Adolescent Girls and Young Women Overcoming Adherence Challenges with Vaginal and Oral PrEP Use: A Longitudinal Qualitative Study from a Crossover Trial in South Africa, Uganda, and Zimbabwe

Abstract

Rates of HIV acquisition remain high among adolescent girls and young women (AGYW) in sub-Saharan Africa. We explored South African, Ugandan, and Zimbabwean AGYW's experiences in a crossover trial of two HIV prevention products: Daily oral pre-exposure prophylaxis pills and a monthly dapivirine vaginal ring. A subset of participants (n = 25) across all sites completed up to three serial in-depth interviews (SIDIs). The SIDIs explored barriers to product use, coping strategies, and the resulting outcomes. Coded textual data were analyzed using a product acceptability conceptual framework. Participants in the SIDIs described managing the array of challenges they encountered through formal adherence support, strategic product disclosure, and personally adapted strategies. For both products, perceived discreetness of the product and decision-making around disclosure was an important component of participants' narratives. Participants tailored their coping strategies based on available personal resources (e.g., cell phone alarms for PrEP reminders, social support through disclosure) or study provided resources (e.g., encouragement from staff, adherence groups). Notably, challenges participants encountered with each product during the crossover period helped inform product selection during the choice period. Our findings suggest that-even in a context where AGYW have access to several options for HIV prevention-challenges to consistent product use remain, but accessible support mechanisms and informed choice can help mitigate these challenges. Enacting that choice may also empower AGYW to reach their short and long-term life goals-including for HIV prevention. (NCT03593655, 20th July 2018).

Keywords: Adherence support; Adolescent girls and young women; HIV prevention; Pre-exposure prophylaxis; Qualitative; Sub-Saharan Africa.

Fig. 1

Schematic of study periods and serial in-depth interviews. The first interview (SIDI1) was focused on understanding the experiences early in the study, and initial experiences with the first product to which they were assigned. The second interview (SIDI2) similarly asked questions about initial experiences with the second product to which they were assigned, and also asked them to reflect back on their first product, comparing experiences with each. Finally, the third interview (SIDI3) delved into how the participant thought about the options (vaginal ring, oral PrEP, or neither), considerations when making their choice, and experiences to date with their chosen product