Barriers and Facilitators to PrEP Uptake and Adherence among Adolescent Girls and Young Women Attending Family Planning Clinics in Mulanje District, Malawi: A Qualitative Study

Barriers and Facilitators to PrEP Uptake and Adherence among Adolescent Girls and Young Women Attending Family Planning Clinics in Mulanje District, Malawi: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and Facilitators to PrEP Uptake and Adherence among Adolescent Girls and Young Women Attending Family Planning Clinics in Mulanje District, Malawi: A Qualitative Study Martin Kayange, Patty Mopamboli, GRACE OGBONNA, Vincent Jumbe This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5775233/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Introduction Adolescent girls and young women (AGYW) in Malawi, with an 8% HIV prevalence, are disproportionately affected by HIV ( 1 ), making PrEP a fundumental prevention mechanism. However, PrEP uptake is affected by individual, interpersonal, community, institutional, and structural factors. Identifying these factors is important to improving HIV prevention and achieving the 95-95-95 HIV goals. This study aims to explore these factors influencing PrEP uptake and adherence among AGYW in Mulanje District, providing understing for targeted interventions to increase PrEP coverage and reduce HIV incidence. Methods This research employed a Hybrid Type 1 qualitative design, focusing on Adolescent Girls and Young Women (AGYW) aged 15–24. The study was stratified based on PrEP status, including current users, those identified as eligible but not initiated, and those who have discontinued PrEP. Data collection involved interviews with 30 participants and one focus group discussion with healthcare providers. Thematic analysis was conducted to identify patterns and insights, and the results are presented through a comprehensive narrative and tables highlighting key themes and quotes. Results Our analysis revealed several barriers and facilitators to PrEP uptake and adherence among AGYW. Barriers included stigma and social perception, Healthcare accessibility challenges, and limited awareness and education. Facilitators involved social and peer support, healthcare provider engagement, and convenient and responsive services by staffs. Strategies to enhance PrEP adherence included increasing accessibility, awareness campaigns, integrating PrEP with other health services, and peer and social support initiatives. These findings highlight the need for multi-faceted approaches to address barriers and strengthen facilitators to improve PrEP uptake and adherence, and also implement the suggested interventions. Conclusion Addressing barriers to PrEP uptake among AGYW in Mulanje District requires a complex approach. Key barriers include stigma, healthcare access issues, and low awareness, while facilitators like involved social and peer support, healthcare provider engagement, and convenient and responsive services by staffs. Recommendations to improve PrEP use include enhancing healthcare access, using peer support, and integrating PrEP with other services, and initiating community awareness campaigns. These strategies are important for overcoming barriers, improving adherence, and supporting HIV prevention in Malawi. Adolescent girls and young women (AGYW) PrEP HIV Prevention Malawi Chapter 1: Introduction 1.1 Background According to UNAIDS, adolescent girls and young women (AGYW) in sub-Saharan Africa are disproportionately affected by HIV, with Malawi having one of the highest HIV prevalence of 8% among this population group (2)(1). Pre-exposure prophylaxis (PrEP) has been shown to be an effective prevention method in reducing HIV acquisition among AGYW (3)(4). Its effectivity is when the pill is taken every day. However, its implementation among AGYW in Malawi faces several challenges, including limited awareness and knowledge of PrEP, partner resistance, and gendered norms regarding sexuality, stigma, drug side effect and frequent relocation of beneficiaries (5). A study conducted in Zimbabwe, identified the following factors including at individual (high HIV risk perception and preventing HIV/desire to remain HIV negative), interpersonal (peer influence, social support and care for PrEP uptake), community (adequate PrEP information and sensitization, evidence of PrEP efficacy and safety), institutional (convenient and responsive services, provision of appropriate and sufficiently resourced services), and structural (access and availability of PrEP, cost of PrEP) levels as facilitators of PrEP uptake (6). Identifying the barriers and facilitators to PrEP uptake and adherence among AGYW is not only integral to addressing these challenges but also crucial in the broader effort to control HIV/AIDS and achieve the 95-95-95 goals (7). By addressing these barriers and enhancing facilitators, it contributes to the comprehensive strategy of reaching ambitious HIV control goals, which aim to diagnose 95% of all HIV-positive persons, provide antiretroviral therapy (ART) for 95% of those diagnosed, and achieve viral suppression for 95% of those on ART. Through this research, the aim was to develop targeted interventions that would increase PrEP coverage and reduce HIV incidence in this key population group, aligning our efforts with the broader global commitment to combat HIV/AIDS effectively According to the World Health Organization (WHO), PrEP is recommended for populations at substantial risk of HIV infection (defined as incidence greater than 3%), including adolescent girls and young women (AGYW) in high HIV burden settings, such as Malawi (8). According to the Centers for Disease Control and Prevention (CDC), PrEP has been shown to reduce the risk of HIV infection by up to 99% when taken consistently (9). A study conducted by Jourdain et al (10) showed that among a total of 46,706 individuals, PrEP users accounted for 29% of cases and 49% of controls. The study found that PrEP effectiveness was 60% overall, reaching 93% for a high amount of PrEP consumption and 86% if excluding periods after PrEP discontinuation. However, the study also found that PrEP effectiveness was significantly reduced in people younger than 30 years (26%) and in those who were socioeconomically deprived (64%), both of which groups showed low amounts of PrEP consumption and high rates of PrEP discontinuation. The reasons why effectiveness was low in young people and socioeconomically deprived areas was not determined. The study sought to identify the barriers and facilitators to PrEP uptake and adherence among adolescent girls and young women (AGYW) in Mulanje District. These barriers includes issues related to; at individual (fear of HIV, fear of side effects, and PrEP characteristics), interpersonal (parental influence, sexial partners), community (peer influence, social stigma), institutional (long waiting times at clinics, attitudes of health workers), and structural (accessibility concerns) levels (6). Furthermore, it's worth noting that while the introduction of long-acting CAB LA for PrEP is a promising development (11), its nationwide rollout beyond Blantyre (BT) and Lilongwe (LL) is expected to take time. Given this transitional phase, understanding the dynamics around the continued use of oral Truvada remains the crucial thing. One potential implementation strategy for PrEP uptake is to develop targeted PrEP marketing campaigns that are culturally appropriate and effectively communicate the benefits of PrEP while addressing common misconceptions and concerns (12). They called for campaigns, like those targeting young men with voluntary male medical circumcision (VMMC), to make young women aware of PrEP. Extensively, about the role and need for schools to educate AGYW and young men about PrEP: Campaigns about PrEP should be done in the community and in schools. Another strategy is to provide comprehensive counseling services to AGYW at the point of care. These counseling sessions should be specifically tailored to AGYW who express interest in using PrEP. The counseling should address issues related to consent, confidentiality, partner resistance, and cost, as well as gendered norms regarding sexuality. Counseling sessions may also include information about HIV testing, condom use, and other sexual health topics. Additional implementation strategies may include training and educating stakeholders to provide PrEP services and integrating PrEP into existing healthcare services, such as family planning and maternal health programs (13). It may also be important to address structural barriers to PrEP access, such as limited availability of laboratory equipment and staff and workflow, insufficient HRH, and geographic barriers. Another option would be to decentralize access to PrEP through Health Surveillance Assistants (HSAs). This strategy would involve training healthcare workers, including HSAs, to provide PrEP services and integrating PrEP into existing healthcare programs such as family planning and maternal health services. By decentralizing access, AGYW can access PrEP services in their local communities, reducing the need for extensive travel and overcoming geographic barriers. To implement the strategies they is a need to establish a comprehensive set of metrics to gauge the effectiveness of the strategies in bolstering PrEP uptake and adherence among AGYW in the country. These metrics includes PrEP initiation rates, retention PrEP programs, and knowledge and attitude changes among AGYW, Partner Support and involvement by asking AGYW about their partners' awareness of PrEP, willingness to support its use, and whether partners accompany them to PrEP services and qualitative feedback on their experiences with the interventions. 1.2 Statement of the problem HIV and AIDS remain a substancial public health issue in Malawi, with Mulanje District experiencing a disproportionately high burden. HIV prevalence in this district stands at 8.8% among individuals aged 15-49 (14), exceeding the national prevalence of 8.0% (1). The impact is particularly intense among women in Mulanje, where the prevalence is 10.8% compared to 10.0% nationally, while among men, it is 6.4% compared to 5.8% nationally (1). Additionally, the Southern region of Malawi, with Mulanje district being among the most hard-hit areas with 25.9% of women between the ages of 15 and 49 being HIV positive compared to men (14.2%) in the same age group. These alarming statistics highlight the important need for effective HIV prevention measures, such as (PrEP), especially for AGYW, who face intense vulnerability to HIV attainment. Despite the affirmed efficacy of PrEP in preventing HIV, uptake and adherence remain low due to various individual, social, and structural barriers. While previous studies, such as one in Blantyre which focused on female sex workers, have shown challenges related to PrEP use in other populations, there is limited data on the factors affecting PrEP uptake and adherence among AGYW in high-prevalent areas like Mulanje. This study fills this gap by exploring the barriers and facilitators to PrEP utilization among AGYW attending family planning clinics in Mulanje District. 1.3 Objectives of the study 1.3.1 Broad Objective The main aim of this study was to identify the barriers and facilitators to PrEP uptake and adherence among adolescent girls and young women (AGYW) Attending Family Planning Clinics in Mulanje District, Malawi. 1.3.2 Specific Objectives The following were the specific objectives: To identify the main barriers influencing PrEP uptake among adolescent girls and young women. To explore the key facilitators contributing to the successful PrEP uptake among adolescent girls and young women. To develop evidence-based strategies to enhance adherence to PrEP among adolescent girls and young women. Chapter 2: Methodology 2.1 Type of study This research adopted a Hybrid Type 1 design to evaluate the effectiveness of an implementation strategy targeted at improving the uptake and adherence of PrEP among Adolescent Girls and Young Women (AGYW) attending Family Planning Clinics. Hybrid Type 1 helps in gathering information on its delivery and/or potential for implementation in a real-world context (15). This design allowed for a complex exploration of AGYW's multifaceted experiences, attitudes, and beliefs related to the utilization and adherence to PrEP. The study conducted a comprehensive examination of the factors influencing PrEP uptake and adherence in AGYW. Qualitative research methods played an essential role in this exploration, providing a detailed understanding of the barriers and facilitators specific to PrEP utilization and adherence within this demographic area. 2.2 Study place HIV and AIDS in Malawi is a major public health concern, with Mulanje district being one of the most affected areas. The HIV prevalence in Mulanje district is high, with 8.8% of the total population between 15 and 49 years old being infected with HIV (14).This is higher than the national prevalence rate of 8.0% in Malawi. Notably, HIV prevalence among women in Mulanje is 10.8%, which is higher than the national rate of 10.0%, while among men in Mulanje, it is 6.4% compared to the national rate hard-hit areas with 25.9% of women between the ages of 15 and 49 being HIV positive compared to men (14.2%) in the same age group. These statistics highlight the urgent need for effective of 5.8% (1). The Southern region of Malawi has a higher prevalence as compared to the central and Northern regions, with Mulanje district being among the most HIV prevention strategies, such as PrEP, especially among AGYW who are at a higher risk of acquiring HIV. It is important to note that another study was conducted in Blantyre, focusing on barriers to the uptake and oral use of PrEP among female sex workers, providing valuable insights into PrEP utilization in a different population group (16). The identification of barriers and facilitators to PrEP uptake and adherence among AGYW attending Family Planning Clinics through qualitative research helped to inform the development of targeted interventions to increase PrEP coverage and reduce HIV transmission rates in this population. 2.3 Study population The study population for this research consisted of Adolescent Girls and Young Women (AGYW) between the ages of 15-24 in Mulanje District. 2.3.1 Inclusion criteria: AGYW who were using PrEP AGYW who were identified as eligible for PrEP but have not been initiated AGYW who, despite being identified as eligible, has not started using PrEP AGYW who had previously used PrEP but had discontinued its use. 2.3.2 Exclusion criteria: AGYW with cognitive or communication impairments. AGYW who had participated in other research studies related to HIV prevention or sexual health. 2.5 Sample size considerations The anticipated sample size was specified upfront within a range of 25-30 interviews. The final sample was determined through a process of data saturation, where data collection continued until no new themes or insights emerged. This combination of upfront specification and data-driven determination ensured both practicality and comprehensiveness in the study's sample size. 2.6 Data Collection procedure 2.6.1 Recruitment of Study Participants: The recruitment of participant involved purposive sampling of AGYW aged between 15-24 years. Participants were chosen from those either currently taking PrEP or identified as eligible but not initiated or have discontinued it. Collaboration with family planning clinics in Mulanje District hospital will facilitate participant identification using their registers. The sample was stratified according to variables of PrEP status (currently taking PrEP, identified as eligible but not initiated, or have discontinued it) to capture diverse perspectives. Recruitment activities involved reaching out to potential participants through phone calls or visits with the help of local health surveillance assistants (HSAs) wherein the study's purpose was explained, informed consent obtained, and interviews were scheduled. The involvement of family planning clinics ensured access to individuals with varying PrEP experiences, contributing to a comprehensive understanding of barriers and facilitators among different subgroups of AGYW. We conducted one focus group discussion interviews with healthcare workers (HCWs). This approach enabled us to explore their experiences, perceptions, and practices related to PrEP and AGYW's healthcare. This added depth to the study's insights by providing valuable perspectives on the social dynamics and support structures that affect AGYW's decisions regarding PrEP. 2.6.2 Data Collection Method: In-depth semi-structured interviews were the primary method of data collection. The interviews were conducted in Chichewa, the local language mainly spoken in this area. For the healthcare workers (HCWs), focus group discussions for each group were employed to collect data. These interviews were audio-recorded and transcribed verbatim to maintain the richness of participants' responses. The interview guide, structured by integrating insights from existing research, explored critical areas such as partner resistance, cost barriers, gendered norms, healthcare provider perspectives, and community perceptions related to PrEP. 2.7 Data Management and Analysis 2.7.1 Data Management 2.7.2 Transcription and Organization: Audio recordings of the interviews, conducted in Chichewa, underwent rigorous transcribing to capture the richness and nuances of participant’s responses. Verbatim transcription were translated into English by trained research assistants. The results from the transcripts were systematically organized, employing a structure that includes participant identifiers. This systematic organization was essential for efficient reference during subsequent stages of data analysis. Each transcript saved as a comprehensive record, facilitating a detailed examination of participants' perspectives on PrEP uptake and adherence among AGYW in the District. 