https://orcid.org/0000-0003-3315-6207
ABSTRACT
Background
Adolescent girls and young women accounted for 25% of all new HIV infections despite representing only 10% of the population in Sub Saharan Africa. PEPFAR has launched the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) initiative, a comprehensive HIV prevention program including PrEP services. Among adolescent girls and young women, PrEP adherence is currently sub-optimal. Tailored strategies for adolescent girls and young women to improve access and use of PrEP delivery are urgently needed to maximise its potential. Recommended interventions include peer-delivered interventions using mobile technology. However, data on the feasibility and acceptability of this approach is limited for SSA.
Objectives
We assessed the feasibility and perceived acceptability of providing mHealth peer-delivered interventions to support PrEP services among adolescent girls and young women in Botswana.
Methods
This cross-sectional study included HIV-negative women aged 18–24 years old seeking health services at DREAMS-supported facilities. Participants completed a survey assessing the feasibility and perceived acceptability of the mHealth peer-delivered interventions, which included the Acceptability of Intervention Measure (AIM). Descriptive analyses were performed.
Results
A total of 131 participated in the study. Overall, 89% owned a mobile phone (feasibility). There was no difference in cell phone ownership between participants from rural and urban settings. Among participants, 85% reported interest in participating in a mHealth peer-delivered intervention if it was available to them. Regarding perceived acceptability for mHealthpeer support groups for PrEP, the average score on the AIM was 3.8 out of 5 (SD = 0.8).
Conclusion
mHealthpeer-delivered interventions appear to be feasible and perceived acceptable among adolescent girls and young women in Botswana. This modality should be incorporated into PEPFAR’s programmatic toolkit of implementation strategies to improve PrEP services.
Responsible Editor Stig Wall
Background
HIV/AIDS is the leading cause of death among adolescent girls and young women aged 15–24 years in sub-Saharan Africa (SSA) [Citation1]. In 2020, adolescent girls and young women accounted for 25% of all new HIV infections, despite representing only 10% of the population in SSA [Citation2]. In response to this situation, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) has launched the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) initiative across 15 countries, including Botswana. The DREAMS initiative includes a core package of interventions including pre-exposure prophylaxis (PrEP) services [Citation3]. Daily oral PrEP has been shown to decrease the risk of HIV acquisition by ≥ 90% [Citation4,Citation5]. However, among adolescent girls and young women, PrEP adherence is currently sub-optimal [Citation6–9]. Tailored strategies for adolescent girls and young women to improve PrEP services delivery are urgently needed to maximise the potential of PrEP.
Peer-delivered interventions have been used for various health conditions, including HIV treatment, contraceptives use and mental disorders [Citation10–13]. Peer-delivered interventions can be defined as enlisting individuals who are similar to them in terms of demographic or social characteristics to promote and sustain health-related behaviours and can be offered through 1:1 or group sessions [Citation14,Citation15]. For adolescents and young adults living with HIV, peer-delivered interventions have been shown to improve health outcomes along the HIV treatment care continuum [Citation16,Citation17].
In recent years, especially within the context of COVID, which impacted in-person services due to movement restrictions, alternative service models for HIV prevention and treatment have been recommended including using mobile technology (mHealth) [Citation18]. mHealth is defined as using mobile phone technology to improve the delivery of health services [Citation19]. Despite this recommendation, the feasibility and perceived acceptability of peer-delivered interventions using mHealth (peer-delivered interventions delivered through mobile technology) remain limited, especially for PrEP among adolescent girls and young women in SSA. PEPFAR recommends that DREAMS health facilities implement technology-based peer support for PrEP (e.g. WhatsApp groups) while emphasising the critical need to evaluate these interventions, a major implementation gap [Citation20]. A few quantitative studies have rigorously evaluated peer-delivered interventions on PrEP outcomes among adolescent girls and young women [Citation21,Citation22]. Peer-delivered interventions using mobile technology may experience challenges due to intermittent electricity and connectivity, data access and affordability. The aim of this study was to assess the feasibility and perceived acceptability of providing peer-delivered interventions using mHealth to support the use of PrEP from the perspectives of adolescent girls and young women to inform the development and implementation of future mHealth interventions for adolescent girls and young women in Botswana.
