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Successful scale-up of PrEP for HIV prevention in African adolescent girls and young women (AGYW) requires integration of PrEP into young women’s everyday lives. We conducted interviews and focus group discussions with 137 AGYW PrEP users aged 16–25 from South Africa and Kenya. Individual and relational enablers and disablers were explored at key moments during their PrEP-user journey from awareness, initiation and early use through persistence, including PrEP pauses, restarts, and discontinuation. PrEP uptake was facilitated when offered as part of an integrated sexual reproductive health service, but hampered by low awareness, stigma and misconceptions about PrEP in the community. Daily pill-taking was challenging for AGYW due to individual, relational and structural factors and PrEP interruptions (intended or unintended) were described as part of AGYW’s PrEP-user journey. Disclosure, social support, adolescent-friendly health counseling, and convenient access to PrEP were reported as key enablers for PrEP persistence.

Background Daily doses of pre-exposure prophylaxis (PrEP) can reduce the risk of acquiring HIV by more than 95 %. In sub-Saharan Africa, adolescent girls and young women (AGYW) are at disproportionately high risk of acquiring HIV, accounting for 25 % of new infections. There are limited data available on implementation approaches to effectively reach and deliver PrEP to AGYW in high HIV burden communities. Methods We explored the feasibility and acceptability of providing PrEP to AGYW (aged 16–25 years) via a community-based mobile health clinic (CMHC) known as the Tutu Teen Truck (TTT) in Cape Town, South Africa. The TTT integrated PrEP delivery into its provision of comprehensive sexual and reproductive health services (SRHS). We analyzed data from community meetings and in-depth interviews with 30 AGYW PrEP users to understand the benefits and challenges of PrEP delivery in this context. Results A total of 585 young women started PrEP at the TTT between July 2017 – October 2019. During in-depth interviews a subset of 30 AGYW described the CMHC intervention for PrEP delivery as acceptable and accessible. The TTT provided services at times and in neighborhood locations where AGYW organically congregate, thus facilitating service access and generating peer demand for PrEP uptake. The community-based nature of the CMHC, in addition to its adolescent friendly health providers, fostered a trusting provider-community-client relationship and strengthened AGYW HIV prevention self-efficacy. The integration of PrEP and SRHS service delivery was highly valued by AGYW. While the TTT’s integration in the community facilitated acceptability of the PrEP delivery model, challenges faced by the broader community (community riots, violence and severe weather conditions) also at times interrupted PrEP delivery. Conclusions PrEP delivery from a CMHC is feasible and acceptable to young women in South Africa. However, to effectively scale-up PrEP it will be necessary to develop diverse PrEP delivery locations and modalities to meet AGYW HIV prevention needs.

Adolescents and young adults (AYA) living with HIV face several challenges to engaging in HIV care, which can impact adherence to antiretroviral therapy (ART). Point-of-care (POC) diagnostics that detect tenofovir in urine may be a useful tool to support ART adherence, but perspectives from AYA in South Africa have not been explored. We conducted in-depth interviews (IDIs) among young people (age 18-24) newly diagnosed with HIV in Cape Town, and a focus group discussion (FGD) with HIV care providers to understand their perspectives regarding the use of POC urine tenofovir testing to support ART adherence. Transcripts were analyzed using Dedoose, with an iterative thematic approach. Transcripts from 8 IDI participants and 8 FGD participants were included in the analysis. Major themes identified during analysis related to beliefs about POC urine adherence testing and recommendations for future clinical implementation. Most IDI participants indicated they would want to use the tests if clinically available, and both IDI and FGD participants believed the tests would be helpful to clinicians. Participants believed the tests could motivate people to take their ART regularly, either by reassuring them ART was present in their bodies, or to avoid the negative consequences of being found to be non-adherent. Drawbacks of POC adherence testing identified by respondents included not wanting to be caught skipping ART doses, concerns about privacy, how the test results would be explained, and adding to the amount of testing required for HIV clinical care. AYA living with HIV in South Africa had favorable views toward POC tenofovir adherence testing and felt utilizing these tests in HIV clinical care would motivate people to remain adherent to ART.

