Unraveling PrEP persistence: mental health and substance use among adolescent girls and young women in an implementation program.

OBJECTIVE

To examine associations between mental health, substance use, and pre-exposure prophylaxis (PrEP) persistence among South African adolescent girls and young women (AGYW).

DESIGN

A longitudinal analysis of a decentralized PrEP implementation program.

METHODS

We analyzed data from FastPrEP, a youth-focused program delivering PrEP with peer-navigator support through community-based mobile clinics and public clinics near Cape Town. Female participants aged 15-29  years who received a one-month supply of daily oral PrEP at program enrollment were included. Moderate to severe depression/anxiety symptoms (PHQ-4 ≥6) and hazardous alcohol use (AUDIT-C ≥3) were assessed at enrollment. Log-binomial regression was used to estimate overall and age-stratified adjusted prevalence ratios (aPRs) for associations with short-term PrEP persistence at the one-month follow-up visit.

RESULTS

From April 2022 to April 2024, 6,271 AGYW were enrolled in FastPrEP and dispensed daily oral PrEP (median age 21  years); 75% enrolled at mobile clinics. At enrollment, 8% reported moderate to severe depression/anxiety symptoms and 50% hazardous drinking. Only 10% returned and received PrEP within a 28-day window of their one-month follow-up visit. Moderate-severe depression/anxiety symptoms were associated with greater PrEP persistence (aPR = 1.37, 95% confidence interval [95% CI] 1.04-1.79), as was hazardous drinking (aPR = 1.46, 95% CI 1.23-1.75). Associations were strongest among AGYW aged 15-19  years (depression/anxiety: aPR = 1.71, 95% CI 1.11-2.65; hazardous drinking: aPR=1.60, 95% CI 1.16-2.19).

CONCLUSION

Contrary to expectations, mental health and substance use challenges were associated with greater short-term PrEP persistence, particularly among younger AGYW. These findings suggest that youth-centered, peer-supported delivery models may help sustain engagement among higher-risk AGYW.