Peer-led Dynamic Choice HIV Prevention for Women at Elevated HIV Risk in Uganda

Despite remarkable progress in HIV testing and treatment, HIV incidence remains unacceptably high among women and girls in eastern and southern Africa. In Uganda, HIV infections are concentrated among women at elevated HIV risk due to factors such as working in venues. Although oral pre-exposure prophylaxis is being scaled up, many women at elevated HIV risk face barriers to accessing oral pre-exposure prophylaxis at health facilities and to storing and adhering to pills. A new era of choice in biomedical HIV prevention, including the dapivirine vaginal ring and long-acting cabotegravir, presents an opportunity to reduce new infections. Post-exposure prophylaxis could fill gaps in coverage. As new choices in HIV prevention are rolled out, strategies are needed to empower women to choose among prevention products and support sustained use. Our study team developed and tested the Sustainable East Africa Research in Community Health Dynamic Choice HIV Prevention intervention (including product choice, with option to switch over time, choice of facility or community-based visits, and provider training). In three randomized trials, Dynamic Choice HIV Prevention increased time covered by a biomedical prevention product over two-fold compared to standard of care prevention services. However, there were gaps in engaging women at elevated HIV risk. We have conducted formative work, in collaboration with our Community Advisory Board, to tailor the effective Dynamic Choice HIV Prevention intervention to further reach and engage women at elevated HIV risk. Key recommendations from this work included increasing access to long-acting product choices, expanding outreach beyond facilities, and extending existing peer services. Peer approaches are recommended in national guidelines and are being successfully implemented to reach women at elevated risk for HIV testing and prevention services – but peer models have not yet been deployed to deliver biomedical prevention choices. We propose to optimize and test a Peer-led Dynamic Choice HIV Prevention intervention to catalyze choice and use of biomedical prevention products. We will test the hypothesis that Peer-led Dynamic Choice HIV Prevention (with choice of pre-exposure prophylaxis product will increase biomedical HIV prevention coverage compared to standard of care among women at elevated HIV risk in southwestern Uganda. The proposed aims are: 1) To refine and optimize the Peer-led Dynamic Choice HIV Prevention intervention; 2) To determine the effect of the Peer-led Dynamic Choice HIV Prevention intervention on biomedical prevention coverage in a Hybrid Type 1 effectiveness-implementation cluster randomized trial; 3) To assess costs, efficiency, and cost-effectiveness of Peer-led Dynamic Choice HIV Prevention. Collectively, these aims will provide evidence for peer-led models to deliver choice of HIV prevention products for women at elevated HIV risk to enhance HIV prevention coverage using current and next-generation prevention modalities.