2.7.3 Coding The data underwent coding process. Initial coding, this involved open exploration of the data, generating preliminary codes to encompass key concepts and ideas. Subsequently, axial coding was refined and organized these codes into meaningful categories, establishing connections between different themes. Finally, selective coding, involved the identification and emphasis of main themes, which highlighted the most significant aspects of the data. 2.8 Data Analysis: 2.8.1 Thematic Analysis. In data analysis through thematic analysis followed a systematic and comprehensive process. The initial step involved the researcher familiarization with the data, dedicating time to understand deeply with the content obtained from in-depth semi-structured interviews and focus group discussions with AGYW. This immersive engagement allowed for a profound understanding of the nuances, perspectives, and contextual complexities embedded in the participant’s narrative regarding PrEP uptake and adherence. Following familiarization, the researcher progressed to generating initial codes. These codes were systematically applied to segments of the data, highlighting interesting features or patterns that had emerged from the discussions with AGYW. This coding process saved as the foundation for the subsequent stages of analysis, capturing key concepts and ideas related to barriers and facilitators of PrEP utilization. As the analysis unfolded, the focus shifted to theme development. Codes were grouped into potential themes, enabling the identification of recurrent patterns across the dataset. This step was crucial for extracting overarching insights into the experiences and attitudes of AGYW towards PrEP, shedding more light on commonalities and variations within their narratives. The thematic analysis continued with the reviewing and refining of themes. Researcher critically evaluated the coherence and relevance of identified themes in relation to the entire data they are based on. This process ensured that the themes accurately represent the complexities of AGYW's experiences and perspectives on PrEP, contributing to a nuanced understanding of the factors influencing uptake and adherence. The final stage involved defining and naming themes. Clear definitions and names were assigned to each theme, capturing the essence of the underlying content. This process added to clarity and structure to the analysis, facilitating the articulation of key findings that would inform the development of effective implementation strategies to increase PrEP coverage among AGYW in Malawi. 2.9 Ethical Considerations Firstly, ethical approval were obtained from the Institutional Review Board. Ethical approval were obtained from Kamuzu College of Health Sciences Research and Ethics Committee (COMREC) before the data was collected. The approval ensured that the study adheres to ethical guidelines and safeguards the rights and welfare of the participants. Prior to participation, individuals provide both verbal and written informed consent. The consent process were emphasized that participation in the study was voluntary and that individuals had the right to withdraw from the study at any time without facing any negative consequences. Participants were provided with all the necessary information about the study, including its purpose, procedures, potential risks, and benefits, which made them to make an informed decision regarding their participation. The participants received a Malawian Kwacha equivalent of 10 USD to compensate for their time and reimburse the travel costs. The study prioritized the safety and well-being of participants by minimizing potential risks. To safeguard privacy and confidentiality, data collection procedures were carefully designed. Measures will be implemented to protect participant anonymity by using identifiers and prevent inadvertent disclosure of personal information. Additionally, precautions were taken to prevent data breaches and unauthorized access to collected data. Physical discomfort risks, such as prolonged sitting during questionnaires, were addressed by providing comfortable chairs and shade rooms. CHAPTER 3.0: RESULTS 3.1 Results summary We enrolled 30 AGYW aged (15-24) from Mulanje District Hospital and health centers in the district that offers PrEP. The study also included one focus group discussion with 10-member group. We were supposed to have one focus group discussion with parent, but since most participants were not linked to parents, we were unable to conduct interview. The parents/guardians did not meet the criteria. In analyzing the barriers to PrEP Uptake, the following sub-themes emerged; i) stigma and social perception ii) Healthcare accessibility challenges iii) limited awareness and education. Key facilitators to successful PrEP uptake included; i) social and peer support ii) healthcare provider engagement iii) convenient and responsive services by staffs. Strategies identified to enhance PrEP adherence were categorized into the following sub-themes; i) increasing accessibility ii) awareness campaign iii) Integration with other health iv) Peer and Social Support Initiatives. We discuss these sub-themes below. 3.2 Code Book OBJECTIVES THEMES QUOTES 1.To identify the main barriers influencing PrEP uptake among adolescent girls and young women a.Stigma and social perception In my case I have a friend and I told her that if you want to protect yourself, you have to be taking PrEP and she thought I was lying and that I take ARVs. (AGYW, -20) A lot of times when I use prep, I have ever explained it to my loved one the benefit of PrEP but he is not okay with it. He feels that I doubt him a lot. (AGYW, -09) The fact that they know that I am taking ARVs, they think they are positive yet they are HIV negative, they get confused and I think they need a lot of time for counselling, explaining more, telling the client what type of medication she or he will be taking from that time, what are the side effects, what are the advantages and disadvantages so that the client can have more information, so that they can make an informed choice whether to start or not to start. (Health worker, 06-FGD) b.Healthcare accessibility challenges The problem is mostly transportation, some of us come from far and in some instances the challenge comes when you have moved and you go to another hospital and there when the hospital is far it is hard to go to the hospital to access PrEP. (AGYW, -19) c.Limited awareness and education The problem I have encountered mostly is that the service providers do not mention anything about side effects of PrEP, and they only mention the benefits. A lot of people don’t know about the side effects. (AGYW, -02) 2.To explore the key facilitators contributing to the successful PrEP uptake among adolescent girls and young women a.Social and Peer support What I can say that, I explained it to my girlfriend and she knows that she I take prep. She helps to remind me about the time to take prep and also that I should go to take it. (AGYW, -11) b.Healthcare provider engagement I was sick, with STIs and when I got here at the hospital, I was told that there is this method called prep, which helps someone to prevent HIV and to prevent that, there is prep which has a substance that fight the HIV and when you use this, there is no problem and I decided to use prep so that one day I don’t suffer from this disease, unfortunately they did not mention the side effects the drug. (AGYW, -06) c.Convenient and Responsive Services by staffs Almost every cadre, and department and on collaboration, we are also good just starting from screening the client up to, initiating this client, it does not only involve those who were trained or the professionals, it involves even those that are not really trained like HIV diagnostic assistants, treatment supporters, we have got statistical clerks as you have already heard, we have got even hospital ward attendants, so for one to be elicited for prep, this client goes through a lot of individuals who have different experiences. ( Health worker, 08-FDG ) d.Motivation and Protection I decided to use PrEP because of my husband’s lifestyle and the risk of contracting HIV. (AGYW, -17) we have been meeting a lot of clients from whether its antenatal department, we have those clients whom we know they are negative but they don’t know that there is PrEP, but don’t know about PrEP, so we advise those clients, give them enough information about prep especially when we see there is a high risk and a need for them to be on prep. ( Health worker, 10-FDG ) 3. To develop evidence-based strategies to enhance adherence to PrEP among adolescent girls and young women. a.Increasing accessibility PrEP should be available all the time like how I am, I need to protect myself and the forthcoming baby if prep is unavailable things will not be okay. (AGYW, -24) Accessibility would be good with HSAs and we would minimize him number of defaulters and here at the DHO, it’s a big facility and we cater for, people from even Blantyre which is so far. So think it would be good. (Health worker, 03-FDG) It’s not good because for prep to work effectively, it needs to be in a room with the right temperature, we know how the Pharmacy stays like and to keep the value of the drug, it needs to be stored at the right temperature. So even if we give the HSA the prep, we don’t know the temperature and the kind of house they are staying, also, due to their poor knowledge, you may find that the drugs expire right in their houses, and may even continue giving it to people, hence we will see that prep is not working in the people because they are taking expired drugs. (Health worker, 03) . b.Awareness campaign As for me, as I have come here, you have explained to me about the benefits of PrEP and I can be able to explain to my friends the same information, leaders who are leading programs of PrEP, using radios and at the church . (AGYW, -19) c.Integration with other health services I could have loved to have a one stop center for proving PrEp services- HIV testing sites should also be sites for receiving the medication . (AGYW, -28). To my side integrating PrEP with other services, I think it’s okay because before talking about prep one has to be tested, for us to know the status, already, risk assessment has been done and the client has to know if they are at a high risk, with that we need to talk about condoms because prep does not protect against STIs. These two go together. We intergrade the two for the client to be informed and make a choice. ( Health worker, 06-FDG ) d.Peer and Social Support Initiatives Another way would be to have peer groups in the communities and those can be trained and the information can spread to others. (Health worker, 09-FDG) 3.3 Main barriers influencing PrEP uptake among AGYW 3.3.1 Stigma and social perception AGYW reported facing significant social stigma and fear regarding PrEP utilization, as community members often associate PrEP with HIV treatment. Many worry that taking PrEP may lead others to conclude that they are HIV-positive, discouraging open use due to potential judgment. Additionally, some participants reported limited support from partners and peers, with partners sometimes believing that PrEP use implies doubt or promiscuity. In my case I have a friend and I told her that if you want to protect yourself, you have to be taking PrEP and she thought I was lying and that I take ARVs. (AGYW, -20) A lot of times when I use prep, I have ever explained it to my loved one the benefit of PrEP but he is not okay with it. He feels that I doubt him a lot. (AGYW, -09) Key informants highlighted issues of stigma and social perception, saying that some clients think taking PrEP is similar taking ART, which leads them to believe that they are HIV-positive when they are not, causing confusion and discontinuation of the treatment. They further narrated, the issue of stigma and social misconception has made adherence a critical affecting the continuation of PrEP. The fact that they know that I am taking ARVs, they think they are positive yet they are HIV negative, they get confused and I think they need a lot of time for counselling, explaining more, telling the client what type of medication she or he will be taking from that time, what are the side effects, what are the advantages and disadvantages so that the client can have more information, so that they can make an informed choice whether to start or not to start. (Health worker, 06-FGD) 3.3.2 Healthcare accessibility challenges Some AGYW reported that they have to travel for longer distances to access PrEP at the few established centers in the district. Sometimes they miss appointment when they lack transport to reach clinics. AGYW also reported that people receiving PrEP queue alongside with those receiving ART, resulting in long waiting times at healthcare facilities. Additionally it was reported that some clinics, particularly in health centers, experience inconsistent availability of PrEP. The problem is mostly transportation, some of us come from far and in some instances the challenge comes when you have moved and you go to another hospital and there when the hospital is far it is hard to go to the hospital to access PrEP. (AGYW, -19) Key informants explained that meeting the appointment dates it is a big challenge. Sometimes the drugs may not be available since they are provided to them on monthly basis. Additionally, some clients comes from distance areas, and if they lack transport, they miss their appointments. As a result, attending on time is not always a priority. The challenge comes when trying to meet the appointment dates, where may be the drugs will not be available since they are told on monthly basis, some come from far and if they don’t have transport to come then that is a miss, they do not prioritize that they should come in time. Many clients come at the wrong time. ( Health worker, 02-FGD ) 3.3.3 Limited awareness and education Some AGYW reported low PrEP awareness rural and underserved communities, as people do not feel comfortable discussing these matters in public. They explained that most people come across information about PrEP only when they visit hospital for other hospital services rather than in their own communities. Many AGWY reported limited knowledge about PrEP, particularly regarding side effects –none of them mentioned any and eligibility. Many AGYW also receive inadequate information from healthcare providers, who often mention the benefit of PrEP. The problem I have encountered mostly is that the service providers do not mention anything about side effects of PrEP, and they only mention the benefits. A lot of people don’t know about the side effects. (AGYW, -02) 3.4 Key Facilitators to Successful PrEP Uptake 3.4.1 Social and Peer support Many AGYW reported receiving support from family, peers and partners in adhering to their PrEP regimen. They explained that supportive family and peers are primarily encouraging them to continue using PrEP. However, other participants mentioned that they were not comfortable discussing PrEP with their families and peers, although a few did provide encouragement. Peer and partners often help by providing reminders about when to take PrEP and staying consistence with medication. Some AGYW also noted that their sexual partners may have mixed reaction on PrEP usage, with some offering support while others not, due to their own HIV status. What I can say that, I explained it to my girlfriend and she knows that she I take prep. She helps to remind me about the time to take prep and also that I should go to take it. (AGYW, -11) 3.4.2 Healthcare provider engagement Most AGYW reported that they learnt about PrEP when they visited the hospital for other health services, such as HIV testing and STI services. During the course of receiving these services, health care workers provided explanations about what PrEP is and its benefit in preventing HIV. However, some AGYW noted that certain healthcare did not explain the side effect of PrEP, focusing solely on its benefit. I was sick, with STIs and when I got here at the hospital, I was told that there is this method called prep, which helps someone to prevent HIV and to prevent that, there is prep which has a substance that fight the HIV and when you use this, there is no problem and I decided to use prep so that one day I don’t suffer from this disease, unfortunately they did not mention the side effects the drug. (AGYW, -06) 3.4.3 Convenient and