One of the most ambitious programs to roll out oral pre-exposure prophylaxis (PrEP) to populations at risk of HIV so far is Kenya’s Bridge to Scale project, also known as Jilinde, and run by Jhpiego (a Johns Hopkins University affiliate). Jilinde has built in a robust evaluation process that continuously tests and changes its messages and outreach aimed at adolescent girls and young women (AGYW), among other populations. This process was based on an iterative strategy using human-centered design and broad stakeholder engagement that could inform efforts the world over to reach persistently underserved populations with HIV prevention at scale.
The introduction of PrEP in Kenya was backed by a substantial government commitment, and as of October 2019, Kenya counts 56,000 people who have started PrEP. The only country with higher numbers is the US at approximately 132,000 people. Since launching in 2016, Jilinde (a consortium of partners that includes Jhpiego, NASCOP, PS Kenya, ICRH-K and Avenir Health) has rapidly scaled up PrEP. Kenya surpassed a national target set with PEPFAR in 2018 by 559 percent, and there are plans for bold targets in 2020. But bringing PrEP to AGYW and helping them stay on PrEP for as long as they need remains an urgent matter—AGYW age 15-24 made up almost 25 percent of all new HIV infections in Kenya in 2018.
To get PrEP to the people who need it most, in 2017, implementers in Kenya embraced a marketing strategy called segmentation, which groups end-users by behaviors, attitudes, beliefs—rather than only demographics—and develops messages for each based on the traits they share. Segmentation in the context of HIV prevention then uses those groups to inform investments in products and programs designed to meet their needs.
Jilinde’s segmentation work drew from qualitative and quantitative research with end-users conducted by ThinkPlace and Busara Center for Behavioral Economics, and from a series of workshops with young women, civil society, key populations and NASCOP.
Messages and strategies for reaching each segment of end-users were prototyped, designed and piloted. The implementation process led by Jilinde brought in civil society organizations to an early-phase workshop, and included them in efforts to pilot outreach and messages based on what had been learned. Throughout, the team kept an ear out for the distinct fears, aspirations and needs of each segment—to develop messages that spur action.
Initially, Jilinde used a single message for AGYW in the 10 counties targeted for PrEP rollout—an upbeat Swahili slogan in primary colors that reads “KujiPrEP Ni Kujipanga Poa,” which when translated to English means: “PrEP yourself, and plan yourself well”.
“We built that message from insights that young people want to be in charge of their health, that no one will care about you more than yourself, and your health is a responsibility,” said Aigelgel Kirumburu, who brings communications and marketing expertise to Jilinde. Creating messages that increase awareness of PrEP among the general population is important especially when a new intervention is first introduced. As the program matured, reaching more AGYW was a priority. Developing tailored messages that recognized and resonated with different segments of AGYW helped to tap into their different motivators for seeking HIV prevention.
Staff also took notice of research from other settings that dug deep into the complex challenges young women face when it comes to primary prevention, sexual and reproductive health, stigma, community norms, parental attitudes, personal agency and the powerful influence of male partners in their lives.
“We looked at developmental science, Adolescent 360’s Nigeria Insights and HIV Prevention Market Manager’s Breaking the Cycle of Transmission and began to understand how hard it can be for a young girl to see her own risk as both real and preventable,” Aigelgel explained. “Plus, relationships are always a primary concern—they [AGYW] don’t want to do anything that puts important relationships at risk.” For example, key insights from the Breaking the Cycle of Transmission found that AGYW in South Africa overestimate their ability to judge risky partners, are rewarded in their environments for minimizing prevention and underestimating risk. In addition, seeking current prevention strategies often involves conflict with disapproving partners, parents, and health care professionals. Meanwhile, those providers who are empathetic often transmit erroneous information to young clients.
Aigelgel says in 2019 the team reexamined the segments they had defined among AGYW. It was time to develop more tailored messages for each of them and design outreach efforts to more effectively reach the various segments. Recognizing that AGYW’s relationship to PrEP varies and can change over time, Jilinde created specific messages for each segment around PrEP awareness, uptake, adherence, and discontinuation. “We’ve realized that one segment is very different from another. What may be important to one girl would not be important to the other,” says Aigelgel.
Table 1: Jilinde AGYW Segments
Jilinde has been piloting this refined approach to engage each unique segment, work that continued through the end of 2019. When testing the new messages, Jilinde found that AGYW liked simple messages they could relate to.
“PrEP keeps me on top of my game” emerged as one message that was easy-to-understand, while AGYW thought “PrEP keeps me lit” and “Life is good when PrEP is Fly” were less clear.
“PrEP keeps me secure” and “PrEP is my future” resonated with girls who saw PrEP as a tool to cement their futures and care for their families.
Messages that didn’t spark an interest included: “PrEP is popular, using it makes me fit in” and “PrEP is fun.”
Messages that included a visual—such as photos of other AGYW in the community—got them interested in what the messages had to say.
Beyond messaging, other interventions also came out of the process. To foster girls’ sense of empowerment, Jilinde developed Brighter Future Events: community-based youth-focused gatherings. These events offer PrEP and reproductive health services alongside activities such as bead-making and entrepreneurship lessons, allowing girls to relate PrEP use to their aspirations. Additionally, satisfied PrEP users leverage the power of peer influence to identify eligible girls with whom to talk about PrEP and emphasize its benefits. PrEP users also hand out AGYW-friendly, relatable and easy-to-understand information and education materials (IEC), which reinforce the idea that PrEP is the “in” thing. This peer-to-peer engagement creates a safe space, providing ambivalent young women opportunity to discuss their reservations with their peers and hear testimonials in a non-judgmental environment.
Moving forward, Jilinde intends to incorporate preferred messages in a guide for peer educators, disseminate them to service providers, and promote unified communications for demand creation and service delivery. At the end of 2019, Jilinde transferred management of Kenya’s PrEP program over to the Kenya government’s NASCOP. As part of the transition, Jilinde has contributed to NASCOP’s technical guidance on demand creation, provided campaign materials for PrEP and transferred its PrEP communications materials and social media platforms to NASCOP. “It has been such an important priority to make this a smooth transition,” Aigelgel says.
Looking ahead in 2020, Jilinde will undertake formal research on the impact of its outreach strategies. Aigelgel emphasizes it is vital to continue to learn if AGYW like the messages, show up at Brighter Future Events, engage with the peer-driven conversations, use safe spaces, and respond to campaigns. Findings will be part of an iterative body of evidence to determine where the Kenyan government should invest and what interventions have the greatest impact.
For more resources on AGYW segmentation, see: