Evaluating Measures Of Hiv Risk Perception With A Mixed Method Approach Among Adolescent Girls And Young Women Using Prep In Kenya PDF Download

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Evaluating Measures of HIV Risk Perception with a Mixed Method Approach Among Adolescent Girls and Young Women Using PrEP in Kenya

Evaluating Measures of HIV Risk Perception with a Mixed Method Approach Among Adolescent Girls and Young Women Using PrEP in Kenya
Author: Murugi Micheni
Publisher:
Total Pages: 32
Release: 2020
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Pre-exposure prophylaxis (PrEP) for HIV prevention is a promising HIV prevention option for young African women. The evidence of effective PrEP use in this population group is mixed, and has been tied to poor adherence. Discordance between assessed HIV risk and the actual experience of risk may underlie the dissonance observed between epidemiologic risk, risk perception, uptake of and adherence to prevention measures. We examined the contribution of research methods used in characterising HIV risk to this dissonance by contrasting HIV risk awareness as assessed by standard structured questionnaires and qualitative in-depth interviews. Methods: We conducted secondary analysis of data from a trial of African women aged 18 to 24 years interested in taking PrEP. Enrollment took place at two sites in Thika and Kisumu, Kenya, and participants were followed up for a period of 24 months between 2017 and 2020. We conducted a multi-step mixed methods assessment of HIV risk awareness and related decision-making behaviour. First, a quantitative analysis of survey data with descriptive statistics to characterize the cohort, proportion testing for trend and generalised estimating equations to assess the association between predictors of risk and risk perception. Secondly, an inductive content analysis of interview data for narrative themes; and lastly, joint display methodology to summarise findings from the two analytical methods. We enrolled 350 young women with a median age of 21 years (IQR 19, 22). At baseline, 182 (52%) participants reported feeling at risk for HIV. In multivariable analysis, reporting a lot of HIV worry was significantly associated with higher odds of risk perception (OR 1.95 [CI 1.31, 2.91]), while significantly lower odds were associated with visits at month 12 (OR 0.30 [CI 0.18, 0.48]) and 24 (OR 0.21 [CI 0.09, 0.20]), living with other family or employer (OR 0.56 [CI 0.33, 0.95]) and being single with a steady partner (OR 0.48 [CI 0.33, 0.70]). Qualitative data from 75 serial interviews provided insight into the changes observed over time in report of both risk awareness and sexual behavioural choices. We identified three major themes from the combined qualitative and quantitative analysis: risk dynamism, behavioural risk patterns and the influence of the social environment. HIV risk awareness and decision making was both intentional and contextual; driven primarily by HIV literacy, PrEP use, assessment of a partner0́9s HIV risk profile and the self-agency to exercise held knowledge. Effective risk mitigation was contingent on intimate partner relationship dynamics and was hindered by the fear of intimate partner violence. Supportive social environments enabled disclosure and promoted the self-agency to effectively mitigate risk. Knowledge of partner status and PrEP use emerged as the primary determinants of risk awareness and related decision making, informing both risk perception and mitigation. We observed complementarity and contrast between the two quantitative and qualitative data in how HIV risk was defined and rationalised, and identified factors at the individual, partnership and societal levels that informed risk awareness and related decision-making. Interview data expounded on the quantitative findings and revealed a more dynamic and rationalised experience of risk than was observed in survey data. The experience of HIV risk by young African women was not haphazard, but rather was rationalised based on HIV and PrEP literacy, current knowledge of partner status and attitudes, and prevailing sexual and economic needs. HIV related decision making was dependent not just on having access to preventive measures, but also on the agency and wherewithal to actualize known mitigation measures. Further work on how knowledge of partner HIV status and PrEP use can be leveraged to support HIV prevention and other sexual reproductive health programs targeting young women is warranted.

