1022- South Africa- Adaptive implementation strategies for the delivery of long‐acting injectable PrEP with young female sex workers in South Africa

The main goal of this project is to inform the delivery of long-acting injectable pre-exposure prophylaxis to maximize HIV prevention impact among female sex workers in South Africa.

This project will be integrated within an existing R01 funded by the National Institutes of Health (NIH) focused on the implementation of pre-exposure prophylaxis (PrEP) at TB HIV Care, the largest provider of PrEP for female sex workers (FSW) and adolescent girls and young women in South Africa. Within this larger study, we are conducting additional research to guide the implementation of long-acting injectable PrEP. Long-acting cabotegravir (CAB-LA) was approved for use in South Africa in December 2022 and represents a paradigm shift in HIV prevention for women at high risk of HIV. While this represents an exciting opportunity, further research is needed to understand preferences around LAI and oral PrEP and how best to optimize service delivery for populations at high risk of HIV, including FSW. Differentiated care strategies which recognize that prevention needs are likely not static over time and preferences likely vary among FSW will be essential to optimize individual outcomes and ensure LAI-PrEP achieves its full potential in South Africa and sub-Saharan Africa more broadly. Thus, a more immediate opportunity to assess implementation of LAI-PrEP with a small number of individuals seeking care through the TB HIV Care PrEP program will offer important insights into ways to optimize LAI-PrEP delivery, and support this future rollout.

This work will comprise qualitative research through focus group discussions with FSW and in-depth interviews with FSW, PrEP providers, and governmental stakeholders of PrEP. A subsequent quantitative questionnaire and discrete choice experiment (DCE) will evaluate preferences for PrEP delivery with FSW. Finally, repeated implementation assessments with FSW who are taking LAI-PrEP will evaluate user experiences and changes in preferences over time. Together, lessons learned from this research will support the impending rollout and implementation of PrEP within South Africa for women at high risk of HIV.

Students supporting with work will also have the opportunity to participate in the larger R01 study. This research utilizes the MOST (Multiphase Optimization Strategy) Framework to identify and test strategies to support PrEP uptake and persistence among young women at high risk for HIV in South Africa. Given the substantial individual, social, and structural barriers to PrEP use that marginalized young women experience, we aim to evaluate the relative effectiveness of various permutations of four PrEP support strategies on increasing PrEP uptake among marginalized young women. To assess feasibility and potential for scale-up, a cost-effectiveness analysis will be conducted for this study assessing costs associated with programmatic standard of care activities as well as research-related expenses associated with implementation of the trial.

The student will work collaboratively with local staff at TB HIV Care and the JHU team to support the day-to-day study activities of this project. Activities may include the development and adaptation of study protocols and instruments; qualitative data analysis with outputs from focus group discussions and in-depth interviews; quantitative data management and quality assurance; and quantitative analysis. Opportunities to contribute to manuscript writing and conference abstracts may also be available depending on the interests of the student. Activities will occur primarily in Durban at the TB HIV Care site; however, there is the opportunity for short-term travel to Mbombela (Nelspruit) where study activities will also take place.

The student will also engage in work related to the larger R01 PrEP study, including collection of costing data by liaising with TB HIV Care research and program staff to document costs associated with research and programmatic activities involved in the MOST fractional factorial trial. The student will have the opportunity to engage in analyzing cost-effectiveness of the interventions included in the trial both individually and as packages of services to identify the most cost-effective strategies for future scale-up in the TB HIV Care program. The student may also support the trial implementation and logistics as needed, with potential opportunities for short-term travel to the uMgungundlovu site where the trial will take place.

This project offers an opportunity that is both professional and academic to gain critical skills in the intersection of health systems strengthening and epidemiological approaches through data capacity-building, community and stakeholder engagement and relationship building, as well as experience working on HIV-related implementation science and research activities aiming to impact public health practice in a low-to-middle-income country. Working in the field with local counterparts gives the applicant the opportunity to develop skills in project management and stakeholder engagement that will help them critically analyze how they would design future projects.

The professional work environment at the site is extremely positive and fosters mentorship and productivity across team members, partners and program staff. In addition to the TB HIV Care staff, the on-site team will include fellow graduate students completing complimentary placements. The workplace operates in a mature, respectful matter and collaboration and team work are hallmarks of the project. Moreover, we as a team are always available for support and ongoing communication throughout this collaboration.

This placement would be a good fit for someone who is motivated and can take the lead on projects. Regular mentoring and supervision will be provided by investigators and staff in the United States and South Africa; however it will be the responsibility of the student to use the ideas and advice provided by the investigative team to move aspects of the project along, requesting additional support along the way when needed. Students with an interest in key populations, women’s health, implementation research, and qualitative research are encouraged to apply.

Epidemiology and Biostatistics (620 series or above preferred); courses in health communications, qualitative research, health equity, and implementation science are a plus, but not required.

Experience working with marginalized populations and on sensitive topics preferred.

A minimum of 20 weeks is required unless COVID-19 related travel restrictions prohibit this duration, although students who wish to stay longer are encouraged to do so and expenses will be covered to support this. Students who continue to work with the project for longer than 20 weeks will likely have more of an opportunity to assist with data analysis and manuscript development.

Name: Katherine Rucinski, Department of International Health, rucinski@jhu.edu

I would describe my communication and mentorship styles as... 

I am supportive of students and available to provide thoughtful feedback and guidance at any point either in-person, by phone/Zoom, or via email and WhatsApp. I operate using a group mentorship model that comprises other faculty within our core team, staff, and graduate students across multiple degree programs in the School of Public Health. As a complement to this model, I am also available to meet individually with students to support individual goal setting and career development.

A complementary student would have a working style and mentorship expectations that are..

A complementary student will be extremely interested in the work, detail oriented, hardworking, and able to work independently and collaboratively. We are looking for students that are excited about the key elements of the research, willing to learn and grow, and are interested in being embedded within a large HIV prevention program in South Africa. Students who are able to take initiative and ownership of their responsibilities within the project will be a good fit for this placement.

The monthly stipend is sufficient to cover housing, food and use of public transport if able to safely travel due to COVID-19. Students wishing to further travel for personal reasons may incur out of pocket expenses.

We will work with the student to develop a budget to cover monthly expenses including housing, transportation, groceries, and other basic living expenses. Any living expenses not covered by the GHEFP grant will be covered by the project. The project will cover the student’s airfare to and from South Africa, if appropriate.