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A new report, What we know and don’t know about adolescent girls and young women and HIV prevention in sub-Saharan Africa: Mapping findings across completed, ongoing and planned projects, analyzes data from 49 projects in 20 countries to identify steps that will advance HIV prevention awareness, uptake and adherence by adolescent girls and young women (AGYW). Among the findings is the existence of a robust body of knowledge that explores young women’s attitudes about HIV prevention. But the field knows far less about the effect of communities on attitudes and behaviors related to prevention, even though that support is thought to be crucial to the uptake of HIV prevention. These and other findings in the report can inform implementers and policy makers now, and they also point to where more research is needed.
Adolescent girls and young women (AGYW) comprise the majority of new HIV infections in sub-Saharan Africa. According to UNAIDS, young women between the ages of 15 and 24 in sub-Saharan Africa are twice as likely to be living with HIV than young men of the same age, and 75 percent of all new infections in 15- to 19-year-olds are found in AGYW. Responding to the needs of AGYW is critical to ending the epidemic in the region. Many programs have implemented HIV prevention interventions aimed at AGYW, with varying success, as they confront the unique challenges, concerns and vulnerabilities faced by AGYW.
Oral PrEP is one such HIV prevention option, which is US FDA-approved, WHO-recommended, and demonstrated to be very effective in research studies. But, in many settings, implementers have faced challenges rolling out PrEP, a reminder that the efficacy of a product alone is not a predictor of real-world success. When people do not like a product, face structural or social barriers to accessing it, or have difficulty incorporating it into their daily lives—and thus don’t use it—efficacy by itself cannot overcome that.
So, what do AGYW need and want from a prevention product or program? What program features or social factors will galvanize them to use a product or participate in a program, continue with that intervention and ultimately champion it with their peers and communities? The report, produced by the the HIV Prevention Market Manager and Clinton Health Access Initiative (CHAI) and funded by the Bill & Melinda Gates Foundation, explores these questions, drawing from 49 projects focusing on AGYW in sub-Saharan Africa, for which HIV prevention is a primary objective. It examines 308 individual key findings reported by these projects to highlight what approaches have worked best and why, and where data gaps exist in the field. (Through the HIV Prevention Market Manager, AVAC has also undertaken human-centered design research in South Africa to better understand the factors that encourage or discourage AGYW’s engagement with HIV prevention.)
The report’s analysis maps the findings along two continuums, the social ecological model and behavior change framework. The number of findings along either of these continuum point to stronger or weaker areas of knowledge in the field. For instance, most findings focus on the individual and the initial “awareness” stage of behavior change, an indication that many AGYW are not yet using prevention methods and fewer have begun championing them with others.
Recurrent themes in the findings:
- Privacy: Many AGYW make choices around product use based on how effectively they can maintain their privacy. The perceptions of male partners, family, and community members may dictate or limit what products AGYW are able to use, so products that are discreet, last longer, and limit clinic visits are favorable. Product developers and implementers should consider these factors when designing an intervention.
- Messaging: HIV prevention messaging for AGYW should focus on empowerment, control, and safety. Messages should differ among segments of populations at high risk of HIV, so that messages for female sex workers (FSWs) or rural versus urban AGYW are tailored to reflect their lifestyles. Interventions should concurrently target those who influence AGYW to maximize the support they receive around the decisions they make. Reaching influencers is critical to reaching AGYW. To illustrate, 40 percent of the insights reviewed contain information on influencers, and of these, 38 percent focused on male partners. In one study, male partners were the determinant in nearly all AGYWs’ decisions around using oral PrEP, and another revealed that intimate partner violence negatively impacted AGYW product use, which links to why privacy is paramount to AGYW decision-making. Because there is little HIV prevention information in many communities, AGYW often shoulder the education of partners, families, and peers, yet are not always perceived by influencers to be the best messengers. Male partners indicated that receiving accurate information on PrEP directly from health providers bolsters their support of AGYW partners. AGYW expressed that more community education would ease the burden on themselves.
- Providers: Negative provider bias around girls’ and young women’s sexual activity adversely affects the accuracy, quality of information and prevention options they will offer. As a result, AGYW are disillusioned with the health system and want friendly, non-judgmental spaces to discuss HIV prevention. Non-traditional service delivery sites, including schools, libraries, mobile cafés, bars, brothels, and using community health entrepreneurs to provide products and information outside of a clinic, have proven effective at reaching them.
- Structural and social factors: To ensure they are holistic, interventions should address the structural barriers AGYW face when trying to access HIV prevention. For instance, many AGYW and FSWs work or go to school school far from home, or live far from health facilities, which can impede their access to health services; these factors contributed to loss to follow-up. Socioeconomic factors such as cost of products and cost of travel to health facilities, as well as stigma, myths and misconceptions around prevention products are additional hurdles for AGYW.
Insights gleaned from existing projects, such as these, can be applied when creating HIV prevention programs and products geared toward AGYW. Girls and young women should be consulted and listened to at every stage of research and program design and implementation. To this end, end-user research and human-centered design can be a valuable, more user-driven approach to distilling actionable conclusions about AGYW and HIV prevention. Future research can focus on areas in which there are fewer learnings from available research, such as the influence of community norms on AGYW’s uptake of HIV prevention. Gathering this knowledge is crucial in order to pinpoint what factors influence AGYW to embrace and champion HIV prevention.