Responsive Services by staffs Key informants reported that the collaboration between departments has improved patient guidance on PrEP services in the hospital setting. They explained that every cadre and department, from screening the client up to initiating PrEP, is involved – not only those who were formally trained or are professionals, but also who are not specifically trained, such as HIV diagnostic assistance, treatment supporters and statistical clerks all of whom interact with client throughout the process. Almost every cadre, and department and on collaboration, we are also good just starting from screening the client up to, initiating this client, it does not only involve those who were trained or the professionals, it involves even those that are not really trained like HIV diagnostic assistants, treatment supporters, we have got statistical clerks as you have already heard, we have got even hospital ward attendants, so for one to be elicited for prep, this client goes through a lot of individuals who have different experiences. ( Health worker, 08-FDG ) 3.4.4 Motivation and Protection Many AGYW reported that their primary motivation for taking PrEP is the protection it provide against HIV. They explained that, beyond health benefits, PrEP offered them peace of mind and empowers them to take control of their sexual health particularly due to concerns over potential exposure to HIV, especially in high-risk relationships. I decided to use PrEP because of my husband’s lifestyle and the risk of contracting HIV. (AGYW, -17) Key informants also stated that they play an important role in motivating clients, especially those at high risk, such as antenatal clients, by providing them with sufficient information about PrEP. we have been meeting a lot of clients from whether its antenatal department, we have those clients whom we know they are negative but they don’t know that there is PrEP, but don’t know about PrEP, so we advise those clients, give them enough information about prep especially when we see there is a high risk and a need for them to be on prep. ( Health worker, 10-FDG ) 3.5 Strategies to Enhance PrEP Adherence 3.5.1 Increasing accessibility AGYW from local health centers reported that PrEP should be available all the time in their respective health centers for easy accessibility. Some participant explained that health care providers should be readily available to them providing PrEP which is a challenge in most health centers. They further explained that health care providers must be well trained on PrEP as to provide more evidence on how PrEP works and counselling. PrEP should be available all the time like how I am, I need to protect myself and the forthcoming baby if prep is unavailable things will not be okay. (AGYW, -24) Similarly, key informants had mixed reactions on whether HSAs should be used as PrEP providers. Some said that using HSAs as providers would reduce the number of defaulters. However, others expresses concerns that if the drugs were given to HSAs, they might not be stored at the correct temperature, which could affect their effectivity. Additionally, some noted that HSAs, may not be able to assess clients the eligibility accurately, as it requires a more clinical approach. Accessibility would be good with HSAs and we would minimize him number of defaulters and here at the DHO, it’s a big facility and we cater for, people from even Blantyre which is so far. So think it would be good. (Health worker, 03-FDG) It’s not good because for prep to work effectively, it needs to be in a room with the right temperature, we know how the Pharmacy stays like and to keep the value of the drug, it needs to be stored at the right temperature. So even if we give the HSA the prep, we don’t know the temperature and the kind of house they are staying, also, due to their poor knowledge, you may find that the drugs expire right in their houses, and may even continue giving it to people, hence we will see that prep is not working in the people because they are taking expired drugs. (Health worker, 03-FDG) 3.5.2 Awareness campaign AGYW stated that targeted awareness campaign among youth would be more relevant and widely accepted enhancing its reach. These targeted awareness campaign would be like civic education in school, church and youth clubs, and partnership with cultural groups and community leaders, use of peers, community faith leaders, radios. As for me, as I have come here, you have explained to me about the benefits of PrEP and I can be able to explain to my friends the same information, leaders who are leading programs of PrEP, using radios and at the church . (AGYW, -19) 3.5.3 Integration with other health services Most AGYW reported that implementing the integrated PrEP with other health services, would facilitate PrEP access, link to PrEP care, increase in the willingness to use PrEP, and make pills available on the same day. These other services includes family planning methods, HIV testing, management of STIs and delivering of coordinated health services. I could have loved to have a one stop center for proving PrEp services- HIV testing sites should also be sites for receiving the medication . (AGYW, -28). They key informants also supported the idea of integrating PrEP services with other health services as this would help the client to undergo vigorous risk assessment, that would inform the client whether he/she is at high risk or not. To my side integrating PrEP with other services, I think it’s okay because before talking about prep one has to be tested, for us to know the status, already, risk assessment has been done and the client has to know if they are at a high risk, with that we need to talk about condoms because prep does not protect against STIs. These two go together. We intergrade the two for the client to be informed and make a choice. ( Health worker, 06-FDG ) 3.5.4 Peer and Social Support Initiatives The participant reported that there is a need to be receiving encouragement from friends and partners which would provide an ongoing support, helping them staying consistent with PrEP usage. Furthermore, they explained that, social support from friends and family helps in adhering to their PrEP regimen and proving counselling sessions. Key informants further emphasized the important of having peer groups in the villages that are well- trained on PrEP usage. These individuals could assist in disseminating the information effectively. Another way would be to have peer groups in the communities and those can be trained and the information can spread to others. (Health worker, 09-FDG) Chapter 4: DISCUSION 4.1 Introduction The findings from this study provide a detailed analysis of the barriers and facilitators influencing PrEP uptake and adherence among adolescent and young woment (AGYW) in Mulanje District. As highlighted by the qualitative analysis, several factors at the invidual, interpersonal, community, insititutional and structural level play an important role influencing the experiences for AGYW when taking PrEP. Regardless the proven effectiveness of PrEP in reducing HIV attainment, challenges such as stigma and social perception, Healthcare accessibility challenges, and limited awareness and education, which hinder maximal uptake and adherence. The discussion further describes the facilitators that contribute to successful PrEP uptake among AGYW, including social and peer support, healthcare provider engagement, and convenient and responsive services by staffs. The experiences gathered in this study highlights the importance of targeted interventions that connect with the lived experiences of AGYW. By understanding and addressing these diverse factors, customized strategies can be developed to promote PrEP adherence, eventually contributing to the broader effort to reduce HIV incidence and support the Malawi's commitment to the 95-95-95 goals. Through the integration of targeted intervention and health systems support, this study aims to promote sustainable improvements in PrEP engagement among AGYW, ensuring that this effective prevention tool reaches its full potential in addressing HIV transmission within high-prevalence settings. 4.2 Summarizing key findings The study recruited 30 adolescent girls and young women (AGYW) from Mulanje District, showing significant barriers and facilitators to PrEP uptake and adherence. The key barriers identified include stigma and negative social perception, as PrEP is often mistakenly related with HIV treatment, leading to conclusion and fear among users. Some AGYW encounterd partner resistance, and insufficient knowledge further escalated the problem. Furthermore, healthcare accessibility challenges were remarkable, with long distances, inconsistent PrEP availability, and long wait time due to intergrated health service at the facilities. Limited awareness, especially in rural areas, was also identified, as many responded lacked comprehensive education concerning PrEP’s benefits, its side effects, and eligibility. Alternatively, key facilitators for effective PrEP uptake include strong social and peer support systems, healthcare provider engagement, and effective interdepartmental staff collaboration in hospitals. AGYW stressed the role of family and partners in promoting adherence and the vital role of healthcare providers in educating them during routine visits. Suggested strategies for enhancing PrEP uptake and adherence included increasing accessibility, awareness campaigns, integrating PrEP with other health services, and peer and social support initiatives. Forming youth clubs and utilizing peer support groups were seen as beneficial in encouraging community dialogue and reducing stigma. However, concerns about confidentiality and training limitations for Health Surveillance Assistants (HSAs) were noted. 4.3 Interpreting results 4.3.1 Barriers influencing PrEP uptake among AGYW Our study shows that social stigma and fear for being mistaken with HIV-positive, prevent AGYW from using and adhering to PrEP. Misconceptions about PrEP, such as the belief that taking it is similar to taking ART, along with limited support from partners and peers, discourage open use and disrupt its continuation due to community perception of promiscuity. A similar study conducted among young people in Uganda, Zimbabwe, and South Africa found that the participants refrained from taking PrEP due to its with antiretroviral drugs and HIV-related stigma (17). This was a key barrier to uptake, as participants linked taking daily tablets to people living with HIV. Another study was conducted in Kenya to explore community perceptions around AGYW PrEP use, and it was noted that community perceived PrEP use as unacceptable for AGYW because of the potential to increase “promiscuous” behavior, STIs, and pregnancy (18). Our study found that AGYW meet significant healthcare accessibility challenges when accessing PrEP, including long travel distances to limited centres and long waiting times due to queues with ART patients. Additionally, some health centres experience inconsistent availability of PrEP, and clients often miss appointments because of transportation issues, making timely access to the medication a problem. A study which was conducted in Uganda among female sex workers (FSW) on their perspective on PrEP delivery, found that FSW reported dissatisfaction with the facility’s clinic due to delays, such as waiting in line for blood draws, receiving test results, and then having to queue again to see health workers for their prescriptions and to receive PrEP at the pharmacy (19). Similary, a study conducted in Uganda, Zimbabwe, and South Africa revealed that participants preferred quick access to PrEP without having to spend long hours in queues waiting to receive PrEP (17). Instances when facilities are busy and they are required to wait for a long time was seen as a barrier to using PrEP.These delays had a negative impact on the overall experience of receiving PrEP care. This study also noted long travel distance due to limited PrEP centres in the district, and some health centres experience inconsistent availability of PrEP and supply of PrEP affecting its the accessibility, aligning with the results scoping review in sub-Saharan Africa (20)(21). The study also noted that AGYW in rural and underserved communities had limited awareness and education on PrEP, with most learning about it during other health hospital visits. We noted gaps in knowledge about side effects and eligibility, and healthcare providers often provides limited information like its benefit. Before any other factors influencing PrEP uptake come into play, both individuals at risk and healthcare providers need to be aware of the existence of PrEP as a preventive option. In an article from Austraria, ndividual-level barriers to PrEP uptake and persistence have been characterised, such as low awareness, and low willingness to use PrEP which is consistence with our findings (22). Similarly, a narrative review found that awareness of PrEP remains low in populations at risk and is inadequate in some healthcare providers settings, leading to a recommendation for educational initiatives (23)(24). However, there remains skeptism whether healthcare providers have sufficient knowledge to provide PrEP, as evidenced by the limited information they offer. 4.3.2 Facilitators to Successful PrEP Uptake AGYW received support from family, peers, and partners in adhering to PrEP, with encouragement and reminders to retain their regimen. However, some were not comfortable discussing PrEP with their families, and their partner’s had mixed reactions, usually influenced by their own HIV status, so they may not be supportive. A study conducted in Kenya and South Africa reported that most famiy members, particularly mothers, provided instrumental, emotional, informational and appraisal support to participants using PrEP, including reminders, encouragement, and problem-solving (23). Further, Participants reported that family members with insufficient information about PrEP safety and efficacy and who voiced concerns were a substantial barrier to their use, aligning with our findings. Similarly, a study conducted in Kampala, Uganda some participants reported social support from friends, especially those who were also using PrEP and from family members to whom they had disclosed their PrEP use (25). Little has been discussed about whether sexual partners influence in PrEP uptake and adherence, but our study has shown that partners can offer support, though with mixed reactions due to their own HIV status. This a ligned with the study conducted in Kampala which reported that disclosure of PrEP use to sexual partners was not a common practice among participants because they feared that their sexual partners would suspect them of infidelity or that they would assume that they were HIV positive. Our study found that most AGYW learn about PrEP during hospital visits receiving other health related services, such as HIV testing and STI treatment. A systematic review and qualitative meta-synthesis in low- and middle-income countries reported that heathcare workers integrate PrEP counseling and delivery services into the current health system, such as obtaining drugs in general clinics rather than sexual health clinics, which may reduce the potential stigma (26). Despite the effort that is made by healthcare workers, they often focus sorely on PrEP's benefits in HIV prevention, without addressing effects. Similarly, a study on identifying opportunities to discuss PrEP highlited the issue of incomplete information being provided to client (27). This lack of complehesinve counselling can hinder client from making informed decisions about PrEP uptake. Improved interdepartmental collaboration in hospitals, with various cadres, including non-specialists like HIV diagnostic assistants and treatment supporters, actively guiding clients through PrEP services, makes access to services easier. A study from Uganda, Zimbabwe, and South Africa it was reported that health care services are often at a signifcant distance from the people, hence health care services in many insititution needed to be designed in an adaptive and innovative way, so that many young people who would beneft from it and receive PrEP (17). Protection against HIV was the primary motivation for taking PrEP, noting its health benefits, peace of mind, and empowerment in managing their sexual health, especially in high-risk relationships, such as antenatal patients. A study conducted in Lilongwe, Malawi found that Women initiating PrEP during pregnancy were highly motivated to obtain HIV protection for themselves and their unborn child, often due to perceived HIV risk connoted by a recent sexually transmitted infection and/or concerns about partner non-monogamy (28). A study from Uganda, Zimbabwe, and South Africa reported that high HIV risk perceived by some clients as being at risk of contracting HIV was a key facilitator to PrEP uptake (17). The aspects like not knowing the HIV status of one’s partner, dislike and fear of going for an HIV test by their partners, created a fear of becoming infected. The introduction of PrEP was therefore viewed as an opportunity to reassure someone that they are protected and will not be infected. 