A Multilevel Intervention to Reduce PrEP Stigma and Increase Effective PrEP Use Among Adolescent Girls and Young Women in Kenya - Project Summary/Abstract The goal of this small R01 application is to develop and pilot test a multilevel, community-based intervention to reduce pre-exposure prophylaxis (PrEP) stigma and increase PrEP uptake and continuation among adolescent girls and young women ages 15–24 (“young women”). Young women experience a disproportionate burden of HIV acquisition in the United States (US): In the South, where HIV incidence is highest, women and youth each account for 1 in 5 new HIV diagnoses. Despite the effectiveness of daily oral PrEP in reducing HIV acquisition, uptake is exceptionally low in this population, making studies of PrEP use difficult. Therefore, we will conduct this study in western Kenya, where the substantially higher HIV incidence and prevalence of PrEP use in young women provide a unique opportunity to test a stigma-reduction intervention in a real-world, high-burden setting not readily available in the US. Young women in both the US and Kenya report significant stigma around PrEP use from friends, male partners, and the broader community (i.e., “influencers”), and in our formative work in Kenya, PrEP stigma was associated with 30–50% lower PrEP adherence. To address this challenge, we propose to develop an intervention to reduce PrEP stigma among influencers and mitigate the impact of stigma among young women (Aim 1) using education, skills-building, empathy-building, and psychosocial support strategies at the community, interpersonal, and individual levels. Guided by established best practices for stigma reduction, we will conduct co-design workshops with 30 young women and stakeholders to identify change mechanisms and effective delivery platforms to target the drivers of PrEP stigma. We will pretest our intervention materials with approximately 12 young women, 56 influencers, and 8 intervention providers. We will then assess feasibility, acceptability, and preliminary evidence of effectiveness through a pilot cluster-randomized controlled trial (cRCT) in four communities (Aim 2). We will enroll 20 young women ages 15–24 from each community (n=80 total) with follow-up at intervention midpoint (3 months) and endpoint (6 months), supplemented by pre-post-intervention surveys with 80 influencers and post-intervention qualitative data from 16 young women, 12 influencers, and all intervention providers. Primary outcomes are intervention feasibility; acceptability to young women, influencers, and providers; and PrEP stigma scores among young women. Secondary outcomes include stigma among influencers and PrEP uptake, PrEP continuation (measured with a urine tenofovir biomarker), and depression and anxiety symptoms among young women. The knowledge gained will have direct potential to improve the health of Americans by developing evidence-based, scalable strategies to combat PrEP stigma, which can be adapted for young women in US communities to enhance PrEP use, reduce HIV incidence, and advance public health programming.
