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      Adolescent girls and young women’s PrEP-user journey during an implementation science study in South Africa and Kenya

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          Abstract

          Successful scale-up of PrEP for HIV prevention in African adolescent girls and young women (AGYW) requires integration of PrEP into young women’s everyday lives. We conducted interviews and focus group discussions with 137 AGYW PrEP users aged 16–25 from South Africa and Kenya. Individual and relational enablers and disablers were explored at key moments during their PrEP-user journey from awareness, initiation and early use through persistence, including PrEP pauses, restarts, and discontinuation. PrEP uptake was facilitated when offered as part of an integrated sexual reproductive health service, but hampered by low awareness, stigma and misconceptions about PrEP in the community. Daily pill-taking was challenging for AGYW due to individual, relational and structural factors and PrEP interruptions (intended or unintended) were described as part of AGYW’s PrEP-user journey. Disclosure, social support, adolescent-friendly health counseling, and convenient access to PrEP were reported as key enablers for PrEP persistence.

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          Most cited references 48

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          Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention

          Research shows that gender power inequity in relationships and intimate partner violence places women at enhanced risk of HIV infection. Men who have been violent towards their partners are more likely to have HIV. Men's behaviours show a clustering of violent and risky sexual practices, suggesting important connections. This paper draws on Raewyn Connell's notion of hegemonic masculinity and reflections on emphasized femininities to argue that these sexual, and male violent, practices are rooted in and flow from cultural ideals of gender identities. The latter enables us to understand why men and women behave as they do, and the emotional and material context within which sexual behaviours are enacted. In South Africa, while gender identities show diversity, the dominant ideal of black African manhood emphasizes toughness, strength and expression of prodigious sexual success. It is a masculinity women desire; yet it is sexually risky and a barrier to men engaging with HIV treatment. Hegemonically masculine men are expected to be in control of women, and violence may be used to establish this control. Instead of resisting this, the dominant ideal of femininity embraces compliance and tolerance of violent and hurtful behaviour, including infidelity. The women partners of hegemonically masculine men are at risk of HIV because they lack control of the circumstances of sex during particularly risky encounters. They often present their acquiescence to their partners' behaviour as a trade off made to secure social or material rewards, for this ideal of femininity is upheld, not by violence per se, by a cultural system of sanctions and rewards. Thus, men and women who adopt these gender identities are following ideals with deep roots in social and cultural processes, and thus, they are models of behaviour that may be hard for individuals to critique and in which to exercise choice. Women who are materially and emotionally vulnerable are least able to risk experiencing sanctions or foregoing these rewards and thus are most vulnerable to their men folk. We argue that the goals of HIV prevention and optimizing of care can best be achieved through change in gender identities, rather than through a focus on individual sexual behaviours.
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            Enhancing the quality and credibility of qualitative analysis.

            Varying philosophical and theoretical orientations to qualitative inquiry remind us that issues of quality and credibility intersect with audience and intended research purposes. This overview examines ways of enhancing the quality and credibility of qualitative analysis by dealing with three distinct but related inquiry concerns: rigorous techniques and methods for gathering and analyzing qualitative data, including attention to validity, reliability, and triangulation; the credibility, competence, and perceived trustworthiness of the qualitative researcher; and the philosophical beliefs of evaluation users about such paradigm-based preferences as objectivity versus subjectivity, truth versus perspective, and generalizations versus extrapolations. Although this overview examines some general approaches to issues of credibility and data quality in qualitative analysis, it is important to acknowledge that particular philosophical underpinnings, specific paradigms, and special purposes for qualitative inquiry will typically include additional or substitute criteria for assuring and judging quality, validity, and credibility. Moreover, the context for these considerations has evolved. In early literature on evaluation methods the debate between qualitative and quantitative methodologists was often strident. In recent years the debate has softened. A consensus has gradually emerged that the important challenge is to match appropriately the methods to empirical questions and issues, and not to universally advocate any single methodological approach for all problems.
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              Women’s Experiences with Oral and Vaginal Pre-Exposure Prophylaxis: The VOICE-C Qualitative Study in Johannesburg, South Africa

              Background In VOICE, a multisite HIV pre-exposure prophylaxis (PrEP) trial, plasma drug levels pointed to widespread product nonuse, despite high adherence estimated by self-reports and clinic product counts. Using a socio-ecological framework (SEF), we explored socio-cultural and contextual factors that influenced participants’ experience of daily vaginal gel and oral tablet regimens in VOICE. Methods In Johannesburg, a qualitative ancillary study was concurrently conducted among randomly selected VOICE participants assigned to in-depth interviews (n = 41), serial ethnographic interviews (n = 21), or focus group discussions (n = 40). Audiotaped interviews were transcribed, translated, and coded thematically for analysis. Results Of the 102 participants, the mean age was 27 years, and 96% had a primary sex partner with whom 43% cohabitated. Few women reported lasting nonuse, which they typically attributed to missed visits, lack of product replenishments, and family-related travel or work. Women acknowledged occasionally skipping or mistiming doses because they forgot, were busy, felt lazy or bored, feared or experienced side effects. However, nearly all knew or heard of other study participants who did not use products daily. Three overarching themes emerged from further analyses: ambivalence toward research, preserving a healthy status, and managing social relationships. These themes highlighted the profound and complex meanings associated with participating in a blinded HIV PrEP trial and taking antiretroviral-based products. The unknown efficacy of products, their connection with HIV infection, challenges with daily regimen given social risks, lack of support–from partners and significant others–and the relationship tradeoffs entailed by using the products appear to discourage adequate product use. Conclusions Personal acknowledgment of product nonuse was challenging. This qualitative inquiry highlighted key influences at all SEF levels that shaped women’s perceptions of trial participation and experiences with investigational products. Whether these impacted women’s behaviors and may have contributed to ineffective trial results warrants further investigation.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: SoftwareRole: VisualizationRole: Writing – original draft
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: Writing – review & editing
                Role: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: SupervisionRole: VisualizationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                14 October 2021
                2021
                : 16
                : 10
                Affiliations
                [1 ] Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
                [2 ] RTI International, Women’s Global Health Imperative (WGHI), Berkeley, CA, United States of America
                [3 ] Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
                [4 ] Kenya Medical Research Institute, Kisumu, Kenya
                [5 ] International Clinical Research Center, University of Washington, Seattle, WA, United States of America
                [6 ] Harvard Medical School, Harvard University, Boston, MA, United States of America
                [7 ] Centre for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
                [8 ] Gilead Sciences, Inc., Seattle, WA, United States of America
                [9 ] Centre for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, United States of America
                Washington University in Saint Louis, UNITED STATES
                Author notes

                Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests:JMB, LGB, CC, SD and ER received personal fees for advisory board participation from Gilead Sciences outside of this current scope of work. JMB is employed by Gilead Sciences, Inc.

                Article
                PONE-D-21-13674
                10.1371/journal.pone.0258542
                8516266
                © 2021 Rousseau et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 1, Tables: 2, Pages: 18
                Product
                Funding
                Funded by: USAID
                Award ID: AID-OAA-A15-00034
                Award Recipient :
                The research leading to these findings received funding from USAID (AID-OAA-A15-00034). PrEP (Truvada) was sponsored by Gilead Sciences Inc. The funding body reviewed the final version of this manuscript before submission for publication.
                Categories
                Research Article
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
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                Custom metadata
                All relevant data are within the manuscript and its Supporting Information files. Other data are available from the University of Washington Institutional Ethics Committee for researchers who meet the criteria for access to confidential data (contact via larakid@ 123456uw.edu ).

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