“My heart is at peace because I know that I am protected:” understanding the factors that facilitate adolescent girls and young women’s uptake of long-acting injectable PrEP in Zambia

Abstract

Adolescent girls and young women (AGYW) in EASTERN AND SOUTHERN Africa face a disproportionate risk of HIV acquisition. While effective, uptake of daily oral pre-exposure prophylaxis (PrEP) for HIV prevention among this population has remained inadequate. Hypothetical preference studies suggested that long-acting injectable PrEP (LAI-PrEP) would be preferred to oral PrEP. However, little is known about the real-world implementation of LAI-PrEP. Zambia was one of the first countries to integrate cabotegravir LAI-PrEP into its national guidelines. This qualitative study explored factors influencing uptake of LAI-PrEP among AGYW in a community setting in Zambia. We conducted semi-structured interviews with 33 AGYW aged 16–24 at two community-based Determined, Resilient, Empowered, AIDS-free, Mentored and Safe initiative (DREAMS) centers in Southern Province, Zambia, in late 2024. Andersen’s Behavioral Model of Health Service Use informed our work. Five key themes explained uptake: (1) partners cannot be trusted; (2) injectable PrEP’s discretion reduces PrEP stigma and associated discrimination; (3) the freedom of a long-acting modality eliminates daily pill-taking burdens; (4) established intervention programs counter community misinformation about new health technologies; and (5) friends foster uptake through peer support. Participants expressed that cabotegravir addressed their concerns related to oral PrEP uptake barriers for AGYW including stigma, disclosure, and cognitive burden. The DREAMS program’s established community trust was essential for overcoming misinformation and facilitating uptake. LAI-PrEP enables young women to maintain sexual health autonomy within contexts of unequal gender power dynamics, offering discreet protection compared to oral PrEP formulations.