Service Delivery Preferences for Long-acting Pre-exposure Prophylaxis among Pregnant and Breastfeeding Women in South Africa and Botswana

Abstract

Objective HIV particularly affects women during pregnancy and postpartum, where they face a two-fold or more increased risk of HIV acquisition. Structural and individual barriers hinder effective use of daily oral pre-exposure prophylaxis (PrEP). We explored preferences for long-acting PrEP and multipurpose prevention technologies among pregnant and breastfeeding women (PBFW) without HIV. Design Between April and December 2023, we evaluated preferences for long-acting PrEP in a discrete choice experiment among pregnant and breastfeeding, postpartum women accessing maternal services at the primary healthcare level. Methods The study included individuals with prior experience using oral PrEP (Cape Town, South Africa) and those PrEP naive (East London, South Africa, and Gaborone, Botswana). The discrete choice experiment was developed through qualitative interviews and focus group discussions. Analysis included demographic characterization, site stratification, mixed effects logistic regression, and latent class modelling. Results We surveyed 450 pregnant and breastfeeding women (52% pregnant, 47% breastfeeding). Women strongly disfavoured vaginally inserted and implanted PrEP compared to oral PrEP. Preferences varied by study population: clinic PrEP pick-up was preferred in East London and Gaborone, while Cape Town showed more indifference for community delivery. Women in East London and Gaborone prioritized PrEP effectiveness over frequency. Three latent classes emerged: Class 1, ‘comprehensive delivery seekers’ (43%); Class 2, ‘physical and physiological prioritisers’ (25%), and Class 3, ‘vaginal insertion avoiders’ (32%). Conclusions PrEP modality (long-acting), frequency, and pickup location were important factors in PrEP delivery. Future PrEP programs should prioritize user-centered approaches, aligning with user values and preferences to foster effective use.