Methods
Study design and setting, and participants
We conducted a cross-sectional survey using a convenient sample of four facilities implementing the DREAMS initiative in Gaborone (n = 2) and Kweneng East districts (n = 2) from June 2022 to August 2022. In Gaborone, 12 facilities offered the DREAMS initiative while five offered DREAMS in Kweneng East districts. HIV prevalence is estimated at 11% in Gaborone (urban setting) and 18.7% in Kweneng East (rural) [Citation23] In Botswana, the prevalence of HIV among women aged 20–24 years is 6.7% compared to 2.7% among men of the same age group [Citation23]. Eligible participants included HIV-negative women aged 18–24 years old who sought health services at DREAMS supported facilities. At each clinic, a trained data collector approached eligible women during clinic hours during the study period, provided information about the study, and sought consent for individuals who were interested in participating in the study.
Measures
The 15-min tablet-based survey included questions about the feasibility and perceived acceptability of using mHealth peer support groups for PrEP services. Feasibility, the extent to which an intervention, can be successfully implemented within a setting [Citation24], was measured by assessing the proportion of adolescent girls and young women who own a cell phone, including a smartphone. For the perceived acceptability of the mHealth peer-delivered interventions, we used the validated Acceptability of Intervention Measure (AIM) developed by Weiner and colleagues [Citation25]. AIM includes four questions answered using a scale from 1 to 5 (1= completely disagree to 5=completely agree) and has been used in the context of sub-Saharan Africa [Citation26]. No specialised training is needed to administer or interpret the results. In addition, the survey also included questions about suggested implementation strategies to support the delivery of PrEP services. Demographic data and location of facilities (urban and rural) were collected.
Data collection procedures and analysis
Consenting participants completed the survey in Setswana or English based on preference. The survey included closed- and open-ended questions. The research team trained the survey interviewers on data collection tool, ethics and data quality, security and confidentiality.
We completed a descriptive analysis using means and standard deviation (SD) for continuous variables. We used proportions and calculated chi-square or Fisher's exact test for categorical variables to compare by location of facilities (rural or urban). Cronbach’s Alpha statistic was estimated to determine the reliability of the AIM score [Citation27].
Results
Participants demographics
Among 138 adolescent girls and young women who were asked to participate, 131 agreed and provided consent (94.9%). The mean age was 20.5 years old (SD 1.8). Overall, 54.2% were from urban areas (n = 71/131), 67.2% completed secondary school (n = 88), 35.9% attended school in the last 12 months (n = 47), and 90.8% were single (n = 119). Level of education, occupation in the last 12 months and marital status differed significantly between adolescent girls and young women living in rural areas compared to urban (p value < .05) ().
Table 1. Demographic characteristics among adolescent girls and young women participants.
Feasibility, preferences and acceptability
With regard to the feasibility of peer-delivered interventions through mHealth, 88.6% owned a mobile phone and among adolescent girls and young women who owned a cell phone, 93.1% had a smartphone. Ninety-seven percent communicated using WhatsApp in the last 12 months. No difference was observed between rural and urban groups ().
Table 2. Feasibility and perceived acceptability of peer-delivered interventions using mHealth.
Overall, 26.7% (n = 35/131) had previously participated in peer-delivered interventions using mobile technology offered by the clinic. In terms of interest in peer-delivered interventions through mHealth, 84.7% (n = 111) reported being interested if it was available to them by the facility. There was no difference between participants seeking HIV services in urban and rural locations. Among individuals who indicated their preferences for the type of peer support group (n = 85), 44 (51.8%) preferred a hybrid model (combination of in-person and mHealth), 26 (30.6%) through mobile technology, 13 (15.3%) in-person at the facility and 2(2.4%) in-person in the community. There was no significant difference between adolescent girls and young women living in rural compared to urban settings ().
Table 3. Experience and interest towards peer-delivered interventions using mHealth.