4.3.3 Strategies to Enhance PrEP Adherence Our study suggested the need to increase accessibility by ensuring PrEP is consistently available in all local health centers, maintaing the presence of healthcare providers, and enhancing healthcare provider training on PrEP use and counseling. Utilizing HSAs to provide PrEP could help reduce defaulting rates; however, concerns were raised about drug storage, maintaining efficacy and confidentiality, and HSAs' ability to accurately assess client eligibility due to the clinical expertise required. While many studies have recommended youth clubs for awareness campaigns, it was also reported that AGYW PrEP‐users can access PrEP through these youth clubs for PrEP refills (29). A study in a united state examining primary care providers’ knowledge, attitudes and beliefs about HIV Pre-exposure Prophylaxis (PrEP) reported that continuing medical education (CME) courses are the best information source for PrEP providers (30). CME was identified as the most consistent source of receiving information about new and current practices for providers. It was suggested CME be delivered through videos, brief webinars, and apps so that they can easily navigate them on their phones. Little has been discussed relating consistency of PrEP availability in health centres and presence of healthcare providers; hence, this was identified as unique findings and as a strategy. Targeted awareness campaigns involving schools, churches, youth clubs, community leaders, peers, and local media were recommended to increase acceptance and understanding. A scoping review in low-income and middle-income countries done in high risk of HIV study found that strategies to increase PrEP continuation included SMS reminders, drug-level feedback, peer group supports and conditional economic incentives (31). Another study that looked on the recommendation from healthcare providers in eastern Zimbabwe, the healthcare providers called for; PrEP marketing campaigns, youth‑friendly services or corners, improved PrEP delivery mechanisms, greater engagement with key stakeholders, including with young people themselves (engage AGYW) (32). These strategies aim to provide non-judgemental services, improve knowledge about PrEP through school-based campaigns, and mobilise AGYW and involve PrEP users. To improve access, encourage uptake, and enhance efficiency in care, PrEP has to intergrate with other health services, such as family planning, HIV testing, and STI management. The benefits of coordinated services, including comprehensive risk assessment and facilitate PrEP access, and also link up care. Cluster randomized trial conducted in Kenya reported that intergrating PrEP delivery to existing FP systems and staffing has tremendous potential to address barriers that women face in accessing HIV prevention and PrEP care, including lack of time, cost, and stigma of visiting a facility solely for HIV prevention (33). A scoping review reported the successful strategies for PrEP integration included initiating PrEP and contraception at the same time and by the same provider or HIV self-testing (34). Adolescents are strongly influenced by the home and family environment, and therefore social support for PrEP use, and factors operating at the household, social and community levels, are critical in the successful enrolment, retention and adherence to PrEP amongst AGYW (21). Peer and social support were seen as valuable for consistent PrEP usage. PrEP users they need for encouragement from friends and partners who are already are using it. They recommended establishing well-trained peer groups in villages to provide effective PrEP education and support. 4.4 Limitations of the study Findings from this study should be interpreted with consideration of its limitations. Mulanje district had few PrEP centres; out of 23 health centres in the district, only six were able to provide PrEP. Consequently, the participant interviewed at these six health centres may not be representative of the district’s population. Additionally, the study intended to conduct a focus group discussion with parents/guardians. However, since most participants were not linked to their parents or guardians, we were unable to conduct FDGs interviews to them. As a result the perspectives of parents/guardians, which could have had an impact on the study, were omitted. 4.5 Implications for future research Future research need to concentrate on addressing the barriers and facilitators to PrEP uptake and adherence among AGYW, particularly by developing strategies that reduce stigma and misconceptions. This may include community-based education campaigns and integrating PrEP awareness into broader sexual and reproductive health programs. Studies should also assess the role of healthcare providers in providing comprehensive counseling, including both the benefits and potential side effects of PrEP, to ensure informed decision-making the PrEP users. Additionally, advanced solutions to improve healthcare access, such as mobile clinics or telemedicine, should be explored, especially in rural areas where logistical challenges limit access. Lastly, research is needed to investigate the influence of partners and families on PrEP use and adherence, and also the effectiveness of peer support groups and youth clubs in reducing stigma and promoting awareness among AGYW. CHAPTER 5: Conclusion and recommendations 5.1 Conclusion This study highlight the varied barriers and facilitators influencing PrEP uptake and adherence among AGYW in Mulanje District, emphasizing the importance of addressing individual, interpersonal, community, institutional, and structural factors. The main barriers to PrEP use include stigma and social perception, Healthcare accessibility challenges, and limited awareness and education, while facilitators such as social and peer support, healthcare provider engagement, and convenient and responsive services by staffs contribute to successful PrEP uptake. The findings emphasize the need for targeted interventions that align with AGYW's lived experiences and address both social and logistical barriers, ensuring PrEP becomes a sustainable HIV prevention tool in high-prevalence areas. Strategies such as increasing accessibility, awareness campaigns, integrating PrEP with other health services, and peer and social support initiatives can enhance uptake and adherence, eventually supporting Malawi’s commitment to the 95-95-95 goals. 5.2 Recommendations To strengthen PrEP utilization among AGYW, the study recommends several key strategies. These include improving healthcare access by ensuring consistent availability of PrEP in health centers, broadening the role of healthcare providers through improving training, and using peer support groups and youth clubs to promote awareness and reduce stigma. Additionally, integrating PrEP services with other health programs, such as family planning, STI management and HIV testing, can reduce barriers and increase efficiency in healthcare provision. Moreover, community-based interventions, including targeted awareness campaigns involving schools, churches, and local media, are essential for modifying perceptions and improving knowledge about PrEP. By addressing these barriers and utilizing facilitators, interventions can effectively support long-term PrEP adherence, reducing HIV transmission risk among AGYW. Abbreviations AGYW: Adolescent Girls and Young Women ART: Antiretroviral Therapy BT: Blantyre CAB LA: Cabotegravir Long-Acting CDC: Centers for Disease Control and Prevention COMREC: College of Medicine Research and Ethics Committee DHO: District Health Office HCW: Healthcare Workers HSA: Health Surveillance Assistants HIV: Human Immunodeficiency Virus LL: Lilongwe MHIRST: Malawi HIV Implementation Research Scientist Training Program PrEP: Pre-exposure Prophylaxis URPC: University Research and Publication Committee USD: United States Dollar VMMC: Voluntary Male Medical Circumcision WHO: World Health Organization CME: continuing medical education Declarations Ethics Approval declaration This study received ethical approval from Kamuzu College of Health Sciences Research and Ethics Committee (COMREC), approval reference number P.01/24-0533. Prior to participation, all participants provided both verbal and written informed consent. The consent process emphasized the voluntary participation and the participants had the right to withdraw from the study at any time without facing any negative consequences. Participants were provided with comprehensive information about the study, including its purpose, procedures, potential risks, and benefits of the study. Consent for publication Not applicable in this study. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Competing interests The authors declare that they have no competing interests. Funding The study was funded by Malawi HIV Implementation Research Scientist Training (M-HIRST), under UNC with a decicion to publish the manuscript. Author Contribution M.K. analyzed and interpreted the patient data While the rest authors read and approved the final manuscript. Acknowledgements Not applicable References MPHIA. 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Improving access to pre-exposure prophylaxis for adolescent girls and young women: recommendations from healthcare providers in eastern Zimbabwe. 2022;22(399). Mugwanya KK, Matemo D, Scoville CW, Beima-Sofie KM, Meisner A, Onyango D, et al. Integrating PrEP delivery in public health family planning clinics: a protocol for a pragmatic stepped wedge cluster randomized trial in Kenya. Implement Sci Commun [Internet]. 2021;2(1):1–12. Available from: https://doi.org/10.1186/s43058-021-00228-4 Gotsche CI, Steyn PS, Narasimhan M, Rodolph M, Baggaley R, Kiarie JN. Integrating pre-exposure prophylaxis of HIV infection into family planning services: A scoping review. BMJ Sex Reprod Heal. 2023;49(3):210–8. Additional Declarations No competing interests reported. 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Pre-exposure prophylaxis (PrEP) has been shown to be an effective prevention method in reducing HIV acquisition among AGYW (3)(4). Its effectivity is when the pill is taken every day. However, its implementation among AGYW in Malawi faces several challenges, including limited awareness and knowledge of PrEP, partner resistance, and gendered norms regarding sexuality, stigma, drug side effect and frequent relocation of beneficiaries (5). A study conducted in Zimbabwe, identified the following factors including at individual (high HIV risk perception and preventing HIV/desire to remain HIV negative), interpersonal (peer influence, social support and care for PrEP uptake), community (adequate PrEP information and sensitization, evidence of PrEP efficacy and safety), institutional (convenient and responsive services, provision of appropriate and sufficiently resourced services), and structural (access and availability of PrEP, cost of PrEP) levels as facilitators of PrEP uptake (6).\u003c/p\u003e\n\u003cp\u003eIdentifying the barriers and facilitators to PrEP uptake and adherence among AGYW is not only integral to addressing these challenges but also crucial in the broader effort to control HIV/AIDS and achieve the 95-95-95 goals (7). By addressing these barriers and enhancing facilitators, it contributes to the comprehensive strategy of reaching ambitious HIV control goals, which aim to diagnose 95% of all HIV-positive persons, provide antiretroviral therapy (ART) for 95% of those diagnosed, and achieve viral suppression for 95% of those on ART. Through this research, the aim was to develop targeted interventions that would increase PrEP coverage and reduce HIV incidence in this key population group, aligning our efforts with the broader global commitment to combat HIV/AIDS effectively\u003c/p\u003e\n\u003cp\u003eAccording to the World Health Organization (WHO), PrEP is recommended for populations at substantial risk of HIV infection (defined as incidence greater than 3%), including adolescent girls and young women (AGYW) in high HIV burden settings, such as Malawi (8). According to the Centers for Disease Control and Prevention (CDC), PrEP has been shown to reduce the risk of HIV infection by up to 99% when taken consistently (9). A study conducted by Jourdain et al (10) showed that among a total of 46,706 individuals, PrEP users accounted for 29% of cases and 49% of controls. The study found that PrEP effectiveness was 60% overall, reaching 93% for a high amount of PrEP consumption and 86% if excluding periods after PrEP discontinuation. However, the study also found that PrEP effectiveness was significantly reduced in people younger than 30 years (26%) and in those who were socioeconomically deprived (64%), both of which groups showed low amounts of PrEP consumption and high rates of PrEP discontinuation. The reasons why effectiveness was low in young people and socioeconomically deprived areas was not determined.\u003c/p\u003e\n\u003cp\u003eThe study sought to identify the barriers and facilitators to PrEP uptake and adherence among adolescent girls and young women (AGYW) in Mulanje District. These barriers includes issues related to; at individual (fear of HIV, fear of side effects, and PrEP characteristics), interpersonal (parental influence, sexial partners), community (peer influence, social stigma), institutional (long waiting times at clinics, attitudes of health workers), and structural (accessibility concerns) levels (6). Furthermore, it\u0026apos;s worth noting that while the introduction of long-acting CAB LA for PrEP is a promising development (11), its nationwide rollout beyond Blantyre (BT) and Lilongwe (LL) is expected to take time. Given this transitional phase, understanding the dynamics around the continued use of oral Truvada remains the crucial thing.\u003c/p\u003e\n\u003cp\u003eOne potential implementation strategy for PrEP uptake is to develop targeted PrEP marketing campaigns that are culturally appropriate and effectively communicate the benefits of PrEP while addressing common misconceptions and concerns (12). They called for campaigns, like those targeting young men with voluntary male medical circumcision (VMMC), to make young women aware of PrEP. Extensively, about the role and need for schools to educate AGYW and young men about PrEP: Campaigns about PrEP should be done in the community and in schools. Another strategy is to provide comprehensive counseling services to AGYW at the point of care. These counseling sessions should be specifically tailored to AGYW who express interest in using PrEP. The counseling should address issues related to consent, confidentiality, partner resistance, and cost, as well as gendered norms regarding sexuality. Counseling sessions may also include information about HIV testing, condom use, and other sexual health topics.\u003c/p\u003e\n\u003cp\u003eAdditional implementation strategies may include training and educating stakeholders to provide PrEP services and integrating PrEP into existing healthcare services, such as family planning and maternal health programs (13). It may also be important to address structural barriers to PrEP access, such as limited availability of laboratory equipment and staff and workflow, insufficient HRH, and geographic barriers. \u0026nbsp;Another option would be to decentralize access to PrEP through Health Surveillance Assistants (HSAs). This strategy would involve training healthcare workers, including HSAs, to provide PrEP services and integrating PrEP into existing healthcare programs such as family planning and maternal health services. By decentralizing access, AGYW can access PrEP services in their local communities, reducing the need for extensive travel and overcoming geographic barriers.\u003c/p\u003e\n\u003cp\u003eTo implement the strategies they is a need to establish a comprehensive set of metrics to gauge the effectiveness of the strategies in bolstering PrEP uptake and adherence among AGYW in the country. These metrics includes PrEP initiation rates, retention PrEP programs, and knowledge and attitude changes among AGYW, Partner Support and involvement by asking AGYW about their partners\u0026apos; awareness of PrEP, willingness to support its use, and whether partners accompany them to PrEP services and qualitative feedback on their experiences with the interventions. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e1.2 Statement of the problem\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eHIV and AIDS remain a substancial public health issue in Malawi, with Mulanje District experiencing a disproportionately high burden. HIV prevalence in this district stands at 8.8% among individuals aged 15-49 (14), exceeding the national prevalence of 8.0% (1). The impact is particularly intense among women in Mulanje, where the prevalence is 10.8% compared to 10.0% nationally, while among men, it is 6.4% compared to 5.8% nationally (1). Additionally, the Southern region of Malawi, with Mulanje district being among the most hard-hit areas with 25.9% of women between the ages of 15 and 49 being HIV positive compared to men \u0026nbsp; (14.2%) \u0026nbsp;in the same age group. These alarming statistics highlight the important need for effective HIV prevention measures, such as (PrEP), especially for AGYW, who face intense vulnerability to HIV attainment.