Improving Pre-exposure Prophylaxis Delivery for Young Women in Kenya

Improving Pre-exposure Prophylaxis Delivery for Young Women in Kenya
Author: Valentine Adhiambo Wanga
Publisher:
Total Pages: 82
Release: 2020
Genre:
ISBN:
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The rollout of pre-exposure prophylaxis (PrEP) for HIV prevention to priority populations, including young women, is expanding in sub-Saharan Africa. However, existing barriers to PrEP rollout at the individual, community and policy levels could slow progress and impede the success of PrEP implementation programs. In order to achieve success in HIV prevention, it is crucial to address these barriers, particularly among young women, a population especially vulnerable to HIV. In this dissertation, we evaluated the links among risk perception, sexual behavior and PrEP adherence in serodiscordant couples, evaluated the impact of incorporating HIVST in PrEP delivery for young women and assessed the cost of delivering PrEP to young women. In Aim 1, we used data from HIV-negative adults enrolled in a study of PrEP and antiretroviral therapy for HIV-serodiscordant couples in Kenya and Uganda to examine associations between: 1) condom use and risk perception and 2) risk perception and PrEP adherence. In Aim 2, we offered HIV self-testing (HIVST) to young women enrolled in a PrEP implementation study in two family planning clinics and assessed satisfaction with HIV testing and clinic experience, and the impact of HIVST on PrEP delivery procedures. In Aim 3, using the same population as that in Aim 2, we used micro-costing methods to estimate the incremental cost of delivering PrEP to young women. We found that sexual behavior aligned with perceived HIV risk, which can facilitate an HIV-negative individual's decisions about PrEP use. Additionally, we found HIVST to be feasible and acceptable for young women using PrEP, highlighting the need to evaluate its utility to streamline PrEP delivery and provide more testing options for young women on PrEP. Lastly, using practical data from PrEP implementation, we estimated the cost of delivering PrEP to young women, providing valuable data to inform budget impact and cost-effectiveness analyses as well as local resource allocation for scale-up of PrEP delivery to young women. Collectively, these studies addressed some of the barriers to PrEP delivery, proposed solutions to these barriers and drew attention to priority research needs for PrEP delivery to young women.

Risk Perception Among HIV Serodiscordant Couples in East Africa Taking Oral PrEP for HIV Prevention

Risk Perception Among HIV Serodiscordant Couples in East Africa Taking Oral PrEP for HIV Prevention
Author: Jennifer J. Carroll
Publisher:
Total Pages: 34
Release: 2015
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ISBN:
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Levels of adherence varied across trials for pre-exposure prophylaxis (PrEP) for HIV prevention. One hypothesis for this inconsistency is that low perceived risk of HIV infection drove low adherence in trials where PrEP produced no reduction in risk. Using a mixed methods approach, we explored the level of perceived risk of incident HIV infection in the Partners PrEP Study, in which adherence was generally high. The Partners PrEP Study followed 4747 serodiscordant couples in Kenya and Uganda. A brief cross-sectional survey assessed perceived risk of HIV via questionnaire at 12 months after enrollment. Logistic regression was used to analyze the relationship between perceived risk and demographic variables, sexual behavior, and other objective measures of risk. 3226 couples from the Partners PrEP Study were included in this analysis. Perceived risk was low across the entire study cohort, with only 15.4% of participants reporting high or moderate perceived risk. Participants objectively assessed to be at higher risk for HIV were more likely to report high perceived risk (OR=1.60, 95%CI: 1.30-1.95, p

