Implementation preferences for the management of sexually transmitted infections in the South African health system: a discrete choice experiment.

OBJECTIVES: Despite strengthening HIV prevention with the introduction of pre-exposure prophylaxis (PrEP), STI services have remained relatively unchanged and the standard of care remains syndromic management. We used a discrete choice experiment to investigate service users' preferences for the diagnosis and treatment of STIs in South Africa. METHODS: Between 1 March 2021 and 20 April 2021, a cross-sectional online questionnaire hosted on REDCap was administered through access links sent to WhatsApp support groups for HIV PrEP users and attendees of two primary healthcare clinics and two mobile facilities in the Eastern Cape and Gauteng provinces aged between 18 and 49 years. Participants either self-completed the questionnaire or received support from a research assistant. We used a conditional logit model for the initial analysis and latent class model (LCM) to establish class memberships, with results displayed as ORs and probabilities. RESULTS: We enrolled 496 individuals; the majority were female (69%) and <30 years (74%). The LCM showed two distinct groups. The first group, comprising 68% of the participants, showed a strong preference for self-sampling compared with no sampling (OR 2.16, 95% CI 1.62 to 2.88). A clinic follow-up appointment for treatment was less preferable to same-day treatment (OR 0.78, 95% CI 0.63 to 0.95). Contact slip from index patient (OR 0.86, 95% CI 0.76 to 0.96) and healthcare professional (HCP)-initiated partner notification (OR 0.63, 95% CI 0.55 to 0.73) were both less preferable than expedited partner treatment (EPT). The second group included 32% of participants with a lower preference for self-sampling compared with no sampling (OR 0.65, 95% CI 0.41 to 1.04). There was no treatment option that was significantly different from the others; however, there was a strong preference for HCP-initiated partner notification to EPT (OR 1.53, 95% CI 1.10 to 2.12). CONCLUSIONS: Our results suggest that service users preferred STI testing prior to treatment, with the majority preferring self-taken samples and receiving aetiology-based treatment on the same day.

Perceptions of the attributes of new long-acting HIV pre-exposure prophylaxis formulations compared with a daily, oral dose among South African young women: a qualitative study.

Oral PrEP is highly effective against the acquisition of HIV but is underutilised by young women. New options, like the monthly dapivirine vaginal ring (DVR) and injectable long-acting cabotegravir (CAB-LA), are emerging. However, little is known about young women's perceptions of these alternatives. This qualitative study explored perceptions of the attributes of PrEP technologies in South Africa. Young women accessing sexual health services were purposively selected to participate in 22 in-depth interviews, five focus group discussions and two workshops using the nominal group technique, between August 2022 and March 2023. A thematic approach guided by the diffusion of innovation attributes, including relative advantage, compatibility with the student's lives, complexity of the technology, and trialability, was used for data analysis. The DVR was the least preferred because of lower efficacy, the perceived complexity of inserting it in the vagina and some safety concerns. Oral PrEP, which some had tried and discontinued, was least compatible with students' busy schedules. Integrating PrEP and contraceptives with similar return visit patterns could enhance service delivery. Intensive deman-creation campaigns will be needed to increase PrEP utilisation and dispel myths about the vaginal ring.

Preferences, educational messaging, and demand creation channels for multipurpose-prevention technologies (MPTs) among women in South Africa.

