"Something Like That": Awareness and Acceptability of HIV PrEP and PEP Among Kenyan Adolescents.

BACKGROUND: Adolescents account for 15% of new HIV cases in Kenya. HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are highly effective prevention tools, but uptake is low among adolescents, particularly in resource-limited settings. We assessed awareness and acceptability of PrEP and PEP among Kenyan adolescents. METHOD: Focus group discussions were conducted with 120 adolescent boys and girls ages 15 to 19 in Kisumu. Data were analyzed using the Framework Approach. RESULTS: Adolescent participants often had not heard of or could not differentiate between PrEP and PEP. They also confused these HIV prevention tools with emergency contraceptives. Taking a daily pill to prevent HIV was perceived as analogous to taking a pill to treat HIV. Boys were aware of and willing to consider using PrEP and PEP due to their dislike for using condoms. Adolescents identified insufficient information, cost, and uncomfortableness speaking with healthcare workers about their HIV prevention needs due to sexuality stigma as barriers to using PrEP and PEP. CONCLUSION: Low awareness and poor understanding of PrEP and PEP among adolescents reveal the need for increased education and sensitization about these HIV prevention options. Expanding access to sexual and reproductive health services that are tailored to the needs of adolescents and staffed with non-judgmental providers could help reduce sexuality stigma as a barrier to accessing care. New HIV prevention approaches such as long-acting injectables or implants, on-demand regimens, and multipurpose prevention technologies may encourage increased uptake of PrEP and PEP by adolescents.

Brief Report: HIV Pre-Exposure Prophylaxis Awareness and Use Among Adolescents in Kenya.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is an effective prevention tool; however, use among adolescents is thought to be low. To determine the unmet need and opportunity to expand use, we assessed awareness, prior use, and willingness to take PrEP among Kenyan adolescents. METHODS: The Maneno Yetu study recruited a community-based sample of adolescents aged 15-19 years (N = 3061) in Kisumu for a survey using respondent-driven sampling. RESULTS: Overall, 50% of adolescents had heard of PrEP and 2% had used PrEP. Girls were more likely than boys to have heard of PrEP (53.4% vs. 45.1%; P < 0.001) and used PrEP (3.6% vs. 0.3%; P < 0.001). Among participants, 14% engaged in transactional sex and 21% experienced forced sexual contact. PrEP use was higher among adolescents who engaged in transactional sex (4.8% vs. 0.6%; P < 0.001) and experienced forced sexual contact (2.7% vs. 0.7%; P < 0.001) compared with those who did not. Among adolescents with no prior use, 53% were willing to consider using PrEP, although girls were less willing than boys (49.7% vs. 55.9%; P = 0.001). CONCLUSIONS: PrEP is an important prevention tool, especially for adolescents whose circumstances potentially expose them to HIV-positive or unknown status sexual partners, yet remains underused, particularly in resource-limited settings. Although many expressed willingness to use PrEP, low awareness and use highlight the need to expand HIV prevention education and services tailored for adolescents. Our finding that boys were more willing to use PrEP suggests campaigns should also be designed to reach male youth to narrow the gender gap and expand uptake in the adolescent population.

HIV Infection Among Adolescents Residing in Urban Informal Settlements of Kenya.

Adolescents comprise approximately 15% of new HIV infections in Kenya. Impoverished living conditions in informal settlements place residents at high risk for HIV infection. We assessed factors associated with HIV infection among adolescents residing in urban informal settlements in Kisumu. We recruited 3,061 adolescent boys and girls aged 15-19. HIV prevalence was 2.5% overall, all newly identified cases were among girls and infection was positively associated with not completing a secondary education (p < .001). Girls who had ever been pregnant (p < .001) or out-of-school without completing a secondary education (p < .001) were more likely to be HIV-positive. Our findings of higher HIV prevalence among adolescent girls who had been pregnant or did not complete secondary school highlight the need to facilitate access to HIV testing, HIV pre-exposure prophylaxis, and sexual and reproductive health services as components of a comprehensive prevention strategy to decrease HIV infections in this priority population.

A stigma-reduction intervention targeting abortion and contraceptive use among adolescents in Kisumu County, Kenya: a quasi-experimental study.

