Stakeholders’ Perspectives on Pre-Exposure Prophylaxis Innovative Interventions Implemented During COVID-19 Among Adolescent Girls and Young Women in North-West Province of South Africa

Abstract

South Africa’s health system was affected by the various mitigation measures implemented to control the rapid spread of the COVID-19 pandemic. However, innovative interventions were introduced to ensure service continuity. This study sought to explore the perspectives of stakeholders regarding the pre-exposure prophylaxis (PrEP) innovative interventions implemented during the COVID-19 lockdown period among adolescent girls and young women (AGYW), as well as their successes and improvements. We selected and interviewed 12 PrEP stakeholders, including professional nurses, case managers, peer educators, and counselors from the TB HIV Care programme in the Dr. Kenneth Kaunda District, in the North-West Province. The qualitative questions explored (1) how PrEP services were disrupted during the lockdown period, (2) how the disruptions were managed, and (3) the challenges and successes of the innovative interventions implemented. The interviews were audio-taped, transcribed, and thematically analyzed through Tesch’s eight steps of analysis. The stakeholders confirmed that COVID-19 disruptions affected the provision of PrEP services in terms of recruitment, counseling, HIV testing, and adherence support offered in different community hotspots. Responding to these difficulties, alternative avenues such as social media platforms were implemented and used for service continuity. The themes that emerged were organized into the following two categories: PrEP services provided during and after the COVID-19 lockdown period, as well as the successes and challenges. The current study provides further insight into COVID-19, aiming to inform preparations for future pandemics. Innovative PrEP interventions alleviated COVID-19 disruptions in some settings and improved HIV services, but this was not the case in the selected study area.

1. Introduction

In addition to the impact of the COVID-19 pandemic on healthcare services, South Africa continued to experience its own ongoing HIV crisis in 2020 [1]. According to Statistics South Africa [2], in 2020 alone, South Africa reported an estimated overall prevalence of 18.7% HIV-positive women aged 15–49 years. New HIV infections were also higher among adolescent girls and young women (AGYW). In 2021, nearly 64% of all new infections occurred among women in South Africa, with AGYW making up over 37% of these cases [3]. Due to the COVID-19 pandemic, there were concerns raised that HIV prevention and treatment services would be disrupted [4].

In South Africa, the average weekly testing for HIV viral load and CD4+ cells declined by 22% and 33%, respectively, compared to pre-lockdown [5]. Moreover, a pre-exposure prophylaxis (PrEP) program for pregnant women in Cape Town reported over twice the odds of missed antenatal care visits, while sexual activity remained unchanged since the implementation of lockdown measures [6]. Another study, also conducted in Cape Town, reported that young women were unable to access services like contraceptives or family planning during the lockdown period—this includes a quarter of them living with HIV—while youth reported difficulties in accessing condoms, HIV/STI testing and treatment, as well as PrEP and post-exposure prophylaxis (PEP) [7].

Mitigation and innovative interventions were put in place for the provision of HIV services during the lockdown period. These innovative interventions included WhatsApp applications, decentralizing PrEP through community groups, and mobile clinics used for HIV testing, as well as PrEP initiation and refills in a community setting [8,9,10]. Studies reflecting on how PrEP services were adopted are limited. Service providers from Birmingham, Alabama, reported that, during the lockdown period, they had to close their walk-in HIV/STI testing services but continued to offer counseling and support group meetings either through telephone or secure video conferencing [11]. In another study, the service providers highlighted their inability to provide the main HIV services, including testing, PrEP education, and referrals to physicians for medication and adherence support [12]. Furthermore, stakeholders from a community-based organization in China indicated that they limited in-person antiretroviral treatment collection and opted for mail delivery, which became a major source of refills for people living with HIV in China [13].

The implemented social media platforms enabled communication between service providers and users regarding the service uptake. Irrespective of the significant role played by these platforms in healthcare delivery, their adoption among service providers remain relatively low in emerging countries like South Africa [14,15]. To build on the growing literature on the adaptations made during COVID-19 for HIV service continuity, we present the stakeholders’ perspectives on the PrEP interventions implemented, which were provided in a mobile-based facility setting. Furthermore, the paper presents the types of PrEP innovative interventions implemented to sustain PrEP outcomes during the COVID-19 lockdown period.

