“I didn’t support PrEP because I didn’t know what it was”: Inadequate information undermines male partner support for young women’s PrEP use in western Kenya

Abstract

The HIV infection rate is higher among adolescent girls and young women (AGYW) in Africa than men their age. Pre-exposure prophylaxis (PrEP) can be used by women discretely; however, for most AGYW, male partner (MP) approval is desired. We explored PrEP use in the context of relationship violence and power dynamics through focus group discussions (FGDs) and support club sessions with AGYW, in-depth interviews (IDIs) and male sensitization sessions with MPs of AGYW, and joint sessions with AGYW and their MPs. Many MPs reported hesitancy in supporting partner’s PrEP use without sufficient information; most of these became supportive following their engagement in study activities; and most preferred participation in decisions around PrEP use. To AGYW, male involvement minimized partner violence around their PrEP use. The findings support the need for correct PrEP information to MPs of AGYW and to involve them in decision-making about PrEP use early. This is likely to improve uptake of and adherence to PrEP.

INTRODUCTION

Optimizing the effectiveness of proven biomedical prevention interventions is critical to reducing the high incidence of HIV among adolescent girls and young women (AGYW), a priority population for HIV prevention (UNAIDS, 2014; UNAIDS, 2015). Despite the scale-up of HIV testing and HIV treatment services, HIV incidence among AGYW has remained high compared to other population segments (MacQueen, 2017; Celum et al., 2019). In sub-Saharan Africa, AGYW account for 25% of new HIV infections among adults, and have three to five times the prevalence of adolescent boys and young men (UNAIDS, 2015; Wilton et al., 2016; Hamilton et al., 2017). In Kenya, AGYW contribute 28% of all new infections (MOH, 2018).

As a priority population, AGYW are impacted by social norms, inequalities, and stigma based on their age and sex (Celum et al., 2019; Ward et al., 2019). Their vulnerability to HIV is enhanced by socio-behavioral factors such as early sexual debut, early and forced marriage and childbirth, sexual relationships with older men, economic pressure for transactional sex, and inability to negotiate condom use (Muula, 2008; Underwood et al., 2011; UNAIDS, 2018). Structural factors, such as unavailability of youth-friendly health services and less access to education, also add to young women’s vulnerability to HIV (Jukes et al., 2008; Mathews et al., 2011; Grépin & Bharadwaj, 2015). AGYW often lack decision-making autonomy with regard to their health, which could negatively impact their use of innovative prevention technologies (Dodoo, & Tempenis, 2002; Nalwadda et al., 2010; Woodsong et al., 2013; Lanham et al., 2014; Carroll et al., 2016; Delany-Moretlwe et al, 2018; Celum et al., 2019).

One of the most effective HIV prevention interventions identified in the last decade is pre-exposure prophylaxis (PrEP) – the use of antiretroviral drugs by people who do not have HIV to reduce the risk of acquiring HIV (WHO, 2014). In September 2015, the World Health Organization (WHO) recommended that as part of combination HIV prevention, PrEP should be offered as an additional prevention choice for people at substantial risk of HIV infection (WHO, 2015). A systematic review of oral PrEP that included 18 studies found that PrEP use with greater than 70% adherence demonstrated the highest effectiveness (RR = 0.30, 95% CI: 0.21-0.45, p < 0.001) compared to placebo, confirming that oral PrEP significantly reduces the risk of HIV with high rates of efficacy when taken consistently (Fonner et al., 2016). With this evidence, eastern and southern African countries have rolled out PrEP as an HIV prevention strategy for high-risk populations, including AGYW (Van der Elst et al., 2013).

