Background
Long-acting injectable PrEP (LAI-PrEP) represents an efficacious HIV prevention strategy, but rollout in 2024 has been limited, constraining our understanding of LAI-PrEP implementation within real-world HIV programs. We explored preferences and potential barriers to uptake and continuation of LAI-PrEP among female sex workers (FSW) accessing routine community-based HIV prevention services in South Africa.
Methods
In May-June, 2024, we conducted two focus group discussions (FGD) and 24 in-depth interviews (IDI) with FSW in Ehlanzeni (rural) and eThekwini (urban) municipalities. Using the Consolidated Framework for Implementation Research (CFIR), FGDs explored preferences in PrEP modalities and service delivery features; and IDIs assessed knowledge of LAI-PrEP, coupled with perceived barriers to uptake and continuation. Using rapid thematic analysis, we deductively identified salient concepts and emerging themes across FSW.
Results
Among 44 FSW (median age: 30 [IQR 26-38]) most reported past oral PrEP use, with determinants of LAI-PrEP use and implementation identified across three domains of the CFIR: innovation characteristics, implementation process, and the inner setting (Figure 1). FSW demonstrated autonomy in PrEP modality choice, believing in their own capability and decision-making power to start LAI-PrEP when ready. However, insufficient knowledge around how long LAI-PrEP remains in the body, coupled with concerns around potential side effects, made participants eager for additional education and counseling. FSW also expressed hesitancy in being the first of their peers to initiate LAI-PrEP and concerns surrounding potential interactions with other medications, including injectable contraceptives. Decentralized delivery via mobile van was generally preferred over drop-in-centers and clinics to support adherence to LAI-PrEP; however, FSW in eThekwini remained concerned about potential missed injections given frequent travel home, including away from South Africa
Conclusions
Nearly two years after Cabotegravir received regulatory approval in South Africa, FSW remain largely unable to access LAI-PrEP, despite established efficacy and community interest. As LAI-PrEP products become increasingly available, strategies supporting counseling, education, and diversity in PrEP delivery sites for FSW can optimize implementation and equitable LAI-PrEP uptake and continuation.