Identifying Opportunities to Discuss PrEP During Contraceptive Coaching Discussions with Urban Adolescent Women

Abstract

Purpose

HIV pre-exposure prophylaxis (PrEP) reduces HIV transmission and is approved for adolescents ages 12–17. Adolescent girls and young women (AGYW) have modest PrEP uptake rates, while many receive reproductive health counseling. We sought to identify opportunities for incorporating PrEP education in contraceptive counseling delivered to AGYW.

Methods

We performed a secondary analysis of data from the Health Coaching for Contraceptive Continuation pilot study, which supported contraceptive use among AGYW. Participants were 14–22 years-old, sexually active with males, and not desiring pregnancy within 12-months. Coaches were sexual health educators with ≥5 years’ experience providing contraceptive and PrEP counseling to youth. Participants completed a baseline visit within 30-days of contraceptive initiation and completed up to five monthly coaching sessions. Of thirty-three enrollees, this analysis includes the twenty-one who completed ≥4 sessions. Two coders deductively coded session transcripts for five themes: opportunities to discuss PrEP; HIV knowledge, risk perception, and testing attitudes; changes in HIV risk status; condom use knowledge and skills; and sexually transmitted infection (STI) knowledge and risk perception.

Results

Of the 111 transcripts coded, twenty-four contained opportunities to discuss PrEP and were inductively analyzed. Thematic analysis demonstrated three types of opportunities for PrEP discussions: failure to introduce information, and provision of incomplete information or misinformation. Analysis also revealed four opportunity contexts: STI prevention strategies, HIV risk reduction, avoidance of adverse sexual health outcomes, and disclosures of condom non-protected sexual behaviors. Only one transcript mentioned PrEP.

Conclusions

Multiple opportunities to introduce PrEP counseling exist within contraceptive counseling provided to AGYW.

HIV pre-exposure prophylaxis (PrEP) reduces HIV transmission risk by >90% in adherent users [1]. This efficacy is particularly valuable for vulnerable populations (ex. sex workers, sexual minority youth), who may experience an elevated exposure risk exacerbated by barriers to PrEP uptake [2–6]. Adolescent girls and young women (AGYW) have had modest PrEP uptake, constituting <4.7% of PrEP users nationally [7]. In some regions, modest uptake proves especially concerning: Philadelphia youth ages 13–24 are 3.0-times more likely to be diagnosed with HIV than youth nationwide, and Philadelphia females of all ages are 2.4-times more likely than females nationwide to be diagnosed with HIV [2,8]. In key populations like these, PrEP cannot achieve intended benefits without targeted interventions to augment awareness and uptake. Many providers who see AGYW, such as OB/GYNs, pediatricians, and family planning providers, display low PrEP awareness and counseling skills [9]. Given many AGYW seek family planning [10], there exists a need to integrate PrEP within family planning services to assist AGYW in achieving their reproductive health goals, including remaining HIV-free.

Increasing AGYW’s PrEP awareness is unlikely to translate into uptake unless providers also cultivate AGYW’s understanding of HIV risk perception and PrEP’s ability to mitigate HIV transmission [11]. Early PrEP trials in women failed to show efficacy due to poor adherence, largely driven by low HIV risk perception [12,13]. HIV transmission, unlike sexually transmitted infection (STI) transmission, occurs via non-sexual routes [14]; nonetheless, sexual contact accounts for most HIV cases amongst AGYW [15]. Delineating differences and commonalities between transmission of HIV and STIs can support AGYW’s understanding of HIV risk perception [16,17]. PrEP stigma (negative social connotations ascribed to PrEP/PrEP users) also diminishes AGYW’s willingness to initiate PrEP [18]. Normalizing PrEP in ways that counteract stigma can help promote an accurate understanding of PrEP and its utility among AGYW [19]. Comprehensive sexual health education that increases contraceptive and STI/HIV knowledge and prevention behaviors can promote accurate understandings of HIV risk perception amongst AGYW while supporting stigma-free PrEP awareness.

