JMIR Publications

ABSTRACT

Background:

Facility-based pre-exposure prophylaxis (PrEP) services often deter potential users through privacy and stigma concerns, travel requirements, waiting times, and restricted operating hours. Digital models may help address some of these barriers but evidence on hybrid digital and telemedicine PrEP pathways for general adult populations in African settings remains limited.

Objective:

To assess the feasibility and acceptability of a digitally enabled hybrid oral PrEP delivery pathway combining digital engagement and HIV self-testing (HIVST) with home-based nurse assessment, virtual physician prescribing, pharmacist dispensing, courier delivery of medication, and HIVST-supported follow-up in Gauteng Province, South Africa.

Methods:

We used a multiphase mixed methods design. In May 2023, 127 adults recruited by convenience sampling via an online platform and community pharmacies participating in the PPREPP-SA PrEP implementation project in Johannesburg and Cape Town completed a market survey. In June 2023, study staff invited adults who were available and willing to participate at pharmacies in both cities; 30 completed formative interviews which were analysed descriptively. During implementation (July 2023-July 2024), users self-enrolled through the online platform, and website analytics and programmatic data described progression to PrEP initiation (n=155). At 6-7 months, the midpoint of the 13 month follow up period, criterion-based purposive sampling selected users from three engagement groups: active, missed-appointment, and lost-to-follow-up. Seven users completed midline interviews. In addition, one senior manager from the online platform completed a key informant interview. Pre-implementation interviews were analysed descriptively, midline interviews thematically, and findings integrated using a joint display.

Results:

Among the 127 market survey respondents, 96 (75.6%) preferred pharmacy-based PrEP, whereas 17 (13.4%) selected online access; 83 (65.4%) were willing to pay for PrEP-related services. During implementation, 567 users ordered an HIV self-test, 457 (80.6%) received it, 253 reported a nonreactive result, 192 requested a nurse visit, 157 completed the visit, and 155 initiated PrEP. Initiation represented 61.3% (155/253) of users reporting a nonreactive result and 27.3% (155/567) of all users who ordered a test. Among participants who initiated PrEP, 97 (62.6%) were assigned male at birth, 123 (79.4%) had tertiary education, and 110 (71.0%) were employed. Privacy, discretion, and convenience supported acceptability. The absence of clearly identifiable addresses, courier delivery and laboratory delays, scheduling difficulties, and communication breakdowns between participants and study staff affected progression through the pathway. Participants and the platform stakeholder also raised concerns about affordability, poststudy access, and financial sustainability.

Conclusions:

The digitally enabled hybrid PrEP pathway supported PrEP initiation among users who valued privacy and convenience. Its feasibility was conditional on coordination among multiple service components. Wider implementation will require streamlined clinical and logistical processes, equitable digital access, flexible delivery or collection options, and sustainable financing that complements existing pharmacy and facility based PrEP services. Clinical Trial: NCT07006246