\u003c/p\u003e\n\u003cp\u003eDespite the affirmed efficacy of PrEP in preventing HIV, uptake and adherence remain low due to various individual, social, and structural barriers. While previous studies, such as one in Blantyre which focused on female sex workers, have shown challenges related to PrEP use in other populations, there is limited data on the factors affecting PrEP uptake and adherence among AGYW in high-prevalent areas like Mulanje. This study fills this gap by exploring the barriers and facilitators to PrEP utilization among AGYW attending family planning clinics in Mulanje District.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e1.3 Objectives of the study\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e1.3.1 Broad Objective\u003c/h3\u003e\n\u003cp\u003eThe main aim of this study was to identify the barriers and facilitators to PrEP uptake and adherence among adolescent girls and young women (AGYW) Attending Family Planning Clinics in Mulanje District, Malawi.\u003c/p\u003e\n\u003ch3\u003e1.3.2 Specific Objectives\u003c/h3\u003e\n\u003cp\u003eThe following were the specific objectives:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eTo identify the main barriers influencing PrEP uptake among adolescent girls and young women.\u003c/li\u003e\n \u003cli\u003eTo explore the key facilitators contributing to the successful PrEP uptake among adolescent girls and young women.\u003c/li\u003e\n \u003cli\u003eTo develop evidence-based strategies to enhance adherence to PrEP among adolescent girls and young women.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Chapter 2: Methodology","content":"\u003ch2\u003e\u003cstrong\u003e2.1 Type of study\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis research adopted a Hybrid Type 1 design to evaluate the effectiveness of an implementation strategy targeted at improving the uptake and adherence of PrEP among Adolescent Girls and Young Women (AGYW) attending Family Planning Clinics. Hybrid Type 1 helps in gathering information on its delivery and/or potential for implementation in a real-world context (15). This design allowed for a complex exploration of AGYW\u0026apos;s multifaceted experiences, attitudes, and beliefs related to the utilization and adherence to PrEP. The study conducted a comprehensive examination of the factors influencing PrEP uptake and adherence in AGYW. Qualitative research methods played an essential role in this exploration, providing a detailed understanding of the barriers and facilitators specific to PrEP utilization and adherence within this demographic area.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e2.2 Study place\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eHIV and AIDS in Malawi is a major public health concern, with Mulanje district being one of the most affected areas. The HIV prevalence \u0026nbsp;in Mulanje district is \u0026nbsp;high, with 8.8% of the total population between 15 and 49 years old being infected with HIV (14).This is higher than the national prevalence rate of 8.0% in Malawi. Notably, HIV prevalence among women in Mulanje is 10.8%, which is higher than the national rate of 10.0%, while among men in Mulanje, it is 6.4% compared to the national rate hard-hit areas with 25.9% of women between the ages of 15 and 49 being HIV positive compared to men \u0026nbsp; (14.2%) \u0026nbsp;in the same age group. These statistics highlight the urgent need for effective of 5.8% (1). The Southern region of Malawi has a higher prevalence as compared to the central and Northern regions, with Mulanje district being among the most HIV prevention strategies, such as PrEP, especially among AGYW who are at a higher risk of acquiring HIV. It is important to note that another study was conducted in Blantyre, focusing on barriers to the uptake and oral use of PrEP among female sex workers, providing valuable insights into PrEP utilization in a different population group (16). The identification of barriers and facilitators to PrEP uptake and adherence among AGYW attending Family Planning Clinics through qualitative research helped to inform the development of targeted interventions to increase PrEP coverage and reduce HIV transmission rates in this population.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e2.3 Study population\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study population for this research consisted of Adolescent Girls and Young Women (AGYW) between the ages of 15-24 in Mulanje District.\u003c/p\u003e\n\u003ch3\u003e2.3.1 Inclusion criteria:\u003c/h3\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eAGYW who were using PrEP\u003c/li\u003e\n \u003cli\u003eAGYW who were identified as eligible for PrEP but have not been initiated\u003c/li\u003e\n \u003cli\u003eAGYW who, despite being identified as eligible, has not started using PrEP\u003c/li\u003e\n \u003cli\u003eAGYW who had previously used PrEP but had discontinued its use.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003e2.3.2 Exclusion criteria:\u003c/h3\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eAGYW with cognitive or communication impairments.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAGYW who had participated in other research studies related to HIV prevention or sexual health.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003e\u003cstrong\u003e2.5 Sample size considerations\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe anticipated sample size was specified upfront within a range of 25-30 interviews. \u0026nbsp; The final sample was determined through a process of data saturation, where data collection continued until no new themes or insights emerged. This combination of upfront specification and data-driven determination ensured both practicality and comprehensiveness in the study\u0026apos;s sample size.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e2.6 Data Collection procedure\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e2.6.1 Recruitment of Study Participants:\u003c/h3\u003e\n\u003cp\u003eThe recruitment of participant involved purposive sampling of AGYW aged between 15-24 years. Participants were chosen from those either currently taking PrEP or identified as eligible but not initiated or have discontinued it. Collaboration with family planning clinics in Mulanje District hospital will facilitate participant identification using their registers. The sample was stratified according to variables of PrEP status (currently taking PrEP, identified as eligible but not initiated, or have discontinued it) to capture diverse perspectives.\u003c/p\u003e\n\u003cp\u003eRecruitment activities involved reaching out to potential participants through phone calls or visits with the help of local health surveillance assistants (HSAs) wherein the study\u0026apos;s purpose was explained, informed consent obtained, and interviews were scheduled. The involvement of family planning clinics ensured access to individuals with varying PrEP experiences, contributing to a comprehensive understanding of barriers and facilitators among different subgroups of AGYW.\u003c/p\u003e\n\u003cp\u003eWe conducted one focus group discussion interviews with healthcare workers (HCWs). This approach enabled us to explore their experiences, perceptions, and practices related to PrEP and AGYW\u0026apos;s healthcare. This added depth to the study\u0026apos;s insights by providing valuable perspectives on the social dynamics and support structures that affect AGYW\u0026apos;s decisions regarding PrEP.\u003c/p\u003e\n\u003ch3\u003e2.6.2 Data Collection Method:\u003c/h3\u003e\n\u003cp\u003eIn-depth semi-structured interviews were the primary method of data collection. The interviews were conducted in Chichewa, the local language mainly spoken in this area. For the healthcare workers (HCWs), focus group discussions for each group were employed to collect data. These interviews were audio-recorded and transcribed verbatim to maintain the richness of participants\u0026apos; responses. The interview guide, structured by integrating insights from existing research, explored critical areas such as partner resistance, cost barriers, gendered norms, healthcare provider perspectives, and community perceptions related to PrEP.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e2.7 Data Management and Analysis\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e2.7.1 Data Management\u003c/h3\u003e\n\u003ch3\u003e2.7.2 Transcription and Organization:\u003c/h3\u003e\n\u003cp\u003eAudio recordings of the interviews, conducted in Chichewa, underwent rigorous transcribing to capture the richness and nuances of participant\u0026rsquo;s responses. Verbatim transcription were translated into English by trained research assistants. The results from the transcripts were systematically organized, employing a structure that includes participant identifiers. This systematic organization was essential for efficient reference during subsequent stages of data analysis. Each transcript saved as a comprehensive record, facilitating a detailed examination of participants\u0026apos; perspectives on PrEP uptake and adherence among AGYW in the District.\u003c/p\u003e\n\u003ch3\u003e2.7.3 Coding\u003c/h3\u003e\n\u003cp\u003eThe data underwent coding process. Initial coding, this involved open exploration of the data, generating preliminary codes to encompass key concepts and ideas. Subsequently, axial coding was refined and organized these codes into meaningful categories, establishing connections between different themes. Finally, selective coding, involved the identification and emphasis of main themes, which highlighted the most significant aspects of the data.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e2.8 Data Analysis:\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e2.8.1 Thematic Analysis.\u003c/h3\u003e\n\u003cp\u003eIn data analysis through thematic analysis followed a systematic and comprehensive process.\u003c/p\u003e\n\u003cp\u003eThe initial step involved the researcher familiarization with the data, dedicating time to understand deeply with the content obtained from in-depth semi-structured interviews and focus group discussions with AGYW. This immersive engagement allowed for a profound understanding of the nuances, perspectives, and contextual complexities embedded in the participant\u0026rsquo;s narrative regarding PrEP uptake and adherence.\u003c/p\u003e\n\u003cp\u003eFollowing familiarization, the researcher progressed to generating initial codes. These codes were systematically applied to segments of the data, highlighting interesting features or patterns that had emerged from the discussions with AGYW. This coding process saved as the foundation for the subsequent stages of analysis, capturing key concepts and ideas related to barriers and facilitators of PrEP utilization.\u003c/p\u003e\n\u003cp\u003eAs the analysis unfolded, the focus shifted to theme development. Codes were grouped into potential themes, enabling the identification of recurrent patterns across the dataset. This step was crucial for extracting overarching insights into the experiences and attitudes of AGYW towards PrEP, shedding more light on commonalities and variations within their narratives.\u003c/p\u003e\n\u003cp\u003eThe thematic analysis continued with the reviewing and refining of themes. Researcher critically evaluated the coherence and relevance of identified themes in relation to the entire data they are based on. This process ensured that the themes accurately represent the complexities of AGYW\u0026apos;s experiences and perspectives on PrEP, contributing to a nuanced understanding of the factors influencing uptake and adherence.\u003c/p\u003e\n\u003cp\u003eThe final stage involved defining and naming themes. Clear definitions and names were assigned to each theme, capturing the essence of the underlying content. This process added to clarity and structure to the analysis, facilitating the articulation of key findings that would inform the development of effective implementation strategies to increase PrEP coverage among AGYW in Malawi.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e2.9 Ethical Considerations\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eFirstly, ethical approval were obtained from the Institutional Review Board. Ethical approval were obtained from Kamuzu College of Health Sciences Research and Ethics Committee (COMREC) before the data was collected. The approval ensured that the study adheres to ethical guidelines and safeguards the rights and welfare of the participants.\u003c/p\u003e\n\u003cp\u003ePrior to participation, individuals provide both verbal and written informed consent. The consent process were emphasized that participation in the study was voluntary and that individuals had the right to withdraw from the study at any time without facing any negative consequences. Participants were provided with all the necessary information about the study, including its purpose, procedures, potential risks, and benefits, which made them to make an informed decision regarding their participation.\u003c/p\u003e\n\u003cp\u003eThe participants received a Malawian Kwacha equivalent of 10 USD to compensate for their time and reimburse the travel costs.\u003c/p\u003e\n\u003cp\u003eThe study prioritized the safety and well-being of participants by minimizing potential risks. To safeguard privacy and confidentiality, data collection procedures were carefully designed. Measures will be implemented to protect participant anonymity by using identifiers and prevent inadvertent disclosure of personal information. Additionally, precautions were taken to prevent data breaches and unauthorized access to collected data. Physical discomfort risks, such as prolonged sitting during questionnaires, were addressed by providing comfortable chairs and shade rooms.\u003c/p\u003e"},{"header":"CHAPTER 3.0: RESULTS ","content":"\u003ch2\u003e\u003cstrong\u003e3.1 Results summary\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eWe enrolled 30 AGYW aged (15-24) from Mulanje District Hospital and health centers in the district that offers PrEP. The study also included one focus group discussion with 10-member group. We were supposed to have one focus group discussion with parent, but since most participants were not linked to parents, we were unable to conduct interview. The parents/guardians did not meet the criteria. \u0026nbsp;In analyzing the barriers to PrEP Uptake, the following sub-themes emerged; i) stigma and social perception ii) Healthcare accessibility challenges iii) limited awareness and education. Key facilitators to successful PrEP uptake included; i) social and peer support ii) healthcare provider engagement iii) convenient and responsive services by staffs. Strategies identified to enhance PrEP adherence were categorized into the following sub-themes; i) increasing accessibility ii) awareness campaign iii) Integration with other health iv) Peer and Social Support Initiatives. We discuss these sub-themes below.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e3.2 Code Book\u003c/strong\u003e\u003c/h2\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOBJECTIVES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTHEMES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQUOTES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e1.To identify the main barriers influencing PrEP uptake among adolescent girls and young women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ea.Stigma and social perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eIn my case I have a friend and I told her that if you want to protect yourself, you have to be taking PrEP and she thought I was lying and that I take ARVs.\u0026nbsp;\u003c/em\u003e(AGYW, -20)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eA lot of times when I use prep, I have ever explained it to my loved one the benefit of PrEP but he is not okay with it. He feels that I doubt him a lot.\u0026nbsp;\u003c/em\u003e(AGYW, -09)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThe fact that they know that I am taking ARVs, they think they are positive yet they are HIV negative, they get confused and I think they need a lot of time for counselling, explaining more, telling the client what type of medication she or he will be taking from that time, what are the side effects, what are the advantages and disadvantages so that the client can have more information, so that they can make an informed choice whether to start or not to start. (Health worker, 06-FGD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eb.Healthcare accessibility challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eThe problem is mostly transportation, some of us come from far and in some instances the challenge comes when you have moved and you go to another hospital and there when the hospital is far it is hard to go to the hospital to access PrEP.\u0026nbsp;\u003c/em\u003e(AGYW, -19)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ec.Limited awareness and education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eThe problem I have encountered mostly is that the service providers do not mention anything about side effects of PrEP, and they only mention the benefits. A lot of people don\u0026rsquo;t know about the side effects.