As PrEP enters family planning settings, we must understand where, when, and how we can integrate PrEP counseling to help AGYW situate PrEP within their reproductive health goals. To address this, we performed a secondary data analysis of transcripts from a 6-month health coaching program designed to support correct, consistent contraceptive use amongst AGYW while addressing reproductive health-related knowledge gaps (ex. regarding STIs, HIV). The Health Coaching for Contraceptive Continuation (HC3) program’s longitudinal, person-centered design facilitates evaluation of PrEP counseling for AGYW seeking family planning. Our objective was to identify and characterize opportunities for discussing PrEP that arose during contraceptive discussions between AGYW and experienced sexual health educators.

METHODS

Study Design

This is a secondary analysis of qualitative data collected from the HC3 pilot study performed between June 2017-May 2018. Participants completed a ~20–40-minute baseline visit within 30-days of contraceptive initiation, followed by ~30-minute monthly coaching sessions for up to five months. Two sexual health educators, each with >5 years’ experience in contraceptive and HIV/STI risk reduction counseling in settings targeting youth and young adults prior to and after PrEP licensure, were hired as coaches. Each completed National Society of Health Coaches training [20], and helped develop the HC3 coaching manual.

Health coaches delivered unscripted support to help clients achieve goals by providing medically accurate knowledge, increasing intrinsic motivation to undertake health-supportive behaviors, and nurturing individuals’ ability to identify and address barriers. Coaches also provided tailored reproductive health education based on participants’ ranked topics of interest (Appendix), including HIV/STI education. Coaches reassessed barriers to contraceptive use, referred participants to clinical care for management of side effects, and fostered accountability for personal health goals. Similar to other health coaching programs, if participants could not attend an in-person visit, phone coaching was offered [21,22]. The Children’s Hospital of Philadelphia’s (CHOP) Institutional Review Board and AccessMatters, a nonprofit which disseminates Title X funds to the two family planning study sites, approved this study.

Eligibility, Recruitment and Setting

Eligible participants were ages 14–22 years, sexually active with a male in the prior 12-months, not desiring pregnancy within 12-months, English-speaking, able to provide written informed consent, and had initiated a new contraceptive method in the prior 30-days (hormonal pill, transdermal patch, vaginal ring, intramuscular medroxyprogesterone injection, intrauterine device, or etonogestrel implant). Although sexual or gender minority status was not an exclusion criterion, all participants self-identified as women; participants are subsequently referred to as women. Participants included in the current analysis completed ≥4 coaching sessions. Recruitment occurred at three CHOP-affiliated clinics—an adolescent medicine clinic, and two Title X adolescent family planning clinics—with a combined volume of ~2,000 age-eligible patients/year; sites serve youth residing in zip codes with high rates of early sexual debut, teen pregnancy, and STIs [23,24].

Data Collection

At baseline, coaches conducted a semi-structured interview to identify factors influencing participants’ decisions to use contraception and the method selected. Using interview data, coaches assisted participants with developing a contraceptive coaching plan for identifying and addressing individualized reproductive health information gaps, contraceptive self-management needs, perceived support, and barriers to contraceptive use. Baseline questionnaires assessed demographic characteristics, medical, and sexual histories. After the baseline visit, participants completed follow-up sessions as described in Study Design. Baseline interviews and coaching sessions were audio-recorded and transcribed.

Analysis

Descriptive statistics were calculated for sample characteristics (Stata Statistical Software: Release 15) [25]. The qualitative coding team consisted of three independent coders: two medical students (N.F. and C.A.) and an MPH-level experienced coder who trained the students and served as the criterion coder (D.P.) to ensure establishment of coding reliability. Baseline interview transcripts were reviewed to identify transcripts containing opportunities to discuss PrEP, defined as passages reflecting participants’ HIV knowledge and risk perception, attitudes towards HIV testing, changes in HIV risk status, condom-use knowledge and skills, STI knowledge and risk perception. Transcripts meeting these criteria were inductively coded to characterize opportunities suitable for PrEP discussion.

