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South Africa has one of the largest HIV epidemics in the world, with particularly high prevalence among adolescent girls and young women (AGYW). Oral PrEP was introduced in the public sector in 2016 in a phased manner. Given the important role played by health providers, research was undertaken to understand their experiences of and attitudes towards introduction of PrEP as a new HIV prevention method, and its integration within broader sexual and reproductive health (SRH) services for youth. A survey was undertaken with 48 purposively sampled health providers working in primary health care facilities and mobile clinics in three provinces in South Africa. Qualitative analysis was performed on free-text responses to open-ended questions in the survey, using an inductive approach to code the data in NVivo v.12 software. Health providers expressed concerns about adding a new service to an already overburdened health system, and worried that young people seeking PrEP would divert staff from other critical services. While most recognised the benefits and opportunities afforded by HIV and SRH service integration, providers highlighted the extra time and resources such integration would require. Many were anxious that PrEP would encourage disinhibition and increase unprotected sex among AGYW, and held judgemental attitudes about young people, seen as largely incapable of taking responsibility for their health. Findings underscore the importance of consulting health providers about implementation design and providing channels for them to express their misgivings and concerns, and training needs to be designed to address provider attitudes and values. Opportunities need to be sought to strengthen the provision of adolescent and youth friendly services—including adolescent-health provider dialogues. Insights from this study can assist in guiding the introduction of new HIV prevention methods into the future.
Qualitative data for this analysis were collected as part of Project PrEP’s exploration of the perceptions and experiences of health providers in relation to the introduction of PrEP into comprehensive services for AGYW in South Africa. We analysed free-text responses to open-ended questions in a semi-structured survey undertaken between February 2019 and May 2020 with health providers working in participating PHC facilities and mobile services. The survey coincided with the National Department of Health (NDoH) roll-out of PrEP in public health clinics, which targeted people at substantial risk of HIV infection, including AGYW. At the time of data collection, many of the sites had only just begun to provide PrEP and some health providers had not yet been trained. South Africa’s health system is two-tiered and highly unequal. The underfunded public sector is accessed by the majority of the population, which largely cannot afford the health insurance needed to access the well-resourced private sector (30). Primary care service provision in the public sector is dominated by chronic long-term care (HIV and non-communicable diseases), with additional service streams focused on acute care (minor ailments), preventive and promotive services (maternal and child health and SRH) and health support services. Although service utilisation may vary by site and depending on the local burden of disease, research among primary care facilities in Kwa Zulu Natal has indicated that in 2020, clinic visits for ART follow-up care accounted for almost half of all clinic visits (43%), followed by visits for minor ailments (18%), child health (11%) and hypertension (10%) (31). The study was undertaken in four diverse (urban, peri-urban, and rural) geographical clusters in three provinces in South Africa (Gauteng, KwaZulu-Natal and Eastern Cape). Each project cluster consists of two fixed-site, primary care facilities and a project mobile clinic to extend the reach of services within the surrounding community. Participating facilities offer a range of integrated services for AGYW, including HIV testing, contraception, sexually transmitted infection (STI) and PrEP services, and linkages to HIV treatment services as required. Project facilities were selected based on their burden of HIV, teenage pregnancy, STIs and gender-based violence, as well as their proximity to secondary and tertiary educational facilities where adolescents and youth may be reached. Health providers were purposively sampled from the eight participating facilities and four mobile services, based on their expertise, experience and role in planning the PrEP roll-out or in providing SRH or PrEP services to adolescents. Only health providers working in the project sites and willing to consent to the survey and to administration of the survey being audio-recorded were eligible for recruitment. Participants were eligible irrespective of gender, health provider cadre, or number of years of experience. The study team worked with facility managers, who suggested other eligible healthcare providers within their facility who could be invited to participate in the study. Participants were recruited face-to-face by members of the project team. We also made use of snowball sampling among recruited participants to identify additional participants and build a sample large enough to obtain a diversity of views. Some participants were interviewed twice, in order to capture reflections on the implementation process after the roll-out. Recruitment continued until data saturation was reached, at which point 48 participants had been interviewed across the study sites. Surveys were administered face-to-face and telephonically (the latter for participants who were too busy to meet in person and when COVID-19 restrictions were in place in 2020). Interviewers were trained in research ethics and in the skills required to conduct high-quality, reliable surveys, including how to handle open-ended questions. The survey was administered in the language of participants’ choice (English, isiZulu or seSotho), and open-ended responses were audio-recorded. Participants were assigned a unique number to ensure anonymity when identifying themselves for the audio recording. The open-ended questions in the survey (roughly one-fifth of the tool) focused on a range of topics including: training received on PrEP provision, demand creation strategies, uptake and consistent use of PrEP, major programme challenges and successes, and lessons learned in providing integrated services to adolescents and youth. Descriptive analysis of demographic data was conducted. Audio recordings were translated into English, where necessary, and transcribed verbatim for analysis. A team of three analysts open-coded the transcripts using NVivo software (version 12, QSR International, Melbourne, Australia), using an inductive coding approach influenced by Grounded Theory (32). Analysts consulted with one another throughout the process to build consensus on the coding framework and ensure consistent application of codes. Key themes emerging from the coding were identified and further developed through the writing of detailed coding summaries, which formed the basis of the manuscript. The study was approved by the Human Research Ethics Committee at the University of the Witwatersrand (M180806) and by the World Health Organization (WHO) Ethics Research Committee (Wits-PrEP-AGYW). All participants provided written informed consent before taking part in the interviews.
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