Sexually active teenage girls wanting to protect themselves from HIV infection are more likely to opt for long-acting injectables or vaginal rings than pills as a pre-exposure prophylaxis (PrEP) , a new SA study suggests.
According to the UChoose study that was done by the University of Cape Town-based Desmond Tutu HIV Centre, which evaluated contraceptive experiences among girls aged between 15 and 19 in Cape Town, almost half or 46% indicated that they would prefer an injectable as a potential HIV prevention method due to its ease of administration and long-lasting effects.
Though many were not familiar with the vaginal ring, 33% of the teens showed preference to the ring while only 10% of 130 participants opted for an oral PrEP.
The teens were either put on a two-monthly injectable, Nur-Isterate, the Nuvaring vaginal ring or a monthly pill, Triphasil — which were used as a proxy for HIV PrEP. The majority of girls were not comfortable with the pill as they frequently forgot to take it.
The UChoose study, which was carried out between 2015 and 2017, is the first trial to evaluate adolescent preference for contraceptive options as a proxy for HIV prevention methods. Participants were asked to use Nur-Isterate, the vaginal ring or Triphasil, for 16 weeks.
After this, participants were asked to use one of the other methods on offer, again for 16 weeks. At the end of the 32-week study, participants were asked for their views on these contraception methods and what type of PrEP product they might prefer.
More than two‐thirds of participants had used either oral or injectable contraception before the study but none had used a vaginal ring. As a result, the study ensured all participants tried the vaginal ring plus either the injection or pill.
Teenagers in all three streams were worried about pregnancy, whereas significantly more injection users (46.3%) were concerned that the injection would cause future fertility issues compared to the vaginal ring.
Significantly more injection users or 90% would also recommend that birth control method to a friend in comparison to only 54% of pill users. Injection users (59%) were also more willing to continue using injectables over other methods.
Irrespective of the preferred method, the teens rated ease of use, protection from pregnancy, absence of side effects, being familiar with the method and ease of remembering as the most important factors to be considered, whereas enjoyable sex and a longer dosing regimen did not appear as important.
Writing in the Journal of International Aids Society, lead researcher Katherine Gill and colleagues said the latest results were consistent with the findings of other studies of product preference conducted in young African women, but teenagers’ preferences might change over time as they transitioned into young adults.
Changing preferences may be related to many factors including relationship stability, medical history, ability to negotiate condoms with different partners and perception of risk. Gill noted that sexually transmitted infections (STI) prevalence and STI incidence remained high throughout the study, despite treatment and referral for partner treatment.
“This, along with self-reported high-risk sexual behaviour, emphasise the need to prevent both STIs and pregnancy in adolescent females through integrated adolescent-friendly STI and HIV prevention, sexual health and contraceptive services.”
It was noteworthy that the greatest motivator for contraceptive adherence was participants’ desire to protect themselves from pregnancy.
“It is concerning that despite their high risk sexual activity and SA’s high HIV burden, adolescents perceived themselves to be at low risk for acquiring HIV,” she said.
Women from 15 to 24, and girls between 10 and 19 in particular, are at highest risk of HIV infections and account for about 29% of all new HIV infections in the country.
In 2016, new infections among young women were 44% higher than among young men. In eastern and Southern Africa, young women made up 26% of new HIV infections, despite only accounting for 10% of the population.
In 2017, SA became the first country on the continent to register an antiretroviral, Truvada, to be used as an oral PrEP by people who do not have HIV, to prevent them from becoming infected.
The idea behind PrEP has been to target populations where new infections remain consistently high. These include sex workers, men who have sex with men, those who inject drugs, and young women.
Researchers have expressed concerns about the challenges of introducing PrEP to young women, which include pressure from intimate partners and family members who are often suspicious that taking PrEP means their lovers are being unfaithful, while family members associate ARVs with the stigma of being HIV-positive.
The latest research comes after new research showed that a long-acting injectable, which was tested locally, prevents HIV infection.
The HPTN 083 clinical trial, done by the US-based HIV Prevention Trials Network (HPTN), is the first study to compare the efficacy of long-acting injectable cabotegravir (CAB) with the daily oral Truvada for HIV PrEP. The trial enrolled 4,570 cisgender men and transgender women in seven countries including SA, Thailand and the US who have sex with men.
The injectable PrEP is not just effective but also superior compared to the daily tablet form of PrEP, and only registers a 0.4% HIV incidence rate compared to 1.22% for the tablet form.
While participants showed reluctance to use the vaginal ring initially, Gill noted that when ring familiarity was attained, its desirability increased.
“Adherence to daily pills proved difficult for adolescents in this study. While some preferred vaginal ring use, most preferred a long-acting injectable method for pregnancy and HIV prevention. This choice seems to have been largely motivated by the fear of an inability to consistently adhere to daily regimens.
“It also suggests that familiarity to a method is an important consideration. This study highlights the importance of allowing young women to have method choice as well as information and support as they navigate their sexual and reproductive health options,” researchers said.
Co-author of the study Prof Linda-Gail Bekker estimated that the new long-acting injectable cabotegravir (CAB), which is currently being evaluated by the Food and Drug Administration (FDA) for regulation, is expected to be introduced in SA in two years.
Sunday Times Daily
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