Creating Allies: Qualitative Exploration of Young Women's Preferences for PrEP Methods and Parents' Role in PrEP Uptake and User Support in Urban and Rural Zambia

"Results will help guide community sensitization and implementation efforts."

Zambian adolescent girls and young women (AGYW) have high HIV incidence and face barriers to the use of pre-exposure prophylaxis (PrEP). Perceived and actual key influencer opinions are important factors in AGYW's decisions about initiating and continuing PrEP use. Parental support improves PrEP use and adherence in some settings, but negative parental attitudes toward HIV prevention may inhibit engagement with AGYW. This study explored perceptions of future PrEP methods among AGYW and parents and parent-youth engagement on HIV prevention and PrEP use in Zambia.

In this qualitative descriptive study, 10 focus group discussions (FGDs) and 4 in-depth interviews (IDIs) were conducted with AGYW participants (n = 87) and 7 FGDs and 4 IDIs among parents of AGYW (n = 62) from 5 Zambian provinces representing 3 geographic groups: (i) rural, (ii) urban, and (iii) rural-urban mix with transnational borders (Eastern province). 

During the analysis period, preliminary results were presented at a stakeholder consultation convened in Lusaka, Zambia, July 26-28 2022, to explore challenges to parent–youth engagement on HIV prevention. Participating stakeholders included: representatives of government and parastatal organisations, implementing organisations, civil society organisations (CSOs), and advocacy groups; community leaders and members, including youth delegates from each Zambian province; and participants in the AGYW and parent study. The audience was specifically asked whether the findings resonated with their experience. The researchers summarised their responses to enrich and informally validate the study results with a broader audience (see below).

The study found that most AGYW participants preferred the discreet nature and longer duration of injectable PrEP compared to the PrEP ring and oral PrEP. AGYW participants across all provinces cited DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) centres, clinics, and hospitals (except in Luapula Province, which had no DREAMS sites) as the locations where they would prefer to receive PrEP services. AGYW participants liked the DREAMS centres because they offer faster service than hospitals or clinics, more convenient locations, and a youth-centred philosophy.

AGYW participants across all 3 geographical groups said few parents would be supportive of their children using PrEP. Many AGYWs reported inability to disclose PrEP use to their parents due to lack of parental support based on cultural taboos against premarital sex. Nevertheless, AGYW participants said they would like to talk to their parents about PrEP so their parents could support their use and provide advice.

Many parents also described difficulties discussing PrEP with their daughters because of cultural and religious beliefs about abstinence from sex before marriage. However, parents acknowledged that the threat of HIV is real and said they need PrEP knowledge and guidance on speaking with their children about HIV prevention and PrEP. Parents identified two types of support they need. First, they want knowledge about HIV, what behaviours lead to exposure, and prevention options, including PrEP. Second, parents want to be taught how to discuss these sensitive issues with their children so their children can open up to them and feel supported.

Some parents requested that youth-friendly programmes such as DREAMS conduct programjes on HIV prevention for youth so they can send their children to those programmes rather than to discuss the issue. These parents felt that discussing HIV prevention, PrEP, and other sexual and reproductive health (SRH) issues with their children would incorrectly imply approval of premarital sex. Others suggested sending PrEP information via phones, as the Ministry of Health has done with tuberculosis and malaria information. Participants also said sensitising communities can be done through radio, television, churches, schools, and youth groups. Community volunteers could conduct door-to-door campaigns and sensitise the community about PrEP through dramas at marketplaces. Community members could also be trained through women's groups and churches to disseminate HIV prevention information in their communities.

Stakeholders in the July 2022 consultation agreed that many of the findings were consistent with their understanding. They offered additional context on parents' ability to initiate conversations about HIV and SRH with their adolescents, pointing to social norms, and how they might respond to or support requested PrEP use. For example, most stakeholders endorsed more programming for parents to "rebrand" discussing sensitive issues with young people as desirable and provide training on how to enhance their conversations and relationships with their children. Stakeholders emphasised ensuring that such training include guidance on providing SRH information to adolescents with a level of detail appropriate for their age and stage of development. Youth delegates noted there will always be a role for peer educators to either guide engagement with parents or act as a third-party source for youth who believe their parents cannot or would not have these discussions.

In conclusion: "Although many parents are currently not playing a role in daughters' decisions about PrEP use, both parents and AGYW are willing to engage with each other on HIV prevention issues. To foster parent-child engagement, HIV prevention programs should not only provide information about PrEP but also address social norms that impede discussion of HIV prevention and equip both parents and AGYW with skills and support for such conversations. Community sensitization is also needed as new PrEP products are introduced, to create an enabling environment for parent-child engagement by increasing awareness, countering misconceptions, and reducing stigma."