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Strengthening Health System’s Capacity for Pre-Exposure Prophylaxis for Adolescent Girls and Young Women and Adolescent Boys and Young Men in South Africa (SHeS’Cap–PrEP)

Project Overview

Background

Pre-exposure prophylaxis (PrEP) has offered governments and health systems around the world valuable tools towards preventing HIV incidence especially among vulnerable populations such as adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM). PrEP significantly reduces the incidence of HIV among vulnerable populations. However, we know little about how to optimize PrEP implementation and PrEP operational strategies to achieve high sustained uptake of good quality services for AGYW and ABYM. Evidence about such strategies would guide policy makers and programme planners in designing implementation strategies most applicable to local contexts and reach these vulnerable populations. Various PrEP service delivery models have been implemented in South Africa to improve access to, and uptake of PrEP among vulnerable populations. These include primary facility-based only, school-based only, and community-based only models and ad hoc hybrid school-facility and community-facility models which aim to overcome individual, structural and health systems related barriers to PrEP uptake.

Purpose

The purpose of the project is to strengthen PrEP programme implementation by identifying effective and feasible PrEP service delivery models and implementation strategies to maximize access, service quality and sustainability for AGYW and ABYM.

Aim

The aim of this project is to identify effective and feasible PrEP models of care for improving PrEP uptake, continuation and adherence among AGYW and ABYM. To achieve this, we will draw on the experiences of AGYW and ABYM, programme implementers, and policy makers.

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Objectives
  1. To conduct a scoping review of the literature to identify evidence-based PrEP service delivery models for AGYW and men in sub-Saharan Africa.
  2. To assess the characteristics of AGYW and ABYM in the uMgungundlovu district who initiate PrEP compared to those who do not initiate PrEP.
  3. To determine the rates of uptake of (initiation on) PrEP among AGYW and ABYM in the uMgungundlovu district and continuation on PrEP at 1 (t1), 4 (t3) and 7 (t6) months.
  4. To compare the rates of PrEP uptake and continuation of various existing PrEP-based HIV prevention service-delivery models in the uMgungundlovu district. The service delivery models include facility-only, school-based only models, community-only and hybrid school-facility and community-facility models. The hybrid service delivery model is not an initial point of sample recruitment, as this is a model which we expect to emerge during the study based on client decision-making (e.g., an individual may initiate PREP at a facility, but continue care at a community service delivery point).
  5. To investigate the social, economic, health system, and behavioural factors that facilitate or impede PrEP cascade outcomes among AGYW and ABYM in the uMgungundlovu district, including factors relating to the various models of PrEP service delivery and their acceptability.
Methods/Study design

This programme evaluation was conducted in the uMgungundlovu district municipality (DM), located in the KwaZulu-Natal province of South Africa. It comprised a mapping exercise of PEPFAR-funded and Department of Health PrEP models of care that were being implemented for AGYW and ABYM in this high HIV burden district. These included health facility-based, school-based, and community-based hybrid (school-facility and community-facility) models of PrEP delivery.

A sequential explanatory mixed-methods programme evaluation, involving the systematic application of quantitative and qualitative research methods, was undertaken.

The target population for this study comprised sexually active AGYW aged 15–24 years and ABYM aged 15–35 years who tested HIV negative at the selected service delivery points in each of the seven sub-districts in the uMgungundlovu district, KwaZulu-Natal province.

This programme evaluation recruited about 2,772 AGYW and ABYM who tested HIV negative at selected PrEP service delivery points and followed them up for up to 7 months using quantitative and qualitative data collection methods. Questionnaires were administered, and routine service records were accessed at enrolment and at 1, 4, and 7 months to obtain HIV test results and describe PrEP initiation and continuation.

Focus group discussions (FGDs) and individual interviews were conducted with a sample of participants who initiated PrEP and those who did not initiate PrEP. Two focus group discussions (with eight participants in each group) were conducted from each of the four groups: (i) initiated PrEP within 1 month, (ii) did not initiate PrEP within 1 month, (iii) continued PrEP at 4/7 months, and (iv) did not continue PrEP at 4/7 months. In addition, 48 in-depth interviews (IDIs) were conducted, with 12 participants selected from each of the four groups.

In addition to primary data collection, a scoping review was conducted to synthesise and appraise the effectiveness and feasibility of evidence-based PrEP service delivery models designed to promote PrEP initiation and continuation among AGYW and men eligible for PrEP in sub-Saharan Africa. The objectives of the scoping review were to: (a) summarise service delivery models that promote PrEP initiation; and (b) explore users’ perceptions, as well as barriers and facilitators associated with these models.
Collaborators

South African Medical Research Council (SAMRC)

  1. Edward Nicol (Co-Principal Investigator and Senior Project Leader) Provide oversight and strategic direction.
  2. Cathy Mathews (Co-Principal Investigator)
    Provide strategic support.
  3. Debbie Bradshaw (Co-Investigator & technical advisor).
  4. Carl Lombard (Co-investigator and Chief Statistician).
  5. Kim Jonas (Co-investigator).
  6. Wisdom Basera (Senior Data Manager)
  7. Noluntu Funani (Project Manager and Co-investigator)
  8. Tracy McClinton-Appollis (co-investigator)
  9. Trisha Ramraj (Co-investigator)

Centers for Disease Control and Prevention (CDC), South Africa

  1. Mireille Cheyip (Technical advisor, Co-investigator) Contribute to protocol development, analysis, and publications.
  2. Sibongile Dladla (Technical advisor, Co-investigator) Contribute to protocol development, analysis, and publications.
  3. Jason Bedford (Technical advisor, Co-investigator), to contribute to protocol development, analysis and publications.
  4. Jenn Drummond (Technical advisor, Co-investigator), to contribute to protocol development, analysis and publications.
  5. Sarah Aheron (Technical advisor, Co-investigator) Contribute to protocol development, analysis, and publications.
  6. Ariana Paredes-Vincent (Technical advisor, Co-investigator) Contribute to protocol development, analysis, and publications, and to support protocol compliance monitoring
Funders
  • President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) Cooperative Agreement SAMRC-CDC Cooperative Agreement AG CDC-RFA-GH19-1911-03CONT21/ 1NU2GGH002193-01-00
  • South African Medical Research Council
  • National Research Foundation (NRF) Thuthuka grant. Reference/Grant Number: TTK22052514472 NRF. 2023-2025
Study Outputs