Effectiveness of PrEP product choice on HIV prevention coverage among young women in Kenya seeking reproductive health services - Oral PrEP has been scaled up in the U.S., Kenya, and other locations for young women. We have been studying PrEP delivery in Kenya, where the HIV burden among young women is greater than the U.S. and PrEP use is more common, making it faster and lower cost to conduct this work. For many young women who start oral PrEP, discontinuation is frequent, and it is unlikely that they benefit from long-term HIV protection. Newer products that are longer acting, including dapivirine-eluting vaginal rings and intramuscular injections of cabotegravir, offer 1-2 months of HIV protection and depend less on the user to remember to take a pill every day. For oral PrEP, a key strategy for scale up is integration into existing programs, such as those for reproductive health care (e.g., family planning) and we have been studying ways to optimize integration of oral PrEP into these settings. Through implementation science research protocols, we have worked with public clinic staff to introduce PrEP, train providers to deliver PrEP, develop linkages between clinics and national supply chain mechanisms for PrEP, and support providers and programs to overcome challenges. Despite documented high levels of interest in PrEP yielding high frequency of PrEP initiation, we have continued to see high levels of program drop out and non-adherence. These barriers to PrEP continuation are driven by young women’s needs for PrEP products that afford discretion, convenience, and safety. It is yet unknown whether the availability of multiple HIV PrEP products in a PrEP program will yield choice-based PrEP counseling, support longer term use, and greater HIV prevention coverage. Through a multi-step process, formative work and then a stepped-wedge cluster randomized trial, the research team proposes to determine whether the availability of a suite of PrEP options yields greater HIV protection coverage over a 3- and 6- month period relative to periods when only daily oral PrEP is available. The proposed study aims to: 1) develop a pathway to add injectable cabotegravir and dapivirine ring into existing PrEP services offered through in reproductive health clinics in Kenya leveraging qualitative and community-based research methods, 2) determine whether integration of injectable cabotegravir and dapivirine ring into existing PrEP programs improves PrEP uptake and persistence among young women accessing reproductive health services via a stepped-wedge cluster randomized trial in 12 facilities, and 3) interrogate potential weak points including: a) provider hesitancy and client experiences, b) quality of choice-based HIV prevention counseling. We will conduct this work in Kenya because of efficiencies that allow us to do it faster and at a lower cost, given the higher burden of HIV (more clients for PrEP) and the greater penetration of PrEP into the community-at-large. In the U.S., PrEP delivery within reproductive health services is under development and new PrEP methods are also available, giving our study an opportunity to directly inform the way that programs with multiple PrEP options are rolled out in the U.S.
