Barriers to PrEP use and adherence among adolescent girls and young women in Eastern, Southern, and Western Africa: a scoping review

BACKGROUND: Adolescent girls and young women (AGYW) are disproportionately affected by HIV. Globally, in 2022, an estimated 4000 AGYW 15-24 were newly infected with HIV weekly, and nearly 78% of these infections occurred in sub-Saharan Africa. Oral Pre-Exposure Prophylaxis (PrEP) is a key HIV prevention option within an overall HIV combination prevention approach with an efficacy of over 90% when taken correctly. However, uptake of and adherence to PrEP remains low, particularly among AGYW. This scoping review aims to map available evidence on factors that limit PrEP use among AGYW in Eastern, Southern, and Western African countries to inform research, policy, and practice on delivery of PrEP. Our review identified factors that affect PrEP journey among AGYW along the HIV prevention cascade. METHODS: Guided by Arksey and O'Malley framework and using the PRISMA extension for scoping reviews, we searched the Web of Science, Global Health, and PubMed databases. Our review focused on oral PrEP, specifically papers reporting on barriers to PrEP experienced by AGYW, and peer-reviewed English-language articles published between 2012 and 2023. RESULTS: Of 1063 papers screened, 25 were included. Over half (60%) of the studies were qualitative; 72% were conducted in Kenya and South Africa. The barriers affecting motivation were, fear of side effects and pill burden, percieved low HIV risk, perceived stigma, PrEP use disapproval from parents and partners. PrEP access was limited by healthcare providers' stigma, isolated clinic setup, and lack of resources. Effective PrEP use was limited by a lack of parental or partner support, stigma, and lifestyle changes. CONCLUSIONS: Adolescent girls and young women face multiple and often intersecting barriers to effective PrEP use with stigma being a factor cross-cutting all steps of the prevention cascade. Similarly, lack of social support, reflected through disapproval and judgmental attitudes and low HIV risk perception, also affected two steps of the prevention cascade. Our review identified gaps in available evidence, with most studies conducted in only two countries and few quantitative studies available. Improving PrEP uptake and adherence requires interventions that address barriers across the cascade, with a particular focus on stigma and social support.