\u0026nbsp;\u003c/em\u003e(AGYW, -02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e2.To explore the key facilitators contributing to the successful PrEP uptake among adolescent girls and young women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ea.Social and Peer support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eWhat I can say that, I explained it to my girlfriend and she knows that she I take prep. She helps to remind me about the time to take prep and also that I should go to take it.\u0026nbsp;\u003c/em\u003e(AGYW, -11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eb.Healthcare provider engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eI was sick, with STIs and when I got here at the hospital, I was told that there is this method called prep, which helps someone to prevent HIV and to prevent that, there is prep which has a substance that fight the HIV and when you use this, there is no problem and I decided to use prep so that one day I don\u0026rsquo;t suffer from this disease, unfortunately they did not mention the side effects the drug.\u0026nbsp;\u003c/em\u003e(AGYW, -06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ec.Convenient and Responsive Services by staffs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eAlmost every cadre, and department and on collaboration, we are also good just starting from screening the client up to, initiating this client, it does not only involve those who were trained or the professionals, it involves even those that are not really trained like HIV diagnostic assistants, treatment supporters, we have got statistical clerks as you have already heard, we have got even hospital ward attendants, so for one to be elicited for prep, this client goes through a lot of individuals who have different experiences.\u0026nbsp;\u003c/em\u003e(\u003cem\u003eHealth worker, 08-FDG\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ed.Motivation and Protection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eI decided to use PrEP because of my husband\u0026rsquo;s lifestyle and the risk of contracting HIV.\u0026nbsp;\u003c/em\u003e(AGYW, -17)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ewe have been meeting a lot of clients from whether its antenatal department, we have those clients whom we know they are negative but they don\u0026rsquo;t know that there is PrEP, but don\u0026rsquo;t know about PrEP, so we advise those clients, give them enough information about prep especially when we see there is a high risk and a need for them to be on prep.\u0026nbsp;\u003c/em\u003e(\u003cem\u003eHealth worker, 10-FDG\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e3. To develop evidence-based strategies to enhance adherence to PrEP among adolescent girls and young women.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ea.Increasing accessibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003ePrEP should be available all the time like how I am, I need to protect myself and the forthcoming baby if prep is unavailable things will not be okay.\u003c/em\u003e (AGYW, -24)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAccessibility would be good with HSAs and we would minimize him number of defaulters and here at the DHO, it\u0026rsquo;s a big facility and we cater for, people from even Blantyre which is so far. So think it would be good.\u0026nbsp;\u003c/em\u003e(Health worker, 03-FDG)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIt\u0026rsquo;s not good because for prep to work effectively, it needs to be in a room with the right temperature, we know how the Pharmacy stays like and to keep the value of the drug, it needs to be stored at the right temperature. So even if we give the HSA the prep, we don\u0026rsquo;t know the temperature and the kind of house they are staying, also, due to their poor knowledge, you may find that the drugs expire right in their houses, and may even continue giving it to people, hence we will see that prep is not working in the people because they are taking expired drugs.\u0026nbsp;\u003c/em\u003e(Health worker, 03)\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eb.Awareness campaign\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eAs for me, as I have come here, you have explained to me about the benefits of PrEP and I can be able to explain to my friends the same information, leaders who are leading programs of PrEP, using radios and at the church\u003c/em\u003e. (AGYW, -19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ec.Integration with other health services\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eI could have loved to have a one stop center for proving PrEp services- HIV testing sites should also be sites for receiving the medication\u003c/em\u003e. (AGYW, -28).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eTo my side integrating PrEP with other services, I think it\u0026rsquo;s okay because before talking about prep one has to be tested, for us to know the status, already, risk assessment has been done and the client has to know if they are at a high risk, with that we need to talk about condoms because prep does not protect against STIs. These two go together. We intergrade the two for the client to be informed and make a choice.\u0026nbsp;\u003c/em\u003e(\u003cem\u003eHealth worker, 06-FDG\u003c/em\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ed.Peer and Social Support Initiatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eAnother way would be to have peer groups in the communities and those can be trained and the information can spread to others.\u0026nbsp;\u003c/em\u003e(Health worker, 09-FDG)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e3.3 Main barriers influencing PrEP uptake among AGYW\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e3.3.1 Stigma and social perception\u003c/h3\u003e\n\u003cp\u003eAGYW reported facing significant social stigma and fear regarding PrEP utilization, as community members often associate PrEP with HIV treatment. Many worry that taking PrEP may lead others to conclude that they are HIV-positive, discouraging open use due to potential judgment. Additionally, some participants reported limited support from partners and peers, with partners sometimes believing that PrEP use implies doubt or promiscuity.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn my case I have a friend and I told her that if you want to protect yourself, you have to be taking PrEP and she thought I was lying and that I take ARVs.\u0026nbsp;\u003c/em\u003e(AGYW, -20)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA lot of times when I use prep, I have ever explained it to my loved one the benefit of PrEP but he is not okay with it. He feels that I doubt him a lot.\u0026nbsp;\u003c/em\u003e(AGYW, -09)\u003c/p\u003e\n\u003cp\u003eKey informants highlighted issues of stigma and social perception, saying that some clients think taking PrEP is similar taking ART, which leads them to believe that they are HIV-positive when they are not, causing confusion and discontinuation of the treatment. They further narrated, the issue of stigma and social misconception has made adherence a critical affecting the continuation of PrEP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe fact that they know that I am taking ARVs, they think they are positive yet they are HIV negative, they get confused and I think they need a lot of time for counselling, explaining more, telling the client what type of medication she or he will be taking from that time, what are the side effects, what are the advantages and disadvantages so that the client can have more information, so that they can make an informed choice whether to start or not to start. (Health worker, 06-FGD)\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003e3.3.2 Healthcare accessibility challenges\u003c/h3\u003e\n\u003cp\u003eSome AGYW reported that they have to travel for longer distances to access PrEP at the few established centers in the district. \u0026nbsp;Sometimes they miss appointment when they lack transport to reach clinics. AGYW also reported that people receiving PrEP queue alongside with those receiving ART, resulting in long waiting times at healthcare facilities. Additionally it was reported that some clinics, particularly in health centers, experience inconsistent availability of PrEP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe problem is mostly transportation, some of us come from far and in some instances the challenge comes when you have moved and you go to another hospital and there when the hospital is far it is hard to go to the hospital to access PrEP.\u0026nbsp;\u003c/em\u003e(AGYW, -19)\u003c/p\u003e\n\u003cp\u003eKey informants explained that meeting the appointment dates it is a big challenge. Sometimes the drugs may not be available since they are provided to them on monthly basis. Additionally, some clients comes from distance areas, and if they lack transport, they miss their appointments. As a result, attending on time is not always a priority.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe challenge comes when trying to meet the appointment dates, where may be the drugs will not be available since they are told on monthly basis, some come from far and if they don\u0026rsquo;t have transport to come then that is a miss, they do not prioritize that they should come in time. Many clients come at the wrong time.\u0026nbsp;\u003c/em\u003e(\u003cem\u003eHealth worker, 02-FGD\u003c/em\u003e)\u003c/p\u003e\n\u003ch3\u003e3.3.3 Limited awareness and education\u003c/h3\u003e\n\u003cp\u003eSome AGYW reported low PrEP awareness rural and underserved communities, as people do not feel comfortable discussing these matters in public. They explained that most people come across information about PrEP only when they visit hospital for other hospital services rather than in their own communities. Many AGWY reported limited knowledge about PrEP, particularly regarding side effects \u0026ndash;none of them mentioned any and eligibility. Many AGYW also receive inadequate information from healthcare providers, who often mention the benefit of PrEP.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe problem I have encountered mostly is that the service providers do not mention anything about side effects of PrEP, and they only mention the benefits. A lot of people don\u0026rsquo;t know about the side effects.\u0026nbsp;\u003c/em\u003e(AGYW, -02)\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e3.4 Key Facilitators to Successful PrEP Uptake\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e3.4.1 Social and Peer support\u003c/h3\u003e\n\u003cp\u003eMany AGYW reported receiving support from family, peers and partners in adhering to their PrEP regimen. They explained that supportive family and peers are primarily encouraging them to continue using PrEP. However, other participants mentioned that they were not comfortable discussing PrEP with their families and peers, although a few did provide encouragement. Peer and partners often help by providing reminders about when to take PrEP and staying consistence with medication. Some AGYW also noted that their sexual partners may have mixed reaction on PrEP usage, with some offering support while others not, due to their own HIV status.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhat I can say that, I explained it to my girlfriend and she knows that she I take prep. She helps to remind me about the time to take prep and also that I should go to take it.\u0026nbsp;\u003c/em\u003e(AGYW, -11)\u003c/p\u003e\n\u003ch3\u003e3.4.2 Healthcare provider engagement\u003c/h3\u003e\n\u003cp\u003eMost AGYW reported that they learnt about PrEP when they visited the hospital for other health services, such as HIV testing and STI services. During the course of receiving these services, health care workers provided explanations about what PrEP is and its benefit in preventing HIV. However, some AGYW noted that certain healthcare did not explain the side effect of PrEP, focusing solely on its benefit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI was sick, with STIs and when I got here at the hospital, I was told that there is this method called prep, which helps someone to prevent HIV and to prevent that, there is prep which has a substance that fight the HIV and when you use this, there is no problem and I decided to use prep so that one day I don\u0026rsquo;t suffer from this disease, unfortunately they did not mention the side effects the drug.\u0026nbsp;\u003c/em\u003e(AGYW, -06)\u003c/p\u003e\n\u003ch3\u003e3.4.3 Convenient and Responsive Services by staffs\u003c/h3\u003e\n\u003cp\u003eKey informants reported that the collaboration between departments has improved patient guidance on PrEP services in the hospital setting. \u0026nbsp;They explained that every cadre and department, from screening the client up to initiating PrEP, is involved \u0026ndash; not only those who were formally trained or are professionals, but also who are not specifically trained, such as HIV diagnostic assistance, treatment supporters and statistical clerks all of whom interact with client throughout the process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAlmost every cadre, and department and on collaboration, we are also good just starting from screening the client up to, initiating this client, it does not only involve those who were trained or the professionals, it involves even those that are not really trained like HIV diagnostic assistants, treatment supporters, we have got statistical clerks as you have already heard, we have got even hospital ward attendants, so for one to be elicited for prep, this client goes through a lot of individuals who have different experiences.\u0026nbsp;\u003c/em\u003e(\u003cem\u003eHealth worker, 08-FDG\u003c/em\u003e)\u003c/p\u003e\n\u003ch3\u003e3.4.4 Motivation and Protection\u003c/h3\u003e\n\u003cp\u003eMany AGYW reported that their primary motivation for taking PrEP is the protection it provide against HIV. They explained that, beyond health benefits, PrEP offered them peace of mind and empowers them to take control of their sexual health particularly due to concerns over potential exposure to HIV, especially in high-risk relationships.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI decided to use PrEP because of my husband\u0026rsquo;s lifestyle and the risk of contracting HIV.\u0026nbsp;\u003c/em\u003e(AGYW, -17)\u003c/p\u003e\n\u003cp\u003eKey informants also stated that they play an important role in motivating clients, especially those at high risk, such as antenatal clients, by providing them with sufficient information about PrEP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ewe have been meeting a lot of clients from whether its antenatal department, we have those clients whom we know they are negative but they don\u0026rsquo;t know that there is PrEP, but don\u0026rsquo;t know about PrEP, so we advise those clients, give them enough information about prep especially when we see there is a high risk and a need for them to be on prep.\u0026nbsp;\u003c/em\u003e(\u003cem\u003eHealth worker, 10-FDG\u003c/em\u003e)\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e3.5 Strategies to Enhance PrEP Adherence\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e3.5.1 Increasing accessibility\u003c/h3\u003e\n\u003cp\u003eAGYW from local health centers reported that PrEP should be available all the time in their respective health centers for easy accessibility. Some participant explained that health care providers should be readily available to them providing PrEP which is a challenge in most health centers. They further explained that health care providers must be well trained on PrEP as to provide more evidence on how PrEP works and counselling.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePrEP should be available all the time like how I am, I need to protect myself and the forthcoming baby if prep is unavailable things will not be okay.\u003c/em\u003e (AGYW, -24)\u003c/p\u003e\n\u003cp\u003eSimilarly, key informants had mixed reactions on whether HSAs should be used as PrEP providers. Some said that using HSAs as providers would reduce the number of defaulters. However, others expresses concerns that if the drugs were given to HSAs, they might not be stored at the correct temperature, which could affect their effectivity. Additionally, some noted that HSAs, may not be able to assess clients the eligibility accurately, as it requires a more clinical approach.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAccessibility would be good with HSAs and we would minimize him number of defaulters and here at the DHO, it\u0026rsquo;s a big facility and we cater for, people from even Blantyre which is so far. So think it would be good.\u0026nbsp;\u003c/em\u003e(Health worker, 03-FDG)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt\u0026rsquo;s not good because for prep to work effectively, it needs to be in a room with the right temperature, we know how the Pharmacy stays like and to keep the value of the drug, it needs to be stored at the right temperature. So even if we give the HSA the prep, we don\u0026rsquo;t know the temperature and the kind of house they are staying, also, due to their poor knowledge, you may find that the drugs expire right in their houses, and may even continue giving it to people, hence we will see that prep is not working in the people because they are taking expired drugs.