Title: Uptake of and Adherence to Oral Pre-Exposure Prophylaxis among Adolescent Girls and
Young Women at High Risk of HIV-infection in Kampala, Uganda: A Qualitative Study of
Experiences, Facilitators and Barriers
Version: 1 Date: 13 Mar 2022
Reviewer's report:
This is a well structured and written manuscript that comprehensively interrogates the concepts
of awareness, barriers and facilitators to PrEP uptake and adherence. The results are well
structured and articulated within the socio-ecological model. Nonetheless, a few comments for
consideration:
1. Would the authors reconsider revising the title for the manuscript given the content of the
manuscript is centered around both PrEP uptake and adherence.
2. Oral PrEP is being scaled up to many populations in SSA, beyond Key Populations. Countries
such as South Africa, Zambia, Kenya, Lesotho e.t.c have national programs targeting many other
populations including AGYW, sero-discordant couples and the general population. Could the
authors consider revising the introduction to expound on this.
3. The authors could provide more context in the introduction on why AGYW are a population
of interest for this study, with reference to Uganda.
4. In the methods section, the reference to the category "those who opted out" may be confusing,
since it is not very clear if the reference is to those who declined PrEP, or discontinued PrEP. I
suggest the authors use the terms "declined" or "discontinued" for clarity.
5. Could the authors clarify the time frame for the adherence measures.  Was this measured
across the whole duration that participants were on PrEP? Also just to note that this is at
times a problematic construct in the absence of objective measures of adherence. Some authors
use adherence as a proxy for continuation/persistent use but many studies in the field use
continuation as a measure for persistent use over time.
6. The authors point out that they conducted "thematic content analysis". However, I don't get
a sense that content analysis was used, rather they employed thematic analysis.  That said,
the authors could slightly improve their data analysis section. The authors have provided an
exemplary description of the initial open coding steps that included developing the master code
book both priori and a priori. It would have been helpful if they described the application of the
master codebook in the axial and selective coding slightly better for clarity of the analysis.
7. In line 213-214, the authors note "Though only four participants were initially aware of PrEP,
factors such as age, education level, employment or marital status were not associated with PrEP
awareness." I am curious how the authors deduced these associations qualitatively?
8. In the discussion and conclusion, it would be helpful if the authors paint out the different
yet complementary roles of awareness and demand creation. Awareness (above the line
communication) is critical in product recognition and norming PrEP across the general
population to create an environment supportive of use.  Targeted demand creation (below the line
communication) is geared to generate interest in PrEP among the actual beneficiaries leading
to evaluation, trial and adoption. It may be helpful if the authors acquaint themselves with the
consumer adoption process to articulate these concepts clearly. The authors could also refer
to this review article that tackles the subject in the PrEP context https://www.thelancet.com/
journals/lanhiv/article/PIIS2352-3018(21)00129-6/fulltext
9. I take note that the authors have acknowledged in their limitations the type of high risk AGYW
they recruited, with a bias for sex workers. Do the authors consider that some of the findings
would have been different among AGYW who are not necessarily sex workers? For instance,
while sex workers have a higher risk perception, a number of studies have found a generally
low risk perception among AGYW. It would be beneficial if the authors would situate some of
their findings in the discussion, in comparison to studies among AGYW who are not particularly
sex workers.