South African adolescent girls and young women (AGYW) remain at extraordinarily high risk of HIV infection. Oral pre-exposure prophylaxis (PrEP) has the potential to alter the epidemic curve in this vulnerable population, given compelling evidence that if adhered to, PrEP is efficacious in women. Yet, a critical question is whether AGYW will adopt and adhere to oral PrEP in numbers sufficient to reduce population incidence. Creating demand?generating interest among at-risk AGYW, who may know little about PrEP and be wary of using it?is critical. The barriers that drove non-adherence to PrEP in the VOICE trial?low perceived risk, stigma around taking ARVs, mistrust of biomedical products, worries about potential adverse effects, and concerns about partner reactions?may also dampen AGYW's uptake of oral PrEP, even given known efficacy. But, whereas considerable research is aimed at identifying adherence support approaches for AGYW, limited attention has focused on creating demand and motivating uptake, a gap we aim to address. We propose that two innovations can reach young, at-risk AGYW, inform them about PrEP and motivate them to use it: (1) introducing PrEP through a gender lens in a one-session group workshop; and (2) peer-driven recruitment? recruiting women to attend the workshop by those who have already attended it. Guided by gender theory and the Information Motivation Behavior (IMB) model, and in collaboration with a Working Group of AGYW, we will develop a single-session group-based Gender-Enhanced Workshop to provide PrEP information and address AGYW's barriers to using it. To inform intervention development, we will conduct eight focus groups with at-risk AGYW (aged 16-25) and 20 qualitative interviews with men (10 HIV-positive, 10 HIV-negative or of unknown status) partnered with women in this age range that will explore knowledge of, beliefs about, motivators for, and concerns about using PrEP in the context of gendered relationship dynamics and PrEP-related stigma. In a pilot, we will compare AGYW (N=100) randomized to GE or to an Information-Only (IO) Workshop on undergoing PrEP clinical assessment (primary outcome); if PrEP-eligible, uptake of PrEP and 3-month PrEP retention (secondary outcomes); and, for all women, hypothesized mediators (risk perception, gender barriers, peer norms, self-efficacy, outcome expectancies, PrEP-stigma, attitudes, information) post-intervention and at 3-months. For Peer-driven recruitment (PDR) AGYW randomized to either workshop type (GE or IO) will be invited to become Peer Health Advocates (PHAs), who are paid to talk to social network members and refer them to the workshop type the PHA attended. We will (1) evaluate acceptability and feasibility of PDR using pre-specified performance criteria (on average >50% attendees become PHAs and >2 recruitees/PHA attend a workshop); and (2) evaluate reach of PDR (percent who score high on a new HIV risk tool; percent who never tested or attended family planning). If promising, these approaches will be further tested and can be rapidly scaled to enhance the roll-out of PrEP to SA AGYW.
Oral pre-exposure prophylaxis (PrEP) has the potential to reduce young African women's extraordinarily high risk of HIV infection. Now is a critical moment to identify effective and scalable approaches for reaching young, at-risk AGYW, informing them about PrEP, and motivating them to use it. This study will develop and test two strategies: (1) a workshop to promote PrEP based on a gender perspective and informed by qualitative data from women and men; and (2) peer-driven recruitment to reach AGYW to attend the workshop.