In Kenya, PrEP delivery is scaling up through various public-sector facilities, including Maternal and Child Health and Family Planning clinics (Masyuko et al., 2018; Pintye et al., 2018). However, studies among AGYW in high HIV burden regions in Kenya have reported low PrEP uptake, as well as low continuation rates. In one study conducted in Kisumu County, Western Kenya, by Oluoch, et al., (2019) only 4% of eligible AGYW initiated PrEP at their visit to Family Planning clinics for contraceptive services. Mugwanya, et, al., (2019) in their study also conducted in Kisumu county, found that only 41% of those who initiated PrEP returned for at least one refill visit. In another study conducted in western, central and coastal Kenya by Were et al., (2020), the PrEP adherence cascade indicated that of the 3 138 AGYW eligible for PrEP, 2 900 (92%) initiated PrEP; however, only 914 (32%) and 154 (6%) continued to be on PrEP at months 1 and 3, respectively.

PrEP use is also highly impacted by the social context in which AGYW live, including their intimate partners (Newman et al., 2007). In heterosexual relationships, lack of support and/or violent disapproval by male intimate partners is a major barrier to PrEP initiation by women, especially among AGYW (Kacanek et al., 2013; Cabral et al., 2018; Hartmann et al., 2019). Women often have to balance their motivation for HIV prevention with fear of their partner’s reactions and possible violence (van der Straten et al., 2014; Hartmann et al., 2020). Studies have also shown that intimate partner violence (IPV) has been associated with non-adherence to PrEP (Roberts et al., 2016; Cabral et al., 2018; Palanee-Phillips et al., 2018). In their study in Kenya, Haberer, et al., (2019) found that AGYW can best take PrEP when their male partners encourage them to do so; however, gender norms and power dynamics influence men’s acceptance and support of women’s PrEP use (Mathur & Pulerwitz, 2016). Male partners (MPs) may perceive non-disclosure of PrEP use by their AGYW partners as confirming their suspicion of infidelity or implying lack of faith in the relationship (Population Council, 2017). Thus, being engaged in decision around PrEP use or being asked for approval may shift MP’s thoughts from unfaithfulness and mistrust to concern about AGYW’s health.

While women in heterosexual relationships are capable of using female-initiated HIV prevention products such as PrEP without the knowledge, approval or support of their MPs, they often desire or feel it is culturally appropriate to seek MP approval (Montgomery et al., 2015; Braksmajer & McMahon, 2016) and have expressed a desire for strategies to engage partners. We advance the theory that many MPs would support their AGYW partner in using PrEP, but can only do so if provided with sufficient and accurate information about PrEP, and are engaged early in the decision-making process. Most PrEP studies and programs focus solely on AGYW, leaving out their MP who then remain uninformed or misinformed about PrEP and therefore object to its use out of ignorance (Montgomery et al., 2013; Lanham et al., 2014; Stadler et al., 2014). Additionally, MP’s support can be enhanced if AGYW disclose their plan to use PrEP prior to initiation, and engage their MPs in the decision-making process (Muralidharan et al., 2014; Population Council, 2017). We developed and pilot-tested an intervention, called Tu’washindi na PrEP (We’re winners with PrEP), to increase PrEP uptake and adherence among AGYW in heterosexual relationships in the context of GBV and unequal relationship power. In this paper, we explore the views of AGYW and their male partners on how the intervention supported PrEP uptake, persistence, and adherence among AGYW.

METHODS

Study design and participants

Tu’Washindi na PrEP was conducted among AGYW enrolled in the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, Safe) program in Siaya County, western Kenya. We worked with AGYW and PrEP providers to design and pilot a 6-month intervention that comprised of community-based PrEP male sensitization meetings, couples’ events (i.e. “Buddy Days” sessions) and adherence support clubs (Hartmann, et al., 2021). The pilot study was conducted in six Safe Spaces (DREAMS activity hubs) in the county, pair-matched and randomized 1:1 to the Tu’Washindi intervention or standard services. PrEP was provided as a routine DREAMS service at all six Safe Spaces.