Sexual Behaviour and HIV Risk Among Young Women Using PrEP in Kenya

Sexual Behaviour and HIV Risk Among Young Women Using PrEP in Kenya
Author: Nicholas Boro Thuo
Publisher:
Total Pages: 15
Release: 2021
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ISBN:
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Adolescent girls and young women (AGYW) in sub-Saharan Africa are disproportionately affected by HIV. In 2020, UNAIDS estimated that AGYW contributed 30% of all new HIV infections in sub-Saharan Africa and were 2.5 times more likely to acquire HIV than young men of the same age1. PrEP is an effective HIV prevention tool available to them. However, multiple studies report that PrEP use in this age group is not sustained after initiation. If AGYW maintain sexual activity and multiple partners after discontinuing PrEP, they return to having potential risk for acquiring HIV. Questions remain about whether AGYW maintain a consistent level of sexual activity and HIV risk if this risk can be assessed using validated scoring tools, including the VOICE risk score. Between 2016 and 2018, 350 young women aged 18-24 years with high risk of HIV were enrolled into the monitoring PrEP among young adult women (MPYA) study in Kisumu and Thika, Kenya and followed for up-to 24 months. Participants were offered PrEP, provided adherence support through reminder short message service (SMS), and monitored for PrEP adherence via electronic pill boxes. Data on adherence, sexual risk behavior and risk perceptions were collected during quarterly study visits. We used generalized estimating equations to estimate whether the number of sexual partnerships, condomless sex acts, and self-assessed risk perception were associated with the level of HIV risk score. At baseline, the median age was 21 years, majority reported high school. Completion, 55% were single but had a stable partner, majority being students (38.9%). When comparing those who had a high >̲6) versus a moderate risk score(4,5), The likelihood of having a high risk score was greater among AGYW with more partners (odds ratio [OR] 2.2,95% CI 1.6, 3.1) and those who reported >̲1 casual partners (OR 2.2, 95% CI: 1.6, 3.1) but neither were statistically significant different after adjustment for confounding factors. The likelihood of reporting any condomless sex was similar in both groups with an OR of 1.0 (95% CI 0.7, 1.4). When adjusted for confounding, the difference was statistically significant with an adjusted OR of 1.3 (95% CI: 1.1, 2.5). There was a reduction in self-assessed perception of being at risk of HIV, from 52% at enrolment to 12% at month 24 feeling at risk. There was no association between the score and self-assessed risk perception. In our study we found that sexual risk behavior was similar among those with moderate or high risk on the VOICE scoring tool. We need to identify risk scoring tools that capture HIV sexual risk and the varying levels of risk to support appropriate, client-tailored counseling about HIV and HIV prevention options for AGYW.

"You are Your Own Driver"

Author: Zoe Rogers
Publisher:
Total Pages: 25
Release: 2020
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ISBN:
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Objectives: To understand key influences on decisions to accept or decline pre-exposure prophylaxis (PrEP) for HIV prevention among Kenyan adolescent girls and young women (AGYW). Design: Qualitative interviews were conducted with two groups of HIV-uninfected AGYW aged 15-24 years: 1) those at-risk who declined PrEP ([greater than or equal to]1 sexual partner of unknown HIV status) and 2) those not at-risk who initiated PrEP (reported single HIV-uninfected partner). Methods: Semi-structured interviews (IDIs) were conducted with 47 HIV-uninfected Kenyan AGYW who were offered PrEP through Maternal and Child Health (MCH) and Family Planning (FP) clinics at four facilities in Kisumu County. IDIs were audio-recorded, translated into English, and transcribed. A qualitative descriptive analysis using a combination of conventional (inductive) and directed (deductive) content analysis methods was performed to elucidate common themes influencing PrEP uptake. Results: AGYW's decisions to initiate or decline PrEP were largely influenced by three major themes: 1) relationships with partners shaped perceived risks and benefits of PrEP use, 2) having a role as a mother or caregiver provided a strong desire to protect their child's health and future, and 3) PrEP attitudes, awareness, and logistics (e.g., acquiring, storing, and swallowing pills) facilitated or challenged PrEP uptake. The complex interplay between these factors influenced each women's specific decision to uptake or decline PrEP. Other factors such as being offered PrEP while receiving MCH or FP services, knowing a current PrEP user, and health literacy also affected PrEP use decisions. Conclusion: Future PrEP scale-up for AGYW within MCH and FP clinics should consider priorities and concerns prioritized by AGYW. PrEP demand creation will require increased PrEP awareness and sensitization in the community, messaging that addresses misconceptions and reduces disease- and behavior-related stigma, through targeted messaging in both FP and MCH clinics and the community in general.

