Abstract
ABSTRACT Pre-Exposure Prophylaxis (PrEP) is a potential game-changer for HIV. We used PrEP introduction for Young Women Who Sell Sex (YWSS) in a rural South Africa district to understand community norms and PrEP coverage in YWSS. Between 2017 and 2018, we measured awareness and uptake of PrEP in a representative cohort of 2184 Adolescent Girls and Young Women (AGYW) aged 13–22. We conducted group discussions with young people and community members (19); key informant interviews (9), in-depth interviews with 15–24 year-olds (58) and providers (33). Interviews were analysed using thematic analysis. PrEP awareness increased from 2% to 9%. Among 965 AGYW sexually-active by 2018, 13.4% (95%CI: 11.4%–15.7%) reported transactional sex and 10.6% (95%CI: 8.85–12.7%) sex for money. Of the 194 YWSS, 21 were aware of PrEP, but none had used it. Youth were enthusiastic about PrEP as tool for HIV prevention; whilst older community members were cautious about a technology they had limited experience with but could benefit select groups. Teachers and healthcare providers were concerned that PrEP would lower personal responsibility for sexual health. In conclusion, the narrow and limited introduction of PrEP to YWSS reduced the accessibility and reach. Introducing PrEP as part of sexual healthcare may improve demand and access for YWSS.
Highlights
The human immunodeficiency virus (HIV) epidemic in South Africa (SA) remains an intractable problem (Chimbindi et al, 2018; Human Sciences Research Council (HSRC), 2017; UNAIDS, 2018)
We described characteristics of Adolescent Girls and Young Women (AGYW) at baseline in 2017 using proportions and 95% confidence intervals (CI), and used chi-square test to test for differences between proportions
We present the quantitative findings on the uptake of Pre-Exposure Prophylaxis (PrEP) at a population-level for young women who sell sex (YWSS) and lastly emerging themes on availability, acceptability and affordability of PrEP from our qualitative data
Summary
The HIV epidemic in South Africa (SA) remains an intractable problem (Chimbindi et al, 2018; HSRC, 2017; UNAIDS, 2018). The potential for biomedical HIV prevention, such as PrEP, to have a substantial impact on the epidemic depends on uptake and adherence by those at substantial risk of HIV acquisition and transmission (Hargreaves et al, 2016; Marrazzo et al, 2015; Yun et al, 2018) This has remained a challenge, especially amongst AGYW, with belief in effectiveness of PrEP, social cohesion, support for use from partner, friends and family as facilitators to uptake and adherence (Amico et al, 2017; Marrazzo et al, 2015; Van Damme et al, 2012). Challenges of delivering PrEP Initially, community gatekeepers and owners of bars/ taverns, did not want to be associated with the sexworker programme Another obstacle was the very tight target age and gender eligibility criteria set by funders (YWSS aged 18–24). Implementers struggled to recruit eligible YWSS as they did not self-identify as sexworkers, were highly mobile, constantly changing their identity i.e names and contact details and did not see HIV treatment and prevention as a priority
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