Improving malaria chemoprevention coverage in pregnancy: Surveying stakeholder preferences for new product profiles and community-delivery approaches across five African countries

Sulfadoxine-pyrimethamine (SP) is the only WHO-recommended option for the intermittent preventive treatment of malaria in pregnancy (IPTp). However, coverage is suboptimal, efficacy is limited in areas of high resistance and SP is contraindicated in the first trimester and women living with HIV receiving cotrimoxazole. This study investigated stakeholder perspectives on next-generation IPTp product characteristics and their potential impact on uptake, adherence and community deployment. Surveys were conducted in five malaria endemic countries, including pregnant women (n = 75), nurses/community health workers (CHWs) (n = 53), clinicians (n = 75) and policymakers (n = 51). Surveys included quantitative elements and open-ended questions to examine stakeholder perceptions of chemoprevention product characteristics influencing uptake, adherence and implementation. Additionally, a discrete choice experiment (DCE) conducted among clinicians and policymakers compared next-generation IPTp oral product profiles against SP. Across stakeholders the most important attribute was safety in all trimesters, followed by short duration of therapy, few tablets per day, food requirements and impact on birthweight was the least influential. Clinicians and policymakers also believed resistance markers to be important. All stakeholder groups indicated that a long-acting injectable with at least three months' coverage would enhance adherence. For oral medication, pregnant women believed being able to take food with treatment was the most important attribute to enhance adherence, while a four-tablet daily dosing would decrease adherence. Clinicians and policymakers felt that delivery by CHWs would increase adherence and expand IPTp uptake in currently unreached women. However, three-quarters of pregnant women preferred ante-natal clinic delivery of a new medicine. The DCE favored products without food restrictions most strongly. This study offers important insights for the development and deployment of next-generation IPTp products. Minimizing food-related restrictions and addressing resistance concerns are key priorities, together with safety and tolerability. Long-acting injectable formulations and hybrid delivery models could play a substantial role in improving adherence and uptake.