Implementation considerations for long-acting injectable PrEP rollout among female sex workers in South Africa: A qualitative analysis guided by the Consolidated Framework for Implementation Research

Background Female sex workers (FSW) in South Africa are disproportionately impacted by HIV, yet daily oral pre-exposure prophylaxis (PrEP) initiation and continuation rates among FSW remain low. Long-acting injectable PrEP (LAI-PrEP) may alleviate many oral PrEP adherence challenges; however, LAI-PrEP remains largely unavailable in South Africa. Objectives Explore the multilevel contextual determinants likely to influence LAI-PrEP’s implementation among FSW to inform rollout strategies. Design Cross-sectional, qualitative study with in-depth interviews and focus group discussions. Methods From May to June 2024, 42 adult FSW not living with HIV and accessing services from two decentralized FSW delivery sites in eThekwini and Ehlanzeni participated in interviews (12 per study site; n=24 FSW total) and focus groups (1 per study site; n=18 FSW total). Four providers were also interviewed (2 per study site). Semi-structured guides, based on the Consolidated Framework for Implementation Research (CFIR), elicited client and provider perceptions of contextual factors hypothesized to influence future LAI-PrEP implementation, mapped to CFIR constructs through team-based, deductive thematic analysis. Results Many FSW conveyed strong acceptance and preferences for LAI-PrEP due to perceived advantages over oral PrEP including greater dosing privacy in clinical spaces, fewer dispensing intervals, and reduced stress from daily pill-taking. Providers perceived LAI-PrEP as a priority to augment existing HIV prevention services; however, financial investments, additional staff, and LAI-PrEP counseling training would be needed to enhance programmatic capabilities. Prioritization of non-discriminatory provider attitudes will be crucial to combat persistent racialized and economic inequities that exacerbate stigma against FSW in public healthcare facilities. Finally, decentralized delivery, utilizing community champions, and integrating LAI-PrEP with other health services emerged as promising strategies to ensure an equitable rollout of LAI-PrEP, assuming adequate global or national investment. Conclusion Findings suggest that LAI-PrEP is perceived by both potential recipients and deliverers to effectively address several barriers to oral PrEP continuation, making it a promising advancement in the landscape of HIV prevention. Implementation strategies that integrate identified stakeholder priorities and preferences, anticipated barriers, and existing programmatic strengths, will likely optimize LAI-PrEP rollout among a historically marginalized population in South Africa.