Trust in the PrEP provider is associated with accurate self-reported PrEP adherence among adolescent girls and young women in sub-Saharan Africa


BACKGROUND: Trust is the cornerstone of patient-provider communication, including about pre-exposure prophylaxis (PrEP). Accurate reporting of PrEP adherence by adolescent girls and young women (AGYW) in sub-Saharan Africa is important for providers to determine who needs adherence support. It is not known if trust in the PrEP provider is associated with concordance between patient-reported and tenofovir diphosphate (TFV-DP) levels, an adherence biomarker.
METHODS: HPTN 082, an open-label PrEP demonstration study, enrolled 451 AGYW (ages 16-25 years old) from 2016-2018 in Cape Town and Johannesburg, South Africa, and Harare, Zimbabwe. At month three, participants' responses to indicators of trust were dichotomized as 'agree' (strongly-agree/agree) versus 'disagree' (neither/disagree/strongly-disagree). Patient-reported adherence response to 'In the past month, how often did you take the tablet?' was dichotomized as 'high' (every day/most days), and 'low' (some days/not many days/never). Objective evidence of adherence was defined as 'high' if TFV-DP '¥ 700 fmol/dried blood spot (DBS) punch, and 'low' if < 350 fmol/punch. Log odds of
concordant adherence (high patient-reported and high TFV-DP) and
concordant non-adherence (low patient-reported and low TFV-DP) relative to
discordant non-adherence (high patient-reported and low TFV-DP) were modeled as linear functions of trust, using multinomial logistic regression.
RESULTS: Of 427 (95%) AGYW who initiated PrEP, 354 (83%) had month three TFV-DP and patient-reported adherence data. Most responses were 'agree' for the trust indicators: 'trusting relationship with PrEP provider' was 86%; 'let PrEP-providers know if missed doses' was 78%; and 'I know how to contact the PrEP providers if I have problems or questions about PrEP' was 85%. Nearly 50% were 'discordant non-adherent', 31% were 'concordant adherent', and 20% were 'concordant non-adherent'. AGYW who reported strong trusting relationships with their PrEP providers had increased odds of 'concordant adherence' than 'discordant non-adherence' (aOR 3.72, 95% CI 1.20-11.51, p = 0.02). All three trust indicators had non-significant lower odds of being 'concordant non-adherent' than 'discordant non-adherent'.
CONCLUSIONS: Drug levels provide an objective marker of PrEP adherence and identify AGYW who over-report PrEP adherence. When there is high-level of trust in the PrEP providers among AGYW, there is concordance between patient-reported adherence and biomarker concentration of PrEP.