Adolescent girls and young women are disproportionately affected by human immunodeficiency virus (HIV). The introduction of oral pre-exposure prophylaxis (PrEP) was a game-changer in HIV prevention. In 2023, the dapivirine vaginal ring (DVR) was introduced in select implementation research sites in South Africa, introducing a new dimension into HIV prevention service delivery – people were now able to choose their PrEP method and switch between methods. As new PrEP products are introduced, choice has taken centre stage in HIV prevention service delivery. In these field notes, we describe an iterative, participative process to gain insight into choice counselling training and implementation. Healthcare providers were trained on both DVR and PrEP choice counselling. Guided by the Transfer of Learning Matrix, we embarked on a process with the aim of assessing how choice counselling was being implemented at site level to identify gaps and inform future training and mentoring in relation to effective choice counselling. Healthcare providers involved in delivering DVR in the three implementing clusters were purposefully invited to participate in interviews. A total of 42 interviews were conducted with both clinical and non-clinical providers between December 2023 and January 2024. All interviews were audio-recorded, transcribed verbatim and analysed thematically.
Contribution
Findings include the importance of healthcare providers communicating in a balanced manner and not letting personal bias interfere, and that one-off trainings and job aids for choice counselling are not enough and need to be supplemented by active engagement with healthcare providers on the ground to identify gaps and inform ongoing in-service training and mentoring.
pre-exposure prophylaxisPrEP choicechoice counsellingHIV preventiontrainingtransfer of learningFunding information This work was financially supported by Unitaid (Grant number 2017-21-Wits-PrEP).Introduction
Human immunodeficiency virus (HIV) prevalence in South Africa remains high, with 7.7 million people living with HIV in 2023.1 Women, particularly adolescent girls and young women (AGYW) aged 15–24 years, are disproportionately affected – HIV prevalence in AGYW is three times higher than their male counterparts.2
A major turning point in HIV prevention in South Africa was the introduction of oral pre-exposure prophylaxis (PrEP) in 2016. Although oral PrEP has been a game-changer, challenges in real life implementation are evident including factors such as remembering to take the pill daily, the pill size, fear of others finding out, stigma and poor continuation.3 In addition, healthcare providers have ambivalent perceptions including concerns about PrEP resulting in disinhibition and abandoning condom use.4
The introduction of the dapivirine vaginal ring (DVR) in 2023 ushered in a new and exciting era in HIV prevention options in South Africa. Clients were now able to choose their PrEP method with both oral PrEP and the DVR available at select implementation study sites. The process of informed decision-making and choice in the context of PrEP is an important but new and complex process – both for healthcare providers and for clients, and even more so as we pave the way for the introduction of long-acting injectable methods such as cabotegravir (CAB-LA) and lenacapavir (LEN).5 Choice introduces a new dimension to PrEP service delivery.6 Evidence drawn from contraception tells us that choice enhances product utilisation and continuation.7 From the PrEP field, there is emerging evidence that choice of PrEP methods can increase prevention coverage and reduce the incidence of HIV.8
In this report, we describe one component of an iterative participatory approach used to support healthcare providers with the introduction of new PrEP methods and choice counselling. Drawing from the Transfer of Learning framework,9,10 we embarked on a process with the aim of assessing the implementation of choice counselling after training, in order to identify gaps and inform future training and mentoring.
MethodsProgramme description
Project PrEP (funded by Unitaid), initiated in 2018, is a South African based implementation science study, aiming to inform the introduction of PrEP, coupled with integrated sexual and reproductive health (SRH) services, with a focus on AGYW.11 As an implementation science project, the focus has been on research and evaluation of strategies for demand generation, training and mentorship, and different platforms for service delivery to improve access and support effective PrEP use.11 After DVR and CAB-LA were introduced in August 2023 and April 2024 respectively, the focus expanded to include PrEP choice and decentralised care into community-based service delivery points. Project PrEP has a national office (headquarters) which provides leadership, technical expertise and coordination for the project’s implementation, including research, training, communication and mentoring. The eight project sites are located in three provinces, each comprising two fixed public healthcare clinics and a mobile clinic which provides community-based services (in Gqeberha, Eastern Cape; Mthatha, Eastern Cape; eThekwini, KwaZulu-Natal; and Tshwane, Gauteng).
In this report, we describe the work done in three of the four areas (i.e. Gqeberha, Mthatha, and Tshwane), which have been offering DVR in addition to oral PrEP, and planning for the introduction of CAB-LA.
