High Awareness, Yet Low Uptake, of Pre-Exposure Prophylaxis Among Adolescent Girls and Young Women Within Family Planning Clinics in Kenya

Abstract

Adolescent girls and young women (AGYW) are a priority population for HIV prevention in high-burden settings. We evaluated psychosocial characteristics, behavioral risk factors for HIV, and pre-exposure prophylaxis (PrEP) awareness and uptake among AGYW seeking contraceptive services at four public sector family planning (FP) clinics offering integrated PrEP delivery in Kisumu, Kenya. From October 2018 to June 2019, we approached all AGYW (aged 15-24 years) seeking contraception to participate in a survey following receipt of FP services and PrEP screening. Overall, 470 AGYW were screened for PrEP at their FP visit by facility staff and subsequently enrolled in the survey. Median age was 22 years (interquartile range 20-23), 22% of AGYW were in school, and 55% were married. The most frequent forms of contraception were implants and injectables (41% each). Over a third of AGYW (36%) reported low social support, 13% had symptoms of moderate to severe depression, and 3% reported intimate partner violence. Three-quarters (75%) of AGYW reported recent condomless sex and 42% suspected that their primary partner had other sexual partners. Most AGYW (89%) had previously heard of PrEP; 76% had at least one PrEP eligibility criterion as per national guidelines; however, only 4% initiated PrEP at their current FP visit. PrEP initiators more frequently had high HIV risk perception than noninitiators (85% vs. 10%, p < 0.001). Low perceived HIV risk (76%) and pill burden (51%) were common reasons for declining PrEP among AGYW with HIV behavioral risk factors. PrEP counseling should be tailored to AGYW to guide appropriate PrEP decision-making in this important population.

Keywords: Africa; HIV prevention; PrEP; adolescents; pre-exposure prophylaxis; women.

FIG. 1.

Flow chart of participant inclusion in the analysis among HIV-uninfected AGYW seeking FP services in Western Kenya. ^aCategories describing reasons for ineligibility are not mutually exclusive. ^bReasons for declining enrollment were not captured. Anecdotally, FP clients not having time to complete the survey was frequently reported as a reason for declining by study staff. ^cAGYW who were not screened for PrEP (n = 135) due to PrEP stock-outs or lack of PrEP providers were excluded from the current analysis. AGYW, adolescent girls and young women; FP, family planning; PrEP, pre-exposure prophylaxis.

FIG. 2.

Reasons for declining PrEP among AGYW with high behavioral HIV risk who declined PrEP (n = 111). Behavioral HIV risk was defined using the Balkus et al. HIV risk scoring: age <25 = 1, married = 2, any alcohol = 1, partner provides financial support = 1, and partner has other partners: yes = 2 and do not know = 2. Scores of ≥5 correspond to 5–15 incident HIV cases per 100 person-years in cohorts of African women; risk scores of ≤4 correspond to <5 incident HIV cases per 100 person-years, (high HIV risk: HIV risk score ≥5). AGYW, adolescent girls and young women; PrEP, pre-exposure prophylaxis.