“It Was Not My Aim to Sleep There”: The Impact of Timing and Location of Sex on Adherence to Coitally-Dependent HIV Pre-exposure Prophylaxis

Abstract

The FACTS 001 trial found that vaginal pre- and post-coital application of 1% tenofovir gel did not prevent HIV-1 infection amongst young South African women. The trial included a multi-faceted approach to adherence support and collected objective and self-reported adherence measures. Using qualitative data collected from a random sub-set of FACTS 001 participants (135 in-depth interviews at product discontinuation and 13 focus group discussions at dissemination of trial results), we explore the importance of 'place' and 'timing' in shaping acts of sexual intimacy and product adherence. Demographically, this qualitative sub-sample is similar to the trial cohort of predominantly young, unemployed women living with parents or other family members. Sexual intimacy was largely unpredictable and happened across multiple locations in which women had limited privacy, autonomy, or control over the timing of sex. This made adherence to the dosing strategy challenging. Findings may inform the development of future event-driven pre-exposure prophylaxis regimens or products.

HIV pre‐exposure prophylaxis for adolescent girls and young women in Africa: from efficacy trials to delivery

“…Group‐based interventions for youth offer an effective way to implement intervention content while providing social support from peers, given the importance of peer opinion during adolescence and evidence that peer norms are important in shaping adolescent behavior . Adherence support clubs were pioneered in the FACTS 001 trial , were found to be feasible and acceptable to participants and staff, and were identified spontaneously by participants during in‐depth interviews as an important source of adherence support . In HPTN 082, adherence clubs were incorporated into the standard adherence package that all participants received, were reported to be highly acceptable and rewarding, and club attendance was associated with higher adherence at three months (>700 fmol/punch TFV‐DP per punch) .…”

Adolescent girls and young women’s PrEP-user journey during an implementation science study in South Africa and Kenya

“…However, similar to previous research, for some AGYW, changes in relationship dynamics impacted their perception of HIV risk over time. Furthermore, the inability to accurately forecast sex complicated the practice of prevention-effective adherence [ 20 , 32 , 41 , 42 ]. In this study, convenient PrEP access within an integrated SRH, adolescent-friendly service supported both PrEP pauses and sometimes discontinuation.…”

Disclosure of PrEP use by young women in South Africa and Tanzania: qualitative findings from a demonstration project

“…These experiences also bring to light the practical challenges of daily pill-taking under the watchful eyes of others who share the same living space. Since residences in these settings are often cramped and overcrowded (Scorgie et al 2018), this may have restricted privacy for those who wished to hide their PrEP, ultimately forcing disclosure to household members. Arguably, PrEP's 'visibility' in this context is increased by its resemblance to antiretrovirals, its daily regimen, and need for pill storage, suggesting that the physical characteristics of the product itself may also have shaped disclosure within households.…”