Reaching at-risk women for PrEP delivery: What can we learn from clinical trials in sub-Saharan Africa?

Abstract

Introduction ARV-based pre-exposure prophylaxis (PrEP) has the potential to avert many new HIV infections, yet little is known about how to reach women at high risk for HIV infection and motivate them to initiate PrEP. Clinical trials have succeeded in recruiting at-risk participants, evidenced by control arm HIV incidence ≥3% (defined by the World Health Organization as “substantial risk”). We examined experiences from HIV prevention trials to document recruitment strategies and identify practical, potentially effective strategies for reaching women in real-world PrEP delivery. Methods We conducted semi-structured qualitative phone interviews with 31 staff from five countries who had worked on one or more of seven ARV-based HIV prevention clinical trials. Questions explored recruitment strategies used to reach women at risk of HIV and to successfully communicate about PrEP (inclusive of oral and vaginal formulations). We structurally coded data in NVivo and analyzed codes to derive themes. We conducted results interpretation webinars with research and programmatic stakeholders to validate findings and develop recommendations. Results Clinical trial researchers employed a range of recruitment strategies to recruit at-risk women. They recommended engaging the local community and potential PrEP users via community events, meetings with gatekeepers, and use of community advisory boards; and they encouraged interpersonal communication like presentations in waiting rooms and door-to-door recruitment to address personal concerns and prevent misinformation. Participants also stressed the importance of addressing the challenges that already exist within the health system to create a more enabling environment and delivering positive messages through a variety of communication channels to normalize PrEP. Conclusions Findings from this study provide important insights into potentially effective ways for countries currently rolling out oral PrEP to reach at-risk women with information about PrEP and promote uptake.

Test and Prevent: Evaluation of a Pilot Program Linking Clients With Negative HIV Test Results to Pre-exposure Prophylaxis in Zimbabwe

“… 37 Community sensitization should not target just potential PrEP users, but also partners and family members to foster support. 38 , 39 While community sensitization has the potential to make it easier for providers to counsel on PrEP, higher PrEP demand has workload implications that need to be considered in this context.…”

Health Care Providers’ Attitudes Toward and Experiences Delivering Oral PrEP to Adolescent Girls and Young Women in Kenya, South Africa, and Zimbabwe

“…At the same time, building the skills and e cacy of stigmatized groups to challenge stigma has been identi ed as a best practice [62]; training AGYW to be PrEP ambassadors in their communities could help reduce PrEP stigma and promote AGYW PrEP use [63,64]. Finally, promoting PrEP as a method for anyone who wants to promote wellness, rather than a method for high-risk -and often highly stigmatized -groups, could help reduce stigma [49,[65][66][67]. Study results also informed the development of an HIV Prevention Ambassador Training Curriculum for Adolescent Girls and Young Women, which prepares AGYW ambassadors to support their peers to learn about PrEP as part of combination HIV prevention and to support peers who decide to use PrEP.…”

Low Awareness of Oral and Injectable PrEP Among High-risk Adolescent Girls and Young Women in Kampala, Uganda

“…The majority of volunteers (> 90%) in our study engaged in transactional sex; alcohol consumption in this context occurs within sex work venues such as bars and nightclubs often as a way of coping with sex work (42). It is possible that during the national oral PrEP roll out, the Ministry of Health and other stakeholders prioritized oral PrEP educational interventions in locations where key populations congregated, e.g., bars and nightclubs (43).…”