Safe spaces defined.

In this study, we describe safe spaces as girls-only meeting avenues where they discuss issues affecting their well-being. A physical space is considered safe when it has been vetted by government officials, parents, guardians, and young women. Safe spaces consist of the mentor and the adoescent girls and young women (AGYW) as mentees and are designed to reduce power imbalances and enhance peer-to-peer communication and experience sharing among participants. The safe spaces are located centrally with the communities to reduce transport costs that hinder attendance, participation, and service access. The physical safe spaces are primarily in community structures such as schools and churches. They are segmented into different demographic categories and vulnerabilities such as age, marital status, those with children, in school, or interventions such as PrEP. This segmentation allows for easy administration of specific services to each group. A mentor (usually one of their peers from the same geographical area) manages a safe space. Mentors undergo over five weeks of training on social asset building and work with other community resource persons, including community health promoters (CHPs) and other healthcare providers. They schedule activities in the safe spaces and ensure service providers are frequently invited to the safe spaces to talk and provide various services, including sexual and reproductive health services.

In-depth interview.

One-on-one in-depth interviews were conducted to clarify individual motivations, beliefs, feelings, and experiences with the safe spaces. In-depth interviews are critical to understanding individual experiences and allow researchers to explore sensitive topics with participants. An effective IDI involves creating a listening space where viewpoints are communicated [23]. We conducted IDIs with young girls and women (n = 20) participants of different ages to explore the effectiveness of community-driven safe spaces in addressing structural violence in the prevention and treatment of HIV in girls and young women. In-depth interviews were conducted in individual homes by trained qualitative interviewers and lasted approximately 60 minutes. Questions during the interview included individual perceptions and experiences. For example, we asked participants questions like, “How does taking PrEP and other services at the safe space make you feel? What do you worry about when accessing safe spaces, and how would you describe your personal journey here?

Focus-Group Discussion (FGD).

To qualitatively understand and describe the community norms, perceptions, and inter-group dynamics in the safe spaces, we conducted two focused group discussions with young women (n=16) participating in safe spaces from two villages. The FGDs were conducted in identified community spaces, which provided privacy and confidentiality to the participants and lasted for about 60-90 minutes. More broadly, participants were asked about various issues, including the socioeconomic benefits/barriers and the cultural norms and practices, especially those concerning how girls and young women are perceived and expected to behave. For example, participants were asked, “How do the families, partners, and spouses react to service provision in the safe space, especially for PrEP?” with specific probing on norms, traditions, family practices, and expectations for young women.

3.1.1. Improving physical access to health services through safe spaces.

This study revealed difficulties in accessing HIV-related health services due to the distance from where health facilities are located. For school-going girls, time and money to go to the health facility were always constraints since hospitals only operated during weekdays when they needed to be in school and were further away from home. Because safe spaces are located within the community, participants reported they could easily walk to them and get their services. Most participants reported safe spaces made it easy, especially to access their drugs (PrEP) and attend other scheduled check-up appointments. One participant, while narrating her challenges with access, said:

“I am still going to school and cannot comfortably walk to the clinic to pick up my drugs (PrEP) and attend clinic appointments. Walking to and from the facility would mean I miss my classes and ask for permission from my teachers. However, for the sake of my drugs, I have to find a means. When this safe space started, the “doctor” allowed one of my group members to pick up my drugs for me at the safe space. I am happy that I only go to the hospital every three months and only when my check-up is due. (Focused group discussion, 02; participant 03)

A few participants expressed that the health facilities they visited lacked private rooms or areas to discuss their concerns. As a result, many missed their medication pickups or clinic appointments. During a detailed interview, one participant shared that on the days she needed to collect her medications, she would time her visit for late in the day when the hospital was less crowded, hoping to receive the nurse’s attention more easily.