Two coders independently coded each transcript for HIV/STI topics using the constant comparative method (NVivo 12Plus) [26]. Coders identified recurrent themes within and across participants and the relationships between these elements. Kappa statistics (benchmark, ≥0.7) were calculated to ensure inter-rater reliability regarding passages reflecting key coding domains and themes. Discrepancies were resolved via consensus; the MPH-level coder served as final arbitrator. A codebook was developed delineating definitions and examples for each coding domain and associated sub-themes. Coders then recoded transcripts using this codebook, comparing coding after every five transcripts. Passages related to opportunities to discuss PrEP were reviewed separately to understand how these events arose within the dyadic narrative.

RESULTS

Sample Characteristics

Table 1 shows the characteristics of the 21 participants who completed ≥four coaching sessions. Participants’ mean age was 17.5-years. Most had private insurance, had previously used contraception, and reported inconsistent-to-no condom usage; one-quarter reported prior STI diagnosis. The 21 participants completed 111 coaching sessions. Twenty-four coaching sessions from 14 participants were coded as containing opportunities to discuss PrEP. Of these 14 participants, six (43%) were ≥18-years. Twenty-one coded transcripts were from Coach A, with the remaining three from Coach B.

Table 1:

Demographic Characteristics

Characteristic	All participants with ≥4 coaching sessions (N=21) Number (%)
Mean age, years ± SD	17.5 ± 2.3
Race
Non-Hispanic Black	17 (81.0)
Non-Hispanic White	3 (14.3)
Other	1 (4.8)
Hispanic	3 (14.3)
Education level
Less than HS diploma	14 (66.7)
Graduated HS or equivalent	1 (4.8)
Some college	6 (28.6)
Insurance
Public/Government	7 (33.3)
Private	14 (66.7)
Reproductive History
Prior contraceptive use	17 (81.0)
Prior adverse reproductive outcome†	5 (23.8)
Baseline contraceptive method‡
Short acting reversible contraceptive (SARC)	12 (57.1)
Long acting reversible contraceptive (LARC)	9 (42.9)

SD: standard deviation

^†Adverse reproductive outcome: sexually transmitted infection or unplanned pregnancy

^‡Baseline contraceptive method: method began in 30 days prior to program initiation

Opportunity Types

Thematic analysis demonstrated three types of opportunities for PrEP discussions, including when coaches provided incomplete information, misinformation, or failed to introduce information about PrEP as an HIV prevention strategy (Table 2). Almost half (46%) of transcripts contained incomplete information, while 43% of transcripts contained failures to introduce information.

Table 2:

Exemplary Quotes Representing Opportunities to Discuss PrEP

Theme	Exemplary quote	Participant age, years
Types of Opportunities to Discuss PrEP
Incomplete information	Coach: So, the testing recommendation is going to be really different depending on how much sex someone is having and with who. Um, but if someone was having a lot of different partners and they weren’t ever using protection than the suggestion, the recommendation would generally be to get tested more often. Um, whereas if someone doesn’t have that many partners the- the general recommendation is to get tested every 6–12 months. Participant: Oh, I didn’t know that. M: What do you think about that…are you surprised, I couldn’t tell from your voice. Participant: Yes, I’m surprised. M: Yeah, what makes you surprised about that? Participant: I feel like people should get tested more often. M: And I mean and in your first scenario like, if someone is having a lot of different partners and not using protection than absolutely. You know, they might want to get tested more regularly like, every two months or even, or every three months.	18
Misinformation	Coach: First of all I’m so glad that you’re…so aware that condoms are such an important thing to use in order to protect yourself from HIV…that’s excellent because for people who are having sex, you know, condoms really are the only thing to protect against something like HIV.	15
Failure to introduce information	Participant: And I don’t see myself ever having an STD. Coach: Mm-hmm. How come? Participant: I mean, I can’t say that because we don’t use condoms at all. We don’t. But…I don’t see him not using condoms with nobody else. Coach: Okay. How do you know that? Participant: I don’t know for sure, but…He’s like, no, he wouldn’t…I know for sure he did it with some girl who did it with seven other people, so…I’m pretty sure if he’s doing it with anybody else, he’s using condoms with that.	21
Context for Discussing PrEP
STI prevention strategies	Participant: And don’t condoms help you not get a STD? Coach: Yeah. Exactly. So condoms are actually the only thing going that prevents STDs, other than abstinence…If someone’s having sex, condoms are the best thing to use – the only thing to use to prevent STDs. Yep. And that’s for vaginal sex and anal sex. Condoms are really important.	15
HIV risk reduction	Coach: …someone can have HIV …there are precautions you can take if you’re sleeping with that person that include taking something called PrEP and using condoms, like if you’re practicing safe sex and um taking PrEP and your partner is taking their medication then the likelihood of transmission is very low.	15
Avoidance of adverse sexual health outcomes	Coach: Mm-hmm. Mm-hmm. Yeah. So it’s a good idea to use condoms, even when you’re on birth control because exactly what you said, birth control isn’t 100 percent effective. And then also birth control doesn’t prevent against STDs. Participant: Right. Coach: So you have to have condoms involved to prevent against STDs. And then it’s also an extra way to prevent against pregnancy, in addition to the other birth control method. Participant: Right.	15
Disclosure of condom non-protected sexual behaviors	Coach: [Y]ou’ve been really honest with me about some of the things that you’re willing to think about doing and some of the things that you know just aren’t gonna be a reality for you. And I, of course, want you to do the things that are gonna keep you the safest. And so that’s using condoms and using the patch regularly…I really appreciate your just genuine honesty with me about what you feel like you can do…so at this point, my take is that…you’re gonna keep thinking about how to protect yourself against STDs and you’re good with that[.] Participant: Yeah. Coach: And you’re still not sure about the condom piece and the STD piece. Do I have all of that right? Participant: Yep.	16

HIV: human immunodeficiency virus; PrEP: HIV pre-exposure prophylaxis; STD: sexually transmitted disease; STI: sexually transmitted infection

Incomplete information was defined as when coaches relayed information about reproductive health practices that could involve PrEP, yet did not mention PrEP. One coach explained,

“[T]here’s lots of ways to prevent against STDs. Condoms is obviously one of them…but there are other choices…like getting tested…and making sure your partner[‘s] tested, [especially] if you [don’t] use condoms…[lastly,] there are [incurable] STDs[.]

Here, the coach described STI prevention and the existence of incurable infections, but did not include HIV by name, nor PrEP’s ability to prevent HIV transmission.

Misinformation was defined as a coach’s delivery of incorrect information about sexual health relating to PrEP. For instance, one coach stated, “[F]or [sexually active] people…condoms really are the only thing to protect against something like HIV.” While well-intentioned, this conversation overlooked the utility of alternative means of protecting against HIV transmission—namely PrEP.

Passages were classified as a failure to introduce information when the coach did not capitalize on a participant’s statement that could have prompted PrEP counseling based on conversational content, or on the coach’s knowledge about a participant’s or their partner’s HIV/STI related behaviors. In one session, a participant disclosed that “the biggest factor” keeping her from using a condom is “how it feels.” This was an opportunity for the coach to inform the participant that PrEP confers HIV protection without affecting sexual sensations; the coach did not mention PrEP at all. Another participant said, “[S]ome people don’t use condoms [while on birth control]…if you don’t use condoms you’ll end up catching something.” Here again, the coach could have relayed that individuals using birth control can also employ PrEP to reduce their risk of STI acquisition. In such scenarios, a participant raised a line of discussion relevant to PrEP education, and the coach failed to bring up information about PrEP.

Opportunity Contexts

We also identified four contexts in which opportunities to discuss PrEP arose. These contexts included discussions about STI prevention strategies, HIV risk reduction, avoidance of adverse sexual health outcomes, and disclosures of condom non-protected sexual behaviors (Table 2). Most (57%) opportunities occurred during discussions concerning STI prevention strategies, followed by disclosures of non-condom protected sexual behaviors (18%).