BACKGROUND: South African women, including female sex workers (FSWs), are disproportionately affected by HIV, experience a high unmet need for contraception and high rates of sexually transmitted infections (STIs). Products that address the interlinked risk between HIV, unplanned pregnancy, and other STIs are needed. There are several multipurpose-prevention technologies (MPTs) in development, aimed at preventing both HIV and pregnancy. This study aimed to explore educational messaging and demand creation channels to improve the potential uptake of a hypothetical MPT implant, using participatory action research. It also aimed to look at product and service provision attributes preferred by potential end users. METHODS: Between July and August 2022, 303 PrEP-eligible adolescent girls and young women (AGYW) (18-24 years), women > 24 years, and FSW's (≥ 18 years) participated in 4-hour workshops, where they were asked about their ideal messaging and demand creation channels and their preferences for different attributes of an MPT implant. Quantitative descriptive analysis was conducted to determine the frequency and ranking for each demand creation message, channel, and each product and service provision attribute, by population group. A chi-square test was used to assess MPT implant characteristics associated with age. Qualitative data were analysed using deductive and thematic analysis. RESULTS: A total of 104 AGYW, 157 women > 24 years, and 42 FSWs participated in the PAR workshops. Participants preferred demand creation messages that were empowering, motivational and encouraged body autonomy. The use of slang was popular. Community radio stations and newspapers, social media, and information at hospitals and clinics were participants' preferred MPT demand creation channels because they were easily accessible. Providing long-term and dual HIV and pregnancy protection, receiving implant services at the local clinic, manageable side effects, discreet and private implant, and numbing the area before insertion and removal, were the most preferred product and service provision attributes. CONCLUSION: Early considerations for women's product preferences are key to product development. Educational messaging around the MPT implant should be empowering and in local languages, this may motivate women to learn more about it and use it. Multiple demand creation channels should be used to engage both young and older populations, which may ensure better reach.

A systematic review of antimicrobial resistance in Neisseria gonorrhoeae and Mycoplasma genitalium in sub-Saharan Africa.

OBJECTIVES: Limited antimicrobial resistance (AMR) surveillance coupled with syndromic management of sexually transmitted infections (STIs) in sub-Saharan Africa (SSA) could be contributing to an increase in AMR in the region. This systematic review aimed to synthesize data on the prevalence of AMR in common STIs in SSA and identify some research gaps that exist. METHODS: We searched three electronic databases for studies published between 1 January 2000 and 26 May 2020. We screened the titles and abstracts for studies that potentially contained data on AMR in SSA. Then we reviewed the full text of these studies to identify articles that reported data on the prevalence of AMR in Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium in SSA. We summarized the data using a narrative synthesis. RESULTS: The 40 included studies reported on AMR data from 7961 N. gonorrhoeae isolates from 15 countries in SSA and 350 M. genitalium specimens from South Africa. All four SSA regions reported very high rates of ciprofloxacin, tetracycline and penicillin resistance in N. gonorrhoeae. Resistance to cefixime or ceftriaxone was observed in all regions except West Africa. Azithromycin resistance, recommended as part of dual therapy with an extended-spectrum cephalosporin for gonorrhoea, was reported in all the regions. Both macrolide and fluoroquinolone-associated resistance were reported in M. genitalium in South Africa. Studies investigating AMR in C. trachomatis and T. vaginalis were not identified. CONCLUSIONS: There is a need to strengthen AMR surveillance in SSA for prompt investigation and notification of drug resistance in STIs.

Measuring and evaluating sexual health in the era of digital health: challenges and opportunities.

Digital health has become increasingly embedded within sexual health service delivery and is now an established part of the user journey. It can support the provision of information and access to care across the sexual health continuum and facilitate the delivery of differentiated care with tailored and layered interventions that meet an individual's and target populations' need. However, despite advances in digital health, many challenges remain in the measurement and evaluation of sexual health. Reaching underserved populations, ensuring that both the intervention and the outcomes being measured are appropriate, and consistent collection of data (across settings and over time) are all potential obstacles to a full realisation of these opportunities. In order for digital health to improve sexual health and wellbeing, and reduce morbidity, the following need to occur: (1) ensure the necessary digital, health care, laboratory, legal and regulatory and surveillance infrastructure is in place to provide access to those with a sexual health need; (2) empowerment of end users and communities to take control of their own health through engagement in the development of interventions, and to ensure that outcomes of importance are measured; (3) tailoring and layering of interventions to provide equitable access to care; (4) integrating the digital ecosystem with the existing healthcare and external ecosystem; (5) measure and evaluate the unmet needs, gaps and quality of the experience, taking a realist evaluation approach; and (6) measure and evaluate the economic and distributional impacts associated with digital services or interventions in sexual health.

Introducing the Dapivirine Vaginal Ring in Sub-Saharan Africa: What Can We Learn from Oral PrEP?

