PHARMA-GIRL: Empowering adolescent girls and young women with choice and prevention in pharmacy-based HIV interventions - ABSTRACT Sub-Saharan Africa's (SSA) 400 million adolescent girls and young women (AGYW, age 15-24) face disproportionate rates of HIV acquisition and suboptimal HIV care engagement. Despite the widespread availability of oral PrEP at public health facilities, uptake is impeded by low awareness, socio-cultural and access barriers, provider bias, and user dissatisfaction. Moreover, among PrEP-aware AGYW, uptake and continuation of PrEP is low due to side effects, fear of being seen with medicines, and low adherence support, undermining PrEP's preventative effects and leaving AGYW in need of critical HIV prevention. Our team and others have demonstrated that AGYW are interested in PrEP, especially newer modalities such as injectables, and that they prefer to seek HIV care at locations that foster privacy, are convenient, and are girl-friendly. Given the growing recognition that pharmacies, staffed by health workers who can be trained to provide expanded services, outnumber health facilities, can promote beneficial health behaviors, bridge gaps in health services, and mitigate health workforce shortages, we aim to expand this body of research to conduct an implementation science study on potential implementation models of pharmacy-based PrEP provision and adherence support for AGYW. In Uganda, the Community Retail Private Pharmacy Drug Distribution Point (CRPDDP) already provides pharmacy-based anti-retroviral therapy (ART) to over 48,000 clients across 160+ pharmacies (and increasing). Given the Uganda Ministry of Health's interest to expand this pharmacy-based differentiated service delivery model for increased reach and extended prevention offerings, we propose a mixed-methods study to garner foundational evidence to evaluate how this cadre of pharmacies already providing ART refills to PLHIV can include PrEP services generally and specifically tailored to AGYW. We hypothesize that these pharmacies can be well-equipped to reach AGYW with PrEP, given the critical role they already play in the community providing expanded care. As such, we propose to conduct formative research among CRPDDP pharmacies and their AGYW clients to advance implementation of pharmacy-based PrEP and adherence support. Guided by participatory processes of human-centered design, including in-depth interviews with AGYW who are potential PrEP users, pharmacists, and focus groups with pharmacy and youth advisory boards and MOH stakeholders, we will conduct formative research to understand barriers, facilitators, and desires for pharmacy-based PrEP to inform a discrete choice experiment (DCE) (Aim 1). We will then evaluate a series of implementation science outcomes—willingness, acceptability, feasibility, and readiness—among CRPDDP pharmacists (n=~160) (Aim 2), and conduct parallel DCE surveys among CRPDDP pharmacists and their AGYW clients (n=300) to evaluate preferences for pharmacy-based PrEP implementation models (Aim 3). By the end of the study, we will understand how a potentially ready platform of pharmacies can be expanded to provide PrEP care to a key population, and will have identified potential implementation gaps from user, provider, and policy perspectives .
