Table 1.

Considerations for future research with oral PrEP for young African women

Topic	Strategy
1. Understand the end-users for HIV prevention during product development and delivery	• Conduct formative research to understand young African women's needs and preferences about products and delivery strategies for HIV prevention. Methods that could be useful include ethnographic research as part of behaviour-centred and user-centred design, and mental models approaches • Evaluate young women's decision-making about HIV prevention • Assess end-users’ preferences in designing new products
2. Test communication messages and demand creation strategies	• Rigorously test different communication messages to determine which are most salient and young women respond to most strongly, including:  ○ Emotion and desire for status are important drivers of decisions  ○ Deemphasize messages about risk, which is ambiguous, dynamic and can stigmatize sexuality, potentially increasing acceptability for using HIV prevention methods  ○ Frame prevention messaging positively in terms of benefits in intimacy, self-esteem and desire to achieve one's aspirations  ○ Identify ‘positive deviants’ and disseminate compelling narratives from women who have successfully utilized PrEP • Identify effective strategies for demand creation, including ones from implementation of contraceptive services. • Use technology to achieve “wide reach” in disseminating messages and promoting HIV prevention, with interactive platforms, such as social media
3. Develop innovative interventions to motivate HIV prevention behaviours, including PrEP	• Use formative research informed by behaviour-centred design to identify evolutionary motivators and pilot interventions addressing these motivators • Identify ‘levers’ for initiation of PrEP and continued use, pilot and evaluate interventions to increase these behaviours • Identify ways to make pill-taking behaviours automatic and part of young women's routine practices • Evaluate whether a validated empiric risk score increases the uptake of oral PrEP among young women with a significant risk of HIV acquisition • Address medication maintenance factors such as transport and financial barriers for refills, and stigma
4. Evaluate PrEP effectiveness among young African women	• Conduct a demonstration project of open-label oral PrEP among young African women with HIV incidence as the primary outcome, either using a counterfactual with HIV rates in recent trials among women of similar risk or in an immediate-deferred design (such as the PROUD study among MSM in the UK)
5. Test delivery models of PrEP, including integration with family planning and other services	• Evaluate whether uptake of HIV prevention is higher if offered with contraceptive counselling and services (e.g. cervical cancer and STI screening, gender-based violence counselling) as a separate service, and through clinics or community programmes • Test different HIV prevention delivery models, including offering PrEP when women seek contraception (e.g. injectables, implants) or emergency contraception and post-exposure prophylaxis. • As additional PrEP formulations become available (e.g. vaginal rings, injectables), evaluate the family planning delivery model of providing women with choice of methods • Assess cost-effectiveness of delivery of PrEP in demonstration projects
6. Assess behavioural economic approaches to HIV prevention	• Assess whether group or individual incentives are effective for young women's initiation of and/or adherence to PrEP. • Evaluate HIV prevention technologies with measurement of the barriers between inaction and action (e.g. present bias, limited attention, cognitive capacity, bounded rationality including partial information, rumour, inaccuracies about sex and HIV) • Deliver HIV prevention with a focus on convenience, bundling with other services, simple and clear messages about benefits/costs and reminders