PURPOSE OF REVIEW: Clinical trials have found that the dapivirine vaginal ring (DVR) is safe to use and effective at reducing women's risk of acquiring HIV infection. As countries prepare for the introduction of this novel long-acting, woman-controlled prevention method, an examination of key learnings from oral pre-exposure prophylaxis (PrEP) delivery will help programs leverage successful innovations and approaches to support DVR scale-up and expand the method mix for HIV prevention. RECENT FINDINGS: Intensive efforts over the past 5 years have yielded lessons on how to facilitate access to oral PrEP; expand service delivery for PrEP; address the knowledge, attitudes, and skills providers need to support PrEP initiation and effective use; develop messaging that builds community and partner support and combats stigma; and understand the cyclical nature of PrEP use. Evidence from oral PrEP introduction and scale-up can help inform and expedite DVR introduction.

Health care providers' attitudes toward and experiences delivering oral PrEP to adolescent girls and young women in Kenya, South Africa, and Zimbabwe.

BACKGROUND: In Kenya, South Africa, and Zimbabwe, oral pre-exposure prophylaxis (PrEP) is recommended for adolescent girls and young women (AGYW) at high risk of HIV. Health providers play a critical role in the uptake and effective use of sexual and reproductive health services; however, few published studies have explored providers' attitudes toward and experiences delivering PrEP to AGYW. METHODS: We conducted a cross-sectional qualitative study, interviewing 113 providers at 36 public, private, and nongovernmental health facilities in Kenya, South Africa, and Zimbabwe that were offering PrEP during the research period or were likely to offer PrEP in the future. Data were coded in NVivo 11, and an applied thematic analysis was conducted. RESULTS: Most providers preferred that adolescent girls wait until age 18 to have sex but acknowledged that many girls younger than 18 could benefit from oral PrEP. Their primary concern was whether adolescent girls would be able to take PrEP daily, especially if they do not tell their parents or partners they are using it. Providers reported that it was more challenging to deliver PrEP and other HIV services to girls younger than 18. Those with experience providing PrEP pointed to stigma and lack of PrEP awareness in communities as two primary barriers to PrEP uptake and use. CONCLUSIONS: Providers were generally accepting of oral PrEP as an HIV prevention option for AGYW; however, many had negative attitudes about adolescent girls being sexually active and concerns about whether they could take PrEP daily. Results were used to update national PrEP training materials to address negative provider attitudes about PrEP use by AGYW.

Integrating Cervical Cancer Screening Into Safer Conception Services to Improve Women's Health Outcomes: A Pilot Study at a Primary Care Clinic in South Africa.

BACKGROUND: Sub-optimal cervical cancer screening in low- and middle-income countries contributes to preventable cervical cancer deaths, particularly among human immunodeficiency virus (HIV)-positive women. We assessed feasibility and outcomes of integrating cervical cancer screening into safer conception services for HIV-affected women. METHODS: At a safer conception service in Johannesburg, South Africa, HIV-affected women desiring pregnancy received a standard package of care designed to minimize HIV transmission risks while optimizing prepregnancy health. All eligible women were offered Papanicolaou smear, and those with significant pathology were referred for colposcopy before attempting pregnancy. Multivariable analyses identified associations between patient characteristics and abnormal pathology. RESULTS: In total, 454 women were enrolled between June 2015 and April 2017. At enrolment, 91% were HIV-positive, 92% were on antiretroviral therapy (ART) and 82% virally suppressed. Eighty-three percent (376 of 454) of clients were eligible for cervical cancer screening and 85% (321 of 376) of these completed screening. More than half had abnormal cervical pathology (185 of 321) and 20% required colposcopy for possible high-grade or persistently atypical lesions (64 of 321). Compared with HIV-negative women, abnormal pathology was more likely among HIV-positive women, both those on ART <2 years (adjusted prevalence ratio, 2.5; 95% confidence interval, 1.2-5.0) and those on ART 2 years or longer (adjusted prevalence ratio, 2.1; 95% confidence interval, 1.0-4.2). CONCLUSIONS: Integrating cervical cancer screening into safer conception care was feasible with high coverage, including for HIV-positive women. Significant pathology, requiring colposcopy, was common, even among healthy women on ART. Safer conception services present an opportunity for integration of cervical cancer screening to avert preventable cancer-related deaths among HIV-affected women planning pregnancy.

Clients' experiences utilizing a safer conception service for HIV affected individuals: implications for differentiated care service delivery models.