The number of products that can provide pre-exposure prophylaxis (PrEP) for HIV prevention is expanding, with three now approved in South Africa (oral Tenofovir-based PrEP, injectable Cabotegravir, and a Dapivirine-based vaginal ring) and more in the development pipeline. Although highly effective and safe, oral PrEP products have not reduced HIV incidence in South Africa to the extent seen in other countries, primarily due to adherence challenges, rapidly diminishing persistence over time, and insufficient scale-up of PrEP service delivery. The Dapivirine vaginal ring, which provides 1-month-long protection, provides women with a new and discreet choice for PrEP; however, it is Cabotegravir long-acting (CAB LA) that is anticipated to land the largest impact. Administered as an intramuscular injection given every 2 months, CAB LA is safe, highly efficacious, and expected to become available in South Africa in late 2023. Yet, clinical and implementation questions remain, including the need to understand and characterise breakthrough HIV infections amongst CAB LA users, knowledge of how to package each PrEP product in a new context of PrEP choice, and how to avoid the remedicalisation of PrEP access following extensive efforts to make oral PrEP delivery differentiated and community based.

Effective use of oral HIV pre-exposure prophylaxis (PrEP) has been lower among African adolescent girls and young women (AGYW) than among older women, young men who have sex with men, and serodiscordant heterosexual couples in the region. Efforts to build PrEP support have centered around peers and male partners, but the family may also play an important role. This qualitative study aimed to describe family influence on PrEP use among AGYW in in three African cities. POWER (Prevention Options for Women Evaluation Research) was a PrEP demonstration project among 2550 AGYW (16-25 years old) in Johannesburg and Cape Town, South Africa and Kisumu, Kenya conducted from 2017 to 2020. In-depth interviews and focus group discussions were conducted with 136 AGYW participants to explore their PrEP views and experiences, including awareness and interest in PrEP; barriers and facilitators to uptake and use; the influence of family, peers, intimate partners, and community; and the key types of support for their PrEP use. Transcripts were coded and analysed thematically. The decision to initiate PrEP was associated with fear and anxiety linked to anticipated stigma from family members, and with family's lived HIV experience. Family disclosure, especially to mothers, was important to participants, as most lived with their families and considered it essential for them to obtain their mother's approval to use PrEP. Most family members, particularly mothers, provided instrumental, emotional, informational and appraisal support to participants using PrEP, including reminders, encouragement, and problem-solving. Participants reported that family members with insufficient information about PrEP safety and efficacy and who voiced concerns were a substantial barrier to their use. However, they often became supportive after receiving more PrEP information. Families, particularly mothers, can play an important role in supporting PrEP use. PrEP programmes should leverage family support to help with PrEP persistence by providing basic information to families about PrEP safety and efficacy. AGYW using PrEP should be encouraged to selectively disclose PrEP use to build support and counseled on how to disclose and address family concerns.

Background Poor psychological well-being, including depression, anxiety, and low self-esteem, is both prevalent among young South Africans living with HIV and associated with poor HIV clinical outcomes. By impacting food insecurity and employment, the COVID-19 pandemic may have influenced psychological well-being in this population. This analysis sought to examine whether food insecurity and unemployment mediated the relationship between study cohort (pre- versus during-pandemic) and psychological well-being in our sample of young South Africans living with HIV. Methods This was a secondary analysis comparing baseline data from two cohorts of young South Africans ages 18–24 from the Cape Town and East London metro areas who tested positive for HIV at clinics (or mobile clinics) either before or during the COVID-19 pandemic. Baseline sociodemographic, economic, and psychological outcomes were analyzed through a series of bivariate logistic regression and mediation analyses. All data were analyzed in 2023 and 2024. Results Reported food anxiety, insufficient food quality, and insufficient food quantity were lower in the cohort recruited during the COVID-19 pandemic than those recruited before the pandemic ( p  < 0.001). Higher levels of food insecurity predicted higher depressive and anxiety symptoms and lower self-esteem. Food anxiety, insufficient food quality, and insufficient food quantity, but not unemployment, mediated the relationship between study cohort and depressive symptoms, anxiety symptoms, and self-esteem. Conclusion Food insecurity may have decreased amongst our sample of young people during the COVID-19 pandemic. Our findings build on our understanding of how the psychological well-being of young people living with HIV was affected by the COVID-19 pandemic and may lend support to interventions targeting food insecurity to improve psychological well-being in this population.

