Injectable PrEP tops list as the preferred choice for adolescent girls in Cape Town

Adolescent girls prefer long-acting injections and the vaginal ring over daily pills as their product of choice for both contraception and pre-exposure prophylaxis (PrEP) for HIV prevention finds a study from Cape Town, South Africa. The study looked at contraceptive choices of adolescent girls (ages 15 to 19) to establish what type of pre-exposure prophylaxis (PrEP) product they might prefer.

Between 2015 and 2017, 130 participants were asked to use an injectable contraceptive, a monthly contraceptive vaginal ring or a daily pill for 16 weeks. After this, participants were asked to use one of the other methods on offer, again for 16 weeks.

At the end of the 32-week study, participants were asked for their views on these contraception methods and to imagine what type of PrEP product they might therefore prefer.

More than two‐thirds of participants had used either oral or injectable contraception before the study but none had used a vaginal ring. As a result, the study ensured all participants tried the vaginal ring plus either the injection or pill.

Participants’ median age was 17 and the most common age for becoming sexually active was 15. One in five were in relationships with men who were at least five years older than them, and 10% reported having multiple sex partners. Half of the participants reported not using a condom the last time they had sex.

At the end of the study around half of the participants (48%) said they preferred the injection due to its ease of use and long‐lasting effects. This was followed by the ring (preferred by 38% of participants), and lastly the pill (10%). The remaining participants picked contraceptive methods not included in the study, such as condoms. These preferences closely mirrored the imagined choice of PrEP product.

When surveyed, participants’ greatest motivator for using contraception was to protect themselves from pregnancy. Despite their heightened vulnerability to HIV and high‐risk sexual behaviour, most participants perceived themselves to be at low risk for contracting HIV.

This risk is underscored by the high prevalence of sexually transmitted infections (STIs) observed among participants. Almost half (42%) tested positive for at least one curable STI, the most common being Chlamydia. HIV incidence was relatively low with just one HIV infection recorded during the study.

Among participants who tried the ring, 21% changed methods before the 16 weeks ended. By contrast, only one participant who had the injection changed methods early, as did only 8% of those taking contraceptive pills. Reticence towards the vaginal ring may be due to a lack of familiarity with it or a lack of belief that it could prevent pregnancy.

The unpopularity of the pill was largely due to participants’ concerns that they would forget to take it every day. Indeed, adherence proved difficult as only around half of pill users (52%) fully adhered. By comparison, 93% of injection users and 78% of ring users fully adhered.

These findings indicate there is a need to provide integrated, adolescent-friendly STI and HIV prevention, sexual health and contraceptive services to adolescent girls. The diversity of preferences, which are likely to change over time, also shows the need to provide a range of options.

Further work is needed to explore the disconnection between adolescent girls’ perceived and actual risk of HIV. Given that preventing pregnancy is a highly motivating factor for adolescent girls, the development of new technologies that simultaneously prevent HIV and pregnancy might ultimately be the best way to meet adolescent girls’ sexual and reproductive health needs.