BACKGROUND: Safer conception services promote the reproductive health and rights of families, while minimizing HIV transmission risks between partners trying to conceive, as well vertical transmission risks. Implementation data, including clients' experiences utilizing safer conception services in sub-Saharan Africa are limited. METHODS: Hillbrow Community Health Centre began offering safer conception services for individuals and couples affected by HIV in Johannesburg, South Africa in June 2015. A stratified sub-sample of safer conception clients were consecutively recruited from April 2016-August 2017 for a cross-sectional interview assessing clients' perceptions of service acceptability and value, as well as perceived safer conception knowledge and self-efficacy. Visual analog scales from 0 to 100 were used to measure clients' experiences; scores were classified as low, moderate and high acceptance/value/knowledge/self-efficacy if they were < 50, 50-79 and ≥ 80 respectively. Comparisons of scores were made across safer conception visits attended. RESULTS: Among 692 clients utilizing safer conception services, 120 (17%) were sampled for the process evaluation; sub-sample participant characteristics were similar to the overall cohort. Clients gave a mean score of ≥90-points for each question assessing service acceptability and 96% (114/119) indicated a high perceived value (scores ≥80) for regular safer conception attendance until conception. Fifty-eight percent (n = 70) of clients reported learning something new during the visit completed the day of the survey, though acquisition of new information tended to decrease as visits increased (p = 0.09). In terms of safer conception strategies, 80% of clients reported high levels of knowledge on the impact of antiretroviral treatment (ART) and viral suppression on HIV transmission, 67% reported high levels of knowledge of the importance of STI screening and 56% regarding limiting condomless sex to days of peak fertility; 34% in sero-different relationships reported high pre-exposure prophylaxis (PrEP) knowledge. Self-efficacy varied by safer conception methods and was similar across study visits. CONCLUSIONS: Clients perceived high value from their safer conception visits and preferred regular attendance until conception, however we observed a plateau in knowledge and self-efficacy across subsequent visits after initially attending safer conception care. More intensive services may be appropriate for certain clients based on clinical circumstances, but many couples may potentially receive a 'lighter touch' approach while still minimizing HIV transmission risks.

Experiences of oral pre-exposure prophylaxis use among heterosexual men accessing sexual and reproductive health services in South Africa: a qualitative study.

INTRODUCTION: South African men face a substantial burden of HIV and are less likely to test for HIV and initiate antiretroviral therapy if tested positive and more likely to die from AIDS-related causes than women. In addition to condoms and circumcision, guidelines provide for the use of daily oral pre-exposure prophylaxis (PrEP) as an HIV prevention intervention for any men who recognize their need and request PrEP. However, heterosexual men have not been a focus of PrEP programmes, and since its introduction, there is limited literature on PrEP use among men in South Africa. This study explores the experiences, motivators and barriers to oral PrEP use among heterosexual men accessing primary healthcare services in South Africa. METHODS: This study forms part of a mixed-methods implementation science study aimed at generating evidence for oral PrEP introduction and conducted in primary healthcare clinics in South Africa since 2018. Men aged ≥15 years who initiated oral PrEP and enrolled in a parent cohort study were purposefully invited to participate in an in-depth interview (IDI). Between March 2020 and May 2022, 30 men participated in IDIs exploring their motivators for PrEP use, and experiences with accessing health services. Interviews were audio recorded, transcribed and analysed thematically. RESULTS: The final analysis included 28 heterosexual men (18-56 years old). Motivations to initiate PrEP included fear of acquiring HIV, self-perceived vulnerability to HIV and mistrust in relationships; health systems factors which motivated PrEP use included the influence of healthcare providers, educational materials and mobile services. Perceived reduction in HIV vulnerability and changing proximity to partners were reasons for PrEP discontinuation. Side effects, daily-pill burden and stigma were noted as challenges to PrEP use. Health system barriers to PrEP use included limited PrEP availability, school and work demands, and inconsistent mobile clinic schedules. CONCLUSIONS: Our study reports on the experiences of heterosexual men accessing oral PrEP in real-world settings and contributes to the limited literature among this population. We highlight multiple levels which could be strengthened to improve men's PrEP use, including individual support, education among partners and communities, and addressing health system barriers to access.

Prevention method preferences and factors influencing hypothetical choice among women in South Africa: a survey exploring opportunities for a multipurpose prevention technology implant.

