-user journey. Disclosure, social support, adolescent-friendly health counseling, and convenient access to PrEP were reported as key enablers for PrEP persistence.

BackgroundMalawi has one of the highest adolescent pregnancy rates worldwide; at 141 births/1000 girls it is 3-fold higher than the global average. Adolescent pregnancy contributes to poor maternal and neonatal outcomes, school dropout, and poverty. In preparation for an information, education, and communication (IEC) intervention to reduce unintended pregnancy among adolescent girls, formative research was conducted to understand how and what sexual and reproductive health (SRH) information is shared with girls in southern, rural Malawi, and perceptions of such information among key informants.MethodsForty semi-structured interviews were conducted with three participant groups: adolescent girls (n = 18), mothers/female guardians (M/FGs) of adolescent girls (n = 12), and leaders of initiation rites (n = 10). Interviews were conducted in 15 villages. Data were analyzed and coded using Dedoose 7.5.ResultsParticipants widely acknowledged both the health risks and the general social unacceptability of early childbearing, yet adolescent pregnancy is common in the region. Respondents also acknowledged the importance of female school completion and the norm that pregnancy usually marks the end of a girl’s education. Unprotected transactional sex was reported to be common and driven by poverty. Initiation rites were described as prevalent and often encourage girls to practice sex at puberty. Contraceptives, and even condoms, were reportedly discouraged for adolescents due to concerns about inappropriateness for nulliparous and young girls and misconceptions about side effects. Adolescent respondents also noted barriers to accessing condoms and contraceptives. M/FGs were described as gatekeepers to SRH information and services, and many parents reported delaying SRH discussions until after sexual debut due to concerns about encouraging sexual activity. Adolescent and M/FG participants expressed a desire for role models or “outside experts” to provide SRH education and to promote an alternate vision to adolescent motherhood.ConclusionTo improve SRH outcomes for adolescent girls, it is critical to engage key stakeholders and create an enabling environment so that girls can effectively act on the IEC they receive. Initiation counselors remain entrenched information sources; efforts to provide them with training on accurate SRH messaging could leverage an existing channel. Engaging parents, especially mothers, is crucial to encourage earlier SRH education and to gain their acceptance of adolescent access to SRH services. Also important is mobilizing the broader community of influencers in support of girls’ SRH and vision for a healthier future. Sensitization messages focusing on the health, educational and economic benefits of preventing early pregnancy may overcome misconceptions about and barriers to contraceptive use. Finally, fostering girls’ aspirations for school completion and jobs and other income generating opportunities via role models can encourage an alternative to adolescent motherhood. Ultimately, poverty and gen...

There is growing evidence that mobile health (mHealth) approaches including short messaging service (SMS) can improve antiretroviral therapy (ART) adherence, but consensus is lacking regarding communication of HIV-related information. Most interventions to date have delivered SMS that do not overtly refer to HIV or ART in order to avoid risk of status disclosure. In formative work for an ongoing randomized controlled trial (RCT) evaluating one-way and two-way educational SMS for prevention of mother-to-child-transmission (PMTCT) adherence in Kenya, we conducted 10 focus group discussions (FGDs) with 87 HIV-infected peripartum women to determine desirability and preferred terminology of HIV-related content. SMS for the RCT were developed based on FGD findings. Roughly half of FGD participants supported receiving SMS containing overtly HIV-related terms, such as ‘HIV’ and ‘medication’, citing desire for detailed educational messages about ART and PMTCT. Those opposed to overt content expressed concerns about confidentiality. Many participants argued that acceptability of HIV-related content depended on the recipient’s disclosure status and others’ access to her phone. Based on these findings, both covert and overt SMS were developed for the RCT and participants who owned their phone or had disclosed their HIV status to anyone with access to their phone were able to choose one of three options: (1) covert SMS only, (2) overt SMS only in response to HIV-related questions from the participant, (3) overt SMS routinely, initiated by the study. Of the 825 participants in the RCT, 94% were eligible to receive overt SMS. Of these, 66% opted to receive routine overt SMS and 10% to receive participant-initiated overt SMS. These findings show there may be interest in overt HIV-related information by SMS when risk of status disclosure is low, and support use of messaging strategies that allows participant choice in HIV-related content while protecting against undesired disclosure.