Our approach: Iterative, participatory methodology and transfer of learning matrix
In preparation for the pending arrival of the DVR and CAB-LA in South Africa, we wanted to gain insight into healthcare providers’ perceptions about these new biomedical prevention methods. We developed a human centred design (HCD) process12,13 and a workshop was conducted on 23 July 2023 – 24 July 2023 with nine healthcare providers. We used the insights from this workshop to guide the development of training materials and job aids. Before the delivery of the DVR to project sites, training was conducted with healthcare providers. Topics included clinical management of the DVR and choice counselling techniques. The introduction of DVR as a PrEP option commenced at project sites in August 2023.
Three months into the introduction of DVR, we embarked on a process at respective project sites to gain insight and assess how informed decision-making and choice counselling were being implemented on the ground, and importantly, to inform future training, mentoring and support needs. The Transfer of Learning Matrix10 (Figure 1) provided a useful framework to guide our post-training assessment. Based on research from trainers, supervisors and learners in the health field, the Transfer of Learning Matrix outlines important actions that can be taken before, during, and after training to strengthen support for the transfer of knowledge and skills and to improve work performance.10
Transfer of learning matrix.
Purpose
The purpose of these site assessment visits was to understand how the knowledge and skills imparted during the training were being applied in relation to choice counselling, especially because training took place prior to the arrival of the DVR and that choice counselling was a new dimension to PrEP provision. Through interactive engagement with healthcare providers, we were interested in learning about their experiences with choice counselling; their interpretation of choice; respective team members’ roles in providing information and counselling about the PrEP methods, including the newly introduced DVR, and in assessing what further training and support is required to enhance PrEP choice, thereby providing guidance to both supervisors, project mentors and trainers.
Research methodology
The site engagements took place three months after the DVR was introduced between December 2023 and January 2024.
Individual and group interviews were conducted with 43 clinical (professional nurses) and non-clinical (lay counsellors, client navigators and fieldworkers) healthcare providers (Table 1). Participants were purposively sampled to include those providing new PrEP methods and choice counselling. Research staff invited potential participants via phone and email, explained the study to them, and, if they expressed interest, obtained their informed consent to participate.
Description of participants (N = 43).
Characteristics
n
Age group (years)
20–29
10
30–39
21
40–49
10
≥ 50
2
Sex
Female
36
Male
7
Cluster
Mthatha
14
Tshwane
15
Gqerbeha
14
Current position
Professional nurses
11
Lay counsellors
7
Fieldworkers
12
Client navigators
12
Training manager
1
Responsibilities related to PrEP provision (multiple responses)
Prescribing
12
Counselling
19
Community outreach
12
Education
43
A semi-structured interview guide was used to guide the discussions. In addition, participants were given a set of nine cards and requested to arrange, in order of importance, the factors they felt to be most influential of clients’ choice of PrEP methods. Interviews were audio-recorded supplemented by note taking, transcribed verbatim and analysed thematically to inform the summary of key learnings and recommendations. Data were managed and coded inductively using NVivo 14 software. Two researchers independently coded two transcripts, compared results to ensure consistency and collaboratively developed a coding framework. This framework was refined through discussion and then systematically applied to all transcripts for thematic analysis.
Feedback sessions were convened to share findings with key managers and staff responsible for mentoring and training.
Ethical considerations
This workshop formed part of a series of formative work approved by the Human Research Ethics Committee of the University of the Witwatersrand (No. M210849) and the World Health Organization (WHO) Ethics Review Committee. Participation was voluntary, and all participants provided written informed consent.
Results
Below is a summary of key themes which emerged from this process, together with key learnings and recommendations.
Getting the balance right between information and counselling
Effective choice counselling requires a combination of information provision and counselling. We found an imbalance – with more emphasis on information-giving (e.g. the characteristics of respective methods) and less on opening communication to assist clients to assess their vulnerabilities, needs and options.
Key learning
More nuanced training on counselling and communication skills is required, with a focus on facilitating communication so that clients can reflect on their needs, circumstances, vulnerability and how this can inform their method choice.
Healthcare providers’ own views can influence client’s choice
Although there was support for expanded options for PrEP, healthcare providers expressed misgivings about clients’ acceptance of a vaginal product. Concerns were expressed about efficacy, side effects and young clients’ ability to use PrEP as prescribed. There was acknowledgement that personally held views may influence communication about respective methods.
Key learning
In-service training needs to continuously reinforce how methods should be communicated to clients in a sensitive, evidence-guided, factual and balanced manner.
Pre-exposure prophylaxis choice is new – are we on the right track?
Many healthcare providers expressed uncertainty about whether they were on the right track with providing PrEP choice counselling and some providers lacked confidence. The need for reassurance and guidance was expressed.