Introduction: South African women bear an intersecting burden of HIV, sexually transmitted infections (STIs) and unintended pregnancy. Multipurpose prevention technologies (MPTs) are a class of products that address multiple needs and have the potential to improve uptake and use of prevention products. Methods: Analysing survey data from 703 HIV-negative women 18-40 years in three provinces in South Africa, collected between July and November 2022, this study explores their preferences for prevention methods and factors influencing choice of hypothetical prevention methods, including MPTs. Descriptive statistics and multinomial regression analyses were conducted to determine prevention method preferences and factors associated with choosing a pill, injectable or MPT-implant type prevention method. Results: Most women wanted to prevent HIV, STIs and pregnancy. The most important factors when choosing a prevention product were whether it provided dual and long-term protection and if side effects were manageable. If choosing only one method, half of women would choose any MPT-implant and a quarter each would choose a pill or an injectable method, with method choices differing by population group. Discussion: Prevention method choices were influenced by sexual-behavioural factors and current and prior contraceptive method use. Providing a choice of prevention methods and a population specific approach to new method development and introduction with access to accurate information could enhance their ability to fill a gap in prevention needs.

Factors influencing the uptake of a mono-PrEP implant for the prevention of HIV: Males' perspectives from three South African provinces.

INTRODUCTION: Oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method; however, males over 15 years face challenges with its effective use. Long-acting prevention products could address barriers to effective PrEP use. This study aimed to estimate the potential uptake of a mono-PrEP implant and the factors influencing uptake among males in South Africa. The study also examined messaging and demand creation tactics that males perceive will improve HIV prevention uptake. METHODS: We conducted a mixed methods study comprising participatory workshops and a self-administered survey among 142 PrEP-eligible males (18-40 years) in three provinces (Gauteng, Eastern Cape, and Kwa-Zulu Natal) in South Africa from July to November 2022. Logistic regression was used to assess the relationship between the potential uptake of a hypothetical, non-biodegradable mono-PrEP implant and socioeconomic and behavioural factors. Workshop data were analysed using content analysis. RESULTS: The top three HIV prevention products that males would consider using were the monthly pill (74.6%), the mono-PrEP implant (62.7%), and event-driven oral PrEP (59.2%). If one prevention option was available, 31.7% of participants stated that they would use the monthly oral pill, 28.2% would use the six-monthly injection, and 19.7% the mono-PrEP implant. Four key themes were noted as influential to potential mono-PrEP uptake: "Health Over Everything", "Mono-PrEP Implant Concerns", "Potential Disclosure of Mono-PrEP Use", and "Information Distribution Channels". Participants preferred social and mainstream media as information distribution channels to receive information on HIV prevention services, including the mono-PrEP implant. CONCLUSION: In this study among predominantly heterosexual men in South Africa, there was interest in long-acting HIV prevention methods but concerns about the mono-PrEP implant. A comprehensive and participatory introduction will be needed for the implant, to improve acceptability and address potential concerns. Demand-creation strategies utilising social media and health campaigns should be considered to engage and reach males.

Key programmatic and policy considerations for introducing multipurpose prevention (MPT) methods: reflections from healthcare providers and key stakeholders in South Africa.

Introduction: Multipurpose prevention technologies (MPTs) simultaneously prevent HIV, other sexually transmitted infections, and/or unintended pregnancy. Key gatekeepers, [healthcare providers (HCPs) and key stakeholders] require proactive engagement before product implementation. This manuscript identifies HCP demand creation strategies, key stakeholder considerations for the adoption of MPTs in South Africa. Methods: Formative research was conducted in three districts in three South African provinces (July to November 2022). Nurses initiating oral PrEP at facility and mobile study sites participated in 4-hour participatory workshops, exploring HIV prevention, including MPTs, demand creation strategies, and preferred MPTs training packages. Activities were observed, transcribed, and thematically analysed. Five online in-depth interviews (IDIs) with Key informants (KIs) (National/district programme implementers and technical leads) and one in person, exploring key programmatic and policy considerations for MPT adoption. IDIs were approximately 40 min long, audio recorded, transcribed, and thematically analysed. Results: Twenty-one Professional Nurses completed workshops: 19 female. Six IDIs were conducted with 4 Facility Managers, 1 NDoH representative and 1 DoH Provincial Deputy Director. All participants were females, aged 30-60+ years with >10 years' in SRH/HIV policy/advocacy/research. Community conversations and information at the clinic were the best MPT demand creation methods among HCPs. KIs identified five considerations for future MPT implementation: HCP training; demand creation and messaging; existing PrEP policy amendments; preparing users for additional choice; and sustaining MPT provision. Conclusion: Contraceptive implant and oral PrEP implementation lessons learned should be proactively considered when preparing for MPT introduction. HCP training and demand creation are of particular importance before MPT introduction.

