Kohler, Pamela K.Vera, Melissa Renée2023-04-172023-04-172023-04-172023Vera_washington_0250E_25236.pdfhttp://hdl.handle.net/1773/49827Thesis (Ph.D.)--University of Washington, 2023Introduction: Adolescent girls and young women (AGYW) in Eastern and Southern Africa have high HIV incidence. Pre-exposure prophylaxis (PrEP) once daily oral medication is recommended by the World Health Organization (WHO) as an effective intervention for individuals with risk behaviors associated with HIV acquisition. PrEP initiation is low among AGYW. This dissertation draws from two large studies to explore user experiences of PrEP service delivery for AGYW to determine how to improve quality and tailor services to address AGYW needs: 1) the PrEP Implementation for Young Women and Adolescents Program: Standardized Patient (PrIYA-SP) study, and 2) a pilot study delivering PrEP in retail pharmacies. Methods: PrIYA-SP was a cluster randomized trial based in Kisumu County, Kenya that aimed to improve the quality of PrEP delivery by implementing a standardized patient actor (SP)-led training for providers to enhance communication skills and adherence to national PrEP guidelines. At baseline and after conclusion of the intervention training, unannounced patient actor (USP) “mystery shoppers” presented to clinics portraying AGYW in common PrEP scenarios to assess PrEP delivery. To understand PrEP seeking experiences by the USPs, we added open-ended questions to their quantitative checklist evaluations of PrIYA-SP PrEP providers immediately following their encounters. Debriefings were audio-recorded, transcribed, and analyzed using thematic analyses to identify themes relating to why the USP had a positive or negative experience with the PrEP provider. To understand whether the PriYA-SP training had impact on real-world AGYW, and not just actors, we utilized facility-level PrEP reporting tools to abstract 26 months (May 2019-June 2021) of data to describe patterns of PrEP initiation among AGYW utilizing PrIYA-SP study facilities. We then conducted linear regression analyses to compare the effect of the intervention on AGYW PrEP initiation between intervention and control sites. Finally, to assess whether non-clinic based locations such as retail pharmacies would be more acceptable to AGYW, we analyzed qualitative data from a pilot study in the same region. In this study, PrEP delivery was piloted at three retail pharmacies. AGYW who were purchasing contraception were offered PrEP by study nurses in the pharmacy. Among AGYW who accepted PrEP, we conducted 41 in-depth interviews (IDIs) one month post-PrEP acceptance. We purposefully recruited equal numbers of AGYW who accepted and ingested PrEP and AGYW who took the pills home but did not swallow them. IDIs were audio-recorded, transcribed, and analyzed using thematic analysis to identify themes about user experiences and acceptability of pharmacy-based PrEP delivery for AGYW. Results: We conducted 91 USP debriefings at 24 clinics and identified three primary influences on PrEP service experiences: 1) Privacy improved likelihood of continuing care, 2) respectful attitudes created a safe environment for USPs, and 3) patient-centered communication improved the experience and increased confidence for PrEP initiation among USPs. During the study time period, 1,375 AGYW presented to PrIYA-SP sites and were eligible for PrEP (baseline: n=706, post-intervention: n=669). Among 669 PrEP-eligible AGYW in the post-intervention period (intervention: n=360, control: n=309), 591 (88.3%) initiated PrEP (intervention: n=335, control: n=256). PrEP initiation was 93.9% at intervention sites and 82.8% at control sites. Adjusted for baseline initiation rates, initiation was 12.1% higher at intervention sites compared to control sites (p<0.001, [95% CI: 0.09, 0.15]). Among the 41 AGYW interviewed in the pharmacy study, the median age was 18 years. Approximately half (49%, n=20) purchased emergency contraception at enrollment, and 54% (n=22) had swallowed PrEP pills since obtaining them. AGYW preferred pharmacies over clinics for accessing PrEP and they were willing to pay for PrEP at pharmacies, even if available for free at clinics. Reasons for this preference included ease of access, lack of queues and medication stockouts, privacy, anonymity, and autonomy over one’s health. High-quality counseling from study nurses stationed at pharmacies also facilitated PrEP initiation. AGYW reported that they received more attention, time, and better education regarding PrEP and contraception at pharmacies with nurse delivery compared to public clinics. Conclusion: User experiences, including patient-centered communication, privacy, and respect for autonomy, contribute to AGYW willingness to accept PrEP for HIV prevention. Interventions and policies that improve health provider and clinical setting factors may increase PrEP initiation, and ultimately contribute to decreased HIV acquisition in this priority population.application/pdfen-USnoneadolescentscommunicationhealthcare qualityHIV preventionpharmacyPrEPNursingThesis