“You are your own driver”: Factors Influencing the Decision to Initiate PrEP Among Adolescent Girls and Young Women within Routine Maternal Child Health and Family Planning Clinics in Western Kenya

Abstract

Objectives: To understand key influences on decisions to accept or decline pre-exposure prophylaxis (PrEP) for HIV prevention among Kenyan adolescent girls and young women (AGYW). Design: Qualitative interviews were conducted with two groups of HIV-uninfected AGYW aged 15-24 years: 1) those at-risk who declined PrEP (≥1 sexual partner of unknown HIV status) and 2) those not at-risk who initiated PrEP (reported single HIV-uninfected partner). Methods: Semi-structured interviews (IDIs) were conducted with 47 HIV-uninfected Kenyan AGYW who were offered PrEP through Maternal and Child Health (MCH) and Family Planning (FP) clinics at four facilities in Kisumu County. IDIs were audio-recorded, translated into English, and transcribed. A qualitative descriptive analysis using a combination of conventional (inductive) and directed (deductive) content analysis methods was performed to elucidate common themes influencing PrEP uptake. Results: AGYW’s decisions to initiate or decline PrEP were largely influenced by three major themes: 1) relationships with partners shaped perceived risks and benefits of PrEP use, 2) having a role as a mother or caregiver provided a strong desire to protect their child’s health and future, and 3) PrEP attitudes, awareness, and logistics (e.g., acquiring, storing, and swallowing pills) facilitated or challenged PrEP uptake. The complex interplay between these factors influenced each women’s specific decision to uptake or decline PrEP. Other factors such as being offered PrEP while receiving MCH or FP services, knowing a current PrEP user, and health literacy also affected PrEP use decisions. Conclusion: Future PrEP scale-up for AGYW within MCH and FP clinics should consider priorities and concerns prioritized by AGYW. PrEP demand creation will require increased PrEP awareness and sensitization in the community, messaging that addresses misconceptions and reduces disease- and behavior-related stigma, through targeted messaging in both FP and MCH clinics and the community in general.