Beyond the pill: Understanding barriers and enablers to oral and long-acting injectable PrEP among women in sex work in Zambia

Women engaging in sex work (WESW) in low- and middle-income countries face a disproportionately high risk of HIV infection. This study explores enablers and barriers to the uptake and persistence of oral pre-exposure prophylaxis (PrEP) and long-acting injectable PrEP (LAI-PrEP) among WESW in Lusaka, Zambia. We evaluated Capability, Opportunity, and Motivation behavioral domains, using the COM-B model, which affectied behavioral engagement with PrEP services among newly-initiated WESW from community-based safe spaces. Participants were recruited from July-October 2023 and interviewed using a semi-structured guide to explore barriers and enablers to engagement with HIV prevention. We used a rapid analysis approach-a two-step qualitative method-to identify themes aligned with COM-B domains. Interviews were conducted in English, ChiNyanja, or IchiBemba, audio-recorded, translated into English when necessary, and transcribed verbatim. Among 18 participants with a median age of 28 years (IQR:23-33) and 5 years in sex work (IQR:2,7), education during outreach by peer navigators and program staff was crucial to building trust and demystifying PrEP. Persistent knowledge gaps and misconceptions, especially about daily adherence and alcohol use, were significant barriers. Trustworthy program staff and reliable service provision facilitated continued PrEP use, and women preferring that drugs be delivered to them. Social support systems were mixed, offering both aid and competition. Personal empowerment and health protection motivated PrEP use, with LAI-PrEP preferred for eliminating daily pill burdens and associated stigma. However, inconsistent supply and misconceptions about LAI-PrEP were potential barriers. This study underscores the importance of person-centered care in addressing the complex interplay of individual, community, and programmatic factors influencing PrEP engagement among WESW in Zambia. A holistic focus, and adaptive health service delivery approach are both crucial to ensure that advances in HIV prevention translate into tangible benefits for WESW. Reliable, respectful healthcare programs that provide accurate, and trusted information are essential for improving PrEP uptake and persistence.