PrEP male sensitization meetings were conducted over the first 2-3 months of the intervention period to provide men with educational information about PrEP and to prepare them to engage effectively with their female partners regarding PrEP use. At the male sensitization events, DREAMS clinicians explained what PrEP is, its effectiveness, who can and should use it, how to use it. They also addressed myths and misperceptions about PrEP and highlighted reasons for couples to use PrEP and its safety for women and their partners. In Month 3, couples were invited to attend a community-wide Buddy Day event that included interactive drama to illustrate real-world partner-related challenges to PrEP uptake and followed by facilitated discussion on community attitudes and concerns regarding PrEP use. The discussions were designed to address myths and misperceptions about women’s PrEP use and to facilitate communications about PrEP between each couple with the objective of increasing male partners’ trust and support for AGYW’s PrEP use. Support Club sessions for AGYWs were conducted every 2 weeks for the first 2 months of the intervention period, and then monthly during months 3-6. They provided a forum for AGYW to discuss challenges and successes around PrEP use in relationships with male partners in the context of GBV. The clubs were also designed to help AGYW obtain more information and skills on PrEP disclosure, discreet use and adherence, and healthy relationship dynamics around communication and decision-making [see Tu’Washindi intervention model (Hartmann et al., 2021)]. Intervention arm participants had lower rates of IPV and significantly higher PrEP uptake and adherence than those in the standard of care arm (Roberts et al., 2020).

At the end of the intervention period, to inform our evaluation of Tu’Washindi feasibility and acceptability we conducted small FGDs and IDIs with male partners of the 49 AGYW participating in the 3 intervention Safe Spaces. “Small FGDs” included 4-5 participants each; this approach was selected to allow for increased comfort among adolescent participants as advocated by other researchers working with this population (Delany-Moretlwe et al., 2018). The FGD participants were purposively selected to represent a range of intervention sites, PrEP use status at study start, reported disclosure of PrEP use to their male partner, as well as male partner response, and frequency of support club attendance. Male partners were selected based on their attendance at the Buddy Day event and their reported level of support for PrEP; AGYW were asked permission to contact their male partner for an interview prior to their recruitment to ensure AGYW’s safety. FGDs and IDIs were conducted between November and December 2019 following intervention completion.

Data collection, processing and analysis

All FGDs and IDIs were conducted by trained bilingual research assistants (RA) with prior experience in qualitative research using a semi-structured guide. Since the primary focus of the study was AGYW, all RAs were young women with whom participants would relate and open up to during the interviews and group discussions. The IDIs and FGDs were held in private locations and audio-recorded with the permission of participants. The FGDs with AGYW explored the acceptability of the intervention and its effects on relationship dynamics and the decision to use PrEP. The IDIs with male partners explored knowledge of and support for AGYW’s PrEP use, experiences with participation in male sensitization events and Buddy Day, and feelings about their female partner’s participation in the study. Data were transcribed and coded structurally by question using Dedoose software (Socio-Cultural Research Consultants, LLC, Los Angeles, CA), a web application for managing, analyzing, and presenting qualitative and mixed methods research data. This analysis focused on four broad themes including: disclosure of study participation and conversations about PrEP use; MP involvement in study activities and its effects on perception of and support for PrEP use; AGYW’s views on effects of MP involvement on relationship dynamics in the context of PrEP use; and addressing misperceptions about PrEP use. For IDIs, we have presented the study findings with descriptive indicators where: all is 100% of respondents, nearly all is 80–99%, the majority is more than 50%, about half is around 50%, fewer than half is around 25–45%, a minority is 10–25%, and a few is less than 10% (Guest et al., 2005)”.

Ethical considerations

Ethics approval was obtained from Maseno University Ethics Review Committee (MUERC) (Ref: MSU/DRPI/MUERC/00418/17). RTI International agreed to rely on MUERC’s ethical oversight through a signed IRB Authorization Agreement. All FGD and IDI participants provided written informed consent.