Scaling Up and Out

Scaling Up and Out
Author: Stephanie Roche
Publisher:
Total Pages: 105
Release: 2021
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ISBN:
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In Kenya, daily oral pre-exposure prophylaxis (PrEP) for HIV prevention is a key component of the country’s national HIV/AIDS response. Since its approval by the Kenya national drug regulatory authority in 2015, PrEP has been rolled out predominantly in HIV clinics; however, the country’s 5-year plan for implementing PrEP at scale calls for integration of PrEP into other service delivery models and more efficient use of available resources. Currently, there is limited implementation science research to inform PrEP scale-up (i.e., expansion to additional HIV clinics) and scale-out (i.e., expansion to new service delivery models and populations) in Kenya. Our objective was to identify barriers and facilitators of PrEP integration and/or optimization in three healthcare settings: HIV clinics, family planning (FP) clinics, and retail pharmacies. In Aim 1, we analyzed data from a prospective cohort study delivering integrated PrEP-FP services to adolescent girls and young women (AGYW) at two FP clinics in Kisumu, Kenya. Using the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change (ERIC) compilation, we identified supply-side implementation strategies for integrating PrEP into routine FP services and contextual factors influencing strategy choice and outcome, as captured in routine monitoring and evaluation documents (n=213) and key informant interviews (n=15). We found that, overall, implementing PrEP was more labor intensive at a public FP clinic compared to a private, youth-friendly clinic because it required a series of implementation strategies to make the physical and social environment conductive to offering AGYW-centered care. Nevertheless, provider adoption of PrEP delivery was low at both clinics, likely due to the widespread perception that PrEP was not within their scope of work. We recommend that PrEP implementers approach PrEP implementation, in part, as a behavioral intervention for FP providers and specifically assess the need for implementation strategies that support providers’ clinical decision-making, address workload constraints, and establish clear worker expectations. In Aim 2, we conducted a pilot study of a one-stop shop (OSS) model for PrEP delivery at four public clinics in Western Province, Kenya and evaluated whether this model could improve care efficiency and acceptability without negatively impacting PrEP uptake or continuation. Interviews with clients (n=15) and providers (n=14), technical assistance reports (n=69), and clinic flow maps indicate that the OSS achieved efficiency gains by redirecting PrEP clients away from bottlenecks, moving steps closer together (e.g., relocating supplies; cross-training and task-shifting), and differentiating clients based on the subset of services needed. Analysis of time-and-motion observations (n=47) revealed that, following OSS implementation, median client wait time dropped significantly from 31 minutes to 6 minutes (p=0.02) while median time spent with a provider remained around 23 minutes (p=0.4). Clients and providers expressed a strong preference for the OSS model and additionally identified increased privacy, reduced stigma, and higher quality client-provider interactions as benefits of the OSS model. Controlled interrupted time series analysis of PrEP initiations (n=1227) and follow-up visits (n=2696) revealed no significant difference between intervention and control clinics in terms of trends in PrEP initiation and on-time returns (all p>0.05). We conclude that the OSS model is a promising option for reducing variability in service time and increasing client and provider satisfaction without adding additional human resources. In Aim 3, we conducted a formative research study to understand the acceptability and feasibility of retail pharmacy-based PrEP delivery. Using the CFIR, we conducted and analyzed in-depth interviews with 40 pharmacy clients, 16 pharmacy providers, 16 PrEP clients, and 10 PrEP providers from Kisumu and Kiambu Counties, Kenya. Most participants expressed strong support for expanding PrEP to retail pharmacies, though conditioned their acceptance on assurances that care would be private, respectful, safe, and affordable. Participant-reported determinants of feasibility centered primarily on ensuring that the intervention is compatible with retail pharmacy operations (e.g., adequate staffing; use of documentation systems that meet PrEP reporting requirements). Our findings may inform the development of a tailored package of implementation strategies for integrating PrEP into routine pharmacy practice.

Community Perceptions about Use of Pre-exposure Prophylaxis (PrEP) Among Adolescent Girls and Young Women

