What drives adolescent girls and young women's decisions to persist on PrEP? Results of a comparative qualitative study from a DREAMS program in western Kenya

Oral pre-exposure prophylaxis (PrEP) is a valuable tool to help end HIV, but persistent PrEP use is low amongst adolescent girls and young women (AGYW) in sub-Saharan Africa (SSA), who are at high risk for HIV. To improve persistent PrEP use in AGYW, more research is needed to understand what drives their decisions to continue with PrEP. We conducted a thematic, comparative qualitative analysis of in-depth interviews with 32 AGYW who participated in PEPFAR's DREAMS program in western Kenya: 16 were randomly sampled among those who persisted with PrEP and 16 among those who discontinued. We compared results between these groups to explore drivers for the decision to persist with PrEP. We interpreted findings using the Integrated Behavior Model, which posits that the decision to persist is influenced by attitudes, social norms and personal agency. Three themes emerged that illuminated AGYW's decision to persist with PrEP. First, having positive attitudes towards PrEP was insufficient to ensure persistence in absence of correct knowledge. All AGYW were positive about PrEP, but those who discontinued often had insufficient/misinformation about PrEP, specifically on its appropriate use during pregnancy/breastfeeding. Second, support from family and friends was critical to overcome societal stigma and could counter lack of support from romantic partners. Third, strong mentors supported PrEP persistence by increasing self-agency, but this was secondary in importance to the need for robust knowledge and social support. To improve PrEP persistence amongst AGYW in SSA, PrEP programs may benefit from increasing education delivered to AGYWs and their communities, specifically family and friends. In particular, messages that PrEP may be used when pregnant/breastfeeding should be reinforced. Other health programs for AGYWs may also benefit from an increased focus on educational messaging to program recipients and people in their existing social networks.