RESULTS

Demographics Characteristics

We conducted 3 FGDs with a total of 13 AGYW and 12 IDIs with MPs of AGYW participating in 3 different DREAMS Safe Spaces. MPs were 28 years (range: 19-43 years) and AGYW 22 years (range: 18-24 years). Six MPs had completed some primary education, four had some secondary education and one had post-secondary education. Eight AGYW had some secondary education while five had some primary education. Most of the MPs were engaged in some economic activities including farming (n=7), boda boda (motorbike public transport) riding (n=5), fish mongering (n=3), vending (n=2) and matatu (minibus public transport) driver (n=1). Majority of the AGYW (n=11) were dependent on their family or partner as sources of income, however, some depended on salaried employment (n=3), informal employment (n=1) and table baking (n=5). All the twelve MPs were either spouses or boyfriends of the Tu’Washindi participants who invited them for the interview. The AGYWs had at least one child ranging for months to 3 years. Out of the twelve MPs, ten were married, of which three were polygamous. Three of the MPs reported having other casual sex partners and one acknowledged having had transactional sex in the last 12 months from the date of interview. Nine of the AGYWs reported taking PrEP at the time of the FGDs.

Disclosure of Study Participation and Conversations about PrEP Use

Most of the MPs were aware of Tu’Washindi and their partners’ participation in the study. Of these, majority reported that the discussions about their partners’ study participation and PrEP use were initiated by the female partners.

“My wife began the conversation about PrEP. She told me that there are drugs that prevent HIV. I had never heard about anything like PrEP.” – IDI with Male Partner, 24 years.

“She is the one who started the discussion because she got the teaching before me and we felt that the teachings were good. I accepted when she told me its benefits because I like good ideas.”– IDI with Male Partner, 25 years.

A few of the MPs reported to have had the conversation about their female partners’ participation in the study and PrEP use after they discovered the drugs in the house.

“To be honest, she joined [the study] without telling me. One day I came back to the house and found those drugs. I then asked her what PrEP was. She said that they are drugs that prevent HIV. I supported her to continue taking them because it was a good idea.” - IDI with Male Partner, 29 years.

“… I did not like it when she first came with it [PrEP]. We sat down afterwards and agreed that she can use it because it is a good idea that can help our lives.” – IDI with Male Partner, 25 years.

Of the MPs who had discussed about Tu’Washindi study with their partners, a half of them understood the study as a project that was providing PrEP for HIV prevention, even though Tu’Washindi was not providing PrEP. However, the remaining MPs admitted not having enough information about the Tu’Washindi study, either because of insufficient explanation by their partner or inadequate time to take in the information.

“… she told me that she was in Tu’Washindi but I did not understand… what they were doing there.” – IDI with Male Partner, 19 years.

“She has not shared with me [much] about Tu’Washindi… the first day I heard about Tu’Washindi was when DREAMS girls had a meeting at [place name redacted]… But I did not follow up because I had some commitments.” - IDI with Male Partner, 28 years.

Female partners in the FGDs attributed their ability to initiate conversation about the study and their use of PrEP to the communication skills they had gained from the Support Club sessions, which they said helped them know how to manage the conversation with their partners without leading to violence.

“When the study begun, we had not gotten the teachings. So the rate of violence was high because your partner might talk to you harshly and you also answer him harshly and that will result in violence and you get injured. So when they came again after three months we were taught how to communicate to them and we come to agreement and that is what reduced violence.” - AGYW FGD participant.

“We were taught about gender-based violence and also communication. When he raises his voice, you lower yours. But when both of you raise your voices, he can beat you. You should wait for him to calm down then talk to him. At first, we had not been taught about GBV. After male sensitization, buddy day and healthy relationship teachings, we knew how to communicate. This helped in reducing violence.” - AGYW FGD participant.

MP Involvement in Study Activities (PrEP Male Sensitization and Couples’ Events)

The majority of the MPs were aware about PrEP male sensitization events, of which four reported to have attended an event. Among the MPs who were invited by their partners to attend a couple’s Buddy Day session, nearly half participated in the activity. The involvement of MPs in the PrEP male sensitization events and couples’ sessions positively impacted the MPs, with some of the MPs appreciating the value of information they received on PrEP, as one expressed below:

“I realized that what I got from there [male sensitization event] I could not compare with 1000 shillings [≈10 US$] that I would be paid from ‘juakali’ (informal employment)… that would not be of help to me but the knowledge I got was helpful.” – IDI with Male partner, 28 years.

