PrEP uptake, persistence, and patterns of choice dynamics between oral and long-acting injectable with cabotegravir among sexually and gender-diverse adolescents in Brazil: a multisite cohort implementation study

Summary Background Long-acting injectable (LAI) pre-exposure prophylaxis (PrEP) is a newly approved HIV prevention method, and scarce data exist on its real-world implementation among sexually and gender-diverse adolescents (SGDA). This study investigated PrEP uptake, persistence, and patterns of choice dynamics between oral and LAI-PrEP in SGDA in Brazil. Methods PrEP15-19 Choices is an implementation study offering both oral and LAI-PrEP with cabotegravir to SGDA aged 15–19, across three Brazilian cities. Data were collected through structured forms and PrEP prescription records (between April 1, 2024, and September 2, 2025). Choice dynamics were defined as the willingness to use each modality of PrEP as well as initiation and switching between injectable and oral options. Descriptive, bivariate, and multiple logistic regression analyses were conducted. Findings Of 2150 adolescents reached, 30.0% (n = 644) initiated a PrEP modality: mean age of 18 years old (standard deviation=1.0), 78.3% were cisgender men who had sex with men and 73.4% self-identified as Black or Pardo. Before consultation, the willingness to use daily oral, event-driven (ED), and LAI-PrEP was 32.4%, 17.1%, and 50.5%, respectively, and the actual initiation rates were 38.4% for daily oral PrEP, 18.3% for ED-PrEP, and 43.3% for LAI-PrEP. Among adolescents who started oral PrEP, 24.7% later switched to LAI-PrEP. Conversely, of those who started LAI-PrEP, 10.7% later switched to oral PrEP. Nineteen suicidality events were reported among 13 participants after LAI-PrEP initiation. Participants had higher odds of initiating LAI-PrEP if they had prior experience with oral PrEP (adjusted odds ratio [aOR] 2.07; 95% confidence interval [CI]: 1.35–3.17) or had experienced discrimination based on gender identity or sexual orientation (aOR 1.69; 95% CI: 1.19–2.41). In addition, participants had higher odds to switching from oral to LAI-PrEP if they were Black or Pardo (aOR 2.03; 95% CI: 1.03–4.02). The persistence rates among oral and LAI-PrEP users were 79.3% and 88.8%, respectively. Interpretation Adolescent-centered HIV prevention should prioritize choice and psychosocial support. The preference for long-acting formulations among adolescents experiencing discrimination and among Black and Pardo individuals highlights their potential to reduce structural barriers and advance equity in PrEP access. Funding UNITAID and Brazilian Ministry of Health.