Regarding perceived acceptability for peer support groups through mHealth for PrEP, the average score on the AIM was 3.8 (SD = 0.8) out of 5. No significant difference is observed in the average score between urban and rural residents. The AIM Cronbach’s alpha was 0.95, suggesting high internal consistency between the AIM’s questions. Across AIM questions, 80% or more of participants either agree or completely agree with the AIM statement. When asked about preferred strategies to support PrEP services, 78.6% (n = 103/131) of participants selected SMS or phone call reminders for PrEP refills, 67.9% (n = 89) peer-delivered interventions (in-person, mobile or hybrid), and 67.2% (n = 88) dedicated safe place at the clinic for PrEP services were among the top preferred. A higher proportion of participants in urban facilities selected peer-delivered interventions than those from rural facilities (76.1% vs. 58.3%, p = 0.03). SMS or phone call reminders for PrEP refills and a dedicated safe place in the clinic for PrEP services were also highly selected within the participant’s top three interventions (). Rural participants selected the need for a dedicated safe place significantly more than urban facilities (83.3% vs. 53.5%).
Discussion
In this cross-sectional study, we found a high proportion of adolescent girls and young women who had access to mobile technology irrespective of the setting, which is consistent with a study from Kenya including adolescent girls and young women in DREAMS program [Citation28] and aligned with a global trend [Citation29]. The increasing accessibility of mobile technology and the internet can be leveraged to increase access to health services to improve health outcomes. A high proportion of participants expressed an interest in receiving peer-delivered interventions using mHealth. Our results are similar to other studies that found peer-delivered intervention groups delivered through mobile phone are acceptable to young individuals [Citation30,Citation31].
Most research on peer-delivered interventions using mHealth includes people living with HIV with less emphasis on HIV prevention [Citation32,Citation33]. For PrEP, mobile technology has been mostly limited to training staff remotely, PrEP demand creation and SMS reminders [Citation34]. Touger et al., (2019) conducted a review on technology-based intervention for PrEP [Citation35]. However, this review focuses primarily on telehealth programmes without information on peer-delivered intervention for PrEP [Citation35] leaving gaps in its implementation and effectiveness to support the effective use of PrEP, such as the incorporation of peer-delivered interventions. As most adolescent girls and young women discontinue PrEP within the first month across geographical settings [Citation9,Citation36,Citation37], it is critical to identify and evaluate new implementation strategies intervening during this critical window to optimise the full potential of PrEP, one of the most effective strategies to prevent HIV acquisition. Although peer support for PrEP services was ranked high across groups, priority preferences for implementation strategies differed between rural and urban groups, highlighting the importance of context and engaging users when developing interventions.
The successful integration of mobile technology for health services, including peer-delivered interventions, will hinge on several determinants. Implementation considerations are needed to ensure privacy, confidentiality and data security [Citation38]. This is especially relevant for PrEP services as physical and virtual environments lacking privacy and confidentiality may discourage adolescent girls and young women from seeking PrEP services due to HIV and sexual stigma associated with PrEP [Citation39,Citation40]. The integration of peers into the health system for HIV prevention is also another important consideration for its effectiveness and sustainability. For HIV treatment, evidence from Botswana suggest that peers can be successfully embedded within the health system with appropriate planning, management, coordination and resources [Citation16].
The study is subject to limitations. The survey was limited to four clinics selected using convenience sampling, which may not be generalisable nationally. However, we included adolescent girls and young women at risk for HIV acquisition (eligibility criteria to be enrolled into DREAMS), a group relevant for peer-delivered intervention using mHealth. The study sample included a similar proportion of adolescent girls and young women who were single (90.8% vs 85.5%) and had a slightly higher proportion of individuals who had completed high school (67.2% vs 59.5%) compared to the overall population of adolescent girls and young women seeking services at DREAMS supported facilities during the study period. The survey consisted of mostly closed-ended quantitative questions; qualitative data would have provided more in-depth data from adolescent girls and young women. Despite AIM used in different settings including sub-Saharan Africa [Citation26], this tool has been validated in high-income countries. The study strengths included the inclusion of adolescent girls and young women from rural and urban settings to include diverse perspectives with a response rate of 95%.
