PrEP in pictures: these photos highlight factors influencing women’s use of PrEP in Kenya

In a study conducted in rural Kenya, young women, their male partners and male peers were given cameras to capture factors in their community that influenced the use of PrEP among young women. The photographs taken by young women indicated that male influence restricted the use of PrEP, with men seen as barriers rather than supporters. Women also perceived that they had little autonomy over their choice to use PrEP.

In 2019, researchers from the Impact Research and Development Organization in Kisumu, Kenya, provided study participants with inexpensive digital cameras. They were trained on how to use them and given guidance on ethics when taking photographs. Young women were tasked with eight photo assignments that focused on identifying factors influencing their PrEP use, while men's four photo assignments focused on identifying ways men support or hinder young women's PrEP use.

The young women were between 18–24 years of age, currently or previously taking PrEP and enrolled in the DREAMS HIV prevention programme. Men were 18 years or older and identified by the young women as a peer or sexual partner. Most participants were married, had completed primary-level education, and were self-employed, housewives, or were engaged in non-formal occupations including agriculture and fishing.

After each photo assignment, participants chose the photographs that they wanted to present during group discussions with their peers, worked with study staff to write descriptions of their images, and shared the photographs with the group. Participants could also ask study staff to present their photographs anonymously during the group discussions if they were uncomfortable sharing with others.

Participants’ photographs were discussed in 12 same-gender group discussions with young women and four same-gender group discussions with men; a total of 22 young women and 17 men participated in one or more of the discussions. Most also participated in four mixed-gender group discussions. During discussions, participants were encouraged to describe what the photos show, what is really happening and why the situation exists.

Men’s influences on young women’s sexual health and risk for HIV

Young women explained that they had little autonomy over their sexual lives and that cultural, economic, and social factors defined when and how sexual encounters occur for women. They described cultural practices where women are obliged to engage in condomless sex in observance of building a house, to mark seasons of food production, upon the death of a spouse or parent.

Several photographs also described situations with men that place women at heightened risk for HIV. Men’s behaviour manifested in intimate partner violence, infidelity and forced sex/rape. Some men instigated couple disharmony, then expected sex (unprotected in most cases) as a way of resolving differences.

Men’s influence on young women’s PrEP use

Many young women said that it was important to consult their husbands when making decisions about family-related issues. Several women reported receiving negative and discouraging comments from their husbands, including disparaging remarks about themselves or their families. They provided multiple photographs illustrating how men can negatively influence their daily use of PrEP by ordering their female partners to stop taking PrEP or by threatening violence.

Young women shared that receiving emotional and instrumental support from men in their lives could increase PrEP adherence. The woman who took the picture at the top of the page explained that men often lacked education about PrEP, leading to limited knowledge or misinformation about it.

“That situation occurs because I can say when we were being taught about PrEP, we were only taught as women alone, we were not taken with our men. So they lack knowledge about PrEP. That’s why it brings difficulty between a man and woman for a woman to find a way of taking PrEP.”

On their part, the men explained that they often hear stigmatising information in the community which leads them to believe that PrEP is not a suitable HIV prevention option. They mentioned that misconceptions such as viewing PrEP as a contraceptive, thinking it can harm foetal development, considering it as a drug for HIV treatment, or believing it is only used by sex workers can negatively impact men’s support for women's use of PrEP.

Some women also shared pictures of how their partners support their use of PrEP.

The majority of men suggested that men should have discussions with their partners and reach an agreement on how PrEP should be used in their households. They also proposed that men should show their support for their partners by taking PrEP themselves.

Men also expressed that the use of PrEP among young women would be more widely accepted if it were better promoted in the community. They recommended community-based programmes to educate men and suggested promoting the benefits of PrEP through radio and TV dramas, in schools, churches, community gatherings, and athletic clubs.

Participants noted that boda boda (commercial motorbike taxi) riders, who are usually male, could significantly influence the community's perception of PrEP. It was mentioned that these riders may spread negative rumours or misinformation about PrEP, but if they were educated about the positive impact of women's PrEP use, they could become influential advocates.

“These motorbike drivers can be bought [for] or issued PrEP-branded reflectors. So they put them on as they ride across the town, so that many people can see their backs branded “PrEP, PrEP”. They will ask each other, “What is PrEP,” and they go into details to find out what PrEP is. From that juncture, the campaign would be accomplished.

Moving forward, men should be included in PrEP community awareness initiatives that focus on young women. This will help educate them about the benefits of PrEP within their relationships, reduce stigma and address their concerns about HIV and sexual and reproductive health.