In equipping a participant with STI prevention strategies, one coach asked about ways to prevent transmission and went on to say, “Condoms are absolutely the best way to prevent STDs…and then using them correctly…getting tested regularly is [another] good way…especially if you[‘re] sexually active.” Another coach employed a strengths-based approach. She encouraged her participant to think of STI protection as “risk reduction,” emphasizing that “us[ing] condoms half the time [is] better than never.” While both quotes include accurate information, such conversations could benefit from explicitly mentioning PrEP when discussing strategies for STI (particularly HIV) protection.

Patients also created conversational contexts germane to PrEP education when disclosing condom non-protected sexual behaviors. Said one young woman,

Participant: I don’t like using condoms[.] Coach: [Why]?

Participant: It feels weird…I just don’t like it. And we ain’t [used] condoms for a long time, so…we just don’t use them.

Coach: And you feel comfortable with…making that choice and taking that risk?

Participant: Yeah.

A patients’ opposition towards condoms may not translate into opposition to PrEP, given their differing administration and impact on sexual experience. Accordingly, health educators should still consider mentioning PrEP. Here, participants who volunteered information about condom non-protected sexual behaviors that could increase HIV risk were often not offered PrEP education.

Conversations about HIV risk reduction also presented opportunities to discuss PrEP. This context encompassed education, and skills-building discussions related to reducing HIV transmission risk. One coach offered an overview:

“[I]f someone has HIV, which stands for the Human Immunodeficiency Virus…and they don’t take any medicine…it can cause [serious] complications …[E]ventually that person…could die if they didn’t get any treatment…[T]he thing about HIV is that there’s a lot of really amazing treatment…if someone took the treatment, they[‘d] be fine, and they could manage it.”

This coach conveyed the gravity of contracting HIV, and of appropriate treatment, but not PrEP as effective prevention.

Finally, PrEP counseling proved relevant to references that included avoidance of adverse sexual health outcomes. One coach reviewed,

Coach: [W]hat would you tell [a friend]…so they would stay safe? Related to STDs and pregnancy.

Participant: Besides abstinence?

Coach: Besides abstinence[.]

Participant: Use condoms and do you want…some form of birth control.

Coach: […]And what about testing? What would you tell them about testing?

Participant: Go every few months.

This conversation, among others, did not reference PrEP as a means of avoiding an adverse sexual health outcome.

Notably, only one transcript referenced PrEP specifically; analysis demonstrated this opportunity type was incomplete information within a context of HIV risk reduction.

DISCUSSION

We aimed to identify and characterize opportunities for introducing PrEP counseling among AGYW receiving contraceptive counseling. Three types of opportunities for PrEP discussions were evident—when coaches provided incomplete information, misinformation, or failed to introduce information about PrEP as an HIV prevention strategy. Furthermore, contexts for PrEP discussions arose during discussions about STI prevention strategies, HIV risk reduction, avoiding adverse sexual health outcomes, and when participants disclosed condom non-protected sexual behaviors. PrEP was explicitly mentioned only once, though coaches were highly experienced PrEP and contraceptive counselors. Therefore, various opportunities for PrEP counseling exist within contraceptive counseling encounters with AGYW. These data can help providers maximize opportunities to integrate PrEP education.

Our findings support the need to revise reproductive health counseling protocols within health systems delivering contraception. Coaches in the HC3 pilot were highly-trained sexual educators; yet, PrEP education was minimal, even when clear opportunities arose. Several reasons explain this. Coaches likely made trade-offs about ancillary information meriting integration within brief, contraception-centered sessions (a related, yet distinct sexual health issue). Our suggestion that encouraging PrEP integration within contraceptive discussions may necessitate protocol changes is supported by data that family planning providers differentially value inclusion of HIV prevention and PrEP education within visits. In a national sample of family planning providers, 73% deemed HIV prevention essential to family planning visits, while <25% thought of PrEP similarly [27]. Although HC3 coaches likely had a greater PrEP knowledge base than the study sample (<50% of surveyed family planning providers correctly answered PrEP knowledge-based questions), this evidence suggests investment in discussing HIV prevention may not necessarily translate into PrEP education. If present, differential investment may have further motivated trade-offs between PrEP education and addressing AGYW’s other pressing sexual health needs to maximize efficiency, even amongst highly trained HC3 personnel. Integrating PrEP counseling into family planning discussions likely necessitates an improved understanding of how providers assess patients in real-time to construct counseling trade-offs.