Some of the participants went further to recommend more male involvement events on PrEP:

“I thought there was no need of attending [the couple’s session], I thought that it would be meaningless. One can go there and sit down the whole day but nothing important going on. Because the teachings that were taught there can change someone’s life, I suggest that it be done frequently so that other people may also attend and get the teachings… I can recommend it to other people so that they … get those teachings.” – IDI with Male Partner, 29 years.

“I would wish other men who have not joined to join and those who have not supported it [the discussions] now as I talk, to support it the way I supported it. That is why I have sacrificed today [to come for the discussion].” - IDI with Male partner, 25 years.

Effect of MP involvement on Perception of and Support for PrEP Use

Most MPs shared that they were hesitant to approve of their partner’s PrEP use without having information about the prevention method. They reported being supportive but only after obtaining sufficient information about PrEP, as these MPs demonstrated:

“Then I could not allow her to use it [PrEP] before I heard more information about it… before I heard information about it we had been invited in a meeting where I was taught about it [PrEP]. Then I told her that it is okay to use it. I don’t have problem with her and I am happy that she uses [PrEP].” – IDI with Male Partner, 28 years.

“At first, I did not feel good about her being involved in Tu’Washindi [study]. But later, after she explained to me the importance of being in Tu’Washindi, I agreed. This was because [initially] I was not understanding [what the study is about].” – IDI with Male partner, 19 years.

Regarding support for PrEP use among AGYW, majority of the MPs admitted that the teachings changed their views about AGYW using PrEP to prevent them from getting infected with HIV.

“My thinking changed … it [PrEP] is good for adolescent girls to use because it can help… They should use it because it can prevent them from acquiring HIV.” – IDI with Male Partner, 24 years.

The same number of MPs also expressed how they would support their partners’ PrEP use by encouraging them to take their pill as prescribed or buying for them PrEP, if that becomes necessary. One of the MPs offered specific ways in which he would support his partner: “By reminding her to go for PrEP refill and also reminding her to take her PrEP when she forgets (IDI with Male Partner, 24 years). Another commented:

“As per now, I cannot feel bad because I know the benefits and risks of using PrEP. If I find out that my partner is using PrEP, I will support her to use it so that she can protect herself from getting HIV.” – IDI with Male Partner, 29 years.

AGYW’s Views on Effects of MP Involvement on Relationship Dynamics in the Context of PrEP Use

Female partners in the FGD sessions acknowledged the positive impact of the PrEP male sensitization events and reported that the activity helped in preventing violent reactions from their partner that could arise from their PrEP use. They shared that before their MPs were sensitized on PrEP, they had conflicts over their use but after attending the event, their partners became supportive:

“So when Tu’Washindi [study] started and we got the teachings… and knew what PrEP is, and they also taught my partner too and he understood… This has made me use PrEP openly without hiding it and this made me happy with Tu’Washindi.” - Small Group Discussion with AGYW.

The female participants also observed positive change in their relationships as a result of couples’ sessions, especially in regard to their male partners’ support for their PrEP use and participation in the study activities. One of the female participants reported that when they attended a couple’s session with her partner, he came to understand that she was not taking PrEP because she had HIV and he stopped being violent.

“Now you find that after attending with him, we were taught and after finishing he went and confirmed that I am not sick [not having HIV] as he thought that I take ARVs secretly. He changed and the violence ended.” - P2: Small Group Discussion with AGYW.

Other female participants in the FGDs also reported that after attending the couples’ sessions with their male partners, they were now able to take PrEP openly without hiding because the their partners now had correct information about PrEP.

“It helped because I was taking PrEP secretly but from that day [couples’ session] he understood and told me to go and collect PrEP… but I had them though he did not know. So the next day I took them and told him that I had collected them.” - Small Group Discussion AGYW.

