1. PrEP introduction for Adolescent Girls and Young Women
Sanyukta Mathur, Population Council
Girls and HIV
AIDS2016 Satellite Session
Durban, South Africa
July 21, 2016

2. What is Oral PrEP? New biomedical tool to prevent HIV infection
Daily use of oral tenofovir-based antiretroviral formulations as pre-exposure prophylaxis—or PrEP

3. What do we know about PrEP efficacy?
PrEP has been shown to be effective for MSM, transgender women, people who inject drugs, heterosexual men and women
PrEP for young women in Africa: one RCT showed a reduction in HIV (age <30), another did not (age <25)
Young women and men had poorer adherence to PrEP, and diminished effectiveness
In open label studies, women self-select, know efficacy of product, have higher adherence, and PrEP had higher effectiveness

4. What don’t we know? Effectiveness for young women
Acceptance (also among providers, policymakers)
Where/how to provide comprehensive HIV prevention, including PrEP
Adherence support strategies

5. Framework for PrEP Introduction
PrEP for AGYW
We position young women in the context of their partner/peers, family, health providers and services, social values/community context, and broader scientific knowledge about PrEP –all of which can interact and influence, sometimes positively and sometimes negatively, the choices that AGYW make or are able to make.
– these factors will be useful to consider when designing PrEP introduction strategies.
The framework consists of two sides that interact, demonstrating the intricacies and dynamic aspects of PrEP introduction among AGYW.
The right side of the framework focuses on the main factors that determine the feasibility of effective introduction of quality PrEP services for AGYW.
- These include the scientific context, political landscape, health system infrastructure, and health service provider dynamics.
- For instance, regulatory guidelines that identify target populations for PrEP can have major implications for who has access PrEP.
-Service providers are gatekeepers of new medical products and their knowledge, attitudes, and perceptions will determine whether and how they offer PrEP to young women as an HIV prevention method.
-An assessment of these factors will determine whether health systems have the capacity to deliver PrEP safely and effectively to AGYW.
The left side of the framework focuses on the main factors that determine whether young women are able to make informed decisions around PrEP uptake and its effective use.
Key factors that influence informed choice, uptake, and use of PrEP include the community context, family dynamics, partner dynamics, and AGYW characteristics.
For instance, broader community-level knowledge about PrEP, parental consent for PrEP use, and experiencing violence within sexual relationships are likely to influence AGYWs’ decisions about PrEP.
Further, young women’s access to education, information, and social support; and their own HIV risk perceptions are likely to significantly influence PrEP uptake.
Examining these factors will highlight key barriers and facilitators to PrEP uptake, use, and adherence among AGYW.
The two sides of the framework are connected to illustrate the interplay between them, which we need to fully understand if PrEP provision for AGYW is to be realized.
AGYW and service providers are depicted toward the center of the framework to demonstrate the relative importance of provider-AGYW interactions.
The factors and relationships depicted in the framework extend beyond the initial phases of PrEP introduction and should be examined as part of ongoing efforts to monitor safety, adherence, and service quality.

6. Who are the key actors? AGYW Health care providers Male partners
Parents, guardians
Policy makers
Let me now segway into the key actors we focus on in this guide.
These include the young women themselves, health care providers, male partners of adolescent girls and young women, their parents or guardians, and policy makers or key opinion leaders.
Deciding which young women need to be reached with PrEP is the first critical step. At the same time we want to engage young women in helping us shape this decision as well.
This decision around which AGYW are being targeted for PrEP introduction will drive the decisions around other actors who need to be engaged in these assessments and in the PrEP introduction and roll-out.
For instance, if PrEP is being introduced to young female sex workers, then the reaching their clients is important
If for instance, PrEP is being introduced to young married women, then we’d need to engage ANC care providers, their marital partners
And so on.
The guidance document is divided into sections.
For each actor, the section provides a brief rationale for a focus on the population, important domains to investigate for guiding PrEP introduction, and suggests data collection methods for engaging each population.
And, we include in here questions that can be adapted to particular context and settings to build the needed evidence.

7. What to ask? Young Women Health Care Providers
PrEP attributes, acceptability and potential use
Risk perception and compensation
Gendered power dynamics
Stigma and social acceptability
Service delivery models and strategies
PrEP knowledge, attitudes and perceptions
Stigma/provider biases
Legal and ethical considerations
Service delivery considerations
Service access and quality of care

8. What we need to do?
Targeted PrEP delivery: Identify girls who are at risk
Conduct demonstration projects—deliver in ”real world” with safeguards
Include PrEP as part of a package of comprehensive HIV prevention methods for young women
Build evidence to guide oral PrEP introduction and roll-out for young women