In conclusion, according to adolescent girls and young women, peer-delivered interventions using mobile technology appear to be feasible and perceived as acceptable across adolescent girls and young women in Botswana. This modality should be considered in the PEPFAR’s programmatic toolkit of implementation strategies to improve PrEP services. Future studies are warranted to assess the effect of peer-delivered interventions on PrEP continuation.
Author’s contributions
MCL, LO, NB, NN, MEC contributed to the conception of the study. MCL, LO, NB, NN, MEC, AHN and KS contributed to the analysis and interpretation of the data and contributed to the drafting of the manuscript. All authors contributed to critically revising the manuscript and approved the final version.
Ethics and consent
The protocol was approved by the Botswana Ministry of Health- Health Research and Development Division Institutional Review Board (IRB) and the University of Maryland Baltimore IRB.
Paper context
PrEP is highly effective against HIV acquisition. Despite the availability of PrEP, most adolescent girls and young women) discontinued PrEP within the first month. Tailored interventions are urgently needed. Peer-delivered through mobile technology could enhance PrEP adherence. However, little is known about the acceptability and feasibility of this intervention in Botswana. Our findings suggest that peer-delivered intervention through mHealth is feasible and acceptable to adolescent girls and young women and should be evaluated to assess its impact.
Acknowledgments
The authors gratefully acknowledge the participants for this study for their time. We also thank the data collectors of the survey.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
- UNAIDS. Miles to go. Closing gaps breaking barriers righting injustices. Geneva, Switzerland: UNAIDS; 2018.
- UNAIDS. Confronting inequalities [Internet]. Geneva; 2021 [cited 2021 Sep 19]. Available from: https://www.unaids.org/sites/default/files/media_asset/2021-global-aids-update_en.pdf
- USAID. DREAMS: partnership to reduce HIV/AIDS in adolescent girls and young women [Internet]. 2021 [cited 2021 Oct 18]. Available from: https://www.usaid.gov/global-health/health-areas/hiv-and-aids/technical-areas/dreams
- Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med [Internet]. 2012 Jul 11 [cited 2021 Dec 18]367:399–7. doi: 10.1056/NEJMoa1108524
- Thigpen MC, Kebaabetswe PM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med [Internet]. 2012 Aug;367:423–434.
- Celum CL, Delany-Moretlwe S, Baeten JM, van der Straten A, Hosek S, Bukusi EA, et al. HIV pre-exposure prophylaxis for adolescent girls and young women in Africa: from efficacy trials to delivery. J Int AIDS Soc [Internet]. 2019 Jul 1 [cited 2021 Sep 8]22:e25298. doi: 10.1002/jia2.25298
- Hodges-Mameletzis I, Fonner VA, Dalal S, Mugo N, Msimanga-Radebe B, Baggaley R. Pre-exposure prophylaxis for HIV prevention in women: current status and future directions. Drugs [Internet]. 2019;79:1263–1276. doi: 10.1007/s40265-019-01143-8
- Velloza J, Kapogiannis B, Bekker LG, Celum C, Hosek S, Delany-Moretlwe S, et al. Interventions to improve daily medication use among adolescents and young adults: what can we learn for youth pre-exposure prophylaxis services? AIDS. 2021;35:463–475. doi: 10.1097/QAD.0000000000002777
- Reed JB, Shrestha P, Were D, Chakare T, Mutegi J, Wakhutu B, et al. HIV PrEP is more than ART‐lite: longitudinal study of real‐world PrEP services data identifies missing measures meaningful to HIV prevention programming. J Int AIDS Soc. 2021;24. doi: 10.1002/jia2.25827
- Tracy K, Wallace SP. Benefits of peer support groups in the treatment of addiction. Subst Abuse Rehabil. 2016;7:154. doi: 10.2147/SAR.S81535
