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Understanding and addressing barriers to pre-exposure prophylaxis (PrEP) continuation among vulnerable adolescent girls and young women in Namibia

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BACKGROUND: Understanding the barriers to PrEP continuation is essential to designing programs that meet clients' needs. There is limited information about the factors hindering PrEP continuation among adolescent girls and young women (AGYW) in Namibia despite a low continuation rate (29%) at a one-month follow-up. This study examines reasons for and outcomes of PrEP discontinuation among AGYW receiving DREAMS services under ACHIEVE, a USAID/PEPFAR-funded project in northern Namibia.
METHODS: The retrospective analysis included programmatic data for AGYW aged 15-24 years from April'to September 2021 who missed follow-up appointments and/or discontinued PrEP in four semi-urban health facilities in Rundu district. Nurses and PrEP ambassadors are responsible for contacting PrEP clients by phone after missing one-month follow-up PrEP appointments. Results are recorded on a standardized client tracing form. During the study period, 1,010 clients newly started PrEP; of those, 614 (61%) missed the one-month follow-up visit, with 376 (age-disaggregated: 138 [15-19 years] and 238 [20-24 years]) followed up. Descriptive analysis was used to present the results.
RESULTS: Sixty percent (225) of 376 AGYW responded, while 15% (55) were not reachable or the phone number was wrong, and 25% (96) refused to respond. Of the 225 respondents, 75 were aged 15-19 and 150 were 20-24 years. The distribution of responses by primary reason for missing appointments was: PrEP no longer needed, 24% (55); forgot the appointment date, 20% (46); traveled away from home, 20% (46); felt unwell after taking PrEP, 13% (29); lack of money to support transport to a facility, 6% (13); lack of food, 5% (12); unclear PrEP instructions, 4% (8); and lack of family/community support, 3% (7). Variation of results by age was not statistically significant.
After clients were contacted, ACHIEVE continued strengthening the provision of PrEP education and counseling. As a result, 27% (60) of the 225 AGYW restarted PrEP, 68% (152) stopped using PrEP though still at risk, and 6% (13) considered themselves no longer at HIV risk.
CONCLUSIONS: Understanding the reasons for the discontinuation of PrEP is critical to designing/improving programs to meet clients' needs and to continue addressing HIV risk among vulnerable AGYW.