“Let me tell you, going to that clinic has always been trouble for me. You go there, and there is only one open area where everything is handled. They call your name loudly and ask you sensitive questions so openly. It is embarrassing, and you can’t discuss anything sensitive. I would go very late if I wanted to talk to the nurse. She is very lovely when she is not under pressure. Safe spaces have been a relief. I walk there when I want to, and I can have lengthy discussions with the nurse who visits. I think a lot has changed since I started attending Safe Space.” (In-depth interview, participant 09)

3.1.2. Improving provider attitude and relations among young women.

Some participants shared their experiences with healthcare providers in public health hospitals and how the negative interactions made them fear going to the hospital unless it was the only alternative. Many mentioned resorting to seeking informal medical advice and treatment, including self-medication on suspected cases of sexually transmitted diseases. However, after joining Safe Spaces, some participants expressed confidence in the nurses and other health providers when they visit Safe Spaces.

“My experience with the clinic has always not been good. I went there when I suspected I had contracted an STI from my abusive partner. Instead, the male clinician I got wanted to take advantage of me and started talking about how he could provide me with better sex and love. Safe space has been different; the health providers who visit our safe space are so friendly; they even visit us at home. They have helped me and other girls a lot.” (In-depth interview, participant16)

3.2.1. Improving knowledge and awareness through Peer-to-peer education among girls and young women.

In the focus group discussion sessions, participants reported that most safe spaces conducted adherence education during their meetings. They described how lack of knowledge prevented some girls from enrolling in PrEP and how the education sessions improved their knowledge of non-adherence risks. In addition, the participants described how they felt supported to talk to their peers about the health benefits of PrEP. Some mentioned how other girls who did not want to take PrEP started to consider enrolling and improving their safe space numbers. This initiative greatly benefited most young women and girls who had started taking PrEP to understand the importance of adherence. A participant said:

“In our safe space, we have nurses coming to teach us about adherence to PrEP; we share our journeys and educate those who are hesitant to be part of us. We do a lot of education; we refer those willing for screening. We are proud because our numbers have risen. We used to be only 10 girls and now we are twenty-five in this space a lot. As the other member mentioned, we are not afraid to talk to our partners about PrEP. Some of us are in discordant relationships, and this drug has saved their lives.” (Focused group discussion 2, participant 09)

Further, some participants mentioned how, initially, they were afraid of discussing their involvement in PrEP with their family members for fear of being labeled promiscuous. However, after several sessions in the safe space and learning from their peers, they felt comfortable talking to their family members and partners about PrEP.

“The safe space has helped me gain courage and tell my family about my life and PrEP. I am not HIV positive, but it is shocking to know how HIV is regarded as a very serious illness, and testing positive, therefore, meant death. I felt my family would be worried if they saw me taking the pills since they are like ARVs. Since I joined this safe space, I found information I did not know. Now, I am confident.” (Focused group discussion 01, participant 12)

In in-depth interview sessions, a participant mentioned how the fear of knowing her HIV status prevented her from enrolling in PrEP since this was a required step and HIV testing was primarily done in hospitals. However, when she started attending safe spaces, she got enough education and support to brave the test.

“I know myself, and HIV testing has always scared me. So, I deliberately delayed starting PrEP even after I visited the safe space severally. I must confess that the way the nurse at the safe space taught me about HIV prevention and risk factors is what made me re-think. I knew that, with my kind of lifestyle, I had to do something. So, I decided to test during the testing session at the safe space. I got screened for PrEP eligibility, and now I am happily on PrEP” (In-depth interview, participant 05).

3.2.2. Overcoming stigma and disclosure among young women.

Most participants reported that fear of being labeled, talked about, and shunned from important community and social events initially prevented many young people from telling people, including their partners and families, that they had enrolled in PrEP. However, some participants noted that after many safe spaces started conducting adherence and disclosure education, most girls embraced PrEP and openly communicated their choices to enroll in PrEP to their partners, friends, and family members. One participant said:

“In our safe space, we have education sessions conducted by the nurses and mentors. We have also been encouraged to share our personal experiences among ourselves. Now, we support each other on drug adherence. Personally, I have received support from my partner since I opened up and told him I am on PrEP. Also, as the other participant has mentioned, most of our partners have accepted testing for HIV.” (Focused group discussion 01, participant 07)

Some participants were worried about where they would pick the drugs because most healthcare workers were people known to them and their parents, and PrEP, according to them, was associated with HIV and promiscuity. Some said the hospitals were too public, and they needed private spaces to access drugs if they were ever to enroll. However, they felt comfortable starting PrEP after learning that they could go to the safe spaces and pick up their drugs.

