Perceptions of Long-Acting HIV Pre-Exposure Prophylaxis and Preferences for Service Delivery Among Young Women in Tertiary Institutions in South Africa

Abstract

Introduction: Despite various HIV prevention strategies, such as free condom distribution and post-exposure prophylaxis (PEP), HIV remains a global challenge. Adolescent girls and young women (AGYW), particularly in sub-Saharan Africa, account for nearly two-thirds of new infections. Oral pre-exposure prophylaxis (PrEP), introduced in South Africa in 2016, has proven effective but faces low uptake among youth due to daily pill requirements and side effects. Recently approved long-acting methods, including injectable cabotegravir (CAB-LA) and the dapivirine vaginal ring (DVR), provide promising alternatives but require effective delivery strategies tailored to young women. This PhD study examines the PrEP preferences of young women in tertiary institutions in South Africa and identifies which attributes of service delivery they prioritise. Methods: This study used a sequential exploratory mixed-methods approach, collecting data from August 2022 to October 2023. The qualitative phase explored young women’s experiences with contraceptive services, focusing on barriers, facilitators, and perceptions of long-acting PrEP technologies. It included 22 in-depth interviews and five focus group discussions, analysed using a thematic approach guided by the socio-ecological and diffusion of innovation models, with NVivo 12 software. A nominal group technique identified service delivery attributes, which informed the development of a discrete choice experiment (DCE). The DCE quantitatively assessed service delivery priorities through trade-offs among 400 participants, with data collected via computer tablets, stored in REDCap, and analysed in Stata 16 using mixed logit and latent class models. Results: We identified multi-level factors influencing contraceptive service utilisation and PrEP method preferences among young women. Individual-level barriers included method discontinuation, primarily due to side effects, while health system barriers centred on negative provider attitudes that deterred service access. Family-level facilitators highlighted mothers' pivotal role in enabling contraceptive use through emotional and logistical support. Regarding PrEP method preferences, CAB-LA was favoured for its lifestyle compatibility, whereas oral PrEP was least preferred due to daily dosing requirements. DVR faced scepticism stemming from discomfort with vaginal insertion of the ring. From the DCE, we found that campus clinics were preferred over public clinics, and young women preferred to return to the clinic for support in managing side effects rather than using digital tools such as ix chatbots. They also preferred providers who were good listeners and specialists in PrEP provision. Conclusion: Young women’s preference for long-acting CAB-LA stems from its lifestyle compatibility and alignment with injectable contraceptives such Nuristerate, enabling opportunities for integrated service delivery. Youth-friendly providers are critical for PrEP accessibility, requiring ongoing training to address stigma and foster non-judgmental care. Campus-based clinics are prioritised by tertiary students, necessitating expansion to reduce barriers. The National Department of Health should scale up nurse training in youth- friendly services and invest in targeted awareness campaigns to address low PrEP literacy, including among mothers and partners. A multipronged approach, combining service integration, provider sensitisation, and demand creation, is essential to ensure sustained method use.