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Introduction: Lesotho has reached epidemic control, PrEP is an important component in maintaining that and in reaching the goal of eliminating mother-to-child transmission. Methods: We conducted a retrospective review of existing, routine PrEP health records in 26 health facilities in Lesotho. PrEP visit data were collected for pregnant and postpartum women screened for PrEP and/or enrolled in PrEP programs from 1 January 2019 through 30 June 2021 with follow-up data collected up to the date of data abstraction per site between October 2021 and May 2022. Poisson regression with robust variance was used to evaluate the association between patient characteristics and continuation of PrEP. Results: Indications for starting PrEP were significantly associated with continuation in PrEP use. Women starting PrEP due to having a partner known to be living with HIV were the most likely to return for follow-up. In all age groups, the most common reason for starting PrEP was being in a serodiscordant relationship, though the proportion varies by age. Conclusion: As Lesotho is now in the process of optimizing PrEP use among pregnant and postpartum women, it is critical to revise data sources to capture information that will link PrEP records and ANC/PNC records and document pregnancy/postpartum status in order to better understand PrEP use and gaps in this population. [ABSTRACT FROM AUTHOR]

Background: Minors who sell sex are likely to have complex mental health needs that may persist into adulthood. This topic is understudied in sub-Saharan Africa. This study hypothesized that adult female sex workers in Eswatini who started selling sex as minors have a higher prevalence of depression than those who started as adults. We also examined correlates of depression and underage initiation of selling sex, including stigma and condom-related behaviors. Methods: From October-December 2014, women aged 18 or older who sold sex in the past 12 months in Eswatini were recruited through venue-based sampling. Participants completed a survey including the 9-item Patient Health Questionnaire (PHQ-9) and a question about the age at which they first sold sex for money. T-tests, χ2 tests and multivariable logistic regression were used to assess associations. Results: Overall, 43.1% of participants (332/770) had probable depression, and 16.6% (128/770) started selling sex as minors under the age of 18. Over half (55.5%, 71/128) of those who started selling sex as minors had depression. This was significantly higher than the 40.7% (261/642) prevalence of depression among participants who started selling sex as adults (p = 0.002). After adjusting for confounders, female sex workers who started selling sex as minors had higher odds of depression than those who started as adults (adjusted odds ratio [aOR] 1.70, 95% confidence interval 1.11-2.60). Conclusion: Results highlight the need for trauma-informed and adolescentfriendly mental health services in settings free of stigma toward female sex workers in Eswatini. [ABSTRACT FROM AUTHOR]