Uncertainty regarding “who owns” PrEP implementation may also have influenced health coaches’ behavior as they straddled two different roles—that of a contraceptive coach and HIV/STI educator. While coaches possessed extensive experience in HIV/STI counseling, and addressed reproductive health knowledge gaps throughout the HC3 pilot, their central task involved encouraging correct, consistent contraceptive use. Counselors may have foregone PrEP counseling in the interest of centering their role as that of a contraceptive counselor. From a health systems perspective, sexual health counseling protocols may need to encourage the shared responsibility of PrEP education. Clarifying responsibilities according to provider role can support their ability to proffer counseling accordingly.

The timing of this ~2017 pilot also accounts for the minimal PrEP counseling, given the FDA approved PrEP for adolescents in 2018. However, 43% of participants were ≥18-years, and potentially eligible for PrEP during the study. Moreover, at this and other centers, prescription of PrEP to mature minors (<18-years) seeking HIV prevention occurred in the context of local regulations prior to specific licensure [28]. Thus, it is unlikely that lack of FDA approval for adolescents fully accounts for the lack of PrEP counseling within coaching discussions, though it may have impacted PrEP discussion with younger participants.

Given how relatively new PrEP is, it is understandable that gaps may exist in STI and HIV prevention education protocols for adolescents, particularly among youth who are not members of vulnerable populations generally targeted for PrEP services [29]. PrEP was only recently deemed a “Grade A,” first-line HIV preventative method by the U.S. Preventive Services Task Force, and judged superior to condoms by the Centers for Disease Control [1,30]. In comparison, the lag between policy recommendation and routine implementation ranges from zero years for amlodipine in cardiovascular disease treatment, to ten years for cognitive-behavioral treatment of depression [31]. In addition to guidelines, widespread PrEP usage among adolescents necessitates addressing individual (e.g. confidentiality limitations), sociodemographic (ex. insurance, housing), and behavioral (i.e. adherence) barriers [28,32]. Nonetheless, guidelines highlight the need to ameliorate variations in provider approach and gaps in counseling protocols to facilitate consistent delivery of quality HIV prevention counseling, including PrEP.

Our findings signify opportunities for individualizing reproductive health education according to AGYW’s diverse risk reduction needs. Providers can use characteristics of opportunities to discuss PrEP as scaffolds, whilst acknowledging nuances of these avenues. For instance, incorporating PrEP counseling within a conversation whose context centers avoidance of adverse sexual health outcomes necessitates different framing than doing so within a conversation about HIV risk reduction. Facilitating context-specific PrEP education enables providers to demonstrate awareness of AGYW’s priorities.

Advancing PrEP education within distinct contexts underscores the importance of understanding unique perspectives amongst AGYW. In this analysis, participant awareness of their vulnerability to HIV infection did not always mirror comfort with usage of traditional protection strategies (condoms, STI testing); an assertion of partner trust did not always represent an objectively “low-risk” situation (i.e. monogamous, tested partners). Consequently, coaches drove many discussions about HIV risk. Such “risk mismatch” indicates that AGYW construct understandings of vulnerability to HIV that may not align with traditional understandings of susceptibility [12,13]. While AGYW thoughtfully construct understandings of their sexual health, providers often carry the onus of offering helpful strategies, including PrEP. Providers may benefit from learning techniques for leveraging situations in which mismatch warrants delivery of succinct, tailored PrEP messages.

Discordance between HIV vulnerability and uptake of HIV preventative practices justifies disseminating strategies to mitigate HIV transmission risk. In this study, coaches often only mentioned condoms as a strategy; despite receiving such education, participants repeatedly deemed condoms undesirable. This may seemingly suggest discussing PrEP would prove futile. However, by offering condoms and PrEP, providers may identify youth who favor one over the other, given their differing trade-offs. Providers should at least discuss PrEP’s advantages/drawbacks, and help AGYW gauge its acceptability. Discussing PrEP and condoms in settings of risk mismatch may or may not impact risk perception, but it equips AGYW with valuable knowledge.

