BackgroundOral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa. However, health care providers’ (HCPs) perspectives and interactions with potential clients can substantially influence effective provision of quality health services. We examine if HCPs’ knowledge, attitude, and skills, as well as their perceptions of facility readiness to provide PrEP are associated with their willingness to provide PrEP to AGYW at high risk of HIV in Tanzania.MethodsA self-administered questionnaire was given to 316 HCPs from 74 clinics in two districts and 24 HCPs participated in follow-up in-depth interviews (IDIs). We conducted bivariate and multivariable Poisson regression to assess factors associated with willingness to provide PrEP to AGYW. Thematic content analysis was used to analyze the IDIs, which expanded upon the quantitative results.ResultsFew HCPs (3.5%) had prior PrEP knowledge, but once informed, 61.1% were willing to prescribe PrEP to AGYW. Higher negative attitudes toward adolescent sexuality and greater concerns about behavioral disinhibition due to PrEP use were associated with lower willingness to prescribe PrEP. Qualitatively, HCPs acknowledged that biases, rooted in cultural norms, often result in stigmatizing and discriminatory care toward AGYW, a potential barrier for PrEP provision. However, better training to provide HIV services was associated with greater willingness to prescribe PrEP.Conversely, HCPs feared the potential negative impact of PrEP on the provision of existing HIV services (e.g., overburdened staff), and suggested the integration of PrEP into non-HIV services and the use of paramedical professionals to facilitate PrEP provision.ConclusionsPreparing for PrEP introduction requires more than solely training HCPs on the clinical aspects of providing PrEP. It requires a two-pronged strategy: addressing HCPs’ biases regarding sexual health services to AGYW; and preparing the health system infrastructure for the introduction of PrEP.

BackgroundWhile links between intimate-partner violence (IPV) and HIV risk have been established, less is known about violence perpetrated by people other than intimate partners. In addition, much of the research on IPV has been conducted with adults, while relatively little is known about violence experienced by adolescent girls and young women (AGYW). We examined experiences of sexual violence and associated sexual and mental health among AGYW in Kenya and Zambia.MethodsUsing cross-sectional surveys with women aged 15–24 years, we assessed experience of partner sexual violence among respondents who reported a boyfriend/husband in the last 12 months (Kenya N = 597; Zambia N = 426) and non-partner sexual violence among all respondents (Kenya N = 1778; Zambia N = 1915). We conducted logistic regression analyses to examine experiences of sexual violence and health outcomes.ResultsSexual violence from intimate partners over the last year was reported by 19.1 percent of AGYW respondents in Kenya and 22.2 percent in Zambia; sexual violence from non-partners was reported by 21.4 percent in Kenya and 16.9 percent in Zambia. Experience of sexual violence was associated with negative health outcomes. Violence from non-partners was associated with increased odds of STI symptoms and increased levels of anxiety and depression. Results were similar for violence from partners, although only significant in Kenya. While sexual violence from a non-partner was associated with increased HIV risk perception, it was not associated when the violence was experienced from an intimate partner.ConclusionsAGYW reported high levels of sexual violence from both intimate partners and non-partners. These experiences were associated with negative health outcomes, though there were some differences by country context. Strengthening sexual violence prevention programs, increasing sexual violence screening, and expanding the provision of post-violence care are needed to reduce intimate and non-partner violence and the effects of violence on AGYW.