Addressing Misperceptions about PrEP Use

The MPs cited various community misperceptions about PrEP, including: PrEP does not prevent HIV; PrEP increases promiscuity; and use of PrEP causes infertility among women. Fewer than half of the MPs appreciated that the information they obtained at the PrEP male sensitization events helped clarify some of the misinformation they heard about PrEP in the community as one of the MPs reflect on below.

“There is somewhere I did not say that… sometimes back we used to hear about family planning pills from those who use them that when you take it there is a way it remains in your stomach… I knew that if you take PrEP it would sometimes develop growth in someone’s stomach. So according to the teachings I did not hear anywhere mentioning growth and any other issues.” – IDI with Male partner, 26 year.

Of the MP who participated in the couples’ session, majority acknowledged that the information they got changed their perceptions about PrEP. One of the MP narrated how his partner told him about PrEP after her initial sessions and confessed that he did not like the idea; however, he reported becoming supportive when she later provided him with more information.

“Sometimes, I used to ask what she got from where she went to… She came with PrEP pills and she told me [about] its goodness. When she first came with it, I did not agree with her given how it looks like. I did not agree with it… I thought they were ARVs. Yes, in the long run she again came back, I got the teachings and I agreed with her idea.” – IDI with Male Partner, 25 years.

This was also confirmed by the female partners in the FGD sessions who reported that MP involvement in Tu’Washindi study activities helped in addressing some of the misconceptions about PrEP in the community.

“Like those men who were doubting about PrEP… after they got the teachings they stopped doubting. Because they learnt what PrEP means… people were saying that if you start using PrEP that means you are a prostitute. That you will be having sex with anybody because you have protected yourself. Yeah, but they removed that [doubt] from their minds.” - Small Group Discussion with AGYW.

DISCUSSION

There is high global commitment to reducing HIV incidence among AGYW (Larsen et al., 2020) and PrEP forms part of expanding set of female-controlled and-initiated strategies to achieving this goal in SSA (Baxter & Abdool, 2016; Baron et al., 2020). Lack of MP support and IPV have been identified as key barriers to PrEP use among AGYW (Lanham et al., 2014; Stadler et al., 2014; Montgomery et al., 2015). The findings in this study are presented in the context of heterosexual relationships, and indicate that the involvement of MPs in decision-making prior to the start of PrEP use and sharing of accurate information about PrEP can open the door for MPs’ support for PrEP use.

PrEP, like other female-controlled biotechnology, was developed to make it easy for women, particularly AGYW who are at a disproportionate risk of acquiring HIV, to use discretely and independently without the knowledge or permission of a male partner (FHI360, 2014). However, evidence from various biomedical intervention trials show that although women appreciate that the products can be used without male partner’s knowledge, some still feel the need to inform their steady partners (Sahin-Hodoglugil et al., 2009; Montgomery, et al., 2010; van der Straten et al., 2012), perhaps as a sign of trust or to forestall negative reaction in the event of inadvertent disclosure (Gafos et al., 2015; Lanham et al., 2014; Jani et al., 2021)

While disclosure to male partners may appear to take away women’s power, the fact that they get to make the decision to disclose or not is in itself empowering. Additionally, women who choose to disclose report that male partner awareness and acceptance positively influences their uptake and adherence of these products (Montgomery et al., 2011; FHI360, 2014) and cements their relationships (Stacey et al., 2014; Falcao et al., 2017; Jani et al., 2021). In our study some of the AGYW reported that when their MP became aware of their PrEP use, episodes of violence reduced. The female participants in the FGDs also reported that after attending the Buddy Day sessions with their male partners, they were able to take PrEP openly without hiding because their partners were aware of PrEP and of their participation in the study. Our study adds to the discourse that some women may find it difficult to use biomedical products such as oral PrEP covertly because doing so would likely result in relationship discord if discovered, where the partner may interpret the covert product use as proof of infidelity.

