PrEP uptake and delivery setting preferences among clients visiting six healthcare facilities in Eswatini

Preference for Service Delivery for Long-Acting Pre-exposure Prophylaxis for HIV Infection Among Pregnant and Breastfeeding Women in South Africa and Botswana

HIV particularly affects women during pregnancy and postpartum, where they face a two-fold or more increased risk of HIV acquisition. We explored preferences for long-acting PrEP and multipurpose prevention technologies among pregnant and breastfeeding women (PBFW) without HIV. From April to December 2023, we conducted a discrete choice experiment at maternal healthcare clinics in Cape Town, East London (South Africa), and Gaborone (Botswana) including PrEP-experienced and PrEP-naive women. Analysis included site stratification, mixed-effects logistic regression, and latent class modeling. Among 450 pregnant and breastfeeding women (52% pregnant, 47% breastfeeding), vaginally inserted and implanted PrEP was least preferred compared to oral. East London and Gaborone preferred clinic PrEP pick-up and effectiveness, while Cape Town showed indifference for community delivery. Three latent classes emerged: 'comprehensive delivery seekers' (43%), 'physical and physiological prioritisers' (25%), and 'vaginal insertion avoiders' (32%). Future PrEP programs should prioritize user-centered approaches, aligning with user preferences for effective use.

HIV Prevention Product Acceptability and Preference Among Women in Sub-Saharan Africa to Inform Novel Biomedical Options in Development: A Systematic Review

The availability of several HIV prevention options may allow women to choose a product that suits their lifestyle and preferences. Product attributes and contextual factors influence product acceptability, which affects uptake and effective use. We conducted a systematic review of acceptability and preference for biomedical HIV prevention products among women in sub-Saharan Africa (SSA) to inform the development of novel products. We used a comprehensive strategy to search three databases for peer-reviewed literature from SSA published between January 2015 and December 2023. A two-stage review process assessed references against eligibility criteria. Data were abstracted using a standardized spreadsheet, then organized by constructs from two theoretical frameworks of acceptability. Results were synthesized based on product classes defined by route of administration. We identified 408 unique references; 100 references met eligibility criteria. References assessed oral PrEP (n = 65), vaginal ring (n = 44), long-acting systemic products (injectable, implant, microarray patch) (n = 28), and other vaginal products (film, insert, gel) (n = 20). Over two-thirds reported qualitative or mixed-methods data, primarily from adolescent girls and young women. Frequent dosing, especially noted for daily oral PrEP, and perceived/experienced side effects were notably negative influences. Most end-users preferred long-acting products (systemically or vaginally delivered), though on-demand products offering user control were also valued. Influencing factors, especially partners, shaped end-user perceptions of product attributes and acceptability. All products were linked to at least some barriers to uptake and/or use, highlighting the need to provide end-users with a range of options and assist them in identifying one that best suits their circumstances and needs. Biomedical HIV prevention development should advance products that address gaps in available options while optimizing favorable product attributes to achieve high acceptability that ultimately supports adoption and use.

HIV Pre-exposure Prophylaxis (PrEP) Care in Belgium: A mixed-methods Study on PrEP Users' Experiences and Service Delivery Preferences

In Belgium, HIV pre-exposure prophylaxis (PrEP) services are mainly provided through specialised HIV clinics. To optimise PrEP uptake and retention in care, we require insights into users' perspectives on PrEP care. We aimed to elicit experiences with, and preferences for, PrEP service delivery among PrEP users in Belgium, including willingness to involve their family physician (FP) in PrEP care. We adopted a sequential mixed-methods design. We used a web-based longitudinal study among 326 PrEP users that consisted of two questionnaires at six-month intervals, and complemented this with 21 semi-structured interviews (September 2020-January 2022). We conducted descriptive analyses and logistic regression to examine factors associated with willingness to involve their FP in PrEP care. Interviews were analysed using thematic analysis. Survey respondents reported high satisfaction with care received in HIV clinics [median score 9 (IQR 8-10), 10='very satisfied']. Interviews revealed the importance of regular HIV/STI screening, and the expertise and stigma-free environment of HIV clinics. Yet, they also contextualised service delivery barriers reported in the questionnaire, including the burden of cost and challenges integrating PrEP visits into their private and professional lives. Although 63.8% (n = 208/326) of baseline respondents preferred attending an HIV clinic for PrEP follow-up, 51.9% (n = 108/208) of participants in the follow-up questionnaire reported to be willing to have their FP involved in PrEP care. Participants reporting trust in FPs' PrEP and sexual health expertise, or who didn't feel judged by their FP, were more likely to be willing to involve them in PrEP care. Therefore, we recommend a differentiated PrEP service delivery approach, including involving FPs, to make PrEP care more client-centred.

Out-of-pocket Expenses and Time Spent on Clinic Visits Among HIV Pre-exposure Prophylaxis Users and Other Clinic Attendees in Eswatini

User costs constitute a barrier to the uptake of HIV pre-exposure prophylaxis (PrEP), but their magnitude appears rarely assessed. In this prospective observational study, we assessed self-reported out-of-pocket expenses (OOPE) and time spent on clinic visits during a PrEP demonstration project in Eswatini. At six public primary care clinics, 240 PrEP users and other clinic attendees were interviewed after a clinic visit. Among the 79.2% of clinic attendees reporting any medical OOPE (e.g., expenses for consultations or drugs) and/or non-medical OOPE (e.g., expenses for transport, food, or phone use), the median total OOPE was $1.36 (IQR 0.91-1.96). Non-medical OOPE occurred mostly due to transport expenses. The median travel time for a clinic visit was 1.0 h (IQR 0.67-2.0). The median time spent in the clinic was 2.0 h (IQR 1.15-3.0). The median opportunity cost of a clinic visit was $7.54 (IQR 5.42-11) when valuing time spent on a clinic visit with Eswatini's per-capita gross domestic product. Our findings can guide measures to reduce the user costs of PrEP in Eswatini and other contexts in which oral PrEP is provided through health care facilities.