2. Materials and Methods

2.1. Study Design and Setting

An explorative, descriptive, and contextual research design was used to explore the stakeholders’ views on the PrEP innovative intervention implemented during the COVID-19 lockdown period for AGYW, as well as their success and improvements thereof. This approach was appropriate for this study, as it enabled the researchers to closely examine the stakeholders’ perspectives while maintaining a strong focus on the data [16]. Additionally, the contextual aspect of this design allowed the researchers to explore the stakeholders’ views within their natural settings [17]. The study was conducted in the Dr. Kenneth Kaunda (Dr. KK) District in the North-West Province of South Africa. “The district is situated in the southern part of the North-West Province and borders both the Gauteng and Free State Provinces”. Moreover, it consists of three local municipalities (i.e., Maquassi Hills, Matlosana, and JB Marks) [18]. As with other settings globally, Dr. KK was impacted by the COVID-19 pandemic, but innovative interventions were implemented within the district to continue with essential services.

2.2. Recruitment and Study Population

The following inclusion criteria guided the recruitment process: (1) HIV PrEP intervention implementers; (2) intervention coordinators; (3) service providers; (4) have experience in PrEP interventions before and during the COVID-19 lockdown period; and (5) reside within the Dr. Kenneth Kaunda District. Participants were recruited through a purposive sampling method to ensure all the relevant stakeholders were included in the study. This technique enabled the researchers to include the most knowledgeable participants [19] in HIV prevention and treatment services within the selected district. All the included participants were recruited by the first author (OL) from TB HIV Care, a South African non-profit organization, which is the country’s largest provider of PrEP for young women and female sex workers (FSWs) within the above-mentioned district [20]. Furthermore, a total of 12 PrEP multiple stakeholders, including nurses, case managers, counselors, peer educators, and a social worker, were included.

2.3. Data Collection

The data collection was conducted at the TB HIV Care facility, where the stakeholders were invited for a one-on-one interview session. Each semi-structured interview lasted around 30 to 45 min per participant and was conducted from 31 July to 30 August 2024. The stakeholders’ written informed consents were obtained before they could take part in the study. Additionally, written permissions were obtained for the interviews to be audio-recorded. Interview questions were guided by the COVID-19 disruptions, how they were handled, as well as the challenges and successes. Additionally, stakeholders were encouraged to be interviewed in the language they preferred, including English and Setswana, which are commonly spoken in that setting. The interviews continued until data saturation—the point at which no new or substantial information emerged [21]—with a total of 12 completed interviews.

2.4. Data Analysis

Upon completion of the interview sessions, the first author (OL) translated the recordings into English and transcribed them verbatim. To enhance the translation accuracy of this study, a back-translation method was employed by the second author (EP), who is also skilled in the Setswana language. Additionally, the collected data included the stakeholders’ basic demographic information, such as age, gender, highest qualification, and level of work experience. An inductive approach was followed using the qualitative thematic analysis method. The analyses were completed independently by the first author (OL) and external co-coder, guided by Tesch’s eight steps for data analysis, as follows: (1) all the transcripts were reviewed and re-reviewed to get a sense of the whole research; (2) one interview transcript was selected as a point of interest; (3) a list of all the emerged topics was compiled; (4) these topics were condensed into codes, which were then assigned to the relevant sections of the text; (5) the most descriptive wording for each topic was created and they were turned into categories; (6) the categories were then shared with the co-coder and discussed to make a final decision on the abbreviation of each category; (7) all the data materials belonging to each category were assembled in one place to perform a preliminary analysis; and (8) where necessary, the existing data were recorded.

2.5. Trustworthiness

The study’s rigor or trustworthiness was maintained throughout the research process and endorsed through Lincoln and Guba’s five epistemological standards, including (1) “credibility, (2) transferability, (3) dependability, (4) confirmability, and (5) authenticity” [22]. The credibility of the study was ensured through extensive discussions on the findings by the co-authors, as well as a thorough review of the interview transcripts. Transferability was established through the rich descriptions of the stakeholders’ expressions of their roles and views regarding the innovative PrEP interventions implemented during the lockdown period. Moreover, dependability was obtained through the code–recode processes; the analyzed data were coded and recorded to enhance consistency. All the necessary documentation (interview transcripts and field notes) used in all the research stages was provided to validate the study’s confirmability. Furthermore, the study’s authenticity was confirmed by the tone of the participants’ views, as conveyed through the findings.

