Antiretroviral therapy based HIV prevention targeting young women who sell sex: a mixed method approach to understand the implementation of PrEP in a rural area of KwaZulu-Natal, South Africa

ABSTRACT

Pre-Exposure Prophylaxis (PrEP) is a potential game-changer for HIV. We used PrEP introduction for Young Women Who Sell Sex (YWSS) in a rural South Africa district to understand community norms and PrEP coverage in YWSS. Between 2017 and 2018, we measured awareness and uptake of PrEP in a representative cohort of 2184 Adolescent Girls and Young Women (AGYW) aged 13–22. We conducted group discussions with young people and community members (19); key informant interviews (9), in-depth interviews with 15–24 year-olds (58) and providers (33). Interviews were analysed using thematic analysis. PrEP awareness increased from 2% to 9%. Among 965 AGYW sexually-active by 2018, 13.4% (95%CI: 11.4%–15.7%) reported transactional sex and 10.6% (95%CI: 8.85–12.7%) sex for money. Of the 194 YWSS, 21 were aware of PrEP, but none had used it. Youth were enthusiastic about PrEP as tool for HIV prevention; whilst older community members were cautious about a technology they had limited experience with but could benefit select groups. Teachers and healthcare providers were concerned that PrEP would lower personal responsibility for sexual health. In conclusion, the narrow and limited introduction of PrEP to YWSS reduced the accessibility and reach. Introducing PrEP as part of sexual healthcare may improve demand and access for YWSS.

KEYWORDS:

• Access framework
• acceptability
• adolescents
• young women who sell sex
• female-sex workers
• pre-exposure prophylaxis (PrEP)
• HIV prevention interventions

Acknowledgements

We would like to thank all the participants who contributed data to this study and the data collection teams from AHRI who collected the quantitative and qualitative data.- Miss D Mthethwa, Mr SD Mdluli, Mr KC Mngomezulu, Miss PN Mthethwa, Mr Z Xulu, Mr M Nhlenyama, Ms NL Ntombela, Mr MT Nzuza, Miss Q Shandu, Miss P Khanyile, Mr S Hlongwane, Mrs NC Fakude, Miss TG Dlamini, Miss SQ Ntshangase, Mr S Nsibande, Miss NN Mbatha, Mrs ZB Mathenjwa, Mrs Z Cumbane, Ms K Ngobese, Ms B Mbatha, Miss G Buthelezi, Ms N Buthelezi, and Ms M Myeni.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics approval and consent to participate

Ethics approval was received from the University of KwaZulu-Natal Biomedical Research Ethics Committee (BFC339/19) and the London School of Hygiene and Tropical Medicine (REF11835). Written informed consent was obtained from all participants prior to data collection.

Data availability statement

The data that support the findings of this study are available from corresponding author [MS] upon reasonable request.

Authors contributions

NC, MS, NM, JS conceptualised the study, NC,TZ, MS, SN, JD performed the research, MS, IB, SF designed the research study. NM, KB, MS, NC analysed the quantitative data and KB, GH, NMcG, MS critically reviewed it. NC, TZ, MS, SN and IB analysed the qualitative data, and LS and JS critically reviewed it. NC and MS wrote the manuscript. All authors read, critically reviewed, edited and approved the final manuscript.

Additional information

Funding

The impact evaluation of DREAMS is funded by the Bill and Melinda Gates Foundation (OPP1136774, http://www.gatesfoundation.org). Foundation staff advised the study team, but did not substantively affect the study design, instruments, interpretation of data, or decision to publish. The research leading to these results has received funding from the People Programme (Marie Curie Actions) of the European Union’s seventh Framework Programme FP7/2007-2013 under REA grant agreement no. 612216 and the National Institutes of Health under award number 5R01MH114560-03. Africa Health Research Institute is supported by core funding from the Wellcome Trust [Core grant number (082384/Z/07/Z)]. NMcG is a recipient of an NIHR Research Professorship award (Ref: RP-2017-08-ST2-008). GH is supported by a fellowship from the Wellcome Trust and the Royal Society (210479/Z/18/Z). All the funding bodies had no role in the design of the study, and collection, analysis and interpretation of data and in writing of the manuscript.