This study assessed the effectiveness of a school-based stigma-reduction intervention focusing on stigmatising attitudes towards girls associated with abortion and contraceptive use. In February 2017, two gender-mixed secondary schools (n = 1368) in peri-urban areas of Kisumu County, Kenya, were assigned to receive either an 8-hour stigma-reduction intervention over four sessions (intervention school: IS) or standard comprehensive sexuality education (control school: CS). A classroom survey entailing two five-point Likert scales - the 18-item Adolescents Stigmatizing Attitudes, Beliefs and Actions (ASABA) scale, which measures abortion stigma, and the seven-item Contraceptive Use Stigma (CUS) scale - was conducted to collect data at baseline, 1-month and 12-months after the intervention. The intervention was to be considered effective if a mean score reduction of 25% was achieved for both the ASABA (primary outcome) and the CUS (secondary outcome) at the IS between baseline and 12-month follow-up. 1207 (IS = 574; CS = 633) students were included in analyses at 1-month follow-up, and 693 (IS = 323; CS = 370) at 12-months (the final-year students had left school). A decrease in mean score on both scales was observed at 1-month at both schools. At 12-months, the score decrease was 30.1% at the IS and 9.0% at the CS for ASABA, and 27.3% at the IS and 7.9% at the CS for CUS. At the IS, the score decrease for ASABA between baseline and 12-months was 23.3% among girls and 31.2% among boys; for CUS, the decrease was 27.3% and 24.3%, respectively. ASABA and CUS were positively correlated (r = 0.543; p < 0.001), implying a broader perspective on reproductive stigma. A four-session, school-based stigma-reduction intervention could lead to transformed values and attitudes towards gender norms among adolescents regarding abortion and contraceptive use. Stigma associated with abortion and contraception should become a priority for high-quality CSE programmes.

Respondent-driven sampling to recruit adolescents in Kenya.

PURPOSE: Respondent-driven sampling (RDS) uses long-chain referral whereby members of the target population recruit other members. We describe the use of RDS for a mixed-methods sexual and reproductive health (SRH) study in Kisumu, Kenya. METHODS: Initial seeds for the cross-sectional surveys were selected from adolescents aged 15-19 residing in urban informal settlements. Participants were provided up to five referral coupons to distribute. RESULTS: Across four communities, 18 seeds were selected, 13,489 coupons distributed, and 3381 adolescents referred, yielding a 25% coupon return rate. We enrolled 3061 participants for a 23% survey rate. Median referral lag time was three days (IQR 1, 7). Demographic characteristics reached equilibrium between recruitment waves 5 to 8 in three communities, and waves 7 to 15 in the fourth. CONCLUSIONS: Our study demonstrated that RDS is a feasible and efficient approach for recruiting a large sample of adolescents. Though our research focused on SRH, many adolescents residing in the impoverished urban environments where our study was implemented also experience food insecurity, housing instability and violence. RDS can therefore be a valuable recruitment approach for future studies to reach vulnerable adolescents and design interventions that address the variety of health-related challenges that affect this underserved population.

"We Don't Fear HIV. We Just Fear Walking around Pregnant.": A Qualitative Analysis of Adolescent Sexuality and Pregnancy Stigma in Informal Settlements in Kisumu, Kenya.

In Kenya, adolescent pregnancy rates are high, contraception utilization is low, and adolescent sexuality is stigmatized. We describe how perceptions of sexuality and pregnancy stigma influence decision-making among adolescents in the informal settlements of Kisumu. We used purposive sampling to recruit 120 adolescent boys and girls aged 15-19 for focus group discussions. A semistructured interview guide was used to elicit social norms and community attitudes about sexual and reproductive health. We analyzed the data using the Framework Approach. The social stigma of adolescent sexuality and the related fear of pregnancy as an unambiguous marker of sexual activity emerged as main themes. This stigma led adolescents to fear social retribution but did not lead to more frequent contraception use due to additional stigma. The intensity of this fear was most acutely expressed by girls, leading some to seek unsafe, sometimes fatal, abortions, and to contemplate suicide. Fear of pregnancy outweighed fear of contracting HIV that was viewed as both treatable and less stigmatized. Our findings illustrate how fear of pregnancy among these adolescents is driven primarily by fears that their community will discover that they are sexually active. Interventions are urgently needed to address adolescent sexual stigma and to prevent negative outcomes.

Stigma surrounding contraceptive use and abortion among secondary school teachers: A cross-sectional study in Western Kenya.

