Empowering women's PrEP choices : qualitative insights into long-acting PrEP preferences and decision-making during pregnancy and breastfeeding in South Africa and Botswana

Abstract

Pregnant and breastfeeding women (PBW) are at heightened risk of HIV acquisition. We aimed to explore PBW’s preferences of various long-acting PrEP modalities. In-depth interviews were conducted with PBW at three sites: Cape Town, East London (South Africa), and Gaborone (Botswana). We conducted thematic analysis, guided by the Health Belief Model, to examine participants’ HIV risk perception during pregnancy and breastfeeding, their perceived individual-level facilitators and barriers of each PrEP modality, and the support needed by participants for PrEP uptake and continuation. 40 participants were interviewed, aged 18–39 years (mean 27 years), including 13 adolescent girls and young women (AGYW; 18–24 years). Participants were either pregnant (n = 20) or breastfeeding (n = 20). Perceived HIV risk during pregnancy motivated PrEP use. Long-acting methods were preferred over daily pills for convenience and perceived reliability, with injectables most favoured due to familiarity with contraceptive injections. However, concerns about pain and side effects persisted. Monthly oral PrEP was seen as easier than daily pills but raised similar concerns about adherence. Implants were met with fear and mistrust, often rooted in negative contraceptive experiences, though some valued their long-term protection. The vaginal ring was least acceptable due to unfamiliarity and discomfort with insertion. Participants emphasised the importance of external support (e.g. reminders), privacy and discretion, and community transparency to support PrEP adherence and reduce stigma. Addressing barriers – especially concerns about the safety and effectiveness of new modalities and challenges around adherence – could help improve strategies to better assist PBW in utilising long-acting PrEP modalities.