PrEP preferences and early acceptability of injectable cabotegravir among pregnant and lactating people in Cape Town, South Africa: findings from the PrEPared to Choose study

Introduction

Providing pregnant and lactating people (PLP) with choice in HIV pre-exposure prophylaxis (PrEP) methods, including long-acting injectable cabotegravir (CAB-LA), may mitigate barriers to effective PrEP use. We evaluated PrEP preferences and acceptability among PLP offered CAB-LA versus oral PrEP in South Africa.

Methods

The PrEPared to Choose study in Cape Town, South Africa, enrolled young people ages 15–29 at one public clinic and one community-based mobile clinic. Using informed choice counselling, participants were offered oral PrEP or CAB-LA, with the option to switch methods at follow-up visits over 18 months. We report baseline CAB-LA and oral PrEP initiations among PLP in the study, acceptability of their initial choice within 3 months of enrolment and theoretical preferences regarding PrEP methods that may become available to PLP. We report descriptive statistics and use Chi-square and Fisher's exact to compare responses by initiated PrEP method and pregnancy status.

Results

From February to August 2024, we enrolled 58 PLP (n = 30 pregnant, n = 28 breastfeeding). Median age 23 years (IQR 19.5−26). Of 30 pregnant participants, 23 (77%) initiated CAB-LA and seven (23%) oral PrEP; among 28 breastfeeding participants, 25 (89%) initiated CAB-LA and three (11%) oral PrEP. Of enrolled PLP, 36 (62%, n = 13 pregnant, n = 23 breastfeeding) completed the acceptability survey. Of these, 83% (n = 12/13 pregnant, n = 20/23 breastfeeding) chose and received CAB-LA, and the remaining (n = 4) chose and received oral PrEP. PLP who received CAB-LA reported liking its ease of use (69%; n = 22/32) and long-acting protection (44%; n = 14/32). Half of CAB-LA users disliked side effects (e.g. injection site pain), although 41% of PLP (n = 13/32) described no CAB-LA dislikes. Almost all (97%; n = 31/32) PLP currently using CAB-LA were interested in continuing CAB-LA, and all PLP using oral PrEP reported interest in trying CAB-LA in the future. Eighty-six percent of surveyed PLP (n = 31/36) did not want to try the dapivirine vaginal ring.

Conclusions

PLP in South Africa had a strong preference for CAB-LA over oral PrEP, and CAB-LA was found to be highly acceptable. Further research is needed to evaluate the effect of offering choice of PrEP methods, including CAB-LA, on PrEP continuation among PLP.