OBJECTIVES: Comprehensive sexual education plays an essential role in adolescent sexual and reproductive health and rights (SRHR). The study aim was to investigate Kenyan secondary school teachers' attitudes toward girls associated with contraceptive use and abortion. STUDY DESIGN: We conducted a cross-sectional study in January 2018 among school teachers (n = 144) at 4 religiously affiliated suburban secondary schools in Kenya and used 2 validated Likert Scales (1-5) to capture contraception and abortion stigma. RESULTS: Overall, 122 teachers responded (85%) (females, 57%; males 43%; age, 21-70 years [mean, 36]). Respondents associated contraceptive use with a promiscuous lifestyle (43%) that will encourage peers to do the same (51%). Respondents indicated that married women were more deserving of contraception than unmarried women (57%), a girl could not herself decide to use contraceptives (50%), and contraceptive use could impair future fertility (57%). Abortion was considered a sin (74%), shameful for the family (48%), a habit (34%), and a behavior that might encourage peers to do the same (51%). Many believed an abortion will lead to worse health (73%). Male and female teachers gave similarly distributed responses. Younger teachers were more likely to find abortion shameful (<29, 64%; 30-39, 39%; ≥40, 39%; p = 0.046). Contraception stigma and abortion stigma were highly correlated (r = 0.355, p < 0.001). CONCLUSIONS: Stigmatizing attitudes associated with contraceptive use and/or abortion were common among teachers in Western Kenya. IMPLICATIONS: Stigma may hinder the sexual and reproductive health and rights of students. Contraceptive use and abortion stigma need to be addressed in teacher education to ultimately improve health outcomes among adolescents.

Seeking a "Sponyo": Insights Into Motivations and Risks Around Intergenerational Transactional Sex Among Adolescent Boys and Girls in Kenya.

PURPOSE: Intergenerational transactional sex (ITS) occurs in Sub-Saharan Africa within the context of widespread poverty and limited employment opportunities. We examined how adolescents describe these relationships, why their peers engage in ITS, and what repercussions adolescents shoulder as a result. METHODS: We conducted 14 focus group discussions with boys and girls (N = 120) aged 15-19 years in informal settlement communities in Kisumu, Kenya. We used a framework approach to guide data analysis. RESULTS: Adolescents referred to a relatively well-off older partner in ITS relationships as a "sponsor." Poverty proved the main driver of ITS. Boys and girls noted family and peer pressure to have a "better life" via sponsors who provided for three levels of need: urgent (e.g., food), critical (e.g., school fees), and material (e.g., clothes). Adolescents described multiple risks, including "no power" to negotiate condom use. Repercussions included dropping out of school because of community stigma, "abandonment" in the event of pregnancy, and unsafe abortions. CONCLUSIONS: Adolescents face the difficult choice between the need for money to contribute to their families' income and the discomfort and health risks of a sponsor relationship. The pressure to have a sponsor was higher among out-of-school adolescents and adolescent mothers because of heightened poverty and vulnerability. Structural interventions, such as eliminating school fees, could help reduce adolescents' perceived need to acquire sponsors. Our findings suggest a need to update guidelines for sexual and reproductive health counseling in schools and community settings to openly discuss why ITS is so commonplace and engage in risk reduction conversations with adolescents.

Abortion and contraceptive use stigma: a cross-sectional study of attitudes and beliefs in secondary school students in western Kenya.

Social stigma related to women's reproductive decision-making negatively impacts the health of women. However, little is known about stigmatising attitudes and beliefs surrounding abortion and contraceptive use among adolescents. The aim of this study was to measure stigmatising attitudes and beliefs regarding abortion and contraceptive use among secondary school students in western Kenya. A self-reported classroom questionnaire-survey was administered in February 2017 to students at two suburban secondary schools in western Kenya. Two scales were used to measure the stigma surrounding abortion and contraceptive use - the Adolescent Stigmatizing Attitudes, Beliefs and Actions (ASABA) scale and the Contraceptive Use Stigma (CUS) scale. 1,369 students were eligible for the study; 1,207 (females = 618, males = 582) aged 13-21 years were included in the analysis. Descriptive statistics, Pearson's χ2 test, and the t-test were used to analyse the data. Binary logistic regression analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI). The students reported stigma associated with abortion (53.2%), and contraceptive use (54.4%). A larger proportion of male students reported abortion stigma (57.7%) and contraceptive use stigma (58.5%), compared to female students (49.0%, p = .003 and 50.6%, p = .007, respectively). Higher scores were displayed by younger rather than older age groups. No associations were identified between sexual debut and abortion stigma (p = .899) or contraceptive use stigma (p = .823). Abortion and contraceptive use are stigmatised by students in Kenya. The results can be used to combat abortion stigma and to increase contraceptive use among adolescents in Kenya.