Provider perspectives on PrEP for adolescent girls and young women in Tanzania: The role of provider biases and quality of care

Nanlesta Pilgrim, Nrupa Jani, Sanyukta Mathur, Catherine Kahabuka, Vaibhav Saria, Neema Makyao, Lou Apicella, Julie Pulerwitz, Nanlesta Pilgrim, Nrupa Jani, Sanyukta Mathur, Catherine Kahabuka, Vaibhav Saria, Neema Makyao, Lou Apicella, Julie Pulerwitz

Abstract

Background: Oral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa. However, health care providers' (HCPs) perspectives and interactions with potential clients can substantially influence effective provision of quality health services. We examine if HCPs' knowledge, attitude, and skills, as well as their perceptions of facility readiness to provide PrEP are associated with their willingness to provide PrEP to AGYW at high risk of HIV in Tanzania.

Methods: A self-administered questionnaire was given to 316 HCPs from 74 clinics in two districts and 24 HCPs participated in follow-up in-depth interviews (IDIs). We conducted bivariate and multivariable Poisson regression to assess factors associated with willingness to provide PrEP to AGYW. Thematic content analysis was used to analyze the IDIs, which expanded upon the quantitative results.

Results: Few HCPs (3.5%) had prior PrEP knowledge, but once informed, 61.1% were willing to prescribe PrEP to AGYW. Higher negative attitudes toward adolescent sexuality and greater concerns about behavioral disinhibition due to PrEP use were associated with lower willingness to prescribe PrEP. Qualitatively, HCPs acknowledged that biases, rooted in cultural norms, often result in stigmatizing and discriminatory care toward AGYW, a potential barrier for PrEP provision. However, better training to provide HIV services was associated with greater willingness to prescribe PrEP. Conversely, HCPs feared the potential negative impact of PrEP on the provision of existing HIV services (e.g., overburdened staff), and suggested the integration of PrEP into non-HIV services and the use of paramedical professionals to facilitate PrEP provision.

Conclusions: Preparing for PrEP introduction requires more than solely training HCPs on the clinical aspects of providing PrEP. It requires a two-pronged strategy: addressing HCPs' biases regarding sexual health services to AGYW; and preparing the health system infrastructure for the introduction of PrEP.

Conflict of interest statement

Competing Interests: The affiliation with CSK Research Solutions does not alter our adherence to PLOS ONE policies on sharing data and materials. The authors declare no competing interests. Additionally, the content of this manuscript has not been published, or submitted for publication elsewhere.

