“Some people fear injection and others don’t want to swallow tablets, while others forget”: Health care provider perspectives on the PrEP (dapivirine) ring in rural Uganda (“ProPrEP”)

BACKGROUND Adolescent girls and young women (AGYW) remain disproportionately affected by HIV globally, accounting for over 60% of adults living with HIV in sub-Saharan Africa (SSA). Expanding the choice in pre-exposure prophylaxis (PrEP) methods is essential for this population, whose autonomy is often constrained by entrenched gender norms. The dapivirine or PrEP ring is now approved in eleven SSA countries, including Uganda. While prior studies have focused on potential users, little is known about healthcare providers’ perspectives despite their central role in impacting its uptake. The aim of this study was to explore the knowledge and perceptions of health care providers (HCPs) regarding the dapivirine ring for use by AGYWs in rural Uganda. METHODS The study utilized a qualitative cross-sectional design. Sixty government HCPs from the Rakai and Kyotera Districts were recruited from the directory of a locally-led, non-governmental organization focused on maternal and newborn health systems. Six focus group discussions (FGDs) were conducted using a hybrid approach, combining in-person and virtual participation. Participants included nurses, midwives, and community health workers. FGDs were transcribed and analyzed using thematic analysis. RESULTS Study participants comprised 25 nurses, 18 midwives, and 17 community health workers (45 females, 15 males). Themes included: user preferences of AGYW PrEP users, health promotion and education challenges; structural, policy and legal considerations; and attitudinal barriers. Participants cited advantages of the PrEP ring as a discreet, non-hormonal method relieving pill-related and HCP burden, due to the potential to reduce the number of visits to healthcare facilities. They expressed concerns regarding certain physical aspects of ring; addressing community and partner stigma; PrEP ring stockouts; and governmental sex education policy. HCPs of all cadres underscored the vital role of men as method champions and the corresponding role of HCPs in educating them. CONCLUSIONS HCPs demonstrated a high level of interest in and enthusiasm for the PrEP ring as a valuable addition to existing HIV prevention options for AGYW. Providers perceived the ring as particularly well suited to address barriers associated with current PrEP modalities. Male involvement in promoting the method and supporting partners in its use was considered critical to success.