“PrEP in this community is like ARVs; it is difficult to pick the drugs if you go to the clinic and you find the people you know. They won’t understand you are there for PrEP and not ARVs. Now, I am relieved because I go to a safe space to get everything I want.” (In-depth interview, participant 20).

3.2.3. Overcoming cultural beliefs and practices.

In one focus group discussion, we found that community-led interventions have also helped deconstruct some cultural beliefs and practices that hindered access to care among young women. For example, one participant reported that being in a safe space has helped her participate in educational activities and learn information about sex and sexuality, which were not readily acceptable in her family and community, especially for girls. She narrates:

“When I started coming to the safe space, my parents were not happy. They said girls are not supposed to go to such spaces on their own. Instead, they wanted me to stay home and help with household chores. They were furious when they heard that we were being taught about safe sex, and they threatened to beat me. I am happy I stayed because I have learned so many things that I did not know. I am also able to get so many services here instead of going to the hospital” (Focused group discussion 02, participant 05)

Similarly, one participant recounted during an in-depth interview how she is consistently reminded of her identity as a girl, which comes with certain expectations. She described how her parents often dismissed her ideas, suggestions, and opinions, repeatedly emphasizing her gender role.

“I live with my parents and three brothers and often feel neglected. Unlike my brothers, I don’t have much of a voice. Frequently, I hear that I shouldn’t do certain things as a girl. I recall when I wanted to enroll in a hairdressing class; I was told that my brothers were still in school and needed money for their fees. Last time, I felt hurt when my dad proposed the idea of marriage since I had finished high school. He mentioned that he deserved the bride price for sending me to school. It has really been difficult for me; my role is only to assist mom with all household chores. I can’t say or suggest anything; yet, it is my family. But I thank God that after the mentor came and talked to my parents, they allowed me to start attending safe spaces. Though I am under strict supervision, including from my younger brothers, I must say that I have benefitted a lot from here and have started doing things independently.” (In-depth interview, participant 15)

3.3.1. Livelihoods and economic empowerment.

Most participants agreed that poverty, especially inadequate income and poor financial knowledge, was one of the reasons why some of them engaged in risky behaviors. However, after joining Safe Spaces and being trained in financial management and entrepreneurship skills, some reported improved income after starting small businesses, which helped them get the essential commodities they needed without relying on their parents or engaging in risky behaviors for financial gain.

“I don’t want to lie to you. There was a time when I had several men. I needed so much to get through high school. Sanitary pads, books, transport, my body oil, and pocket money. Some also contributed to my school after I had stayed home for so long that my parents could not raise the money. I wish we had safe spaces then. Now I have my small business, I am trained in financial literacy, and I can afford to buy the things I need. Honestly, my life, and the lives of others I know in this program, has really changed.” (In-depth interview, 06)

While sharing her experience in a focus group discussion, one participant confirmed that joining a safe space made her join others in economic activities to generate income. She observed that since then, she has been able to get her income to care for her menstrual needs. She illustrated:

“I knew that to join a safe space, one had to be HIV positive. It took me a while to open up and ask questions. I felt ashamed of myself. I would go without sanitary pads even for two days and stay home. Since I joined, I have learned skills to help me generate money, and now I am more confident. I can ask my group members for sanitary pads and borrow money. We can no longer go without pads.” (Focused group discussion, 05)

Another participant in a focus group discussion shared her experience with economic vulnerabilities facing young women. She narrated how some of her friends who were young widows sought alternative activities, such as multiple sexual partners as benefactors to meet their needs. The participant narrated:

“The greatest challenge is that most of our members are young widows who rely mainly on farming. They struggle to feed their families during the dry season. So, they resort to seeking male sexual partners to meet their needs…. Since we joined Safe Spaces, at least we have been engaged in different income-generating economic activities . Some of us got business start-up kits and now have a stable income.” (Focused group discussion 02, participant 08)

In summary, the community safe spaces have created opportunities for the young women and girls in Kisumu County, particularly Seme sub-county, to gain skills and enhance their capabilities to navigate systems of marginalization that increase their risk of acquiring HIV while also providing support to live positively with HIV.