IntroductionStakeholders continue to discuss the appropriateness of antiretroviral-based pre-exposure prophylaxis (PrEP) for HIV prevention among sub-Saharan African and other women. In particular, women need formulations they can adhere to given that effectiveness has been found to correlate with adherence. Evidence from family planning shows that contraceptive use, continuation and adherence may be increased by expanding choices. To explore the potential role of choice in women's use of HIV prevention methods, we conducted a secondary analysis of research with female sex workers (FSWs) and men and women in serodiscordant couples (SDCs) in Kenya, and adolescent and young women in South Africa. Our objective here is to present their interest in and preferences for PrEP formulations – pills, gel and injectable.MethodsIn this qualitative study, in Kenya we conducted three focus groups with FSWs, and three with SDCs. In South Africa, we conducted two focus groups with adolescent girls, and two with young women. All focus groups were audio-recorded, transcribed and translated into English as needed. We structurally and thematically coded transcripts using a codebook and QSR NVivo 9.0; generated code reports; and conducted inductive thematic analysis to identify major trends and themes.ResultsAll groups expressed strong interest in PrEP products. In Kenya, FSWs said the products might help them earn more money, because they would feel safer accepting more clients or having sex without condoms for a higher price. SDCs said the products might replace condoms and reanimate couples’ sex lives. Most sex workers and SDCs preferred an injectable because it would last longer, required little intervention and was private. In South Africa, adolescent girls believed it would be possible to obtain the products more privately than condoms. Young women were excited about PrEP but concerned about interactions with alcohol and drug use, which often precede sex. Adolescents did not prefer a particular formulation but noted benefits and limitations of each; young women's preferences also varied.ConclusionsThe circumstances and preferences of sub-Saharan African women are likely to vary within and across groups and to change over time, highlighting the importance of choice in HIV prevention methods.

BackgroundAs pre-exposure prophylaxis (PrEP) moves closer to availability in developing countries, practical considerations for implementation become important. We conducted a consultation with district-level community stakeholders experienced in HIV-prevention interventions with at-risk populations in Bondo and Rarieda, Kenya to generate locally grounded approaches to the future rollout of oral PrEP to four populations: fishermen, widows, female sex workers, and serodiscordant couples.MethodsThe 20 consultation participants represented the Ministry of Health, faith- and community-based organizations, health facilities, community groups, and nongovernmental organizations. Participants divided into breakout groups and followed a structured discussion guide asking them to identify barriers to implementing HIV-prevention interventions (including PrEP) with each population. Questions also solicited solutions for addressing these barriers, as well as other facilitators for PrEP implementation. In particular, questions focused on how to encourage people to screen for PrEP eligibility by having HIV and other blood tests and how to encourage compliance with ongoing HIV testing.ResultsThe barriers and facilitators/solutions discussants provided were frequently population-specific, but there were also broad-level similarities across populations. Service delivery barriers to HIV-prevention interventions concerned the need for staff trained to address the needs of particular populations. Service delivery facilitators to provision of ongoing HIV testing consisted of offering testing options besides facility-based testing. Stigma was the main community-level barrier for all groups, whereas barriers at the level of target populations included mobility; lifestyle and life circumstances, especially cultural norms among fishermen and widows; and fears, lack of awareness, and misinformation. Proposed facilitators and strategies for addressing community- and population-level barriers included topic-specific education within the populations and community, involvement of partners and family members, mass HIV testing, and peer educators. Barriers to PrEP uptake included non-adherence to pill taking and missing clinic visits. For drug adherence, facilitators were counselling and involving family members. Discussants suggested that client reminders, e.g., home visits, were needed to encourage clients to keep their clinic appointments.ConclusionsStrategies for encouraging eligibility screening and ongoing HIV testing will have local and population-specific aspects. Our results nonetheless apply to similar populations throughout sub-Saharan Africa and reach beyond oral PrEP to other ARV-based PrEP formulations.

Editorial group: Cochrane Fertility Regulation Group. Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 4, 2019.

Qualitative Case Studies Were conducted at seven international sites conducting HIV prevention research in Africa, Asia, and the Americas to identify strategies for ensuring that health needs of research participants identified in the course of research are adequately addressed. Key factors were identified that contribute to the balance between direct care and healthcare referrals at a research site, as well as the overall quality of the healthcare made available to research participants. The case studies exemplify the concept of “moral negotiation” in research (Weijer & LeBlanc, 2006), that is, a process where researchers and sponsors negotiate with increasingly empowered local communities and host countries to achieve meaningful and substantive benefits from biomedical research for all stakeholders.

The female condom could play an important role in reducing HIV infection among female sex workers and their clients in Central America. Acceptability studies have shown that Central American sex workers are amenable to using the female condom, 1-3 but programs have not always successfully promoted long-term use. For example, promotional efforts by the Pan American Social Marketing Organization (PASMO) produced different results in different countries in the region: In Nicaragua in 2005, only 300 female condoms were distributed, and program staff reported acceptability to be low. In contrast, almost 12,000 were distributed in El Salvador from 2003 to 2005; once the supply of female condoms had been depleted, sex workers continued to ask when more would be available. 4 Given that the female condom could increase sex workers' overall number of protected sex acts 5-9 and protect them from STIs (including HIV) and pregnancy, 6,10-14 efforts to promote female condoms effectively to this specific target population are needed 15 -especially because exposure to mass-marketing campaigns does not necessarily translate into uptake. 16,17 To date, successful female condom programs for multiple populations have used provider training; targeted marketing; face-to-face communication with target populations; comprehensive training, including insertion practice and partner negotiation skills; practice with an anatomical model; encouragement; testimonials by satisfied users; integration of female condom use into HIV and STI prevention communications; a sustained supply of female condoms and low-cost distribution through public and private sector channels. [18][19][20][21][22] To encourage uptake and sustained use, program efforts should place particular emphasis on correct and consistent use of female condoms and partner negotiation skills. 12,23,24 In order for access and uptake to be sustained over the long term, programs must create and measure demand, 18 as well as ensure a steady supply of female condoms through the support of governments and donors. [25][26][27] Female condoms should also be easily accessible; in countries where the female condom is available, women have been able to obtain the device from pharmacies, hairdressers, HIV and AIDS support groups, and peers, as well as health clinics. 27 To inform strategies for promoting the female condom to female sex workers in Central America, we conducted formative research with sex workers at three sites in El