IntroductionEthiopia is experiencing an increasingly urban HIV epidemic, alongside a rise in urban adolescent migration. Adolescent migrants are often confronted by unique social challenges, including living in a difficult environment, abuse and mental health problems. These issues can increase adolescents’ vulnerability to HIV and compromise their capacity to protect themselves and others from HIV. We piloted and assessed the effects of a targeted psychosocial intervention to reduce mental health problems and improve HIV-related outcomes among migrant adolescents in Addis Ababa.MethodsA pre- and post-comparison design was used in a cohort of 576 female and 154 male migrant adolescents aged 15 to 18 years in Addis Ababa receiving services from two service delivery organizations, Biruh Tesfa and Retrak. We implemented a three-month client-centred, counsellor-delivered psychosocial intervention, based on findings from formative research among the same target population, to address participants’ increased vulnerability to HIV. The intervention package comprised individual, group and creative arts therapy counselling sessions. Key outcome indicators included anxiety, depression, aggressive behaviour, attention problems, social problems, knowledge of HIV, safer sex practices and use of sexual health services. Longitudinal data analysis (McNemar test and random effects regression) was used to assess changes over time in key indicators by gender.ResultsFor females, aggressive behaviour decreased by 60% (adjusted odds ratio (AOR): 0.4 (0.25 to 0.65)) and any mental health problem decreased by 50% (AOR: 0.5 (0.36 to 0.81)) from baseline to end line. In addition, knowledge of HIV increased by 60% (AOR: 1.6 (1.08 to 2.47)), knowledge of a place to test for HIV increased by 70% (AOR: 1.7 (1.12 to 2.51)) and HIV testing increased by 80% (AOR: 1.8 (1.13 to 2.97)). For males, HIV knowledge increased by 110% (AOR: 2.1 (1.1 to 3.94)), knowledge of a place to test for HIV increased by 290% (AOR: 3.9 (1.02 to 14.9)), HIV testing increased by 630% (AOR: 7.3 (2.6 to 20.7)) and use of sexual health services increased by 220% (AOR: 3.2 (1.62 to 6.27)). We did not find any significant reduction in mental health problems among male adolescents.ConclusionsOur findings suggest that a psychosocial intervention was associated with increased knowledge and uptake of HIV and sexual health services among both male and female migrant adolescents and with reduced mental health problems among female adolescents. Mental health problems varied significantly for male and female adolescents, suggesting that future interventions should be tailored to address their different needs and would benefit from intensive follow-up efforts.

Objectives We examined key gender, interpersonal and community dynamics influencing PrEP acceptability among adolescent girls and young women (AGYW) and their male partners. Methods We administered 12 in-depth interviews (IDI) to partnered, or married AGYW aged 15–24 years living without HIV, and 16 IDIs to male partners living without HIV aged 18 or older, partnered or married to an AGYW in Tanzania. Card sorting, a participatory qualitative method for facilitating systematic discussion, was used to identify attitudes, values, and desires that would influence PrEP acceptability. Results Relationship distrust, partner communication about HIV risk, and need to control HIV risk were highly influential considerations for PrEP use. AGYW and male partners both wanted to discuss PrEP use amidst relationship distrust, while most male partners encouraged AGYW PrEP use for shared protective benefit. Anticipated stigma of being perceived as a person living with HIV, as a result of PrEP use, was a deterrent for both AGYW and male partners while AGYW also feared additional stigma of being considered sexually promiscuous. Conclusions Couples counseling for PrEP uptake and adherence might be a well-placed strategy for couples who are living without HIV to educate one another about the relationship benefits of using PrEP, thereby increasing its acceptance and adherence, addressing unequal power dynamics, and reducing associated relationship distrust. Community awareness and education about PrEP can help curb persistent PrEP stigma, including intersectional stigma.

BackgroundSubstantial concern exists about the high risk of sexually transmitted HIV to adolescent girls and young women (AGYW, ages 15–24) in Eastern and Southern Africa. Yet limited research has been conducted with AGYW’s male sexual partners regarding their perspectives on relationships and strategies for mitigating HIV risk. We sought to fill this gap in order to inform the DREAMS Partnership and similar HIV prevention programs in Uganda.MethodsWe conducted 94 in-depth interviews, from April-June 2017, with male partners of AGYW in three districts: Gulu, Mukono, and Sembabule. Men were recruited at community venues identified as potential transmission areas, and via female partners enrolled in DREAMS. Analyses focused on men’s current and recent partnerships and HIV service use.ResultsMost respondents (80%) were married and 28 years old on average. Men saw partner concurrency as pervasive, and half described their own current multiple partners. Having married in their early 20s, over time most men continued to seek out AGYW as new partners, regardless of their own age. Relationships were highly fluid, with casual short-term partnerships becoming more formalized, and more formalized partnerships characterized by periods of separation and outside partnerships. Nearly all men reported recent HIV testing and described testing at distinct relationship points (e.g., when deciding to continue a relationship/get married, or when reuniting with a partner after a separation). Testing often stemmed from distrust of partner behavior, and an HIV-negative status served to validate respondents’ current relationship practices.ConclusionsAcross the three regions in Uganda, findings with partners of AGYW confirm earlier reports in Uganda of multiple concurrent partnerships, and demonstrate substantial HIV testing. Yet they also unearth the degree to which these partnerships are fluid (switching between casual and/or more long-term partnerships), which complicates potential HIV prevention strategies. Context-specific findings around these partnerships and risk are critical to further tailor HIV prevention programs.