A Systematic Review of Barriers and Facilitators to the Uptake and Adherence of Injectable PrEP Among Adolescent Girls and Young Women in Sub-Saharan Africa.

Abstract

Adolescent girls and young women (AGYW) in sub-Saharan Africa bear a disproportionate burden of HIV. Long-acting injectable PrEP (LAI-PrEP) may address adherence challenges associated with daily oral PrEP, but social and structural barriers threaten real-world implementation. Drawing on parallels with injectable contraception and multipurpose prevention technologies (MPTs), this systematic review synthesizes evidence on barriers and facilitators to LAI-PrEP use among AGYW in sub-Saharan Africa. Following PRISMA guidelines, peer-reviewed studies published January 2015 to February 2025 were identified across four databases. Studies were included if they examined barriers or facilitators to uptake or adherence of injectable PrEP, contraception, or MPTs among AGYW in sub-Saharan Africa. Data were abstracted using a socioecological model adapted for PrEP implementation. Of 1,716 screened references, 53 met inclusion criteria, spanning 37 countries. Most studies focused on injectable contraception; only nine examined injectable PrEP, eight of which assessed hypothetical use. Cross-cutting barriers included fear of side effects, misinformation, stigma, and logistical and cognitive challenges related to return visits. Cross-cutting facilitators included familiarity with injectables, social support, and perceived privacy. Partner and provider power dynamics, restrictive sociocultural norms, provider gatekeeping, and health system limitations further shaped injectable use. Despite biomedical advantages, LAI-PrEP uptake among AGYW may face entrenched barriers similar to other PrEP modalities. Although AGYW's familiarity with injectable contraception may enhance LAI-PrEP acceptability, systemic and interpersonal challenges remain under-addressed. Effective LAI-PrEP implementation in the real-world will require integrating lessons from contraceptive programs, improving provider training, expanding delivery channels, and centering AGYW in decision-making to support equitable scale-up.