Antiretroviral Therapy Based Hiv Prevention Targeting Young Female-Sex Workers: A Mixed Method Approach to Understand the Implementation of Prep in a Rural Area of Kwazulu-Natal, South Africa

Introduction: Pre-exposure prophylaxis (PrEP) has the potential to alter the HIV epidemic in South Africa. Between 2016 and 2018 PrEP was rolled-out for 18-24 year-old female-sex workers (FSW) in a rural KwaZulu-Natal subdistrict with very high HIV incidence among adolescent girls and young women (AGYW). Using a ‘framework of access’ model, we describe PrEP access, awareness and uptake for AGYW, including community members’ attitudes towards PrEP for young people.Methods: We enrolled a cohort of 2184 AGYW aged 13-22 living within the subdistrict and quantitatively measured their eligibility, awareness and uptake of PrEP and other HIV prevention interventions in 2017 and 2018. We supplemented this insight with in depth exploration by conducting 19 group discussions with young people and community members, nine stakeholder key informant interviews, 58 in-depth interviews with 15-24 year-olds and 33 with implementing partners, and participatory observations. All interviews were recorded, transcribed and analysed using thematic analysis.Results: PrEP awareness increased from 2% to 9% from 2017 to 2018. Among 965 AGYW sexually-active by 2018, 13.4% (95%CI: 11.4-15.7%) reported transactional sex and 10.6% (95%CI: 8.8-12.7%) sex for money. Of these latter 194 PrEP-eligible AGYW, 21 were aware of PrEP, but none had ever used it. Wider community members were generally unaware of PrEP but imagined it would benefit young people, HIV-serodiscordant couples and those in long-distance relationships. Youth saw PrEP as a positive alternative to condoms since it “will be in their system” and not get in the way of sex. Teachers and healthcare providers were more apprehensive: worrying that PrEP would lower personal responsibility for sexual health.Conclusions: Although PrEP awareness increased and it was generally acceptable, uptake was low even among eligible AGYW, i.e., who reported FSW activity. Condom use remained undesirable suggesting a need to include PrEP in offers of alternative HIV prevention technologies to comdoms. The targeted nature of public-sector PrEP for FSW may have limited the reach, and the future broader roll-out, of PrEP in this setting. Inclusive approaches to PrEP provision integrated with wider sexual healthmay help improve demand and access to PrEP.