Key learning
This underscored the importance of ongoing support, reassurance and feedback beyond training when introducing new methods – where both confidence and competence are key.
Factors influencing choice
Based on a prioritising activity, healthcare provider views on factors influencing client PrEP method choice varied among interviewees – highlighting the different factors that individuals value when selecting a PrEP method.
Key learning
This underscores the importance of client-centred counselling, understanding and addressing the personalised needs and preferences of clients in the decision-making process, reinforcing similar evidence from implementation research.5,8
Job aids and demonstration models
The project used job aids developed by the Department of Health, which are provided as an addendum to the national DVR implementation guidelines.14 Healthcare providers mentioned that they found the job aids very helpful when explaining PrEP choices to clients; however, they requested that it is enlarged and summarised as a quick reference.
All sites have been provided with pelvic models to explain DVR use to clients, and although useful, it was felt that it may be intimidating to clients.
Key learning
It is important to revisit job aids and to make adaptations based on experience and feedback. More support on how best to use the pelvic model was indicated.
The importance of personalised, face-to-face engagement
The importance of engagement with staff at the site level was underscored through this initiative. As described, the project is structured in such a way that the national office provides technical expertise and training (among other functions) to support project implementation. This process encouraged engagement with staff to reflect on their experiences with choice counselling in a participatory, supportive, non-threatening but honest manner. It is instructive to note that the importance of engaging with staff at site level is embodied in continuous quality improvement methodology where the value of leadership and management going to the actual location where people work is emphasised. This is known as ‘Genchi Genbutsu’ which translates as ‘go look, go see’.15,16
Key learning
The value of engagement with staff at site level for all aspects of project implementation has been reinforced. This is especially important with aspects of project implementation that are pivotal but less easy to define and measure such as the knowledge, attitude and skills involved in choice counselling and communicating about new biomedical HIV prevention methods and choice.
Conclusion
In this report, we describe an iterative, participatory process which aimed to gain insight into healthcare providers’ implementation of choice counselling after training which identified gaps to guide the ongoing work of supervisors, project mentors and trainers.
The findings are supported by other studies looking at the importance of choice counselling as PrEP options expand and reinforce the point that the implementation thereof is a nuanced, complex process which needs to take into consideration respective PrEP methods’ specifications, benefits and drawbacks combined with the individual client’s needs and vulnerability.6,8,17
The use of the Transfer of Learning Matrix underscores the importance of following up training to gauge how knowledge and skills covered in training are interpreted and implemented on the ground.9,10 Healthcare providers need ongoing support to navigate ways to provide PrEP counselling which results in genuine informed decision-making. The process showed that once-off training and job aids for choice counselling are not enough and need to be supplemented by active engagement with healthcare providers on the ground to identify gaps and inform ongoing in-service training and mentoring. The value of engaging with staff at site level was also highlighted.
It is hoped that the methodology and insights gained through this process may be beneficial to others implementing PrEP and PrEP counselling, especially as new methods become available.
Limitations
We acknowledge potential limitations, including social desirability bias due to interactive engagement with healthcare providers, since participants were drawn from project sites, and reliance on self-reported data. These factors may affect the accuracy of responses and limit the generalisability of findings beyond the study settings.
Acknowledgements
The authors would like to thank managers and healthcare providers, who contributed at project sites, for their time and valuable feedback that contributed to this work. The authors acknowledge Maimela Terence Modiba and Sean Arries for their valuable guidance and reflections.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them
in writing this article.
CRediT authorship contribution
Melanie Pleaner: Conceptualisation, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing. Faith Musvipwa: Data curation, Formal analysis, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing. Siphokazi Dada: Data curation, Formal analysis, Investigation, Methodology, Validation, Writing – review & editing. Fatima A. Cholo: Data curation, Formal analysis, Methodology, Validation, Writing – review & editing. Catherine E. Martin: Methodology, Project administration, Supervision, Writing – review & editing. Alison Kutywayo: Methodology, Writing – review & editing. Vusile Butler: Funding acquisition, Project administration, Resources, Supervision, Writing – review & editing. Saiqa Mullick: Funding acquisition, Supervision, Writing – review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.
