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Table 3 Illustrative quotes

From: Health care providers’ attitudes toward and experiences delivering oral PrEP to adolescent girls and young women in Kenya, South Africa, and Zimbabwe

Acceptable age for sexual activity and PrEP use

They are still young…this is when they are still in high school … where you concentrate. It shapes your life from there, so sex can wait.

– Nurse, Kenya, previously provided PrEP

It’s inappropriate for adolescents between age 15 and 18 to engage in sexual intercourse…they shouldn’t take PrEP either. But if they feel […] they are wise enough to engage in such thing, then it’s okay. […] It’s their choice. I mean they have rights but with these rights come responsibilities.

– Community worker, South Africa, not providing PrEP

As a mother, if I see a girl of 17 years taking PrEP, I wouldn’t like it. But that is the reality of what’s happening with these girls today. As a health worker I have seen PrEP helping others, so it’s rather better for her to take the PrEP.

– Nurse, Zimbabwe, providing PrEP

Best HIV prevention options

For me, I would go for PrEP because like I said, women have low bargaining power. […] You know she cannot tell the boyfriend to use a condom.

– Clinician, Kenya, not providing PrEP

She should use both oral PrEP and at the same time using protection [condoms] [...] At least she will have a backup of oral PrEP. Sometimes maybe they can use condoms, [but] at the same time the guy might refuse to use condoms. At least at that time she will be using oral PrEP.

– Nurse, Zimbabwe, not providing PrEP

Concerns about PrEP

She won’t be able to take it correctly because she’s afraid of being found out by [her partner]. […] Maybe he could react negatively and beat her or ask why she didn’t tell him that she is using this prevention.

– Community worker, South Africa, not providing PrEP

She will stop [using condoms]. […] She will say “I’m protected. I can’t get HIV” […] she knows she is protected she can’t get HIV so there are some risky behaviors […] I will [still offer her PrEP] because she is willing to take them [PrEP] home. I think everybody knows his or herself. I know she will find a way of how to take them despite the husband knowing.

– Counselor, Kenya, providing PrEP

Male partners

I usually leave [disclosure] at her discretion, if she wants to its okay and if she does not want to, it’s still okay […] it’s at her comfort because she is the one who knows the boyfriend. […] I would just tell her first try and ask him if he is willing to go for HIV test. If you see the reaction is bad, that means if you start telling him about the PrEP it will also bring more issues to it, so she would rather keep it to herself.

– Nurse, Kenya, providing PrEP

[Her partner] is not the person to talk to […] he will react negatively and also he may even get violent because now at the moment she strongly suspects him of having multiple partners. If she says that she is taking PrEP because of that, maybe they may get into a fight, so I don’t think that she should tell him.

– Community worker, South Africa, not providing PrEP

Parents

Yes, at her age she should tell her parents that she is using oral PrEP. She must inform them so that she is able to take them consistently, and she can also experience side effects and they will not know how best to help her.

– Community worker, Zimbabwe, not providing PrEP

At times someone can come and pick PrEP but later call to inform me, “my mother threw away the drugs. Maybe she doesn’t understand what kind of drugs they are.”

– Community educator, Kenya, providing PrEP

Support needed

Whoever will be administering [PrEP] to her just to check on her least once a month or so [to see] if she takes her pills regularly and how she is doing, if she has side effects or anything. I think she needs an emotional support.

– Community worker, South Africa, not providing PrEP

[She will need] A lot of counseling and advice. And in that particular moment before she starts, I will even try to engage the partner… to talk on behalf of her on the importance of taking this [PrEP] and why it is not a crime on taking them…

– Clinician, Kenya, providing PrEP

[Pendo] needs adherence counseling and side effects management, appointment reminders and relationship counseling would be necessary too […]I would also tell her that PrEP does not protect her from pregnancy and STIs.

– Counselor, Zimbabwe, not providing PrEP

Service delivery to AG versus YW

[Women ages] 20-24 years, I have seen that their [PrEP] retention rate is a little better in comparison to those below 20. Yes, I think they more focused, they know their problems, they know their risk, and they are determined.

– Nurse, Zimbabwe, providing PrEP

At least at that age 20-24 [years] someone has started to mature even when you give them information […] they show up, they listen. You know at around 20 years, someone already knows what they want to do with their lives so they can't let you down.

– Community worker, Kenya, providing PrEP

Uptake, adherence, retention challenges

They [AG] are afraid of their parents, they are afraid of the community, they are afraid of going to access these services because they feel that they are judged by the providers […] with that fear comes the denial that they are sexually active.

– 22-year-old female community educator, South Africa, does not provide PrEP

They are worried about being caught taking [PrEP] tablets cause it’s not known in the community. Their boyfriends do not know about it, so if they see their tablets they will think that they are positive.

– Clinician, Zimbabwe, providing PrEP

The challenge is just about stigma […] If an adolescent girl comes who is HIV-negative and wants PrEP … the next question is how would my parents take me because the drugs are stored at home, so once the parent sees the bottle maybe the parent can have a notion that this girl maybe she is behaving [way] that is not pleasing to the parent … to the society she is taking PrEP because her behavior is not good.

– Clinician, Kenya, providing PrEP

Strategies used to address challenges

There are times when I go beyond and give the adolescents my WhatsApp phone number so that they may get in touch if they have a problem. It is because they do not have anyone to talk to. It becomes easier for them to be in touch if they have a problem after we create rapport. We can be in contact by phone before things escalate.

– Nurse, Zimbabwe, not providing PrEP

I think creating awareness and letting them know that it’s actually okay to come to those clinics and actually talking to not only them but the communities to know that because HIV is not only an adolescents’ issue but a community issue. To make people aware that this is just another way to prevent this disease from spreading even wider.

– Community educator, South Africa, not providing PrEP

We exchange phone numbers so we can talk. When we realize they have missed appointments I say, “You were supposed to come today.” So I make a follow up using WhatsApp, and if I can’t get hold of her I ask the peer counselors to make a follow up.

– Nurse, Zimbabwe, providing PrEP