Community Perceptions about Use of Pre-exposure Prophylaxis (PrEP) Among Adolescent Girls and Young Women
Author: Jaclyn Escudero
Publisher:
Total Pages: 21
Release: 2019
Genre:
ISBN:
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Objectives: Adolescent girls and young women (AGYW) experience disproportionately higher rates of HIV acquisition compared to males of the same age, but PrEP uptake and continuation are low in this population. This study explored community perceptions around PrEP use among AGYW in Western Kenya. Design: Semi-structured in-depth focus group discussions (FGDs) were conducted with Community Advisory Board (CAB) members affiliated with two PrEP implementation projects targeting young women. Methods: FGDs were audio recorded, translated, and transcribed. Conventional content analysis and thematic networks analysis were used to identify themes relating to community perceptions of PrEP use among AGYW. Results: Four FGDs were conducted with 26 CAB members. Barriers to PrEP awareness among AGYW included lack of PrEP education in school HIV curriculum and failure of community leaders to sensitize and engage AGYW. Low uptake was thought to be associated with PrEP myths, and inaccurate understanding of who could benefit from PrEP and duration of use. AGYW may believe that PrEP is only for married/pregnant women or must be taken for life. PrEP use was viewed as unacceptable for AGYW in some communities because PrEP would increase "promiscuous" behavior, leading to decreased use of condoms and contraception, and increased STI incidence and pregnancy rates. Other barriers to uptake included confusion between PrEP and HIV treatment, lack of youth-friendly services at facilities, fear of HIV testing, and ease of access to condoms compared to PrEP. CAB members recommended integrating PrEP delivery into maternal and child health and family planning services, training community health volunteers to sensitize and deliver PrEP, and involving AGYW in policymaking as ways to improve access and uptake among AGYW. Conclusion: PrEP scale-up among AGYW will require community sensitization of AGYW to reduce stigma and clarify misperceptions.

Understanding the Influence of Socio-ecological Factors on Preexposure Prophylaxis (PrEP) Use in Adolescent Girls and Young Women in Africa

Understanding the Influence of Socio-ecological Factors on Preexposure Prophylaxis (PrEP) Use in Adolescent Girls and Young Women in Africa
Author: Geetha Beauchamp
Publisher:
Total Pages: 0
Release: 2022
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African adolescent girls and young women (AGYW) have one of the highest global HIV incidence rates despite increased access to highly effective oral preexposure prophylaxis (PrEP) for prevention, HIV testing, and linkage-to-care/viral suppression among men. Inconsistent PrEP adherence undermines PrEP benefits for AGYW. Qualitative research suggests that barriers to PrEP adherence include fear of disclosure of PrEP use, stigma, provider distrust, and poor social support. A reliable tool for predicting AGYW’s “PrEP readiness” would help identify who could benefit from greater PrEP adherence support. An improved understanding of the pathways affecting AGYW’s adherence is crucial to advancing adherence strategies. This research used data from the open-label HPTN 082 study conducted among AGYW (ages16-25 years) in South Africa and Zimbabwe. The HIV Prevention Readiness Measure (HPRM) questionnaire was adapted from the validated HIV Treatment Readiness Measure, which predicted viral suppression in HIV-positive youth in the U.S. The HPRM was administered to HPTN 082 participants at enrollment and again three months later. The aims of this research were to 1) evaluate the psychometric properties and the utility of the HPRM to predict PrEP adherence; 2) investigate the association between PrEP disclosure and adherence and whether it was moderated by social support and mediated through PrEP support; and 3) assess whether mistrust in the study team was associated with discordance between patient-reported PrEP adherence and an objective biomarker of PrEP adherence, intracellular tenofovir-diphosphate drug concentrations. The findings were: 1) overall HPRM score and the three subscales (self-efficacy, disclosure of PrEP use, and social support) are reliable and predicted increased PrEP adherence; and disclosure of PrEP use increased the odds of persistent adherence; 2) AGYW with supportive adults in their life and disclosed PrEP use to their parents had higher adherence; and 3) AGYW who expressed high trust in their providers had higher odds of both high self-reported and drug level measures of PrEP adherence. The research makes three significant contributions to improving PrEP delivery: 1) HPRM as a tool to assess PrEP readiness and focus adherence support on AGYW who have low self-efficacy, low social support, and no plans for disclosing PrEP use; 2) supporting AGYW to consider disclosing their PrEP use to the supportive adults in their lives; and 3) in provider PrEP training, discuss the importance of AGYW’s trust in their provider as essential to improving AGYW reporting actual PrEP use.