Data availability
The data supporting the findings of this study are available from the corresponding author, Alison Kutywayo, upon request.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
ReferencesUNAIDS. Country factsheets 2024-South Africa [homepage on the Internet]. [cited 2025 Jul 14]. Available from: https://www.unaids.org/en/regionscountries/countries/southafricaZumaK, ZunguNP, MoyoS, et al.; the SABSSM VI team. The sixth South African National HIV prevalence, incidence and behaviour survey, 2022: A summary report [homepage on the Internet]. Cape Town: HSRC Press; 2024[cited 2025 Aug 30]. Available from: https://hsrc.ac.za/wp-content/uploads/2024/07/SABSSM_VI_EXEC_REPORT_2PP.pdfDubyZ, BunceB, FowlerC, et al. ‘These Girls Have a Chance to be the Future Generation of HIV Negative’: Experiences of implementing a PrEP programme for adolescent girls and young women in South Africa. AIDS Behav. 2023;27(1):134–149. https://doi.org/10.1007/s10461-022-03750-1PleanerM, ScorgieF, MartinC, et al. Introduction and integration of PrEP and sexual and reproductive health services for young people: Health provider perspectives from South Africa. Front Reprod Health. 2023;4(1086558):1–12. https://doi.org/10.3389/frph.2022.1086558KirukiM, TzindoliV, NiyibeshahoM, et al. Provider and client perspectives on PrEP choice: Quality of PrEP choice and factors influencing its provision in the CATALYST implementation study. Paper presented at the 5th HIV Research for Prevention Conference (HIVR4P2024 Conference); 6–10 Oct2024; Lima, Peru. [cited 2025 Aug 30]. Available from: https://www.prepwatch.org/wp-content/uploads/2024/11/Provider-and-client-prespectives-on-PrEP-Choice-presentation-final.pdfNaidooNP, AyiekoJ, FonnerVA. Expanding access to a choice-based multi-method PrEP market for HIV prevention. J Int AIDS Soc. 2025;2025(S2):26512. https://doi.org/10.1002/jia2.26512RossJ, StoverJ. Use of modern contraception increases when more methods become available: Analysis of evidence from 1982–2009. Glob Health Sci Pract. 2013;1(2):203–212. https://doi.org/10.9745/ghsp-d-13-00010KamyaMR, BalzerLB, AyiekoJ, et al. Dynamic choice HIV prevention with cabotegravir long-acting injectable in rural Uganda and Kenya: A randomised trial extension. Lancet HIV. 2024;11(11):e736–e745. https://doi.org/10.1016/s2352-3018(24)00235-2DaffronS, MooreS, ChicovskyT. Transfer of learning for health care workers. PAACE J Lifelong Learn [serial online]. 2015;(24):49–66. Available from: https://api.semanticscholar.org/CorpusID:78390639DavidN, WendyD, editors. Transfer of learning: A guide for strengthening the performance of health care workers [homepage on the Internet]. 2002[cited 2025 Aug 27]. Available from: https://www.intrahealth.org/sites/default/files/files/media/transfer-of-learning-a-guide-for-strengthening-the-performance-of-health-care-workers-/TOL_high_res.pdfButlerV, KutywayoA, MartinCE, et al. Implementing differentiated and integrated HIV prevention services for adolescent girls and young women: Experiences from oral PrEP rollout in primary care services in South Africa. J Adolesc Health. 2023;73(6S):S58–S66. https://doi.org/10.1016/j.jadohealth.2023.09.003GöttgensI, Oertelt-PrigioneS. The application of human-centered design approaches in health research and innovation: A narrative review of current practices. JMIR Mhealth Uhealth. 2021;9(12):e28102. https://doi.org/10.2196/28102MukherjeeTI, ZerbeA, FalcaoJ, et al. Human-centered design for public health innovation: Codesigning a multicomponent intervention to support youth across the HIV care continuum in Mozambique. Glob Health Sci Pract. 2022;10(2):e2100664. https://doi.org/10.9745/ghsp-d-21-00664Department of Health. National Dapivirine vaginal ring implementation guidelines. Pretoria: National Department of Health; 2022.AntierensA, BeeckmanD, VerhaegheS, MynyD, Van HeckeA. How much of Toyota’s philosophy is embedded in health care at the organisational level? A review. J Nurs Manag. 2018;26(4):348–357. https://doi.org/10.1111/jonm.12555GodambeSA, ShahRK. Introduction: A case-based approach to quality improvement. In: RKShah, SAGodambe, editors. Patient safety and quality improvement in healthcare. Cham: Springer, 2021; p. 1–12.CelumCL, Delany-MoretlweS, BaetenJM, et al. HIV pre-exposure prophylaxis for adolescent girls and young women in Africa: From efficacy trials to delivery. J Int AIDS Soc. 2019;22(S4):e25298. https://doi.org/10.1002/jia2.25298
How to cite this article: Pleaner M, Musvipwa F, Dada S, et al. PrEP and choice counselling – Insights into implementation. J Public Health Africa. 2026;17(1), a1458. https://doi.org/10.4102/jphia.v17i1.1458