Optimizing the pipeline of multipurpose prevention technologies: opportunities across women's reproductive lifespans.

HIV/AIDS and maternal mortality are the two leading causes of death among women of reproductive age in sub-Saharan Africa. A growing body of research investigates opportunities for multipurpose prevention technologies (MPTs) that prevent unintended pregnancy, HIV, and/or other sexually transmitted infections (STIs) with a single product. More than two dozen MPTs are currently in development, most of them combining contraception with HIV pre-exposure prophylaxis, with or without protection from other STIs. If successful, such MPTs could offer women benefits at multiple levels: greater motivation for effective use; lower product administration burden; accelerated integration of HIV, STI, and reproductive health services; and opportunities to circumvent stigma by using contraception as a "fig leaf" for HIV and/or STI prevention. However, even if women find respite from product burden, lack of motivation, and/or stigma in contraceptive-containing MPTs, their use of MPTs will be interrupted, often multiple times, over the reproductive lifecourse due to desire for pregnancy, pregnancy and breastfeeding, menopause, and changes in risk. Interruptions to the benefits of MPTs could be avoided by combining HIV/STI prevention with other life-stage-appropriate reproductive health products. New product concepts could include combining prenatal supplements with HIV and STI prevention, emergency contraception with HIV post-exposure prophylaxis, or hormone replacement therapies for menopause with HIV and STI prevention. Research is needed to optimize the MPT pipeline based on the populations underserved by available options and the capacity of resource-constrained health systems to deliver novel preventative healthcare products.

Comparing the Integration of Syndromic versus Etiological Management of Sexually Transmitted Infections Into HIV Pre-Exposure Prophylaxis Services for Adolescent Girls and Young Women, in South Africa.

South Africa has a high incidence of human immunodeficiency virus and sexually transmitted infections (STIs), particularly among adolescent girls and young women. National and global guidelines recommend varied strategies for integrating STI and pre-exposure prophylaxis (PrEP) services. PURPOSE: This paper describes the implementation of a syndromic compared to an etiological approach to STI integration within PrEP services in South Africa. METHODS: We analysed program data from eight fixed and four mobile clinics to describe a cascade of STI care and integration of syndromic management among clients accessing PrEP services. Diagnostic testing was conducted in a subset of clients to determine the prevalence of STIs and estimate the burden of disease missed using a syndromic approach. RESULTS: Between December 2018 and December 2021, 22,505 clients sought services and a high proportion (92.9%) was screened for STI symptoms. Of these, 9% of females and 3% of males had symptoms and 89.5% had recorded treatment. In a subset of PrEP clients (406 females, 70 males) screened through laboratory testing, chlamydia was identified in 25.7% of female and 20.0% of male samples, gonorrhea in 14.1% of female and 18.6% of male samples, and syphilis in 2.3% of female and 1.4% of male samples. Highest prevalence was found among females aged 18-20 years. DISCUSSION: Syndromic STI screening and management can be integrated into routine PrEP service delivery and can identify symptomatic STIs, but misses asymptomatic infections. PrEP clients have a high prevalence of treatable STIs. Etiologic approaches can identify more infections than syndromic screening, but cheap point-of-care tests are needed.

Eita! Reaching Communities and Young People to Drive Demand for Oral Pre-Exposure Prophylaxis in South Africa.