Furthermore, integrating PrEP education along with condoms within patient-driven conversations grounds PrEP counseling within patients’ priorities rather than “risky” behavior narratives. Accordingly, providers may avoid perpetuating paradigms that stigmatize PrEP/PrEP users by linking PrEP with the “risk” label [33]. This may prove particularly helpful when supporting women who also comprise vulnerable populations, and may face higher levels of stigmatization even as they may benefit from PrEP counseling [33]. Disconnecting PrEP administration from “high-risk” behavior can create “teachable moments,” supported by an understanding of the utility derived from PrEP education and an aim to present comprehensive sexual health counseling. Themes outlined here help facilitate such moments.

Several study limitations deserve mention. The HC3 pilot was not designed to explore PrEP education. Yet, it was designed to capture contraception-related discussions among sexually active AGYW in communities with high STI/HIV rates. Given coital behaviors confer both pregnancy and STI/HIV risk, HIV risk should have figured prominently in these conversations, making them an ideal data source. Pilot program analysis also enabled us to understand how PrEP counseling might fit coach/provider-patient dynamics based on authentic situations. Separately, this pilot study occurred prior to FDA approval of PrEP for adolescents; generalizability to the post-approval landscape is limited. Still, our findings demonstrate nuances of PrEP discussions among experienced sexual health educators who should be among the earliest to integrate PrEP within counseling narratives. Our study provides an early warning that such discussions may prove more limited than public health experts may like. Furthermore, analyzing data only from participants who completed ≥4 sessions could have favored unmeasured characteristics (e.g. interest in HC3 program) that mediated the low likelihood of PrEP counseling. Nonetheless, choosing these participants enabled us to assess whether coaches capitalized on opportunities to introduce PrEP-related discussions during this longitudinal relationship. Finally, these data are from a pilot between health coaches and participants. Interpersonal dynamics of patient-physician interactions may differ, yielding more frequent PrEP discussions.

This study demonstrates PrEP counseling opportunities of various types and contexts within contraceptive counseling provided to AGYW. It is striking that providers missed opportunities to augment AGYW’s sexual health promotion strategies via PrEP education. AGYW can utilize information about PrEP if/when necessitated by their sexual health goals; they may also share information, strengthening PrEP social norms. An imperative for augmenting AGYW’s knowledge about PrEP exists, even if this population is not perceived as particularly “high-risk” [33]. Future research may characterize best practices for integrating PrEP counseling via feedback from AGYW and/or providers within community-based participatory research, or qualitative analysis validated by post-analysis member conclusion checks. Improving both integration of PrEP counseling within system-level protocols for sexual health/contraceptive services, and provider-level counseling approaches, can bolster our support of AGYW’s HIV-prevention strategies.

Implications and Contribution.

Although many adolescent girls and young women (AGYW) receive reproductive health services, PrEP uptake is low within this group. This qualitative study illuminates opportunities to provide PrEP education to AGYW seeking contraceptive counseling. Such opportunities are well-suited for PrEP education, but even experienced counselors may need support to do so.

Abbreviations:

AGYW

Adolescent girls and young women

CHOP

Children’s Hospital of Philadelphia

PCP

primary care provider

CDC

Centers for Disease Control

HC3

Health Coaching for Contraceptive Continuation

PrEP

HIV pre-exposure prophylaxis

STI

sexually transmitted infection

APPENDIX

Reproductive Health Topics of Interest

Throughout the Health Coaching Contraceptive Continuation Intervention program, coaches provided education about various reproductive health topics selected based on the participant’s preference.

Topics included:

• Sexually transmitted infections

• Contraceptive knowledge

• Strategies for adhering to contraceptive dosing regimens

• Healthy relationships

• Physiology of pregnancy

• Condom use information and negotiation skills