Background: The growing population of adolescents and young people (AYP) aged 15 to 24 in sub-Saharan Africa face a high burden of HIV in many settings. Unintended pregnancies among adolescent girls in the region remain high. Nonetheless, the sexual and reproductive health (SRH) service needs of AYP have remained underserved. We conducted a cluster-randomised trial (CRT) to estimate the impact of community-based, peer-led SRH service provision on knowledge of HIV status and other SRH outcomes, including met need for contraceptives. Methods and findings: Yathu Yathu was a cluster-randomised trial (CRT) conducted from 2019 to 2021 in 2 urban communities in Lusaka, Zambia. The communities were divided into 20 zones (approximately 2,350 AYP/zone) that were randomly allocated to the Yathu Yathu intervention or control arm. In each intervention zone, a community-based hub, staffed by peer support workers, was established to provide SRH services. In 2019, a census was conducted in all zones; all consenting AYP aged 15 to 24 were given a Yathu Yathu card, which allowed them to accrue points for accessing SRH services at the hub and health facility (intervention arm) or the health facility only (control arm). Points could be exchanged for rewards, thus acting as an incentive to use SRH services in both arms. We conducted a cross-sectional survey in 2021 to estimate the impact of Yathu Yathu on the primary outcome: knowledge of HIV status (self-reporting living with HIV or HIV testing in the last 12 months) and secondary outcomes, including use of pre-exposure prophylaxis (PrEP) in the last 12 months, current use of antiretroviral therapy (ART), and met need for contraceptive services. The sampling was stratified on sex and age group, and we analysed data at cluster-level using a two-stage process recommended for CRTs with <15 clusters/arm. A total of 1,989 AYP consented to participate in the survey (50% male); consent was similar across arms (63% consent/arm). Across zones, knowledge of HIV status ranged from 63.6% to 81.2% in intervention zones and 35.4% to 63.0% in control zones. Adjusting for age, sex, and community, knowledge of HIV status was higher in the intervention arm compared to control (73.3% versus 48.4%, respectively, adjusted prevalence ratio (PR) 1.53 95% CI 1.36, 1.72; p < 0.001). By age and sex, results were similar. There was no evidence for impact on any secondary outcomes, including current use of ART and met need for contraceptives. There were no adverse events reported in either arm. A key limitation of our trial is that approximately 35% of the AYP randomly selected for participation in the endline survey could not be reached. Conclusions: Delivering community-based, peer-led SRH services increased knowledge of HIV status among AYP, both males and females, compared with the control arm. Scaling up the highly effective Yathu Yathu strategy has the potential to make a substantial contribution to increasing access to HIV prevention and care services for young people. However, additional implementation research is needed to understand how to improve uptake of broader SRH services, beyond uptake of HIV testing. Trial registration: ISRCTN75609016, clinicaltrials.gov number NCT04060420 Bernadette Hensen and colleagues investigate whether community-based delivery of sexual and reproductive health services by peers increased knowledge of HIV status among adolescents and young people in Zambia. Author summary: Why was this study done?: Adolescents and young people (AYP) have limited access to sexual and reproductive health (SRH) services; rigorous evidence of strategies, co-developed with young people, that improve access to these services is needed. This trial was done to investigate whether community-based delivery of SRH services by peers would increase knowledge of HIV status among AYP aged 15 to 24 in Lusaka, Zambia. What did the researchers do and find?: Through spaces in the community (called hubs), peer support workers, a nurse and supervisor, delivered a range of SRH services, including HIV testing, comprehensive sexuality education, and contraceptives, daily to AYP aged 15 to 24. Service delivery through hubs was complemented by incentives, namely the collection of points for services accessed and the ability to use these points to "buy" rewards, such as soap, toothbrush, and toothpaste. After approximately 24 months, we compared knowledge of HIV status (defined as either self-reporting knowing ones HIV–positive status or having HIV tested in the previous 12 months) between random selections of AYP aged 15 to 24 (N = 1,989) living in areas that received the Yathu Yathu intervention and in areas that did not receive the intervention. We found that knowledge of status was considerably higher in the intervention areas (73.3%) as compared to the non-intervention areas (48.4%), but that there was no difference in uptake of other SRH services, such as linkage to PrEP for the prevention of HIV. What do these findings mean?: These findings show that community-based hubs that deliver a range of SRH services and are complemented by incentives can increase knowledge of HIV status. Additional research is needed to improve delivery of other services, including linkage to prevention and care services, and access to contraceptive services. [ABSTRACT FROM AUTHOR]

Background: Although pre-exposure prophylaxis (PrEP) is recommended for pregnant and breastfeeding women at elevated HIV risk, uptake has been low in Zambia. Methods: In in-depth interviews, we explored beliefs about PrEP among 24 HIVnegative pregnant and breastfeeding Zambian women. Thematic analysis was used to identify behavioural, normative and control beliefs likely to influence PrEP uptake. Results: Most women viewed PrEP as a good method of protecting themselves and their babies from HIV infection. Partners were cited as key referents in decision making about PrEP use. Many women felt that PrEP use was not entirely in their control. Most reported that they would not use PrEP if their partners did not approve. Health care providers with negative attitudes, long distance to clinics, and extended waiting times were cited as barriers to PrEP uptake. Conclusion: HIV-negative pregnant and breastfeeding women had a positive attitude towards PrEP but barriers to uptake are multifaceted. [ABSTRACT FROM AUTHOR]

PrEP has the potential to combat HIV epidemic among Adolescent Girls Young Women (AGYW) in sub-Saharan Africa. This study aimed to review research focusing on AGYW experiences and challenges related to PrEP use to promote prevention programmes. The PRISMA guidelines were used to direct the search, data collection, synthesis and review. PubMed and Embase databases were searched to identify recent studies that used qualitative approaches to report on the experiences of AGYW in using PrEP. The use of PrEP was associated with a believe that AGYW were having multiple sexual partners. These misconceptions made it difficult for AGYW to disclose the use of PrEP to sexual partner and families and compelled them to conceal it. The use of PrEP enacted agency, empowerment and self-worth among AGYW. AGYW ability to exercise decision on the initiation of PrEP and adherence to the course required convenient and supportive context. [ABSTRACT FROM AUTHOR]