2.6. Ethical Consideration

Ethical approval was obtained from the University of Johannesburg’s Research Ethics Committee (UJREC) (REC-2435-2023). Letters of approval for the study were obtained from the North-West Department of Health (NW 202311 010) and TB HIV Care before data collection. During the recruitment stage, the stakeholders were provided with the research information letter, which explained all the necessary details of the study, before they proceeded with signing the written informed consent forms. Also, the stakeholders were assured that their participation would be strictly voluntary during the data collection. Moreover, the stakeholders’ privacy and confidentiality were enhanced using pseudonyms, where the interview transcripts did not contain any identifiable information. Furthermore, all the data collection research materials (informed consent forms, interview transcripts, reflection notes) were stored in a secure cabinet in the supervisor’s office, which is a restricted area.

3. Results

3.1. Participants Characteristics

A total of 12 PrEP stakeholders (2 men and 10 women) aged between 27 and 52 years, who are predominantly black Africans, were included in this study. Each participant played a crucial role in the improved PrEP service delivery among women; these roles are displayed in Figure 1, and their characteristics are shown in

Table 1. Characteristics of the included stakeholders.

Stakeholders	Age in Years	Gender	Roles	Length of Service	Highest Qualification
Stakeholder 1	27	Female	Case manager	7 years	Grade 12
Stakeholder 2	30	Male	Driver	2 years	Diploma
Stakeholder 3	31	Female	General assistant	1 year	Grade 12
Stakeholder 4	31	Female	Nurse	2 years	Honours
Stakeholder 5	33	Female	Nurse	2 years	Diploma
Stakeholder 6	34	Male	Driver/councilor	7 years	Diploma
Stakeholder 7	37	Female	Social worker	6 years	Honours
Stakeholder 8	37	female	Data capturer	7 years	Diploma
Stakeholder 9	44	Female	Peer educator	4 years	Grade 12
Stakeholder 10	47	Female	Peer coordinator	6 years	Grade 12
Stakeholder 11	50	Female	Peer educator	4 years	Grade 10
Stakeholder 12	52	Female	Peer educator	2 years	Grade 10

.

As shown in Table 1, the stakeholders had different lengths of service with TB HIV Care, which enabled the authors to examine how the PrEP services were adjusted during the lockdown period, how they were being delivered, as well as the related successes and challenges.

3.2. Pre-Exposure Prophylaxis Services Provided During COVID-19

This section is divided into two parts. The first part describes the several themes that emerged regarding how the PrEP interventions were continued during the COVID-19 lockdown period, and the second part discusses how services are rendered post-pandemic. Four themes are depicted in Figure 2, along with their subthemes, namely awareness and information on PrEP, the impact of COVID-19 on PrEP services, adaptations made for PrEP service continuity, and challenges in retaining PrEP outcomes during COVID-19.

Theme 1: Awareness and information on pre-exposure prophylaxis service continuity

Due to the lockdown restrictions, the authors were interested in exploring whether the PrEP interventions were continued during the COVID-19 period and whether the service users were aware of this continuity. Theme 1 addresses the above-mentioned questions and consists of four subthemes, elaborated as follows:

Sub-theme 1.1: Decreased access to potential service users affected awareness and information on pre-exposure prophylaxis interventions.

The participants mentioned that regardless of the efforts made to continue with the PrEP services, they did experience a decrease in access to potential service users, particularly at the recruitment stages, which compromised the awareness of treatment benefits.

“And most of those service users that we managed to see were old ones that we originally had on our system, they were not new service users” (P3, female, 44 years old).

Sub-theme 1.2: Use of social media to inform service users of service continuity

In response to the negative impact of the lockdown restrictions, the participants continued to utilize alternative platforms to ensure that service users were made aware of the service continuations. Social media platforms like WhatsApp and Facebook were used to communicate with service users and improve the visibility of TB HIV Care within communities.

“I guess in the long run we found forms of communicating with them through WhatsApp group so that they can avail themselves on some particular days which helped us” (P1, female, 27 years old).

