A qualitative exploration of women’s choices and experiences of using oral and vaginal HIV pre-exposure prophylaxis in Eswatini

Understanding women's decision-making when offered different HIV pre-exposure prophylaxis (PrEP) options is critical for improving uptake. This qualitative study explored factors influencing PrEP choices among Swazi women in 2022-2023. In-depth interviews were conducted with 17 women who accepted or declined oral PrEP or the Dapivirine vaginal ring; and 6 healthcare workers who prescribed PrEP. One focus group discussion (FGD) with eight women eligible for PrEP and three FGDs with six to eight male community members explored attitudes to PrEP. Data were collected in Siswati, transcribed into English, and analyzed thematically. Women's decisions around PrEP use and product preferences were shaped by social norms around sexual relationships, practicalities of use and perceptions of effectiveness. Many preferred "invisible" methods, such as the ring, to avoid stigma or partner violence, while oral PrEP was favored by some women practicing anal sex. Ease of adherence, side-effects and ring insertion practicalities also influenced choices. Some participants questioned PrEP effectiveness or feared it might spread HIV, while some healthcare workers noted that future injectable options could reduce blame in cases of seroconversion. The findings highlight the need to offer women a range of PrEP options, supported by accurate information, to expand coverage in high-incidence settings.