\u0026nbsp;\u003c/em\u003e(Health worker, 03-FDG)\u003c/p\u003e\n\u003ch3\u003e3.5.2 Awareness campaign\u003c/h3\u003e\n\u003cp\u003eAGYW stated that targeted awareness campaign among youth would be more relevant and widely accepted enhancing its reach. These targeted awareness campaign would be like civic education in school, church and youth clubs, and partnership with cultural groups and community leaders, use of peers, community faith leaders, radios.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAs for me, as I have come here, you have explained to me about the benefits of PrEP and I can be able to explain to my friends the same information, leaders who are leading programs of PrEP, using radios and at the church\u003c/em\u003e. (AGYW, -19)\u003c/p\u003e\n\u003ch3\u003e3.5.3 Integration with other health services\u003c/h3\u003e\n\u003cp\u003eMost AGYW reported that implementing the integrated PrEP with other health services, would facilitate PrEP access, link to PrEP care, increase in the willingness to use PrEP, and make pills available on the same day. These other services includes family planning methods, HIV testing, management of STIs and delivering of coordinated health services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI could have loved to have a one stop center for proving PrEp services- HIV testing sites should also be sites for receiving the medication\u003c/em\u003e. (AGYW, -28).\u003c/p\u003e\n\u003cp\u003eThey key informants also supported the idea of integrating PrEP services with other health services as this would help the client to undergo vigorous risk assessment, that would inform the client whether he/she is at high risk or not.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTo my side integrating PrEP with other services, I think it\u0026rsquo;s okay because before talking about prep one has to be tested, for us to know the status, already, risk assessment has been done and the client has to know if they are at a high risk, with that we need to talk about condoms because prep does not protect against STIs. These two go together. We intergrade the two for the client to be informed and make a choice.\u0026nbsp;\u003c/em\u003e(\u003cem\u003eHealth worker, 06-FDG\u003c/em\u003e)\u003c/p\u003e\n\u003ch3\u003e3.5.4 Peer and Social Support Initiatives\u003c/h3\u003e\n\u003cp\u003eThe participant reported that there is a need to be receiving encouragement from friends and partners which would provide an ongoing support, helping them staying consistent with PrEP usage. Furthermore, they explained that, social support from friends and family helps in adhering to their PrEP regimen and proving counselling sessions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKey informants further emphasized the important of having peer groups in the villages that are well- trained on PrEP usage. These individuals could assist in disseminating the information effectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnother way would be to have peer groups in the communities and those can be trained and the information can spread to others.\u0026nbsp;\u003c/em\u003e(Health worker, 09-FDG)\u003c/p\u003e"},{"header":"Chapter 4: DISCUSION ","content":"\u003ch2\u003e\u003cstrong\u003e4.1 Introduction\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe findings from this study provide a detailed analysis of the barriers and facilitators influencing PrEP uptake and adherence among adolescent and young woment (AGYW) in Mulanje District. As highlighted by the qualitative analysis, several factors at the invidual, interpersonal, community, insititutional and structural level play an important role influencing the experiences for AGYW when taking PrEP. Regardless the proven effectiveness of PrEP in reducing HIV attainment, challenges such as stigma and social perception, Healthcare accessibility challenges, and limited awareness and education, which hinder maximal uptake and adherence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe discussion further describes the facilitators that contribute to successful PrEP uptake among AGYW, including social and peer support, healthcare provider engagement, and convenient and responsive services by staffs. The experiences gathered in this study highlights the importance of targeted interventions that connect with the lived experiences of AGYW. By understanding and addressing these diverse factors, customized strategies can be developed to promote PrEP adherence, eventually contributing to the broader effort to reduce HIV incidence and support the Malawi\u0026apos;s commitment to the 95-95-95 goals. Through the integration of targeted intervention and health systems support, this study aims to promote sustainable improvements in PrEP engagement among AGYW, ensuring that this effective prevention tool reaches its full potential in addressing HIV transmission within high-prevalence settings.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e4.2 Summarizing key findings\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study recruited 30 adolescent girls and young women (AGYW) from Mulanje District, showing significant barriers and facilitators to PrEP uptake and adherence. The key barriers identified include stigma and negative social perception, as PrEP is often mistakenly related with HIV treatment, leading to conclusion and fear among users. Some AGYW encounterd partner resistance, and insufficient knowledge further escalated the problem. Furthermore, healthcare accessibility challenges were remarkable, with long distances, inconsistent PrEP availability, and long wait time due to intergrated health service at the facilities. Limited awareness, especially in rural areas, was also identified, as many responded lacked comprehensive education concerning PrEP\u0026rsquo;s benefits, its side effects, and eligibility.\u003c/p\u003e\n\u003cp\u003eAlternatively, key facilitators for effective PrEP uptake include strong social and peer support systems, healthcare provider engagement, and effective interdepartmental staff collaboration in hospitals. AGYW stressed the role of family and partners in promoting adherence and the vital role of healthcare providers in educating them during routine visits. Suggested strategies for enhancing PrEP uptake and adherence included increasing accessibility, awareness campaigns, integrating PrEP with other health services, and peer and social support initiatives. Forming youth clubs and utilizing peer support groups were seen as beneficial in encouraging community dialogue and reducing stigma. However, concerns about confidentiality and training limitations for Health Surveillance Assistants (HSAs) were noted.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e4.3 Interpreting results\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e4.3.1 Barriers influencing PrEP uptake among AGYW\u003c/h3\u003e\n\u003cp\u003eOur study shows that social stigma and fear for being mistaken with HIV-positive, prevent AGYW from using and adhering to PrEP. Misconceptions about PrEP, such as the belief that taking it is similar to taking ART, along with limited support from partners and peers, discourage open use and disrupt its continuation due to community perception of promiscuity. A similar study conducted among young people in Uganda, Zimbabwe, and South Africa found that the participants refrained from taking PrEP due to its with antiretroviral drugs and HIV-related stigma (17). This was a key barrier to uptake, as participants linked taking daily tablets to people living with HIV. Another study was conducted in Kenya to explore community perceptions around AGYW PrEP use, and it was noted that community perceived PrEP use as unacceptable for AGYW because of the potential to increase \u0026ldquo;promiscuous\u0026rdquo; behavior, STIs, and pregnancy (18).\u003c/p\u003e\n\u003cp\u003eOur study found that AGYW meet significant healthcare accessibility challenges when accessing PrEP, including long travel distances to limited centres and long waiting times due to queues with ART patients. Additionally, some health centres experience inconsistent availability of PrEP, and clients often miss appointments because of transportation issues, making timely access to the medication a problem. A study which was conducted in Uganda among female sex workers (FSW) on their perspective on PrEP delivery, found that FSW reported dissatisfaction with the facility\u0026rsquo;s clinic due to delays, such as waiting in line for blood draws, receiving test results, and then having to queue again to see health workers for their prescriptions and to receive PrEP at the pharmacy (19). Similary, a study conducted in Uganda, Zimbabwe, and South Africa revealed that participants preferred quick access to PrEP without having to spend long hours in queues waiting to receive PrEP (17). Instances when facilities are busy and they are required to wait for a long time was seen as a barrier to using PrEP.These delays had a negative impact on the overall experience of receiving PrEP care. This study also noted long travel distance due to limited PrEP centres in the district, and some health centres experience inconsistent availability of PrEP and supply of PrEP affecting its the accessibility, aligning with the results scoping review in sub-Saharan Africa (20)(21).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study also noted that AGYW in rural and underserved communities had limited awareness and education on PrEP, with most learning about it during other health hospital visits. We noted gaps in knowledge about side effects and eligibility, and healthcare providers often provides limited information like its benefit. Before any other factors influencing PrEP uptake come into play, both individuals at risk and healthcare providers need to be aware of the existence of PrEP as a preventive option. In an article from Austraria, ndividual-level barriers to PrEP uptake and persistence have been characterised, such as low awareness, and low willingness to use PrEP which is consistence with our findings (22). Similarly, a narrative review found that awareness of PrEP remains low in populations at risk and is inadequate in some healthcare providers settings, leading to a recommendation for educational initiatives (23)(24). However, there remains skeptism whether healthcare providers have sufficient knowledge to provide PrEP, as evidenced by the limited information they offer.\u003c/p\u003e\n\u003ch3\u003e4.3.2 Facilitators to Successful PrEP Uptake\u003c/h3\u003e\n\u003cp\u003eAGYW received support from family, peers, and partners in adhering to PrEP, with encouragement and reminders to retain their regimen. However, some were not comfortable discussing PrEP with their families, and their partner\u0026rsquo;s had mixed reactions, usually influenced by their own HIV status, so they may not be supportive. A study conducted in Kenya and South Africa reported that most famiy members, particularly mothers, provided instrumental, emotional, informational and appraisal support to participants using PrEP, including reminders, encouragement, and problem-solving (23). Further, Participants reported that family members with insufficient information about PrEP safety and efficacy and who voiced concerns were a substantial barrier to their use, aligning with our findings. Similarly, a study conducted in Kampala, Uganda some participants reported social support from friends, especially those who were also using PrEP and from family members to whom they had disclosed their PrEP use (25). Little has been discussed about whether sexual partners influence in PrEP uptake and adherence, but our study has shown that partners can offer support, though with mixed reactions due to their own HIV status. This a ligned with the study conducted in Kampala which reported that disclosure of PrEP use to sexual partners was not a common practice among participants because they feared that their sexual partners would suspect them of infidelity or that they would assume that they were HIV positive.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study found that most AGYW learn about PrEP during hospital visits receiving other health related services, such as HIV testing and STI treatment. A systematic review and qualitative meta-synthesis in low- and middle-income countries reported that heathcare workers integrate PrEP counseling and delivery services into the current health system, such as obtaining drugs in general clinics rather than sexual health clinics, which may reduce the potential stigma (26). Despite the effort that is made by healthcare workers, they often focus sorely on PrEP\u0026apos;s benefits in HIV prevention, without addressing effects. Similarly, a study on identifying opportunities to discuss PrEP highlited the issue of incomplete information being provided to client (27). This lack of complehesinve counselling can hinder client from making informed decisions about PrEP uptake.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eImproved interdepartmental collaboration in hospitals, with various cadres, including non-specialists like HIV diagnostic assistants and treatment supporters, actively guiding clients through PrEP services, makes access to services easier. A study from Uganda, Zimbabwe, and South Africa it was reported that health care services are often at a signifcant distance from the people, hence health care services in many insititution needed to be designed in an adaptive and innovative way, so that many young people who would beneft from it and receive PrEP (17).\u003c/p\u003e\n\u003cp\u003eProtection against HIV was the primary motivation for taking PrEP, noting its health benefits, peace of mind, and empowerment in managing their sexual health, especially in high-risk relationships, such as antenatal patients. A study conducted in Lilongwe, Malawi found that Women initiating PrEP during pregnancy were highly motivated to obtain HIV protection for themselves and their unborn child, often due to perceived HIV risk connoted by a recent sexually transmitted infection and/or concerns about partner non-monogamy (28). \u0026nbsp;A study from Uganda, Zimbabwe, and South Africa reported that high HIV risk perceived by some clients as being at risk of contracting HIV was a key facilitator to PrEP uptake (17). The aspects like not knowing the HIV status of one\u0026rsquo;s partner, dislike and fear of going for an HIV test by their partners, created a fear of becoming infected. The introduction of PrEP was therefore viewed as an opportunity to reassure someone that they are protected and will not be infected.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e4.3.3 Strategies to Enhance PrEP Adherence\u003c/h3\u003e\n\u003cp\u003eOur study suggested the need to increase accessibility by ensuring PrEP is consistently available in all local health centers, maintaing the presence of healthcare providers, and enhancing healthcare provider training on PrEP use and counseling. Utilizing HSAs to provide PrEP could help reduce defaulting rates; however, concerns were raised about drug storage, maintaining efficacy and confidentiality, and HSAs\u0026apos; ability to accurately assess client eligibility due to the clinical expertise required. While many studies have recommended youth clubs for awareness campaigns, it was also reported that AGYW PrEP‐users can access PrEP through these youth clubs for PrEP refills (29). A study in a united state examining primary care providers\u0026rsquo; knowledge, attitudes and beliefs about HIV Pre-exposure Prophylaxis (PrEP) reported that continuing medical education (CME) courses are the best information source for PrEP providers (30). CME was identified as the most consistent source of receiving information about new and current practices for providers. It was suggested CME be delivered through videos, brief webinars, and apps so that they can easily navigate them on their phones. Little has been discussed relating consistency of PrEP availability in health centres and presence of healthcare providers; hence, this was identified as unique findings and as a strategy. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTargeted awareness campaigns involving schools, churches, youth clubs, community leaders, peers, and local media were recommended to increase acceptance and understanding. A scoping review in low-income and middle-income countries done in high risk of HIV study found that strategies to increase PrEP continuation included SMS reminders, drug-level feedback, peer group supports and conditional economic incentives (31). Another study that looked on the recommendation from healthcare providers in eastern Zimbabwe, the healthcare providers called for; PrEP marketing campaigns, youth‑friendly services or corners, improved PrEP delivery mechanisms, greater engagement with key stakeholders, including with young people themselves (engage AGYW) (32). These strategies aim to provide non-judgemental services, improve knowledge about PrEP through school-based campaigns, and mobilise AGYW and involve PrEP users.