Perceptions of pre-exposure prophylaxis among sexually active adolescent girls and young women in Zimbabwe–A qualitative study

Adolescent girls and young women (AGYW; aged 15-24 years) in Zimbabwe face high risk of contracting HIV. Despite proven effectiveness of Pre-Exposure Prophylaxis (PrEP), its uptake and continuation among AGYW is low. We aimed to explore views on PrEP, norms around sexual behaviour and how programs can improve PrEP uptake among this group. From December 2021 to March 2023 nine focus group discussions were held with 92 (8-12 per group) sexually active AGYW, purposively selected from programs offering sexual and reproductive health (SRH) services to AGYW in Harare, Mazowe and Matabeleland South. Discussions were participatory and analysed thematically. Participants were aged 16-24 years; 73% had attained some high school education, 9% had never tested for HIV and 70% never used PrEP. Across all groups there was recognition that AGYW are at risk of contracting HIV. Knowledge of PrEP varied, with AGYW enrolled in the national sex worker and SRH programs more knowledgeable than the rest. A recurrent theme was that PrEP was viewed as undesirable due to its association with anti-retroviral treatment and risky sexual behaviours. AGYW thought their parents and partners would find their use of PrEP unacceptable. Unmarried sexually active AGYW seemed the most vulnerable and at high risk of HIV acquisition. Issues identified as important for improving uptake and adherence included ensuring private, confidential and free services, education of parents and partners on SRH issues and friendly attitudes of health workers. Additionally, AGYW indicated preference for the long-acting PrEP formulations, viewed as convenient and more private. Despite the recognition of being at risk of HIV, HIV related stigma and concerns about being viewed as having risky sexual behavior prevent them from taking PrEP. There is need to design youth-friendly PrEP programs that uphold privacy & confidentiality, prevent stigma and minimize opposition from parents and partners.