In eSwatini and across sub-Saharan Africa, adolescent girls and young women (AGYW) are at significantly higher risk of HIV infection and poorer sexual and reproductive health (SRH) than their male counterparts. AGYW demonstrate low demand for SRH services, further contributing to poor outcomes. Strategic marketing approaches, including those used by multinational corporations, have potential to support demand creation for SRH services among AGYW, but there is limited empirical evidence on the direct application of private-sector strategic marketing approaches in this context. Therefore, we examined how Project Last Mile worked with eSwatini's Ministry of Heath to translate strategic marketing approaches from the Coca-Cola system to attract AGYW to SRH services. We present qualitative market research using the ZMET® methodology with 12 young Swazi women (ages 15–24), which informed development of a highly branded communication strategy consistent with other successful gain-framing approaches. Qualitative in-depth interviews with 19 stakeholders revealed receptivity to the market research findings, and highlighted local ownership over the strategic marketing process and brand. These results can inform similar efforts to translate strategic marketing to support demand generation in pursuit of public health goals to reduce HIV risk and improve SRH. [ABSTRACT FROM AUTHOR]

Background: Pre-exposure-prophylaxis (PrEP) has been heralded for its potential to put women in control of preventing HIV infection, but uptake and continuation rates have been disappointing in high-incidence settings in sub-Saharan Africa. We explored structural and social factors that influenced PrEP use among young women and pregnant or breastfeeding women in rural Eswatini.Methods: We conducted two in-depth interviews with ten women on PrEP, and one-time in-depth interviews with fourteen women who declined or discontinued PrEP. Interviews covered decision-making processes around PrEP initiation and experiences with pill-taking. In-depth interviews were conducted with nine health workers, covering experiences in delivering PrEP services, and two focus group discussions were held with men to elicit their perceptions of PrEP. Interviews and discussions were audio-recorded, translated, transcribed and analysed thematically, using an inductive approach.Results: PrEP initiation and use were experienced by many women as empowering them to take control of their health and well-being, and stay HIV free, facilitating them to realise their aspirations relating to motherhood and educational attainment. However, the social norms that defined relationship dynamics with partners or family members either undermined or promoted this empowerment potential. In particular, young women were rarely supported by family members to take PrEP unless it was perceived to be for protecting an unborn child. Stigmatisation of pill-taking through its associations with HIV and the burden of daily pill-taking also contributed to PrEP discontinuation.Conclusions: Unlike many prevention tools, PrEP enabled women to achieve a sense of control over their lives. Nevertheless, women's agency to continue and adhere to PrEP was influenced by social and structural factors including gender norms, family expectations of young women, relationship dynamics and stigma related to HIV. Future interventions should address these barriers to promote PrEP use among sexually-active women. [ABSTRACT FROM AUTHOR]

Introduction: Oral pre‐exposure prophylaxis (PrEP) for HIV prevention has been proven to significantly reduce new HIV infections yet scale‐up has been slow. As contexts continue to adjust to make space for PrEP, it is crucial to understand the perspectives and experiences of potential end‐users. In order to inform PrEP and demand creation interventions, this paper examines personal perspectives on adopting and using PrEP among HIV at‐risk populations in sub‐Saharan Africa. Methods: Using the principles of a scoping review in July 2018, we explored the extent, range, and nature of published literature regarding PrEP uptake and use among; men who have sex with men, HIV serodiscordant couples, adolescent girls and young women, pregnant and breastfeeding women, women partners of migrant workers; and people who use drugs. Steps included: identification of the research question; identification of relevant studies; study selection; charting the data; and collation – summarizing and reporting results. PubMed and PsycInfo were searched for papers relating to PrEP uptake and use in sub‐Saharan Africa. Resulting papers were reviewed with data extracted and compiled in Excel for analysis. A broad content analysis was conducted and organized into high‐level themes. Results and discussion: Thirty‐five papers were included in this review. There was little opposition in general to oral PrEP; however, there were significant nuances in its broader acceptability, applicability, and usability. We identified five themes within which these are discussed. These relate to balancing complexities of personal empowerment and stigma; navigating complex risk environments; influences of relationships and partners; efficacy and side effects; and practicalities of use. This body of research suggests that while product attributes and the logistics of PrEP delivery and use are important topics, it is vital to consider stigma, the interactions of PrEP use with relationships, and the need for broader understanding of ARVs for prevention versus treatment. Conclusions: Planning for, programming and promoting the adoption of oral PrEP necessitates a deeper understanding of end‐user priorities in order to ensure successful interventions. This review illustrates the nuances facilitating or deterring PrEP use that may affect the larger effort of PrEP scale‐up. [ABSTRACT FROM AUTHOR]