\u003c/p\u003e\n\u003cp\u003eTo improve access, encourage uptake, and enhance efficiency in care, PrEP has to intergrate with other health services, such as family planning, HIV testing, and STI management. The benefits of coordinated services, including comprehensive risk assessment and facilitate PrEP access, and also link up care. Cluster randomized trial conducted in Kenya reported that intergrating PrEP delivery to existing FP systems and staffing has tremendous potential to address barriers that women face in accessing HIV prevention and PrEP care, including lack of time, cost, and stigma of visiting a facility solely for HIV prevention (33). A scoping review reported the successful strategies for PrEP integration included initiating PrEP and contraception at the same time and by the same provider or HIV self-testing (34).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdolescents are strongly influenced by the home and family environment, and therefore social support for PrEP use, and factors operating at the household, social and community levels, are critical in the successful enrolment, retention and adherence to PrEP amongst AGYW (21). Peer and social support were seen as valuable for consistent PrEP usage. PrEP users they need for encouragement from friends and partners who are already are using it. They recommended establishing well-trained peer groups in villages to provide effective PrEP education and support.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e4.4 Limitations of the study\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eFindings from this study should be interpreted with consideration of its limitations. Mulanje district had few PrEP centres; out of 23 health centres in the district, only six were able to provide PrEP. Consequently, the participant interviewed at these six health centres may not be representative of the district\u0026rsquo;s population. Additionally, the study intended to conduct a focus group discussion with parents/guardians. However, since most participants were not linked to their parents or guardians, we were unable to conduct FDGs interviews to them. As a result the perspectives of parents/guardians, which could have had an impact on the study, were omitted.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e4.5 Implications for future research\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eFuture research need to concentrate on addressing the barriers and facilitators to PrEP uptake and adherence among AGYW, particularly by developing strategies that reduce stigma and misconceptions. This may include community-based education campaigns and integrating PrEP awareness into broader sexual and reproductive health programs. Studies should also assess the role of healthcare providers in providing comprehensive counseling, including both the benefits and potential side effects of PrEP, to ensure informed decision-making the PrEP users. Additionally, advanced solutions to improve healthcare access, such as mobile clinics or telemedicine, should be explored, especially in rural areas where logistical challenges limit access. Lastly, research is needed to investigate the influence of partners and families on PrEP use and adherence, and also the effectiveness of peer support groups and youth clubs in reducing stigma and promoting awareness among AGYW.\u0026nbsp;\u003c/p\u003e"},{"header":"CHAPTER 5: Conclusion and recommendations ","content":"\u003ch2\u003e\u003cstrong\u003e5.1 Conclusion\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study highlight the varied barriers and facilitators influencing PrEP uptake and adherence among AGYW in Mulanje District, emphasizing the importance of addressing individual, interpersonal, community, institutional, and structural factors. The main barriers to PrEP use include stigma and social perception, Healthcare accessibility challenges, and limited awareness and education, while facilitators such as social and peer support, healthcare provider engagement, and convenient and responsive services by staffs contribute to successful PrEP uptake. The findings emphasize the need for targeted interventions that align with AGYW\u0026apos;s lived experiences and address both social and logistical barriers, ensuring PrEP becomes a sustainable HIV prevention tool in high-prevalence areas. Strategies such as increasing accessibility, awareness campaigns, integrating PrEP with other health services, and peer and social support initiatives can enhance uptake and adherence, eventually supporting Malawi\u0026rsquo;s commitment to the 95-95-95 goals.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e5.2 Recommendations\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eTo strengthen PrEP utilization among AGYW, the study recommends several key strategies. These include improving healthcare access by ensuring consistent availability of PrEP in health centers, broadening the role of healthcare providers through improving training, and using peer support groups and youth clubs to promote awareness and reduce stigma. Additionally, integrating PrEP services with other health programs, such as family planning, STI management and HIV testing, can reduce barriers and increase efficiency in healthcare provision. Moreover, community-based interventions, including targeted awareness campaigns involving schools, churches, and local media, are essential for modifying perceptions and improving knowledge about PrEP. By addressing these barriers and utilizing facilitators, interventions can effectively support long-term PrEP adherence, reducing HIV transmission risk among AGYW.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAGYW:\u003c/strong\u003e Adolescent Girls and Young Women\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eART:\u003c/strong\u003e Antiretroviral Therapy\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBT:\u003c/strong\u003e Blantyre\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCAB LA:\u003c/strong\u003e Cabotegravir Long-Acting\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCDC:\u003c/strong\u003e Centers for Disease Control and Prevention\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOMREC:\u003c/strong\u003e College of Medicine Research and Ethics Committee\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDHO:\u003c/strong\u003e District Health Office\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCW:\u003c/strong\u003e Healthcare Workers\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHSA:\u003c/strong\u003e Health Surveillance Assistants\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHIV:\u003c/strong\u003e Human Immunodeficiency Virus\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLL:\u003c/strong\u003e Lilongwe\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMHIRST:\u003c/strong\u003e Malawi HIV Implementation Research Scientist Training Program\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrEP:\u003c/strong\u003e Pre-exposure Prophylaxis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eURPC:\u003c/strong\u003e University Research and Publication Committee\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUSD:\u003c/strong\u003e United States Dollar\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVMMC:\u003c/strong\u003e Voluntary Male Medical Circumcision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO:\u003c/strong\u003e World Health Organization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCME:\u003c/strong\u003e continuing medical education\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from Kamuzu College of Health Sciences Research and Ethics Committee (COMREC), approval reference number P.01/24-0533. Prior to participation, all participants provided both verbal and written informed consent. The consent process emphasized the voluntary participation and the participants had the right to withdraw from the study at any time without facing any negative consequences. Participants were provided with comprehensive information about the study, including its purpose, procedures, potential risks, and benefits of the study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable in this study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analysed during the current study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by Malawi HIV Implementation Research Scientist Training (M-HIRST), under UNC with a decicion to publish the manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.K. analyzed and interpreted the patient data While the rest authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMPHIA. 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Available from: https://r.search.yahoo.com/_ylt=AwrNaRP1UFNlRisL.QZXNyoA;_ylu=Y29sbwNiZjEEcG9zAzEEdnRpZAMEc2VjA3Nj/RV=2/RE=1699987830/RO=10/RU=https%3A%2F%2Fwww.mmh.mw%2Fwhat-we-do%2Fhospital%2Fprimary-health-care%2Fhivaids%2F%23%3A~%3Atext%3DOut%2520of%2520the%2520total\u003c/li\u003e\n\u003cli\u003eHwang S, Birken SA, Melvin CL, Rohweder CL, Smith JD. Designs and methods for implementation research: Advancing the mission of the CTSA program. J Clin Transl Sci. 2020;4(3):159\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eChinele J, Kamatimaleka M, Migoli E, Mneula T, Kumwenda G, Gadama C, Sikwese S, Mpunga E, Banda L, Chilongozi D, Akolo C RM. Barriers to uptake and use of oral PrEP among FSW in Blantyre, Malawi. 2020; Available from: https://academicmedicaleducation.com/meeting/interest-2020/abstract/barriers-uptake-and-use-oral-prep-among-fsw-blantyre-malawi\u003c/li\u003e\n\u003cli\u003eMuhumuza R, Ssemata AS, Kakande A, Ahmed N, Atujuna M, Nomvuyo M, et al. Exploring Perceived Barriers and Facilitators of PrEP Uptake among Young People in Uganda, Zimbabwe, and South Africa. Arch Sex Behav [Internet]. 2021;50(4):1729\u0026ndash;42. Available from: https://doi.org/10.1007/s10508-020-01880-y\u003c/li\u003e\n\u003cli\u003eEscudero JN, Dettinger JC, Pintye J, Kinuthia J, Lagat H, Abuna F, et al. Community Perceptions About Use of Pre-exposure Prophylaxis Among Adolescent Girls and Young Women in Kenya. J Assoc Nurses AIDS Care. 2020;31(6):669\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eMpirirwe R, Mujugira A, Walusaga H, Ayebare F, Musanje K, Ndugga P, et al. Perspectives of female sex workers on HIV pre-exposure prophylaxis delivery in Uganda: A qualitative study. Res Sq [Internet]. 2024;1\u0026ndash;15. 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Available from: http://dx.doi.org/10.1016/S2468-2667(21)00112-2\u003c/li\u003e\n\u003cli\u003eMayer KH, Agwu A, Malebranche D. Barriers to the Wider Use of Pre-exposure Prophylaxis in the United States: A Narrative Review [Internet]. Vol. 37, Advances in Therapy. Springer Healthcare; 2020. 1778\u0026ndash;1811 p. Available from: https://doi.org/10.1007/s12325-020-01295-0\u003c/li\u003e\n\u003cli\u003eMoameri H, Shahrbabaki PM, Tavakoli F, Saberi P, Mirzazadeh A. Facilitators and barriers of HIV pre-exposure prophylaxis use among four key populations in Iran. BMC Health Serv Res [Internet]. 2024; Available from: https://doi.org/10.1186/s12913-024-11933-w\u003c/li\u003e\n\u003cli\u003eIvy Kayesu1*, Yunia Mayanja1 , Catherine Nakirijja1 , Yvonne Wangũi Machira2, Matt Price2, 3, Janet Seeley1 4 and, Siu G. Uptake of and adherence to oral pre-exposure prophylaxis among adolescent girls and young women at high risk of HIV-infection in Kampala, Uganda: A qualitative study of experiences, facilitators and barriers. 2022; Available from: https://r.search.yahoo.com/_ylt=AwriijFCXT1nKwIAcxtXNyoA;_ylu=Y29sbwNiZjEEcG9zAzEEdnRpZAMEc2VjA3Ny/RV=2/RE=1733284419/RO=10/RU=https%3A%2F%2Fbmcwomenshealth.biomedcentral.com%2Farticles%2F10.1186%2Fs12905-022-02018-z/RK=2/RS=Cm94lYSXLa8pbvZiHZZnnKFhx6o-\u003c/li\u003e\n\u003cli\u003eZhang L, Song Y, Zheng X, Liu Y, Chen H. The experience of healthcare workers to HIV pre-exposure prophylaxis (PrEP) implementation in low- and middle-income countries: a systematic review and qualitative meta-synthesis. Front Public Heal. 2023;11(August):1\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003ePetsis D, Akers AY. 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Interventions to increase the uptake and continuation of pre-exposure prophylaxis (PrEP) by adolescent girls and young women at high risk of HIV in low-income and middle-income countries: a scoping review. BMJ Glob Heal. 2022;7(12):1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eMorten Skovdal 1*, Phyllis Magoge‑Mandizvidza2, Freedom Dzamatira2 RM, Constance Nyamukapa2, 3, Ranjeeta Thomas4, Owen Mugurungi5 and Simon Gregson2 3. Improving access to pre-exposure prophylaxis for adolescent girls and young women: recommendations from healthcare providers in eastern Zimbabwe. 2022;22(399). \u003c/li\u003e\n\u003cli\u003eMugwanya KK, Matemo D, Scoville CW, Beima-Sofie KM, Meisner A, Onyango D, et al. Integrating PrEP delivery in public health family planning clinics: a protocol for a pragmatic stepped wedge cluster randomized trial in Kenya. Implement Sci Commun [Internet]. 2021;2(1):1\u0026ndash;12. 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BMJ Sex Reprod Heal. 2023;49(3):210\u0026ndash;8. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent girls and young women (AGYW), PrEP, HIV, Prevention, Malawi","lastPublishedDoi":"10.21203/rs.3.rs-5775233/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5775233/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eAdolescent girls and young women (AGYW) in Malawi, with an 8% HIV prevalence, are disproportionately affected by HIV (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), making PrEP a fundumental prevention mechanism. However, PrEP uptake is affected by individual, interpersonal, community, institutional, and structural factors. Identifying these factors is important to improving HIV prevention and achieving the 95-95-95 HIV goals. This study aims to explore these factors influencing PrEP uptake and adherence among AGYW in Mulanje District, providing understing for targeted interventions to increase PrEP coverage and reduce HIV incidence.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis research employed a Hybrid Type 1 qualitative design, focusing on Adolescent Girls and Young Women (AGYW) aged 15\u0026ndash;24. The study was stratified based on PrEP status, including current users, those identified as eligible but not initiated, and those who have discontinued PrEP. Data collection involved interviews with 30 participants and one focus group discussion with healthcare providers. Thematic analysis was conducted to identify patterns and insights, and the results are presented through a comprehensive narrative and tables highlighting key themes and quotes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur analysis revealed several barriers and facilitators to PrEP uptake and adherence among AGYW. Barriers included stigma and social perception, Healthcare accessibility challenges, and limited awareness and education. Facilitators involved social and peer support, healthcare provider engagement, and convenient and responsive services by staffs. Strategies to enhance PrEP adherence included increasing accessibility, awareness campaigns, integrating PrEP with other health services, and peer and social support initiatives. These findings highlight the need for multi-faceted approaches to address barriers and strengthen facilitators to improve PrEP uptake and adherence, and also implement the suggested interventions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAddressing barriers to PrEP uptake among AGYW in Mulanje District requires a complex approach. Key barriers include stigma, healthcare access issues, and low awareness, while facilitators like involved social and peer support, healthcare provider engagement, and convenient and responsive services by staffs. Recommendations to improve PrEP use include enhancing healthcare access, using peer support, and integrating PrEP with other services, and initiating community awareness campaigns. These strategies are important for overcoming barriers, improving adherence, and supporting HIV prevention in Malawi.\u003c/p\u003e","manuscriptTitle":"Barriers and Facilitators to PrEP Uptake and Adherence among Adolescent Girls and Young Women Attending Family Planning Clinics in Mulanje District, Malawi: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-23 04:20:00","doi":"10.21203/rs.3.rs-5775233/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-22T07:25:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-21T10:24:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-21T10:21:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-01-06T15:58:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"73580983-65a3-4607-babe-c96a3fbe41ce","owner":[],"postedDate":"January 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-02T11:23:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-23 04:20:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5775233","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5775233","identity":"rs-5775233","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}