- Magidson JF, Joska JA, Myers B, Belus JM, Regenauer KS, Andersen LS, et al. Project Khanya: a randomized, hybrid effectiveness-implementation trial of a peer-delivered behavioral intervention for ART adherence and substance use in Cape Town, South Africa. Implement Sci Commun. 2020;1(23). doi: 10.1186/s43058-020-00004-w
- Magidson JF, Joska JA, Regenauer KS, Satinsky E, Andersen LS, Seitz-Brown CJ, et al. “Someone who is in this thing that I am suffering from”: the role of peers and other facilitators for task sharing substance use treatment in South African HIV care. Int J Drug Policy. 2019;70:61–69. doi: 10.1016/j.drugpo.2018.11.004
- Wondimagegene YA, Debelew T, Koricha ZB. Effectiveness of peer-led education interventions on contraceptive use, unmet need, and demand among adolescent girls in Gedeo Zone, South Ethiopia. A cluster randomized controlled trial. Global Health Action. 2023 [cited 2023 Mar 24];16. doi: 10.1080/16549716.2022.2160543
- Simoni JM, Nelson KM, Franks JC, Yard SS, Lehavot K. Are peer interventions for HIV Efficacious? A systematic review. AIDS Behav [Internet]. 2011 Nov [cited 2023 Mar 17]; 15:1589 doi: 10.1007/s10461-011-9963-5
- Simoni JM, Franks JC, Lehavot K, Yard SS. Peer interventions to promote health: conceptual considerations. Am J Orthopsychiatry. 2011 Jul;81:351–359. doi: 10.1111/j.1939-0025.2011.01103.x
- Montebatsi M, Lavoie MC, Blanco N, Marima R, Sebina K, Mangope J, et al. Improving same-day ART in Botswana: effects of a multifaceted national intervention. AIDS. 2021;36:533–538. doi: 10.1097/QAD.0000000000003139
- Mavhu W, Willis N, Mufuka J, Bernays S, Tshuma M, Mangenah C, et al. Effect of a differentiated service delivery model on virological failure in adolescents with HIV in Zimbabwe (Zvandiri): a cluster-randomised controlled trial. Lancet Glob Health. 2020;8:e264–75. doi: 10.1016/S2214-109X(19)30526-1
- US President’s Emergency Plan for AIDS Relief. Country operational plan (COP) 2021 updates to Botswana's Country Operational Plan 2020. Strategic Direction Summary. Washington, DC: US President’s Emergency Plan for AIDS Relief; 2021.
- Forrest JI, Wiens M, Kanters S, Nsanzimana S, Lester RT, Mills EJ. Mobile health applications for HIV prevention and care in Africa. Curr Opin HIV AIDS [Internet]. 2015 [cited 2023 Feb 14];10:464–471. doi: 10.1097/COH.0000000000000198
- US President’s Emergency Plan for AIDS Relief. PEPFAR 2022 country and regional operational plan (COP/ROP) guidance for all PEPFAR- supported countries. Washington (DC): US President’s Emergency Plan for AIDS Relief; 2021.
- Ramskin L, Baron D, Makgamathe K, Schutzman J, Stangl A, Sievwright K, et al. EMPOWER clubs for young women using oral PrEP as part of an HIV pre- vention package: what we’ve learned so far. In: Adherence to HIV Prevention and Treatment. Harare, Zimbawe; 2018.
- Irungu E, Khoza N, Velloza J. Multi-level interventions to promote oral pre-exposure prophylaxis use among adolescent girls and young women: a review of recent research. Current HIV/AIDS Reports 2021. 2021;1:1–10.
- Botswana Ministry of Health. Botswana fifth AIDS impact survey (BAIS V). 2022.
- Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health [Internet]. 2011 Mar [cited 2021 Nov 28];38:65.doi: 10.1007/s10488-010-0319-7
- Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci [Internet]. 2017;12:1–12. doi: 10.1186/s13012-017-0635-3
- Gresh A, Mambulasa J, Ngutwa N, Chirwa E, Kapito E, Perrin N, et al. Evaluation of implementation outcomes of an integrated group postpartum and well-child care model at clinics in Malawi. Bmc Pregnancy Childbirth. 2023 Feb 7 [cited 2023 May 15] Available from;23. doi: 10.1186/s12884-023-05545-1
- Gennarelli R, Goodman MS. Measuring internal consistency of community engage-ment using the APLHA option of PROC CORR. New England SAS Users Group; 2013. p. 1–7.
