Policy considerations for scaling up access to HIV pre‐exposure prophylaxis for adolescent girls and young women: Examples from Kenya, South Africa, and Uganda

Abstract

Adolescent girls and young women (aged 15-24 years; AGYW) continue to carry a disproportionate burden of HIV in sub-Saharan Africa. Pre-exposure prophylaxis (PrEP) helps reduce the risk of acquiring HIV for persons at substantial risk, including AGYW. As countries plan for the rollout of PrEP across sub-Saharan Africa, PrEP policies and programs could address the unique needs of AGYW.The purpose of this analysis was to identify policy considerations to improve AGYW access to PrEP. After reviewing the literature, we identified 13 policy considerations that policymakers and stakeholders could evaluate when developing or reviewing PrEP-related policies. We sorted these considerations into five categories, which together comprise an AGYW Access to PrEP Framework: AGYWfriendly delivery systems, clinical eligibility and adherence support, legal barriers and facilitators, affordability, and community and AGYW outreach. We also reviewed policies in three countries (Kenya, South Africa, and Uganda) to explore how PrEP-related policies addressed these considerations. Some of these policies addressed some of the 13 policy considerations, but none of the policies directly addressed the unique needs of AGYW for accessing PrEP.

Preferences for Long-Acting PrEP Products Among Women and Girls: A Quantitative Survey and Discrete Choice Experiment in Eswatini, Kenya, and South Africa

“…In 2021, WHO broadened PrEP recommendations beyond such narrowly defined groups, which enables more equitable access and is likely to be less stigmatizing than targeting specific risk groups [ 5 ]. These and other policy changes [ 34 ] along with investments in further oral PrEP scale-up have resulted in nearly three-quarters of a million cumulative people initiating PrEP across Eswatini, Kenya, and South Africa to date [ 35 ].…”

“These Girls Have a Chance to be the Future Generation of HIV Negative”: Experiences of Implementing a PrEP Programme for Adolescent Girls and Young Women in South Africa

“…This point is discussed in the literature on the ethical and legal issues of requiring parental/guardian consent for PrEP amongst adolescents, which can inhibit access and uptake for the reason that requesting consent entails disclosure of sexual activity [ 25 , 26 ]. Debates on parental consent for PrEP centre around interpretation of the South African Children’s Act 38 of 2005, which makes provision for children from the age of 12 to give their own consent for medical treatment; in this case, if PrEP is interpreted as ‘medical treatment’, then self-consent for PrEP is permissible for persons over 12 years, if they have the mental capacity and maturity to understand the benefits, risks, social and other implications of the proposed treatment [ 5 , 20 , 27 ]. Opponents to this view posit that whilst the Children’s Act provides clarity on consent to most medical interventions for children under 18 years, it does not directly address the age at which adolescents might self-consent to non-specified preventive interventions such as PrEP [ 5 ].…”

“…Opponents to this view posit that whilst the Children’s Act provides clarity on consent to most medical interventions for children under 18 years, it does not directly address the age at which adolescents might self-consent to non-specified preventive interventions such as PrEP [ 5 ]. However, PrEP proponents argue that although PrEP is not expressly referred to in the Children’s Act, it should be interpreted as being a form of ‘medical treatment’ so that it falls within the ambit of one of consent norms in the Children’ s Act, and therefore can be accessed independently by adolescents from the age of 12 onwards as a form of medical treatment [ 4 , 20 , 28 ]. The matter of parental consent has recently arisen in relation to vaccinations for COVID-19, causing similar debate [ 27 ].…”

“…Clinic and outreach services were intended to be equipped to initiate PrEP for AGYW beneficiaries who tested HIV negative and were assessed to be ‘at risk’ at these sites. Guided by the South African Children’s Act 38 of 2005, which allowed mature adolescent girls to self-consent to PrEP as early as 12 years of age [ 20 ], AGYW were able to initiate onto PrEP without parental consent. Early on in the grant implementation period, each principal grant recipient (PR) developed provincial PrEP Implementation plans with NDoH, to ensure harmonisation of Global Fund PrEP targets, roll-out and delivery methodologies with Departmental procurement, strategies and protocols.…”

Oral PrEP Consultations Among Adolescent Girls and Young Women in Kisumu County, Kenya: Insights from the DREAMS Program

“…Although we cannot disentangle these relationships, this PEP-PrEP connection suggests that AGYW with an existing linkage to the healthcare system were more likely to report PrEP consultations. Due to structural and community barriers, accessing healthcare systems can be precarious for AGYW [ 29 , 79 , 80 ]. Rather than have it siloed in clinics, PrEP services might be best delivered using community-based approaches—such as mobile or pop-up clinics—that bring care to areas that AGYW frequent.…”