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The Invisible Product

Preferences for Sustained-Release, Long-Acting Pre-exposure Prophylaxis to HIV Among South African Youth

Montgomery, Elizabeth T., PhDa; Atujuna, Millicent, PhDb; Krogstad, Emily, PhDa; Hartmann, Miriam, MPHa; Ndwayana, Sheily, BAb; O'Rourke, Shannon, MPHa; Bekker, Linda-Gail, PhD, MDb; van der Straten, Ariane, PhDa,c; Minnis, Alexandra M., PhDa,d

JAIDS Journal of Acquired Immune Deficiency Syndromes: April 15, 2019 - Volume 80 - Issue 5 - p 542–550
doi: 10.1097/QAI.0000000000001960
Prevention Research

Background: Long-acting injectable and implantable approaches aim to overcome some of the documented challenges with uptake and adherence to current HIV prevention methods. Youth are a key end-user population for these methods. We used qualitative methods to examine product attributes and preferences for current and future long-acting HIV prevention approaches.

Methods: Ninety-five South African youth aged 18–24 years, of whom 62 were female and 33 male, completed 50 interviews and 6 focus groups. We purposively selected for previous product experience, including oral pre-exposure prophylaxis, injectable pre-exposure prophylaxis, or the vaginal ring, to ensure participants' opinions were rooted in actual experience.

Results: Irrespective of previous method-use experience, gender, or sexual orientation, the majority expressed a preference for prevention methods formulated as injectables or implants. Several mentioned that their top priority in any product was efficacy, and for some, this overrode other concerns; for example, even if they feared pain, an implant or an injectable would be used if fully protective. Although efficacy was a top priority, there was also a clear desire across all subgroups for a product that would not interfere with sex, would stay in the system to provide protection, and that caused minimal burden, or was not apparent to others, and these characteristics were most salient for long-acting methods.

Conclusions: Narrative explanations for preferences converged thematically around different dimensions of “invisibility” including invisibility to oneself, one's partner and household members, and community members. End-user preferences can be used to inform product development of long-acting HIV prevention approaches formulated as injections or implants to optimize adherence and impact.

aWomen's Global Health Imperative, Center for Global Health/SSES, RTI International, San Francisco Project Office, San Francisco, CA;

bDesmond Tutu HIV Research Centre, Cape Town, South Africa.

cDepartment of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, CA; and

dSchool of Public Health, University of California, Berkeley, CA.

Correspondence to: Elizabeth T. Montgomery, PhD, Women's Global Health Imperative, Center for Global Health/SSES, RTI International, 351 California Street, Suite 500, San Francisco, CA 94104 (e-mail:

Supported by the National Institute of Mental Health (1R01MH105262). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The authors have no funding or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received April 19, 2018

Accepted November 11, 2018

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