- Oluoch-Madiang D. Viability of sustaining access to and uptake of HIV and sexual and reproductive health services for adolescent girls and young women through virtual interventions in Kenya: the PATH experience. In Virtual interventions: global innovations and approaches across the HIV cascade for key populations [Internet]. 2021 [cited 2023 May 18]. Available from: https://www.who.int/news-room/events/detail/2021/06/29/default-calendar/virtual-interventions-global-innovations-and-approaches-across-the-hiv-cascade-for-key-populations
- Pew Research Center. Ownership is growing rapidly around the world, but not always equally [Internet]. 2019 [cited 2021 Dec 17]. Available from: https://www.pewresearch.org/global/2019/02/05/smartphone-ownership-is-growing-rapidly-around-the-world-but-not-always-equally/
- Costa-Cordella S, Grasso-Cladera A, Rossi A, Duarte J, Guiñazu F, Cortes CP, et al. Internet-based peer support interventions for people living with HIV: A scoping review. PLoS One [Internet]. 2022 Aug 1 [cited 2023 Jan 31];17:e0269332. doi: 10.1371/journal.pone.0269332
- Henwood R, Patten G, Barnett W, Hwang B, Metcalf C, Hacking D, et al. Acceptability and use of a virtual support group for HIV-positive youth in Khayelitsha, Cape Town using the MXit social networking jplatform [Internet]. AIDS Care. 2016 Jul 2 [cited 2023 Jan 31];28:898–903. doi: 10.1080/09540121.2016.1173638
- Maloney KM, Bratcher A, Wilkerson R, Sullivan PS. Electronic and other new media technology interventions for HIV care and prevention: a systematic review. J Int AIDS Soc [Internet]. 2020 Jan 1 [cited 2023 Jan 31];23:e25439. doi: 10.1002/jia2.25439
- Flickinger TE, DeBolt C, Waldman AL, Reynolds G, Cohn WF, Beach MC, et al. Social support in a virtual community: analysis of a clinic-affiliated online support group for persons living with HIV/AIDS. AIDS Behav [Internet]. 2017 Nov 1 [cited 2023 Jan 31];21:3087–3099. doi: 10.1007/s10461-016-1587-3
- Kerzner M, De AK, Yee R, Keating R, Djomand G, Stash S, et al. Pre-exposure prophylaxis (PrEP) uptake and service delivery adaptations during the first wave of the COVID-19 pandemic in 21 PEPFAR-funded countries. PLoS One [Internet]. 2022 Apr 1 [cited 2023 Jan 31];17:e0266280. doi: 10.1371/journal.pone.0266280
- Touger R, Wood BR. A review of telehealth innovations for HIV pre-exposure prophylaxis (PrEP). Curr HIV/AIDS Rep. 2019 Feb 15;16:113–119.doi: 10.1007/s11904-019-00430-z
- Kyongo J. How long will they take it? Oral pre-exposure prophylaxis retention for female sex workers, men who have sex with men and young women in a demonstration project in Kenya. In: 22nd International AIDS Conference [Internet]. Amsterdam, Netherland; 2018 [cited 2023 May 18]. Available from: http://programme.aids2018.org/Abstract/Abstract/8788
- Kinuthia J, Pintye J, Abuna F, Mugwanya KK, Lagat H, Onyango D, et al. Pre-exposure prophylaxis uptake and early continuation among pregnant and post-partum women within maternal and child health clinics in Kenya: results from an implementation programme. Lancet HIV [Internet]. 2020 [cited 2021 Dec 7];7:e38–48.
- Phan JM, Kim S, Thị Đ, Linh T, Cosimi LA, Pollack TM, et al. Telehealth interventions for HIV in low- and middle-income countries. Curr HIV/AIDS Rep [Internet]. 1904;1:3. doi: 10.1007/s11904-022-00630-0
- Golub SA. PrEP stigma: implicit and explicit drivers of disparity. Curr HIV/AIDS Rep [Internet]. 2018 Apr 1 [cited 2022 May 31];15:190. doi: 10.1007/s11904-018-0385-0
- Rousseau E, Katz AWK, O’Rourke S, Bekker LG, Delany-Moretlwe S, Bukusi E, et al. Adolescent girls and young women’s PrEP-user journey during an implementation science study in South Africa and Kenya. PLoS One. 2021 Oct 1;16:e0258542.