PURPOSE: This paper describes a holistic but flexible demand creation strategy for pre-exposure prophylaxis (PrEP) in national public health-care settings in low-income to middle-income countries. METHODS: We describe the development and implementation of a model to drive demand for oral PrEP uptake and use as part of comprehensive sexual and reproductive health services in South Africa: The Eita! MODEL: The project adapted two existing response hierarchy models (marketing models used to describe the stages individuals move through from being unaware to using a product), to formulate the Eita! MODEL: Using the RE-AIM framework, we report on the reach, effectiveness, adoption, implementation, and maintenance of the Eita! RESULTS: More than 34 million connections were made from December 2018 to 2021 through a variety of channels: social media and websites, at events and mobile clinic outreach, and radio and community dialogs. There were 42,447 adolescent girls and young women reached in-person during this time, 16,823 adolescent girls and young women presented for sexual and reproductive health services, and of those 14,637 (87%) initiated on PrEP. The model was implemented in eight health-care facilities and four mobile clinics in three provinces in South Africa. A total of 26 trainings were delivered to project staff implementing the strategy. Various demand creation resources, such as materials and online platforms, have since been adopted by the National Department of Health as national tools. DISCUSSION: The Eita! model was successfully implemented to support the uptake of HIV prevention services and rollout of biomedical prevention products, and can be adapted by other low-income to middle-income countries.

Mental Health Needs of Adolescent and Young Adult PrEP Users in South Africa: Implications for Sexual and Reproductive Health Programming.

PURPOSE: Poor mental health is associated with sexual and reproductive health (SRH) risks, including human immunodeficiency virus (HIV) and pre-exposure prophylaxis discontinuation. Adolescents and young people (AYP) are vulnerable to HIV and depression. This paper describes the prevalence and severity of depression and associated factors in AYP accessing SRH services in South Africa. METHODS: A cross-sectional analysis of enrollment data (January 2019 to December 2021) from a cohort of individuals receiving pre-exposure prophylaxis services at eight clinics in three provinces in South Africa was conducted. Females (n = 1,074) and males (n = 231) aged 15-24 years were included. Interviewer-administered questionnaires were conducted, and the prevalence and severity of depression assessed using the Patient Health Questionnaire-9. Multivariate analysis was used to identify factors associated with depression. RESULTS: Over 40% of participants had experienced any depression symptoms (43.7% of females, 38.5% of males). For males, experiencing intimate partner violence was the only predictor of depression symptoms (adjusted odds ratio (AOR) 8.81, 95% confidence intervals (CI) 1.03-75.44). For females, living with both parents (AOR 1.70, 95% CI 1.15-2.51), having transactional sex (AOR 1.63, 95% CI 1.00-2.65), experiencing any intimate partner violence (AOR 1.96, 95% CI 1.34-2.89), and using drugs (AOR 1.78, 95% CI 1.03-3.11) were all positively associated with depression symptoms. Resilience was a protective factor against depression symptoms for both sexes (males: AOR 0.96, 95% CI 0.93-0.98; females: AOR 0.96, 95% CI 0.95-0.97). DISCUSSION: There is a high burden of depression among AYP accessing SRH services in South Africa. Mental health screening should be integrated into SRH and HIV prevention programs for AYP.

Patterns of HIV Pre-exposure Prophylaxis use Among Adolescent Girls and Young Women Accessing Routine Sexual and Reproductive Health services in South Africa.

PURPOSE: This study describes the patterns of pre-exposure prophylaxis (PrEP) use among adolescent girls and young women (AGYW) initiated on daily oral PrEP for the prevention of HIV, within routine sexual and reproductive health services in South Africa. METHODS: We analysed clinical and survey data from a nested cohort of 967 AGYW initiated on oral PrEP between January 2019 and December 2021 in four geographical clusters in South Africa. We describe the periods of PrEP use, and the proportion who discontinued and subsequently restarted PrEP. Logistic regression analyses were conducted to determine factors associated with early PrEP discontinuation, PrEP use for ≥4 months and PrEP restart. RESULTS: PrEP use for ≤1 month was high (68.6%), although 27% returned and restarted PrEP; and 9% restarted more than once. Initiating PrEP at a mobile clinic (AOR 2.10, 95% CI 1.51 - 2.93) and having a partner known to be HIV negative or whose HIV status was unknown (AOR 7.11, 95% CI 1.45 - 34.23; AOR 6.90, 95% CI 1.44 - 33.09) were associated with PrEP use for ≤1 month. AGYW receiving injectable contraceptives were more likely to restart PrEP (AOR 1.61, 95% CI 1.10 - 2.35). Compared to those aged 15-17 years, participants 18 - 20 and 21 - 24 years were less likely to restart PrEP (AOR 0.51, 95% CI 0.35 - 0.74; AOR 0.60, 95%, CI 0.41 - 0.87), as were those initiating PrEP at a mobile clinic compared to a fixed facility (AOR 0.66, 95% CI 0.47 - 0.92). DISCUSSION: Although early PrEP discontinuation was high, it appears that PrEP use is frequently cyclical in nature. Further research is needed to determine if these cycles of PrEP correlate to periods of perceived or actual vulnerability to HIV, which may also be cyclical. PrEP delivery presents a unique opportunity to address multiple unmet health needs of young people.

