New plan to increase demand for PrEP in Malawi

Malawi’s PrEP communication strategy provides a helpful guide on how to address different groups’ knowledge, beliefs and motivations in ways that will encourage them to take PrEP.

What is the strategy about?

Malawi’s PrEP communication strategy outlines how to increase demand for PrEP among groups most at risk of HIV. In Malawi, the Ministry of Health defines these groups as adolescent girls and young women (ages 10 to 24), sero-discordant couples (when one person has HIV and the other does not), female sex workers and men who have sex with men.

Why is this strategy important?

PrEP is proven to prevent HIV infection. But until recently, PrEP access in Malawi was limited to people taking part in implementation studies. Creating demand for PrEP among groups most at risk of HIV is an important next step to rollout.

What is influencing PrEP use in Malawi?

The strategy assessed evidence from PrEP studies in Malawi and the region on what influences PrEP use. Dialogues were also held with sex workers, adolescent girls and young women, married women and health service providers.

The main reason why people want to take PrEP is to avoid getting HIV and to maximise their HIV prevention strategies.

The reasons why people do not want to take PrEP are:

• concerns about side effects
• fear of stigma (because PrEP can be mistaken for antiretroviral treatment)

• concerns about taking medication every day
• the perception that PrEP promotes risky sexual behaviour
• not seeing themselves as being at risk of HIV
• a lack of friendly health services
• negative views on PrEP from partners or family members.

What’s in the strategic plan?

Capability, opportunity and motivation

The strategy uses an approach called ‘capability-opportunity-motivation for behaviour change’. This is the idea that someone will change their behaviour if they have:

1. the capability (the knowledge)
2. the opportunity (the right environment)
3. the motivation (beliefs about consequences and risks, and a belief in their personal ability to act).

Tailored communications

The strategy looks at how to reach each priority group by increasing their capability, opportunity and motivation to take PrEP. It does this by outlining different behaviour change techniques, key messages and communication channels for each group.

The key messages include one ‘promise’ (a motivating reason to take PrEP) and a ‘call to action’ (an encouragement to do something specific).

For all priority groups, the call to action is the same: ‘talk to a health provider to find out if PrEP is right for you’. But the PrEP promise, key messages and behaviour change goals vary.

For example, for adolescent girls and young women, the promise is ‘PrEP allows you to protect your social standing while also protecting your future.’

The behaviour change techniques aim to increase adolescent girls and young women’s:

• correct knowledge about PrEP
• perception of HIV risk
• peer support for PrEP
• confidence in their ability to take PrEP every day when they are at risk.

In comparison, the key promise for female sex workers is: ‘PrEP defends you against HIV, so you are ready when the time comes to settle down and get married.’

The behaviour change techniques aim to:

• increase sex workers’ correct knowledge about PrEP
• reduce the proportion of sex workers that are worried about being stigmatised for using PrEP
• increase sex workers’ confidence in their ability to take PrEP every day when they are at risk.

Creating the right environment for PrEP use

The strategy outlines ways to target the people who influence the views and behaviours of priority groups. This is central to creating the ‘opportunity’ for priority groups to take PrEP. Key influencing groups are:

• parents and family
• teachers, religious and community leaders
• sexual partners
• healthcare providers and support staff
• the media.

General communication objectives

The strategy also includes general communication objectives. These are:

• General awareness raising should be a priority in the first few months of implementation to ensure the general population understands the basic facts about PrEP and does not only associate it with key populations.
• Messages about PrEP should be simple, translated into relevant dialects and tailored to each audience.
• Myths and misconceptions should be monitored and responded to immediately by sharing clear and correct information.
• PrEP messaging should emphasise the importance of other HIV prevention methods and that PrEP might not be right for everyone.
• Advocacy efforts should target policymakers to encourage them to improve priority groups’ access to PrEP.
• Healthcare providers should be targeted to improve their skills and address negative attitudes that affect the quality of services offered to priority groups.

What does this mean for HIV services?

The strategy is specific to PrEP and to the groups most at risk of HIV in Malawi. But its approach can be adapted to other contexts.

The strategy shows how important it is to understand the reasons behind different groups’ behaviours as well as how different groups get their information. Doing these things is key to understanding how to develop and communicate tailored messages that tap into people’s motivations and change their behaviour.

The strategy also shows how important it is to engage those who influence the groups you are trying to reach, and the need to take other issues, such as how these groups are treated by healthcare workers, into consideration.