How can we support the use of oral PrEP among young women who sell sex? A PrEP cascade analysis.

Adolescent girls and young women aged 15-24 account for ~26% of new HIV infections in eastern and southern Africa.1 Among this population, young women who sell sex (YWSS) are at particularly high risk of HIV, reporting higher numbers of partners and less condom use than their peers not involved in sex work, and having poorer access to health services than older female sex workers (FSW).2–4 Reducing HIV incidence among YWSS requires combination prevention that is responsive to their needs and addresses barriers to their service use.5 Oral pre-exposure prophylaxis (PrEP) is efficacious when taken as prescribed.6,7 As YWSS often struggle to negotiate condom use, PrEP offers women more choice and control over their sexual health.8 For PrEP to be effective at population-levels, individuals must have high demand, PrEP services need to be available, accessible and acceptable, and those who initiate PrEP must adhere during periods of use. To maximise the potential impact of PrEP, cascades and continuums have been used to identify gaps in delivery and use,9 and target programmes to support initiation, and optimise adherence and continued use.10 In Zimbabwe, YWSS were among the target population for the DREAMS initiative, which sought to reduce HIV incidence by 40% among adolescent girls and young women in 10 African countries.11,12 In districts where DREAMS funding was available, PrEP availability was a key service for YWSS combined with efforts to increase demand and support use. We previously showed that, while it is plausible that DREAMS may have contributed to reduced HIV risk among YWSS, it did not achieve 40% reduction in HIV incidence.13 We also showed that new HIV infections did not differ by ever-reporting PrEP use in 2019. To inform efforts to support PrEP use among YWSS, we constructed a PrEP cascade to investigate and understand reasons for gaps in PrEP use, and explored whether factors likely to influence demand for and opportunities to access PrEP were associated with uptake.