References

    1. UNAIDS. Prevention Gap Report. Geneva: UNAIDS; 2016.
    1. Tanzania Commission for AIDS (TACAIDS) Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF International Tanzania HIV/AIDS and Malaria Indicator Survey 2011–12. Dar es Salaam, Tanzania: TACAIDS, ZAC, NBS, OCGS, and ICF International; 2013.
    1. Fonner VA, Dalglish SL, Kennedy CE, Baggaley R, O’reilly KR, Koechlin FM, et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS. 2016;30(12): 1973 doi:
    1. World Health Organization. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV Geneva: WHO; 2015.
    1. Nair M, Baltag V, Bose K, Boschi-Pinto C, Lambrechts T, Mathai M. Improving the quality of health care services for adolescents, globally: A standards-driven approach. J Adolesc Health. 2015;57(3): 288–298. doi:
    1. Bruce J. Fundamental elements of the quality of care: a simple framework. Stud Fam Plann. 1990;21(2): 61–91.
    1. Sofaer S, Firminger K. Patient perceptions of the quality of health services. Annu Rev Public Health. 2005;26: 513–59. doi:
    1. Becker D, Koenig MA, Mi Kim Y, Cardona K, Sonenstein FL. The quality of family planning services in the United States: findings from a literature review. Perspect Sex Reprod Health. 2007;39(4): 206–15. doi:
    1. Pilgrim NA, Cardona KM, Pinder E, Sonenstein FL. Clients’ perceptions of service quality and satisfaction at their initial Title X family planning visit. Health Commun. 2014;29(5): 505–15. doi:
    1. Kruk ME, Freedman LP. Assessing health system performance in developing countries: a review of the literature. Health Policy. 2008;85(3): 263–76. doi:
    1. Castel AD, Feaster DJ, Tang W, Willis S, Jordan H, Villamizar K, et al. Understanding HIV care provider attitudes regarding intentions to prescribe PrEP. J Acquir Immune Defic Syndr. 2015;70(5): 520 doi:
    1. Sowicz TJ, Teitelman AM, Coleman CL, Brawner BM. Considerations for implementing oral preexposure prophylaxis: a literature review. J Assoc Nurses AIDS Care. 2014;25(6): 496–507. doi:
    1. Van Damme L, Corneli A, Ahmed K, Agot K, Lombaard J, Kapiga S, et al. Preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2012;367(5): 411–422. doi:
    1. Corneli AL, Deese J, Wang M, Taylor D, Ahmed K, Agot K, et al. FEM-PrEP: adherence patterns and factors associated with adherence to a daily oral study product for pre-exposure prophylaxis. JAIDS J Acquir Immune Defic Syndr. 2014;66(3): 324–31. doi:
    1. Marrazzo JM, Ramjee G, Richardson BA, Gomez K, Mgodi N, Nair G, et al. Tenofovir-based preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2015;372(6): 509–18. doi:
    1. Yun K, Xu J-j, Zhang J, Li J-m, Hu Q-h, Chu Z-x, et al. Female and younger subjects have lower adherence in PrEP trials: a meta-analysis with implications for the uptake of PrEP service to prevent HIV. Sex Transm Infect. 2017. pii: sextrans-2017-053217. doi:
    1. Geibel S, Hossain SM, Pulerwitz J, Sultana N, Hossain T, Roy S, et al. Stigma reduction training improves healthcare provider attitudes toward, and experiences of, young marginalized people in Bangladesh. J Adolesc Health. 2017;60(2): S35–S44.
    1. World Health Organization. Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health care services for adolescents Geneva: World Health Organization; 2015.
    1. Sam-Agudu NA, Folayan MO, Ezeanolue EE. Seeking wider access to HIV testing for adolescents in sub-Saharan Africa. Pediatr Res. 2016;79(6): 838–845. doi:
    1. Donaldson E. Knowledge, attitudes and practices of PrEP providers working with adolescent girls and young women OPTIONS CONSORTIUM; 2016.
    1. Pilgrim N, Mathur S, Gottert A, Rutenberg N, Pulerwitz J. Building evidence to guide PrEP introduction for adolescent girls and young women Washington, DC: Population Council; 2016.
    1. Mathur S, Pilgrim N, Pulerwitz J. PrEP introduction for adolescent girls and young women. The Lancet HIV. 2016;3(9): e406–e408. doi:
    1. Becker D, Koenig MA, Kim YM, Cardona K, Sonenstein FL. The quality of family planning services in the United States: findings from a literature review. Perspectives on sexual and reproductive health. 2007;39(4): 206–215. doi:
    1. Kaiser HF. An index of factorial simplicity. Psychometrika. 1974;39(1): 31–36.
    1. Warenius LU, Faxelid EA, Chishimba PN, Musandu JO, Ong'any AA, Nissen EBM. Nurse-midwives' attitudes towards adolescent sexual and reproductive health needs in Kenya and Zambia. Reprod Health Matters. 2006;14: 119–128. doi:
    1. Ahanonu EL. Attitudes of healthcare providers towards providing contraceptives for unmarried adolescents in Ibadan, Nigeria. J Family Reprod Health. 2014;8(1): 33
    1. Creswell JW, Plano Clark VL. Designing and conducting mixed methods research Los Angeles: SAGE Publications; 2011. p. 457.
    1. Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC medical research methodology. 2003;3(1): 21.
    1. StataCorp. Stata 13 Base Reference Manual. College Station, TX: Stata Press, 2013.
    1. Friese S. Qualitative data analysis with ATLAS. ti: Sage; 2014.
    1. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9): 1277–1288. doi:
    1. Ayres L, Kavanaugh K, Knafl KA. Within-case and across-case approaches to qualitative data analysis. Qual Health Res. 2003;13(6):871–883. doi:
    1. Boeije H. A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Quality and Quantity. 2002;36(4): 391–409.
    1. Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory Thousand Oaks, CA: Sage Publications, Inc.; 2008.
    1. Mack N, Wong C, McKenna K, Lemons A, Odhiambo J, Agot K. Human resource challenges to integrating HIV pre-exposure prophylaxis (PrEP) into the public health system in Kenya: a qualitative study. Afr J Reprod Health. 2015;19(1): 54–62.
    1. Mimiaga MJ, White JM, Krakower DS, Biello KB, Mayer KH. Suboptimal awareness and comprehension of published preexposure prophylaxis efficacy results among physicians in Massachusetts. AIDS Care. 2014;26(6): 684–693. doi:
    1. Seidman D, Carlson K, Weber S, Witt J, Kelly PJ. United States family planning providers' knowledge of and attitudes towards preexposure prophylaxis for HIV prevention: a national survey. Contraception. 2016;93(5): 463–469. doi:
    1. Caceres CF, Borquez A, Klausner JD, Baggaley R, Beyrer C. Implementation of pre-exposure prophylaxis for human immunodeficiency virus infection: progress and emerging issues in research and policy. J Int AIDS Soc. 2016;19(7(Suppl 6)): 21108 doi:
    1. Mullins TL, Zimet G, Lally M, Kahn JA. Adolescent human immunodeficiency virus care providers' attitudes toward the use of oral pre-exposure prophylaxis in youth. AIDS Patient Care STDS. 2016;30(7): 339–348. doi:
    1. Wheelock A, Eisingerich AB, Gomez GB, Gray E, Dybul MR, Piot P. Views of policymakers, healthcare workers and NGOs on HIV pre-exposure prophylaxis (PrEP): a multinational qualitative study. BMJ Open. 2012;2(4). doi:
    1. Shaeer KM, Sherman EM, Shafiq S, Hardigan P. Exploratory survey of Florida pharmacists' experience, knowledge, and perception of HIV pre-exposure prophylaxis. J Am Pharm Assoc (2003). 2014;54(6): 610–617. doi:
    1. Ross I, Mejia C, Melendez J, Chan PA, Nunn AC, Powderly W, et al. Awareness and attitudes of pre-exposure prophylaxis for HIV prevention among physicians in Guatemala: Implications for country-wide implementation. PLoS One. 2017;12(3): e0173057 doi:
    1. Tang EC, Sobieszczyk ME, Shu E, Gonzales P, Sanchez J, Lama JR. Provider attitudes toward oral preexposure prophylaxis for HIV prevention among high-risk men who have sex with men in Lima, Peru. AIDS Res Hum Retroviruses. 2014;30(5): 416–24. doi:
    1. Blumenthal J, Haubrich R. Risk compensation in PrEP: An old debate emerges yet again. Virtual Mentor. 2014;16(11): 909–915. doi:
    1. Bekker LG, Roux S, Sebastien E, Yola N, Amico KR, Hughes JP, et al. Daily and non-daily pre-exposure prophylaxis in African women (HPTN 067/ADAPT Cape Town Trial): a randomised, open-label, phase 2 trial. Lancet HIV. 2018;5(2): e68–e78. doi:

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