Half of young adults diagnosed with HIV in South Africa start antiretroviral therapy (ART). We developed and field tested a facilitator-guided peer support group called Yima Nkqo (\"Standing Tall\" in isiXhosa) to promote treatment initiation for young adults newly diagnosed with HIV in communities around Cape Town. Following an adapted version of the UK Medical Research Council's framework for developing complex interventions, we 1) identified evidence on previous interventions to improve ART uptake in sub-Saharan Africa; 2) collected and analyzed qualitative data on the acceptability of our proposed intervention; 3) proposed a theoretical understanding of the process of behavior change; and 4) developed an intervention manual and feedback tools. During field-testing, participant feedback on intervention acceptability, and team feedback on consistency of content delivery and facilitation quality, were analyzed using an iterative, rapid-feedback evaluation approach. In-depth written and verbal summaries were shared in weekly team meetings. Team members interpreted feedback, identified areas for improvement, and proposed suggestions for intervention modifications. Based on our formative research, we developed three, 90-minute sessions with content including HIV and ART education, reflection on personal resources and strengths, practice disclosing one's status, strategies to overcome stressors, and goal setting to start treatment. A lay facilitator was trained to deliver intervention content. Two field testing groups (five and four participants, respectively) completed the intervention. Participants highlighted that strengths of Yima Nkqo included peer support, motivation, and education about HIV and ART. Team feedback to the facilitator ensured optimal consistency of intervention content delivery. Iteratively developed in collaboration with youth and healthcare providers, Yima Nkqo is a promising new intervention to improve treatment uptake among young adults with HIV in South Africa. The next phase will be a pilot randomized controlled trial of Yima Nkqo (ClinicalTrials.gov Identifier: NCT04568460).

Introduction Providing pregnant and lactating people (PLP) with choice in HIV pre‐exposure prophylaxis (PrEP) methods, including long‐acting injectable cabotegravir (CAB‐LA), may mitigate barriers to effective PrEP use. We evaluated PrEP preferences and acceptability among PLP offered CAB‐LA versus oral PrEP in South Africa. Methods The PrEPared to Choose study in Cape Town, South Africa, enrolled young people ages 15–29 at one public clinic and one community‐based mobile clinic. Using informed choice counselling, participants were offered oral PrEP or CAB‐LA, with the option to switch methods at follow‐up visits over 18 months. We report baseline CAB‐LA and oral PrEP initiations among PLP in the study, acceptability of their initial choice within 3 months of enrolment and theoretical preferences regarding PrEP methods that may become available to PLP. We report descriptive statistics and use Chi‐square and Fisher's exact to compare responses by initiated PrEP method and pregnancy status. Results From February to August 2024, we enrolled 58 PLP (n = 30 pregnant, n = 28 breastfeeding). Median age 23 years (IQR 19.5−26). Of 30 pregnant participants, 23 (77%) initiated CAB‐LA and seven (23%) oral PrEP; among 28 breastfeeding participants, 25 (89%) initiated CAB‐LA and three (11%) oral PrEP. Of enrolled PLP, 36 (62%, n = 13 pregnant, n = 23 breastfeeding) completed the acceptability survey. Of these, 83% (n = 12/13 pregnant, n = 20/23 breastfeeding) chose and received CAB‐LA, and the remaining (n = 4) chose and received oral PrEP. PLP who received CAB‐LA reported liking its ease of use (69%; n = 22/32) and long‐acting protection (44%; n = 14/32). Half of CAB‐LA users disliked side effects (e.g. injection site pain), although 41% of PLP (n = 13/32) described no CAB‐LA dislikes. Almost all (97%; n = 31/32) PLP currently using CAB‐LA were interested in continuing CAB‐LA, and all PLP using oral PrEP reported interest in trying CAB‐LA in the future. Eighty‐six percent of surveyed PLP (n = 31/36) did not want to try the dapivirine vaginal ring. Conclusions PLP in South Africa had a strong preference for CAB‐LA over oral PrEP, and CAB‐LA was found to be highly acceptable. Further research is needed to evaluate the effect of offering choice of PrEP methods, including CAB‐LA, on PrEP continuation among PLP.