Evaluating PrEP Use and Safety Among Women of Reproductive Age in Sub-Saharan Africa

Evaluating PrEP Use and Safety Among Women of Reproductive Age in Sub-Saharan Africa
Author: Randy Matthew Stalter
Publisher:
Total Pages: 122
Release: 2021
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ISBN:
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In sub-Saharan Africa, oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) has emerged as an important HIV prevention strategy for women and is being scaled up rapidly in areas with high HIV burden. New, long-acting PrEP methods are also approaching introduction, including the dapivirine vaginal ring, which women can wear continuously and discreetly for up to one month. Greater choice means women are more likely to find a method that suits their specific needs and preferences. However, questions and challenges regarding PrEP use and safety among women of reproductive age remain, which we aimed to address in this dissertation. First, we validated a novel, urine-based tenofovir immunoassay as a potential point-of-care tool for assessing PrEP adherence using stored samples from the Partners PrEP Study (Chapter 2). Second, we estimated the per-sex-act relative HIV risk reduction among women exhibiting consistent use of the dapivirine ring in the ASPIRE trial based on an objective measure of ring exposure, the rate of dapivirine release from returned rings (Chapter 3). Third, we evaluated differences in changes in bone turnover markers associated with combined use of oral PrEP and depot medroxyprogesterone acetate (DMPA) among young women in Uganda (Chapter 4). Finally, we conducted a literature review on the safety of TDF-based PrEP use during pregnancy (Chapter 5). We demonstrated that urine tenofovir concentrations measured by the novel immunoassay has good sensitivity (87%) and specificity (73%) for detecting tenofovir in plasma. Additionally, tenofovir concentrations over a certain threshold indicative of PrEP use in the past day were predictive of a 71% reduction in HIV risk. We established the first per-sex-act dose-response model for dapivirine ring exposure and estimated 61% per-sex-act risk reduction with ring release rates indicative of continuous ring use. We identified no substantial changes in bone turnover biomarkers after 6 months of combined DMPA and PrEP use. Finally, we found that the current body of evidence on the safety of TDF-based PrEP use during pregnancy is reassuring but that additional data are needed. Additionally, more efforts are needed to increase representation of pregnant women in studies of new HIV prevention products. The findings from this dissertation contribute to efforts for improving women’s uptake of and adherence to PrEP in the coming years by validating a novel urine-based tenofovir immunoassay and providing a better understanding the efficacy of the dapivirine ring. Additionally, this work provides reassuring data on the safety of PrEP use during periods of contraception and pregnancy which may help to facilitate integration of PrEP into family planning and antenatal care services.

Evaluating Feasibility and Potential Impact of Text Messages to Increase HIV Testing Among Young Women in Rural Kenya

Evaluating Feasibility and Potential Impact of Text Messages to Increase HIV Testing Among Young Women in Rural Kenya
Author: Njambi Njuguna
Publisher:
Total Pages: 23
Release: 2015
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Background: More than half of HIV infected individuals in Kenya are unaware of their status and young women carry a disproportionate burden of incident HIV infections. We sought to increase HIV testing in young Kenyan women through a text messaging (SMS) intervention. Methods: We conducted a randomized quasi-experimental study to increase HIV testing among women 18-24 years old. Four technical training colleges in Central Kenya were randomized to have their study participants receive either weekly SMS on HIV and reproductive health topics or no SMS. Monthly 9-question SMS surveys were sent to all participants for 6 months to collect data on HIV testing, sexual behavior, and HIV risk perception. We used multivariate Cox proportional hazards regression to detect differences in the time to the first HIV test reported by women during the study period. Results: We enrolled 600 women between September 2013 and March 2014 of whom 300 received weekly SMS and monthly surveys and 300 received only monthly surveys. On average, women were 21 years of age (interquartile range [IQR] 20-22), 68% had ever had sex and 73% had never tested for HIV. A total of 356 women reported testing for HIV within the 6 months of follow up: 67% from the intervention arm and 51% from the control arm (hazard ratio=1.57, 95% confidence interval 1.28-1.92). Conclusions: Use of weekly text messages about HIV prevention and reproductive health significantly increased rates of HIV testing among young Kenyan women and would be feasible to implement widely among school populations.