Our findings also suggest that supporting women in their decisions about whether and how to discuss PrEP use with their partners is key to getting MP support. Majority of the MPs interviewed reported discussing PrEP use with their female partners and mutually agreeing on its importance. The AGYW confirmed that the communication skills they had gained from the Support Club sessions helped them manage conversations about PrEP with their partners without eliciting violence. However, Support Clubs may not be enough (Delany-Moretlwe et al., 2018; FHI 360, 2014), and sensitizing men directly is also critical to gaining their support. This can address their concerns about the intervention and can help normalize women’s use of PrEP (Kabarambi et al., 2021).

A qualitative study to explore men’s perceptions of the dapivirine vaginal ring (DVR), in Kalungu District, Uganda, found that lack of knowledge about the DVR and misconceptions, among other factors, affected men’s knowledge, attitudes and perceptions towards the DVR, which in turn affected their willingness to allow their female partners to use it (Montgomery et al., 2013). Another qualitative study conducted in Tanzania reported that male partners would support PrEP use by their AGYW partners but the support is dependent on the men receiving appropriate education on PrEP and including them in the decision-making process (Population Council, 2017). In this study, MPs shared that if AGYW did not engage them or covertly used PrEP, it would be viewed as a severe breach of trust within their relationship, which would lead to tense or violent relationships.

This is attested by the findings of a recent study conducted in Tanzania to examined gender, interpersonal and societal dynamics influencing PrEP acceptability among AGYW and their male partners and qualitative findings of the Tu’Washindi formative study conducted in Siaya County, western Kenya. The Tanzanian study showed that lack of informing or educating a male partner about PrEP could potentially result in emotional or physical violence as well as deprivation of financial support or divorce. Some AGYW in this study expressed fear that their MPs might react violently at them if they took PrEP without their knowledge and approval (Jani, et al., 2021). In the Tu’Washindi formative study, the AGYW expressed fear that their male partners would be violent if they asked to use PrEP (Hartmann, et al., 2021). One may argue that the anticipation of violence by women from their MPs could be attributed to the stigma against anti-retroviral therapy in the community being transferred onto PrEP due to similar pill appearance and packaging, and the perception that PrEP use is associated with increased promiscuity, commercial sex workers, and people who are infected with HIV (Jackson-Gibson, et al, 2021).

Other studies have supported the finding that MPs commonly misunderstand product use and are therefore suspicious of the products believing that they may cause harm or encourage infidelity (Stacey et al., 2014). These concerns indirectly influence women’s willingness to use products. In our study, MPs who received information on PrEP from couples’ events described changing their perceptions about the product. Their female partners confirmed that before their partners were sensitized and educated on PrEP, they had conflicts over their use of PrEP but after attending the male sensitization and buddy day meetings, their partners became supportive. We infer from our study findings that conveying PrEP information through clinicians or “Male PrEP champions” could be a potentially impactful approach for Tu’Washindi and future PrEP scale-up efforts (Hartmann et al., 2018).

Additionally, counseling women to make their own decisions on disclosure, and on how to safely disclose if they choose to do so, are critical components of any strategy to promote MP engagement or support. Non-disclosure to MPs by female participants of their participation in intervention studies and use of an HIV prevention drug may impact their product usage behavior and contribute to poor adherence. In a study conducted in KwaZulu-Natal, South Africa, to determine the implication of disclosure of trial participation to a male partner on participant adherence to microbicide gel, Stacey, et al., (2014) reported that most of the women who discussed study participation with their MPs had received a positive or neutral response from their partner and some of these women shared that gel use was easy. Majority of those who did not communicate their study participation to their MPs reported difficulties with adherence.

