PrEP uptake and early persistence among adolescent girls and young women receiving services via community and hybrid community-clinic models in Namibia

PLOS ONE RESEARCH ARTICLE PrEP uptake and early persistence among adolescent girls and young women receiving services via community and hybrid community-clinic models in Namibia a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Barnabee G, Billah I, Ndeikemona L, Silas L, Ensminger A, MacLachlan E, et al. (2023) PrEP uptake and early persistence among adolescent girls and young women receiving services via community and hybrid community-clinic models in Namibia. PLoS ONE 18(8): e0289353. https://doi. org/10.1371/journal.pone.0289353 Editor: Omar Sued, Pan American Health Organization, UNITED STATES Received: October 28, 2022 Accepted: July 17, 2023 Published: August 30, 2023 Copyright: © 2023 Barnabee et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: This study was made possible through funding and support from the President’s Emergency Plan for AIDS Relief (PEPFAR) (https:// www.state.gov/pepfar/) through the United States Centres for Disease Control and Prevention (CDC) (https://www.cdc.gov) Program Area B – Support for Clinical Service Delivery in Namibia, Grant No. Gena Barnabee ID1,2*, Idel Billah1,2, Lylie Ndeikemona3, Lukas Silas1,2, Alison Ensminger1,2, Ellen MacLachlan1,2, Abigail K. Korn ID1,2, Susan Mawire4, Christa Fischer-Walker5¤a, Laimi Ashipala3, Norbert Forster1,2, Gabrielle O’Malley ID1,2, Jennifer Velloza6¤b 1 International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States of America, 2 International Training and Education Center for Health, Department of Global Health, University of Washington, Windhoek, Namibia, 3 Ministry of Health and Social Services, Windhoek, Namibia, 4 Star for Life, Windhoek, Namibia, 5 FHI360, Durham, NC, United States of America, 6 Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, United States of America ¤a Current address: Centers for Disease Control and Prevention, Windhoek, Namibia ¤b Current address: Department of Global Health, University of Washington, Seattle, WA, United States of America * Abstract Introduction Adolescent girls and young women (AGYW) face barriers in accessing clinic-based HIV pre-exposure prophylaxis (PrEP) services and community-based models are a proposed alternative. Evidence from such models, however, is limited. We evaluated PrEP service coverage, uptake, and early persistence among AGYW receiving services through community and hybrid models in Namibia. Methods We analyzed routine data for AGYW aged 15–24 who initiated PrEP within HIV prevention programming. PrEP was delivered via three models: community-concierge (fully community-based services with individually-tailored refill locations), community-fixed (communitybased initiation and refills delivered by community providers on a set schedule at fixed sites), and hybrid community-clinic (community-based initiation and referral to clinics for refills delivered by clinic providers). We examined proportions of AGYW engaged in services along a programmatic PrEP cascade, overall and by model, and assessed factors associated with PrEP uptake and early persistence (refill within 15–44 days after initiation) using multivariable generalized estimating equations. PLOS ONE | https://doi.org/10.1371/journal.pone.0289353 August 30, 2023 1 / 21 PLOS ONE GGH001430 and GGH002242 (Principal Investigator: Gabrielle O’Malley). Jennifer Velloza received support from the National Institute of Mental Health (NIMH K99 MH123369 and NIMH R00 MH123369). The findings and conclusions in this manuscript are those of the author(s) and do not necessarily represent the official position of the funding agencies. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. PrEP uptake and early persistence among DREAMS AGYW in Namibia Results Over 10-months, 7593 AGYW participated in HIV prevention programming. Of these, 7516 (99.0%) received PrEP education, 6105 (81.2%) received HIV testing services, 6035 (98.9%) tested HIV-negative, and 2225 (36.9%) initiated PrEP. Of the 2047 AGYW expected for PrEP refill during the study period, 254 (12.4%) persisted with PrEP onemonth after initiation. Structural and behavioral HIV risk factors including early school dropout, food insecurity, inconsistent condom use, and transactional sex were associated with PrEP uptake. AGYW who delayed starting PrEP were 2.89 times more likely to persist (95% confidence interval (CI): 1.52–5.46) and those receiving services via the community-concierge model were 8.7 times (95% CI: 5.44–13.9) more likely to persist (compared to the hybrid model). Conclusion Community-based models of PrEP service delivery to AGYW can achieve high PrEP education and HIV testing coverage and moderate PrEP uptake. AGYW-centered approaches to delivering PrEP refills can promote higher persistence. Introduction In sub-Saharan Africa (SSA), adolescent girls and young women (AGYW) are disproportionately impacted by HIV, with 25% of new HIV infections occurring among females aged 15–24 years despite representing just 10% of the population [1]. Daily oral pre-exposure prophylaxis (PrEP) is a biomedical HIV prevention method which is highly protective against HIV infection [2–4]. PrEP is an especially promising prevention strategy for AGYW as it is user-controlled, which may mitigate significant challenges AGYW face in negotiating condom use and utilizing other HIV prevention methods. Beginning with open-label trials and followed by demonstration projects in Kenya and South Africa, PrEP service delivery for AGYW has since expanded to more than 15 countries in SSA, where implementation is largely concentrated in high HIV burden areas [4–7]. Despite this progress, substantial gaps remain in access to PrEP services among AGYW, hindering their uptake of and persistence with PrEP. PrEP service delivery models broadly define the way PrEP services are delivered and to-date, PrEP has largely been delivered via clinic-based models. In these models, PrEP services are often delivered within existing HIV care and treatment clinics where considerable HIV-related stigma can prevent AGYW from seeking and using PrEP [8–10]. Judgmental treatment by healthcare providers (HCP) also acts as a barrier to accessing PrEP; providers sometimes question whether adolescents should be using PrEP or other sexual and reproductive health (SRH) services and/or may refuse to provide such services [11, 12]. Gaps in the quality of healthcare (...truncated)