Introduction Adolescent girls and young women (AGYW), a priority population for HIV prevention in Africa, show high interest but difficulty in sustained effective use of pre‐exposure prophylaxis (PrEP). With ongoing PrEP scale‐up focused on increasing access, it is important to understand what influences AGYW's choice of PrEP delivery platforms. Methods The POWER implementation study in Cape Town provided PrEP between 2017 and 2020 to AGYW (16−25 years) from four differentiated delivery platforms: mobile clinic, government facility, courier delivery or community‐based youth club. Healthcare providers at government and mobile clinics provided PrEP (initiation and refills) as part of comprehensive, integrated sexual and reproductive health services. Courier and youth club platforms provided light‐touch PrEP refill services incorporating rapid HIV self‐testing. We conducted in‐depth interviews with a purposive sample of AGYW who had ≥3 months of PrEP‐use and accessed ≥2 PrEP delivery platforms. The thematic analysis explored AGYW's preferences, decision‐making and habits related to PrEP access to inform market segmentation. Results We interviewed 26 AGYW (median age 20) PrEP‐users between November 2020 and March 2021. AGYW PrEP‐users reported accessing different services with, 24 accessing mobile clinics, 17 courier delivery, 9 government health facilities and 6 youth clubs for their PrEP refills. Qualitative findings highlighted four potential behavioural profiles. The “Social PrEP‐user” preferred PrEP delivery in peer spaces, such as youth clubs or adolescent‐friendly mobile clinics, seeking affirmation and social support for continued PrEP use. The “Convenient PrEP‐user” favoured PrEP delivery at easily accessible locations, providing quick (courier) or integrated contraception‐PrEP refill visits (mobile and government clinic). The “Independent PrEP‐user” preferred PrEP delivery that offered control over delivery times that fit into their schedule, such as the courier service. The “Discreet PrEP‐user” highly valued privacy regarding their PrEP use (courier delivery) and avoided delivery options where unintentional disclosure was evident (youth club). Comfort with HIV self‐testing had minimal influence on PrEP delivery choice. Conclusions Market segmentation of AGYW characterizes different types of PrEP‐users and has the potential to enhance tailored messaging and campaigns to reach specific segments, with the aim of improving sustained PrEP use and HIV prevention benefits.

Introduction Pre‐exposure prophylaxis (PrEP) services are linked to increased sexually transmitted infection (STI) diagnoses, which may facilitate PrEP uptake. We hypothesized that point‐of‐care (POC) STI testing and treatment would improve PrEP initiation and persistence. Methods Between September 2023 and November 2024, we conducted a single‐centre, open‐label, unblinded, randomized controlled trial among adolescent girls and young women (15−29 years old) or male partners (any age). Participants were randomized 1:1 to standard syndromic STI management (SOC) or POC testing for C. trachomatis, N. gonorrhoeae, syphilis and T. vaginalis (women only). All participants received standard HIV prevention counselling, including the offer of oral PrEP. The primary outcome was effect of POC STI testing versus syndromic management on PrEP initiation; secondary outcomes included persistence at 1 and 4 months (PrEP prescription), verified in the secondary analysis of tenofovir diphosphate (TFV‐DP) in dried blood spots (DBS) in a random subset. TFV‐DP in DBS was analysed in a subset. Analysis was intention‐to‐treat, adjusted for age and sex. Results We enrolled and randomized 900 participants (452 in intervention; 448 in SOC). The mean age was 20.4 years (SD = 4.2); 48% were female. In the intervention arm, 435 received POC STI testing (96%); 25% (110 of 435 tested) were diagnosed with =>1 STIs; 84% were treated. In SOC, 7% of participants reported symptoms of STIs (31); 88% were treated (27). Overall, 64% of participants in SOC versus 62% in intervention‐initiated PrEP (RR = 0.98, 95% CI = 0.88ng women and partners1.08). In the intervention, 41% persisted on PrEP at 1 month and 25% through 4 months, compared to 46% and 19%, respectively, in SOC (aRR intervention = 1.39; 95% CI = 0.93−2.09; p = 0.08). In participants treated for STIs or syndromically, 77% initiated PrEP versus 60% untreated/diagnosed (aRR = 1.14; 95% CI = 1.02−1.27); 19% versus 14% persisted on PrEP at 4 months (aRR STI/syndrome treated = 1.41; 95% CI = 0.79−2.51). Overall, 30% of 64 DBS had any TFV‐DP levels present with no difference by study arm (RR = 0.74; 95% CI: 0.38−1.41). Conclusions POC STI testing did not increase PrEP initiation or 1‐month persistence but showed a moderate association with 4‐month persistence. STI treatment (syndromic or confirmed) was linked to higher PrEP uptake and persistence. Integrating STI management may improve PrEP persistence among youth.