According to a 2015 article in the Journal of the International AIDS society, three-quarters of young people living with HIV in sub-Saharan Africa are women under the age of 25. Up to this point, many of the existing HIV prevention methods, such as male circumcision and condoms, have largely focused on the male body, leaving women (and particularly young women) little to no power over their own protection. Recently, however, an oral medication called Pre-Exposure Prophylaxis (or oral PrEP for short) was developed that can be taken by both sexes. PrEP is a daily pill that allows HIV negative people to have unprotected sex with HIV-positive people and maintain a negligible risk of infection for themselves. Approved only a few years ago in the US, PrEP has already garnered multitudinous success stories, and the drug has been particularly promoted by New York state governor Andrew Cuomo to help eradicate the disease in New York City. PrEP is anticipated to have the highest efficacy of any HIV prevention method globally, which means it could play a critical role in the crusade against the disease.

There has, however, been one significant hiccup: two different clinical trials (the Voice and FEM-PrEP trials) carried out in the last five years found difficulties in getting African women to adhere to PrEP's required daily dosage. In both trials, fewer than 30 percent of the participating women took the pill every day. The medication does not provide reliable protection to a sporadic user, so this predicted inconsistency in adherence by African women is perceived as a major setback in getting HIV protection to one of the most at-risk populations in the world. It is possible that the adherence issues are simply due to the uncertain nature of a clinical trial and would not be an issue in a real-world setting where a user knows that she is not getting a placebo and that the drug has a previously verified efficacy, but it is also possible that the problem is sociocultural or personal. For example, a poor person may not always have a private space in which to keep the drug, meaning that her usage of PrEP would be on display to her community, and matters of sex and disease often carry a great deal of stigma. Additionally, required daily adherence to a medication can require significant responsibility, a responsibility that only increases if the medication is expensive or one has to travel a great distance to obtain it.

This summer, I am working on a team at Carnegie Mellon University that is trying to figure out why PrEP adherence has been so low amongst African women. Interviews of 80 HIV-negative young men and women are currently taking place at three health clinic sites in sub-Saharan Africa: two in South Africa, at Cape Town and Johannesburg, and one at Kisumu in Kenya. Each participant partakes in two interviews: the first discusses the participant's home life, aspirations, relationships, and feelings about sex, and the second asks for the participant's thoughts on HIV, pregnancy, and PrEP. Once translated and transcribed, these interviews are sent to CMU, where we analyze the interviews through qualitative coding (a method of analyzing a text by chunking it into significant themes). Once all the interviews have been coded, influence diagrams will be created using the codes (significant themes) from the interviews to reflect how people in sub-Saharan Africa decide to have unprotected sex, test for HIV, begin taking PrEP, and adhere to PrEP. The hope is that this study will uncover ways to improve PrEP adherence in sub-Saharan African women once the drug is made available locally and to better HIV prevention in the area.