PrEP use and HIV seroconversion rates in adolescent girls and young women from Kenya and South Africa: the POWER demonstration project

Abstract

Introduction HIV incidence remains high among African adolescent girls and young women (AGYW). The primary objective of this study is to assess pre‐exposure prophylaxis (PrEP) initiation, use, persistence and HIV acquisition among African AGYW offered PrEP in order to inform PrEP scale‐up. Methods POWER was a prospective implementation science evaluation of PrEP delivery for sexually active HIV‐negative AGYW ages 16–25 in family planning clinics in Kisumu, Kenya and youth and primary healthcare clinics in Cape Town and Johannesburg, South Africa. Follow‐up visits occurred at month 1 and quarterly for up to 36 months. PrEP users were defined based on the month 1 refill. PrEP persistence through month 6 was assessed using Kaplan–Meier survival analysis among AGYW with a month 1 visit, defining non‐persistence as an ≥15 day gap in PrEP availability for daily dosing. PrEP execution was evaluated in a subset with PrEP supply from the prior visit sufficient for daily dosing by measuring blood tenofovir diphosphate (TFV‐DP) levels. Results From June 2017 to September 2020, 2550 AGYW were enrolled (1000 in Kisumu, 787 in Cape Town and 763 in Johannesburg). Median age was 21 years, 66% had a sexual partner of unknown HIV status, and 29% had chlamydia and 10% gonorrhoea. Overall, 2397 (94%) initiated PrEP and 749 (31%) had a refill at 1 month. Of AGYW who could reach 6 months of post‐PrEP initiation follow‐up, 128/646 (20%) persisted with PrEP for 6 months and an additional 92/646 (14%) had a gap and restarted PrEP. TFV‐DP levels indicated that 47% (91/193) took an average of ≥4 doses/week. Sixteen HIV seroconversions were observed (incidence 2.2 per 100 person‐years, 95% CI 1.2, 3.5); 13 (81%) seroconverters either did not have PrEP dispensed in the study interval prior to seroconversion or TFV‐DP levels indicated <4 doses/week in the prior 6 weeks. Conclusions In this study of PrEP integration with primary care and reproductive health services for African AGYW, demand for PrEP was high. Although PrEP use decreased in the first months, an important fraction used PrEP through 6 months. Strategies are needed to simplify PrEP delivery, support adherence and offer long‐acting PrEP options to improve persistence and HIV protection.

Prospective study of oral pre‐exposure prophylaxis initiation and adherence among young women in KwaZulu‐Natal, South Africa

“…The HIV incidence rates among oral PrEP users in our study (3.19 [95% CI: 1.70–5.58] per 100 py) were high but comparable to that of other studies. In the POWER study, HIV incidence was 2.1 per 100 py [20] and in HPTN082, 1.0 per 100 py [18]. Similar high HIV incidence rates were observed in the VOICE and FEM‐PrEP trials (5.7 per 100 py and 4.7 per 100 py, respectively) [16, 17].…”

“…A high initiation of oral PrEP has been observed among young African women aged 16–25 years in several recent studies, for example in the HPTN082 and POWER studies, oral PrEP initiation was >90% [18, 20]. However, in clinical trials where oral PrEP was provided as part of HIV prevention standard of care, initiation has been lower—in the ECHO trial, where oral PrEP was provided on‐site during the latter part of the trial, initiation of oral PrEP was 27% at the SA trial sites [24], while in the HVTN702 vaccine study, self‐reported oral PrEP use was <1% [25].…”

“…In HPTN082, oral PrEP initiation was high at 95%, and plasma tenofovir (>40 ng/ml) was 48% at 3 months [18]. Other studies/demonstration projects evaluating oral PrEP initiation and adherence among young women have been conducted in several African countries [7], including the EMPOWER [19], POWER [20] and PLUSPILLS [21] studies. Given ongoing high incidence rates of HIV among young women in SA, we undertook this study to determine oral PrEP initiation and adherence, and its impact on HIV incidence rates in young, sexually active women in KwaZulu‐Natal.…”

Systematic Review of mHealth Interventions for Adolescent and Young Adult HIV Prevention and the Adolescent HIV Continuum of Care in Low to Middle Income Countries

“…Our search was based on a broad interpretation of adherence, including initiation, execution, and persistence of PrEP use [61]. The majority of studies focused on older adolescents and young adults [33,[37][38][39][40][41][42]51]. The technology approaches to PrEP adherence included smartphone-based psychoeducational and medication adherence apps; SMS or telephone-based educational and adherence support messages; and social media outreach.…”

“…Our search of abstracts revealed five additional studies. In a conference abstract about the POWER demonstration project, Celum et al reported high PrEP initiation but low persistence when PrEP was delivered in multiple youth-friendly models in South Africa and Kenya; SMS, WhatsApp, and phone calls were utilized for PrEP refill reminders [39]. Pintye et al conducted a pilot prospective a pre-intervention group, women starting PrEP were more likely to return to clinic and to continue taking PrEP at one month; longer follow-up was not presented.…”