“People have options”: a qualitative study of experiences and influences of PrEP choice among women in South Africa

Introduction

Long-acting injectable cabotegravir and dapivirine vaginal ring were recently introduced in South Africa through demonstration projects, providing additional HIV prevention options to oral pre-exposure prophylaxis (PrEP). PrEP choice marks a pivotal moment in HIV prevention, potentially increasing PrEP uptake and use by offering women a choice of methods best suited to their individual needs. Understanding experiences of PrEP choice in real-world settings is critical to informing the introduction of PrEP choice at scale. This study, embedded within an implementation science study introducing new PrEP methods, explores women's experiences of PrEP choice counselling, and factors influencing PrEP choice.

Methods

Between April and May 2024, we conducted 12 focus group discussions with a sub-set of 126 women (18–57 years) enrolled in a parent cohort study delivering PrEP choice at six fixed and three roving mobile clinics in three areas of South Africa. Cohort participants are HIV-negative men and women ≥ 15 years interested in HIV prevention services. At the time of data collection, non-pregnant and lactating women ≥ 18 years enrolled in the cohort were provided PrEP choice counselling and offered a choice of oral PrEP or dapivirine vaginal ring. Discussions explored women's experiences of PrEP choice counselling and influences of PrEP choice. They were audio recorded, transcribed verbatim and translated into English for thematic analysis.

Results

Women reported positive choice counselling experiences, particularly when it was supplemented by pamphlets, demonstration rings and pelvic models. Participants valued learning about alternative PrEP methods and appreciated friendly healthcare providers who answered their questions. Privacy and emotional support were also crucial. However, negative experiences included the use of complex scientific jargon and insufficient information on PrEP's potential drawbacks. PrEP choices were mainly influenced by concerns about intravaginal products, distrust of new methods, prior oral PrEP experiences, and partner and family opinions.

Conclusions

These findings will guide strategies for PrEP delivery, emphasizing provider training, effective counselling tools and tailored communication. Women valued clear, jargon-free information, visual aids and a welcoming environment, which supported open dialogue. The influence of prior oral PrEP experiences on PrEP choice highlights the need for counselling that addresses specific concerns and preferences.