Some studies have shed light on the reasons why MPs would be supportive of their female partner’s PrEP use after gaining knowledge. In their study, Jani et al., (2021) reported that the MPs would be supportive of their partners’ PrEP use for a variety of reasons, including sharing the benefit of being protected from HIV. This is consistent with the findings of the conducted by Population Council (2017) in Tanzania, which reported that MPs’ support of PrEP use by AGYW was tied to their acknowledgement that both partners are at risk of acquiring HIV. Therefore, being aware of the partners use of PrEP meant that they were both being protected. In a study conducted in Bondo, Kenya, and Pretoria, South Africa to assess facilitators of adherence to the PrEP pills in the FEM-PrEP trial, Corneli, et al., (2015) found that MPs who were aware of their partners’ participation in the trial played a role in facilitating adherence in several different ways: by actively encouraging and supporting trial participation, regularly reminding participants to take their study pill, and not objecting to trial participation. Corneli and colleagues opine that disclosing trial participation to their MPs may have alleviated the burden of keeping study participation a secret, or may have eased the anxiety of experiencing potential negative consequences if their partners learned of their study participation.

Our finding therefore add to the assertion that MPs’ involvement and knowledge of their female partners’ study participation and use of PrEP is likely to help product adherence. Other studies have also recommended involving MPs and their AGYW partners in pre-PrEP counseling, and encouraging and training MPs to support their AGYW partners’ PrEP use can potentially improve adherence to PrEP (Remien & Borkowski, 2005; Ware et al., 2012; Van der Elst et al., 2013). While the dapivirine vaginal ring study conducted in Malawi, South Africa, Uganda and Zimbabwe, showed that disclosure of use of the HIV method was not significantly associated with ring adherence, MP opposition was associated with low adherence (Roberts et al., 2020). Disclosure may increase support, which helps adherence, but sometimes it may lead to opposition, which hinders adherence and may result in violence (Lanham et al., 2014; Hartmann et al., 2019). Counseling women to make their own decisions on disclosure, and on how to safely disclose if they choose to do so, are critical components of any strategy to promote MP engagement or support.

The study had some limitations. First, the sample size was small, which may limit the application of the results to other DREAMS girls and their MPs; however, there was good representation (≈25%) of both AGYW and MPs of all intervention arm participants, and views from AGYW and MP are largely consistent. Enrolling participants solely from the DREAMS program reduces the ability to generalize the results to other AGYW accessing PrEP outside of the Safe Spaces, because AGYW in DREAMS are more empowered than their counterparts (Hartman et al., 2021) in that they are able to determine their own choices, have positive self-confidence as well as a sense of control over their lives and change processes in the context of sexual and reproductive health (Alimoradi et al., 2017). Additionally, even though the AGYW reported lower rates of violence and improved communication skills, we could not determine whether the reported positive changes were long term, considering that participant follow up period was limited by the intervention implementation timeline (data were collected 2-4 months post the intervention)

There was also a risk of social desirability bias in reporting support for the intervention, especially among AGYW who had interacted with the study for over six months and would not have wanted to ‘disappoint’ the staff by expressing disapproval of the intervention. However, the FGD facilitator was not directly involved in intervention delivery and had minimal engagement with participants during the study. There was also the risk of selection bias, meaning only men who supported the intervention agreed to participate in the study. However, we believe that this is unlikely because some participants admitted not knowing about the intervention or all of its components.

CONCLUSION

Even though PrEP is one of the female-controlled biotechnologies that provides women with a HIV prevention method that they can use discreetly and independently without the knowledge or permission of their MP, there is a belief among some women that male partner awareness and acceptance positively influences their uptake and adherence to PrEP. In this study, lack of MP support for PrEP use among AGYW was largely driven by inadequate knowledge and exclusion from decisions about PrEP use. The study findings support our theory that encouraging AGYW to involve their MPs in decision-making early on – if they choose to do so – and disseminating accurate information about PrEP directly to MPs are key implementation pathways that will support initiation of and sustained adherence to PrEP. By addressing MPs’ misperceptions, concerns and negative attitudes towards AGYW’s use of PrEP, programs can address the existing gender dynamics affecting uptake of and adherence to PrEP among AGYW. The Tu’Washindi pilot study demonstrated high PrEP acceptability among AGYW and MPs, with promising outcomes that support future testing of Tu’Washindi as a community-based intervention to address IPV and relationship power to support PrEP use in AGYW.