Improving HIV pre-exposure prophylaxis persistence among adolescent girls and young women: Insights from a mixed-methods evaluation of community, hybrid, and facility service delivery models in Namibia

Abstract

IntroductionDespite the potential for community-based approaches to increase access to pre-exposure prophylaxis (PrEP) for adolescent girls and young women (AGYW), there is limited evidence of whether and how they improve PrEP persistence. We compared PrEP persistence among AGYW receiving services through community and hybrid models in Namibia to facility-based services. We subsequently identify potential mechanisms to explain how and why community and hybrid models achieved (or not) improved persistence to inform further service delivery innovation.MethodsData were collected from PrEP service delivery to AGYW over two-years in Namibia's Khomas Region. We used Kaplan-Meier analysis to estimate survival curves for PrEP persistence beyond three-months after initiation and report the cumulative probability of persistence at one- and three-months. Persistence was defined as any PrEP use within three months after initiation followed by a PrEP refill or previously prescribed supply of at least 30 days at the three-month visit. Interviews were conducted with 28 AGYW and 19 providers and analyzed using a deductive-inductive thematic approach.ResultsFrom October 2017 through September 2019, 372 (18.7%) AGYW received services through a facility model, 302 (15.1%) through a community model, and 1,320 (66.2%) through a hybrid model. PrEP persistence at one- and three-months was 41.2% and 34.9% in the community model and 6.2% and 4.8% in the hybrid model compared to 36.8% and 26.7% in the facility model. Within the community and hybrid models, we identified three potential mechanisms related to PrEP persistence. Individualized service delivery offered convenience and simplicity which enabled AGYW to overcome barriers to obtaining refills but did not work as well for highly mobile AGYW. Consistent interactions and shared experiences fostered social connectedness with providers and with peers, building social networks and support systems for PrEP use. PrEP and HIV-related stigma, however, was widely experienced outside of these networks. Community-to-facility referral for PrEP refill triggered apprehension towards unfamiliar PrEP services and providers in AGYW, which discouraged persistence.ConclusionService delivery approaches that offer convenience and simplicity and foster social connectedness may reduce access barriers and increase social support enabling AGYW to self-manage their PrEP use and achieve improved PrEP persistence.

Preferences, educational messaging, and demand creation channels for multipurpose-prevention technologies (MPTs) among women in South Africa

“…An anticipated benefit of disclosing implant use to parents, friends and partners was support in the form of clinic attendance reminders. Findings from oral PrEP studies have found that the benefits of disclosure after PrEP initiation included social support for PrEP use, adherence reminders, and de-stigmatization of taking PrEP in front of others [ 51 , 52 ]. Similar findings have been noted in contraception use studies [ 53 , 54 ].…”

PrEP uptake and early persistence among adolescent girls and young women receiving services via community and hybrid community-clinic models in Namibia

“…Both models featured provider continuity, where the same DREAMS adolescent-friendly providers delivered all PrEP services. Such continuity, particularly where trusting relationships are formed with adolescent-friendly providers, may facilitate PrEP persistence among AGYW [ 10 , 48 , 49 ]. Both models also featured flexibility in service location, where an individual initiates PrEP in one location and receives refills in a different location.…”

“…Both models also featured flexibility in service location, where an individual initiates PrEP in one location and receives refills in a different location. This flexibility in service delivery, when client-led and client-centered, supports higher rates of persistence [ 49 , 50 ]. Where differences in service location are provider- or model-led, as to some extent in the community-fixed model and completely in the hybrid community-clinic model, it may introduce barriers to persistence, as was also experienced by AGYW receiving PrEP services through a mobile clinic in South Africa [ 48 ].…”

Awareness of Heightened Sexual and Behavioral Vulnerability as a Trigger for PrEP Resumption Among Adolescent Girls and Young Women in East and Southern Africa

“…Data from the DREAMS PrEP Program in Kenya, one of the largest real world demonstration projects, reported a median PrEP persistence time of 56 days among AGYW who initiated PrEP with the proportions of AGYW who persisted in the PrEP program at 1, 2, and 3 month(s) after PrEP initiation being 57%, 46%, and 37% respectively [ 30 ]. Further to this, data collected from DREAMS PrEP service delivery in Namibia’s Khomas Region (372 (18.7%) AGYW through a facility model, 302 (15.1%) through a community model, and 1320 (66.2%) through a hybrid model) showed PrEP persistence at 1 and 3 months to be 36.8% and 26.7% in the facility model, 41.2% and 34.9% in the community model, and 6.2% and 4.8% in the hybrid model [ 31 ]. The TB HIV Care (THC) PrEP program initiated 28100 AGYW on PrEP between 2018 and 2020.…”