title: Rethinking HIV prevention to prepare for oral PrEP implementation for young African women.
abstract: BACKGROUND
  HIV incidence remains high among young women in sub-Saharan Africa in spite of scale-up of HIV testing, behavioural interventions, antiretroviral treatment and medical male circumcision. There is a critical need to critique past approaches and learn about the most effective implementation of evidence-based HIV prevention strategies, particularly emerging interventions such as pre-exposure prophylaxis (PrEP).
  
  
  CONCLUSIONS
  Women in sub-Saharan Africa are at increased risk of HIV during adolescence and into their 20s, in part due to contextual factors including gender norms and relationship dynamics, and limited access to reproductive and sexual health services. We reviewed behavioural, behavioural economic and biomedical approaches to HIV prevention for young African women, with a particular focus on the barriers, opportunities and implications for implementing PrEP in this group. Behavioural interventions have had limited impact in part due to not effectively addressing the context, broader sexual norms and expectations, and structural factors that increase risk and vulnerability. Of biomedical HIV prevention strategies that have been tested, daily oral PrEP has the greatest evidence for protection, although adherence was low in two placebo-controlled trials in young African women. Given high efficacy and effectiveness in other populations, demonstration projects of open-label PrEP in young African women are needed to determine the most effective delivery models and whether women at substantial risk are motivated and able to use oral PrEP with sufficient adherence to achieve HIV prevention benefits.
  
  
  CONCLUSIONS
  Social marketing, adherence support and behavioural economic interventions should be evaluated as part of PrEP demonstration projects among young African women in terms of their effectiveness in increasing demand and optimizing uptake and effective use of PrEP. Lessons learned through evaluations of implementation strategies for delivering oral PrEP, a first-generation biomedical HIV prevention product, will inform development of new and less user-dependent PrEP formulations and delivery of an expanding choice of prevention options in HIV prevention programmes for young African women.
authors.affiliation: Department of Global Health, University of Washington Seattle, WA, USA.|Department of Medicine, University of Washington Seattle, WA, USA.|Department of Epidemiology, University of Washington Seattle, WA, USA; ccelum@uw.edu.
authors.forename: Connie L
authors.initials: CL
authors.lastname: Celum
authors.affiliation: Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Sinead
authors.initials: S
authors.lastname: Delany-Moretlwe
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health Boston, MA, USA.
authors.forename: Margaret
authors.initials: M
authors.lastname: McConnell
authors.affiliation: Human Sciences Research Council, Durban, South Africa.
authors.forename: Heidi
authors.initials: H
authors.lastname: van Rooyen
authors.affiliation: The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
authors.affiliation: College of Nursing, New York University New York, NY, USA.
authors.forename: Ann
authors.initials: A
authors.lastname: Kurth
authors.affiliation: Kenya Medical Research Institute, Nairobi, Kenya.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Bukusi
authors.affiliation: Human Sciences Research Council, Durban, South Africa.
authors.forename: Chris
authors.initials: C
authors.lastname: Desmond
authors.affiliation: Department of Global Health, University of Washington Seattle, WA, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Morton
authors.affiliation: Department of Global Health, University of Washington Seattle, WA, USA.|Department of Medicine, University of Washington Seattle, WA, USA.|Department of Epidemiology, University of Washington Seattle, WA, USA.
authors.forename: Jared M
authors.initials: JM
authors.lastname: Baeten
mesh_terms: D000284:Administration, Oral; D000293:Adolescent; D000328:Adult; D000349:Africa; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006801:Humans; D065129:Pre-Exposure Prophylaxis
chemical_list: D019380:Anti-HIV Agents
keywords: Africa; HIV; pre-exposure prophylaxis; prevention; women