Peer-based clubs may offer valuable PrEP initiation support to adolescent girls and young women
An evaluation of peer support clubs in settings with high HIV and gender-based violence prevalence finds increased self-esteem and self-efficacy among participants.
In-depth interviews with young South African women, published as part of the EMPOWER trial, have highlighted the value of peer support for increasing adherence to pre-exposure prophylaxis (PrEP) and reducing HIV vulnerabilities.
Researchers conducted repeat in-depth interviews with 13 support group attendees from Hillbrow, an inner-city area of Johannesburg. The groups form part of the wider EMPOWER programme, which also offers individual counselling and text message support to help adolescent girls and young women (16-24 years) in South Africa and Tanzania stay on PrEP, and deal with gender-based violence and other factors that increase HIV risk.
The support clubs run monthly over four months and are generally facilitated by a young woman supported by older, trained counsellors. The sessions are a mix of group discussion and interactive exercises, such as role-plays. They aim to increase participants’ sense of empowerment and their skills in partner communication and conflict resolution.
The 13 study participants were aged 18 to 24, and were interviewed two to three times over 13 months. Eight had experienced physical, sexual or emotional violence at some point in their lives. Twelve were in a relationship, 11 of whom described their partner as either ‘controlling’, ‘cheating’ or ‘lying’. Half reported inconsistent condom use.
All 13 women began taking PrEP at the start of the study, and seven used it throughout. Most said mistrust of their partners due to previous infidelities, plus their partners’ controlling and sometimes abusive behaviour, was motivating them to take PrEP. These same issues led some to conceal their PrEP use from their partners, fearing disclosure would lead to conflict or violence.
Most women said they found the sessions personally transformative. Interviewees said their self-esteem increased due to the support groups and they also felt less isolated. They also expressed greater insight into gender-based violence and how to address it. This led some women to confront power imbalances in their relationships or exit them altogether.
Participants said the role-plays particularly equipped them to make better decisions and stand their ground with domineering partners. Participants also appreciated the ‘safe space’ the groups provided for sharing problems.
Overall, 11 of the 13 interviewees attended at least one club session. Time constraints, transport challenges and scheduling conflicts tended to account for non-attendance. When some women swapped groups due to scheduling issues this appeared to undermine group cohesion, especially when rapport, trust and friendships were already established.
Any attempt to roll out clubs in future PrEP programmes will need to address issues of non-attendance, potentially through flexible scheduling that fits in with participants’ busy lives.
Around 430 adolescent girls and young women participated in EMPOWER between August 2016 and February 2018. Interestingly, an additional assessment found no difference in PrEP use after six months between those who had attended the clubs and those who had not.
Despite this, the findings suggest using peer-based PrEP groups provides valuable support to adolescent girls and young women in places with high levels of HIV and gender-based violence.