Oral PrEP consultations among adolescent girls and young women in Kisumu County, Kenya: insights from the DREAMS program

BACKGROUND: In May 2017, Kenya nationally scaled up oral pre-exposure prophylaxis (PrEP). However, PrEP utilization among adolescent girls (AG, aged 15-19 years) and young women (YW, aged 20-24 years) is suboptimal. To inform service delivery, we analyzed PrEP consultations'interactions with a health care provider about PrEP'among AGYW enrolled in DREAMS in Kisumu county, Kenya.
METHODS: In April-June 2018, surveyors captured AGYW's self-reported knowledge, attitudes, and practices related to HIV risk and service access. Using an age-stratified sub-sample of HIV negative sexually active AG (n=154) and YW (n=289), we established the total target population (number with >1 Ministry of Health PrEP eligibility criteria [i.e., PrEP-eligible]), examined individual and cumulative PrEP eligibility criteria in relation to PrEP consultations, and used prevalence ratios (PR, adjusted: aPR) to measure associations.
RESULTS: Most AG (139/154 [90.26%]) and YW (272/289 [94.12%]) were PrEP-eligible, primarily due to inconsistent/no condom use and experiences of violence or STIs. More PrEP-eligible (24.46%) than -ineligible AG reported high perceived HIV risk. Among PrEP-eligible YW, more were ever-married (54.41%), ever-pregnant (80.88%), and out-of-school (78.31%) compared with PrEP-ineligible YW. For PrEP-eligible AGYW, more AG were in-school (52.52%), while more YW were ever-orphaned (58.09%), ever-married, and ever-pregnant. More PrEP-eligible YW reported PrEP consultations than AG (41.18% vs. 24.46%, aPR=1.49 [1.04-2.15]). YW engaged in transactional sex reported more consultations (58.62% vs. 39.09%, p<0.05), but only PEP use (aPR=2.80 [2.30-3.43]) and multiple partnerships (aPR=1.39 [1.06-1.18]) were independently associated with PrEP consultations. Among AG, PEP (post-exposure prophylaxis) users reported more consultations (93.75% vs. 15.45%, aPR=5.64 [3.54-9.01], controlling for travel outside the community). Overall, consultations were low (i.e., <50%) across most criteria totals, especially among those with 1 criterion (AG=11.11%/YW=27.18%). Comparatively, consultations were higher among AG and YW with 2 (aPR=3.70 [1.64-8.34], PR=1.60 [1.07-2.38], respectively) or '¥3 (aPR=2.50 [1.09-5.72], PR=2.05 [1.42-2.97], respectively) criteria.
CONCLUSIONS: Almost all AGYW in our study were PrEP-eligible but few reported PrEP consultations, with significant differences by age and vulnerability. In high HIV-risk settings, PrEP consultations should be conducted with all AGYW. PrEP provision guidelines and their implementation need to be assessed and revised to accelerate PrEP access for at-risk AGYW.