Positive and motivational messages, not a focus on risk, needed for PrEP communications in South Africa

Young women in South Africa prefer demand-creation materials for PrEP that are empowering and motivational, according to a report from a project in a township near Cape Town, published in Gates Open Research. The multiple rounds of consultation with community members resulted in materials that did not focus on risk, prevention or even health. Instead, the campaign video emphasised young people’s control over their lives and being part of a generation that will end HIV.

As part of a PrEP demonstration project led by Professors Connie Celum and Linda-Gail Bekker, demand creation materials were created using a theoretically informed framework, known as behaviour-centred design.

Formative research included ethnographic interviews with eleven women aged 16-25 who had not taken PrEP and with ten women aged 16-29 who had used it. Over two to three hours, the researchers sought to understand the young women’s daily routines, hopes, concerns, social relationships, health-seeking behaviour and perceptions of HIV prevention. At the same time, 16 in-depth interviews were done with men aged 25-35, women living with HIV, community workers and other key informants.

After analysing the data, the researchers took their findings and hypotheses back to the community for verification, first in 22 more interviews, and then in a two-day creative workshop with community outreach staff, community advisory board members, young women from the community, researchers and representatives from a marketing firm.

By this stage, the primary communication challenge was clear: convincing healthy young women with low motivation to take a daily pill to prevent HIV, given that the pill has potential side effects and prevents a disease that the young women do not consistently feel to be at risk from. At the same time, the findings suggested that demand creation could harness young women’s desire to increase their attractiveness to partners, increase emotional intimacy, avoid the social consequences of having HIV, and become a role model by being an early adopter of PrEP.

A participatory process tested the resonance of the formative findings, narrowing 40 insights down to five themes. These five were then taken to be tested in a focus group with nine women aged 16-19 who had taken PrEP as part of a separate study. They endorsed two themes in particular:

• PrEP enhances the power you have. (“You call the shots, make your own decisions, are independent and don’t have to rely on your partner to prevent HIV”).
• Take care of yourself: PrEP increases your self-worth. (“Taking the pill gives you the opportunity to be part of an ‘exclusive group’ that is turning the tide against HIV”).

The three themes which were not taken forward emphasised sexual pleasure and intimacy; protecting your family from the social consequences of HIV; and still being around to support your children.

Now the marketing firm developed a range of creative concepts, which were presented to a further 38 young women in focus groups. Women preferred materials that were simple and clear. While they liked realistic visuals, representing young women in a township, they also wanted materials to feel aspirational.

Some young women thought the campaign should also include young men, demonstrating that PrEP “is for everyone” and that “girls will not have to do this fight alone”. They also found the slogan “We are the generation to end HIV” appealing.

The final demand creation materials included a 90-second video, featuring members of the local community, which appears at the top of the page. They also produced two brochures – one with more detailed information about PrEP for young women and one to help them introduce PrEP to their friends, parents, and partners.

To evaluate its impact, researchers visited households that had been randomly selected from the community census. In 497 of them, a woman aged 16-25 lived there, and in 320 of them, she was home and agreed to watch the video. Afterwards, most said they were interested in taking PrEP (56% ‘definitely interested’ and 13% ‘somewhat interested’). Interest was greatest among women who currently had a primary partner, especially if the relationship had been formed in the last six months.

While the researchers followed a theoretically driven and painstaking process to develop the materials, the final evaluation is limited. The demand creation strategy was not compared with no intervention, or with a different intervention, and ‘interest in taking PrEP’ is a softer outcome than actually starting PrEP.

However, the researchers suggest that, given the low general awareness of PrEP at the time of the project (2015-2017), young women would probably need to encounter PrEP messaging multiple times and through multiple channels before actively seeking PrEP.

Since then, the researchers have used the video and brochure in other PrEP studies in Kenya and South Africa to provide young women with information on PrEP and facilitate recruitment. They have also made it available to other PrEP implementers in sub-Saharan Africa.