The Use of HIV Pre-exposure Prophylaxis Among Men Accessing Routine Sexual and Reproductive Health Services in South Africa.

PURPOSE: This study describes a cohort of men seeking oral pre-exposure prophylaxis (PrEP) services and explores their patterns of PrEP use within an implementation project seeking to integrate PrEP provision within sexual and reproductive health services in public health clinics in South Africa. METHODS: Routine program and survey data from 364 males initiated on oral PrEP between July 2020 and May 2022 were analyzed. PrEP use was examined, including time to first discontinuation and restart patterns. Factors associated with early PrEP discontinuation and PrEP restart were analyzed. RESULTS: Despite primarily focusing on access for adolescent girls and young women, PrEP services reached males with HIV prevention needs. PrEP use for ≤1 month (early discontinuation) was high at 58%; however, 18% restarted on PrEP, with 4% restarting repeatedly. Having depression symptoms was associated with early PrEP discontinuation (adjusted odds ratio [AOR]: 1.71, 95% CI [confidence interval]: 1.06-2.78). Those ≥25 years were less likely to discontinue early, as were those with a partner treated for a sexually transmitted infection in the preceding three months (AOR: 0.33, 95% CI: 0.13-0.84) and those who had been circumcised (AOR: 0.59, 95% CI: 0.36-0.96). Those 18-20 years old were less likely to restart PrEP than those ≥25 years (AOR: 0.43, 95% CI: 0.19-0.97), as were those whose partner's HIV status was unknown (AOR: 0.33, 95% CI: 0.12-0.88). DISCUSSION: This study identified interest and uptake of oral PrEP among an underrepresented population of predominantly heterosexual males seeking sexual and reproductive health services. It found high rates of early PrEP discontinuation, with a subset returning to restart PrEP. Further research is needed to determine whether these periods of PrEP use are associated with periods of HIV risk.

Implementing Differentiated and Integrated HIV Prevention Services for Adolescent Girls and Young Women: Experiences From Oral PrEP Rollout in Primary Care Services in South Africa.

PURPOSE: In South Africa, adolescent girls and young women (AGYW, aged 15-24 years) are disproportionately affected by human immunodeficiency viruses (HIV). Oral pre-exposure prophylaxis (PrEP) has been available in South Africa since 2016; however, there is limited evidence on oral PrEP implementation and integration in real-world settings, particularly among AGYW. Project PrEP is an implementation science project that sought to inform the introduction and integration of oral PrEP as part of combination HIV prevention and sexual and reproductive health services (SRH) in South Africa. The project focused on AGYW, as a priority population in need of HIV prevention. This paper presents strategies Project PrEP employed to increase oral PrEP and SRH service access and utilization. METHODS: We present strategies employed to increase oral PrEP and SRH services uptake. Using routine monitoring data, facility assessments, stakeholder engagement, training and progress reports, and observations, we share implementation lessons learned and describe how strategies can be adapted by HIV prevention programs in different contexts. RESULTS: Approximately 22, 000 people initiated on oral PrEP (December 2018-December 2021) across eight facilities and four mobile clinics. Two-thirds (67%) of initiated clients were AGYW. DISCUSSION: Lessons are to be learned from the introduction of oral PrEP as implementers prepare for the introduction of new PrEP methods. Stakeholders must be continuously engaged to ensure buy-in, and social mobilization and demand creation should be contextual, focused, and innovative. Continuous staff training is needed to reinforce knowledge, and AGYW service delivery models must be local context relevant.