“I Feel Like I Am a Winner:” High Levels of Autonomous Decision-Making Among Women Receiving HIV Pre-Exposure Prophylaxis (PrEP) Choice Counselling in Sub-Saharan Africa

Abstract As pre-exposure prophylaxis (PrEP) options expand, providers play a critical role in supporting clients to select the method that best meets their needs. We examined how client–provider interactions during PrEP choice counselling influenced women’s autonomous decision-making and early continuation on PrEP. CATALYST was a mixed-methods study that delivered an informed choice of oral PrEP, the dapivirine vaginal ring, and injectable cabotegravir among women attending 28 public-sector facilities in Kenya, Lesotho, South Africa, Uganda, and Zimbabwe. We analysed cohort data collected between June 2024 and January 2025 and adapted a family planning Autonomous Decision-Making (ADM) scale into a six-item PrEP-specific measure (PrEP-ADM scale). Factor analysis assessed scale structure, and logistic regression identified factors associated with fully autonomous decision-making (PrEP-ADM score of 18/18) and refilling PrEP within three months. Twenty-six in-depth interviews explored counselling experiences. Among 2,488 women, 92% reported fully autonomous decision-making. Two subscales were identified: “communicating information” and “supporting informed choice”. Women in sero-different partnerships had higher odds of reporting fully autonomous decision-making (adjusted odds ratio [aOR]: 1.63, 95% CI: 1.11–2.39), whereas pregnant (aOR: 0.29, 95% CI: 0.17–0.47) and breastfeeding women (aOR: 0.46, 95% CI: 0.28–0.76) had lower odds. Autonomous decision-making was not associated with PrEP refill. Qualitative findings confirmed clear information exchange and supportive counselling, although pregnant and breastfeeding women described more constrained choices. High levels of perceived autonomous decision-making were observed, though further work is needed to refine these measures and identify the essential elements of informed PrEP choice counselling.