PrEP among high-risk young women in South Africa: real-world barriers to use and patterns of re-initiation and PrEP cycling

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PROJECT SUMMARY Significance: HIV incidence is disproportionately high among adolescent girls and young women (AGYW) and young female sex workers (YFSW) in South Africa. PrEP has been shown to be an efficacious, female- controlled, biomedical opportunity to prevent new HIV infections. Despite the established efficacy of PrEP to prevent HIV, initiation of and retention on PrEP by women in both clinical trial and real-world settings has been poor. National scale-up of PrEP in South Africa has been challenged by the same issues seen elsewhere, including similarly low levels of initiation and retention among young women. To add to this challenge of PrEP retention, PrEP need, unlike treatment need, not only differs among individuals, but also can vary over time within individuals, depending on changing risk. To accomplish the goals of this proposal, we will build on a strong existing partnership with TB HIV Care(THC), the largest PrEP provider to young women in South Africa. Specific Aims: We aim to 1) characterize temporal trends of and individual and structural characteristics associated with PrEP initiation, among PrEP eligible YFSW and AGYW who participated in the THC program between 2016-2020, 2) assess characteristics associated with PrEP retention and examine aggregate changes over time, among YFSW and AGYW who initiated PrEP at the THC program between 2016-2020, and 3) explore patterns of re-initiation and PrEP cycling among YFSW and AGYW who initiated PrEP at the THC program between 2016-2020. Inference generated by this study will directly feed back and inform the THC program. Approach: For all three aims, we will utilize routinely collected data on over 24,000 high-risk young women served by THC, including individual service user clinical files and program logs. For Aim 1, we will quantitatively compare characteristics for those who initiated PrEP and those who did not using discrete time-to-event analysis accounting for competing risks, and model the longitudinal patterns of PrEP initiation. For Aim 2, we will examine retention on PrEP among women who initiated as part of the program, and quantitatively compare characteristics for those who are and are not retained on PrEP. We will also model patterns of PrEP retention over calendar time. For Aim 3, we will use a restricted mean survival time analysis to characterize patterns of re-initiation and PrEP cycling (women discontinuing and re-initiating), including the proportion of women who had originally initiated who are a. retained on PrEP, b. engaged in the program, but no longer on PrEP (both low and high risk), c. lost to the program, and d. HIV-infected over time. Fellowship Information: Proposed PI Rao will leverage the training program, including selected courses, tailored mentorship, and professional development, to further her knowledge, skills, and experience to complete the proposed research and become a successful academic epidemiologist, studying implementation science and the use of routine data to improve HIV services particularly for marginalized women.