Background
In southern Africa the provision of pre-exposure prophylaxis (PrEP) has not translated into population-level impact due to the challenges of taking a daily oral pill. Injectable PrEP provides an opportunity to overcome this barrier. Using clinical process data from the Long-Acting PrEP Integrated with Sexual and Reproductive Health (LAPIS) trial, we explore changes in patterns of PrEP use amongst adolescents and young adults (AYA) following introduction of choice in a high HIV burden setting in rural KwaZulu-Natal (KZN), South Africa.
Methods
We nested LAPIS (NCT066250504) a cluster randomized controlled trial of offering a choice of oral PrEP, two monthly (long-acting) injectable cabotegravir, dapivirine vaginal ring or packs of 28 days of post-exposure prophylaxis (PEP) within a larger trial testing the population impact of community-based delivery of PrEP through sexual reproductive health (SRH) services in rural KZN (NCT05405582). PrEP is offered alongside SRH and testing for sexually transmitted infections, including GeneXpert testing on self-taken samples for gonorrhoea and chlamydia to AYA aged 15-30 years. Here we describe the pattern of PrEP use before and after the introduction of PrEP/PEP choice. Uptake is defined as proportion of participants eligible and offered who initiate PrEP/PEP.
Results
Prior to the introduction of choice (June 2022-May 2024), 3150 AYA attended the mobile SRH clinics. Among 1586 eligible/offered oral PrEP, 1015 (64.0%) initiated PrEP (503 [49.6%] women). Following the introduction of choice (June-September 2024), amongst 375 eligible/offered PrEP, 359 (95.7%) initiated PrEP/PEP (259 [72.1%] women). N=276/359 (76.9%) chose injectable cabotegravir (186 women), 55/359 (15.3%) chose oral PrEP (29 women), and 28/359 (7.8%) chose PEP (14 women). None chose the dapivarine ring. At enrolment, 88/315 (27.9%) had an STI (gonorrhoea or chlamydia). STI prevalence was highest amongst those who chose injectable cabotegravir (32.5%; 82/252) vs 13.3% (6/45) and 0/18 amongst those who chose oral PrEP and PEP, respectively.
Conclusions
Providing a choice of PrEP/PEP modalities resulted in more of those who were offered chosing to take PrEP. The majority, especially women and those who had an STI, chose injectable PrEP. However, one in four chose an oral option. Providing choice that meets adolescents and youth’s preferences may improve effective PrEP use.