Sub-theme 1.4: Word of mouth from other service users informed individuals of the continuation of services

Word of mouth also emerged as a significant tool for increasing the awareness of other service users regarding the continued provision of PrEP services. Stakeholders acknowledged how their existing cohort managed to spread the word and informed other qualifying PrEP users that, despite the lockdown measures, TB HIV Care persisted with the provision of sexual and reproductive health services.

“In terms of reaching the new ones, uhm… yeah, no, that was a bit tricky… [Laughter]…But, yeah, we tried our best through campaigns and word-of-mouth um… and stuff like that…yeah.” (P1, female, 27 years old)

Theme 2: Impact of COVID-19 on pre-exposure prophylaxis services

The second theme is an important theme that informed the study’s findings, because the authors were interested in uncovering how the pandemic impacted services. This theme contains three sub-themes that outline how services were strained due to the measures implemented in response to COVID-19.

Sub-theme 2.1: Decrease in the number of service users recruited

One of the key responsibilities of TB HIV Care stakeholders is to ensure they recruit and connect with as many individuals at an increased risk of acquiring HIV to PrEP care. However, these were performed slowly, as their normal weekly targets decreased drastically during the pandemic.

“But during COVID-19 we did initiate but the numbers were lower during the restricted movement even the adherence was not that much because we would initiate them then they would just stop taking PrEP” (P10, female, 37 years old)

Sub-theme 2.2: Decrease in pre-exposure prophylaxis uptake and adherence

Participants highlighted that they struggled to engage service users in PrEP care due to the restricted individual movements during the COVID-19 period.

“Ey, it was a struggle. Because our service users did not come for their treatment due to the lockdown measures. Some had to relocate to various places and as you can think about the nature of their work, some have to be on the streets, and some would do house calls to their clients, so, due to the lockdown restrictions such as not wandering around, they were all over the place, which made it difficult for us to retain them on treatment.” (P6, female, 37).

Sub-theme 2.3: Prolonged service duration due to the COVID-19 symptom screening as a safety measure

Screening for COVID-19 symptoms was one of the regulatory requirements for healthcare workers or frontline workers to continue providing essential services. However, due to such measures, the normal time to cover one client (counseling, HIV testing, PrEP initiation, etc.) was extended, reducing the daily number of service users assisted.

“Sometimes we would call one person at a time to avoid them coming into groups because we were adhering to the lockdown restrictions. And there were a lot of screenings during those times. So, the process took longer than usual” (P2, 34 years, male)

Theme 3: Adaptations made for pre-exposure prophylaxis service continuity

Daily oral PrEP treatment was one of the vital services that had to proceed amid the lockdown restrictions. Theme 3 displays some of the innovative methods implemented or adapted for service continuity, and it includes three sub-themes.

Sub-theme 3.1: Increased telephone follow-up to arrange face-to-face contact/appointments

Several safety measures were implemented during the lockdown period to control the spread of the virus. One strategy was social distancing, which reduced the number of times individuals came into close contact with each other. Participants highlighted that, during these times, telephone follow-ups were increased to comply with the COVID-19 regulations.

“Yes, we did manage to find the new initiates, but they were just a few of them, in terms of the ones we already have on the system, we called them for the follow-ups and others would even come to the offices for their PrEP pills.” (P3, female, 44 years old)

Sub-theme 3.2: Continued provision of pre-exposure prophylaxis via mobile clinic and social media platforms

Irrespective of the impact of the pandemic, the TB HIV Care stakeholders continued to provide sexual and reproductive health services, including PrEP. These were continued through WhatsApp and a mobile bus clinic, where service users could book follow-up appointments on a group chat and then receive their PrEP package at a preferred location within the community.

“Uhm…yes, they are uhm most of them, okay, my understanding is that most of them know us through our mobile clinic cos now they can recognize us” (P1, female, 27 years old)

Theme 4: Challenges in retaining pre-exposure prophylaxis outcomes during the COVID-19 pandemic

Participants also encountered some challenges as they continued to provide services through the adapted innovative interventions. All these challenges are highlighted in Theme 4, which consists of a few sub-themes as illustrated in Figure 2. Some of these key sub-themes are as follows:

Sub-theme 4.1: Limitations on staff numbers and working hours

Under normal circumstances, TB HIV Care stakeholders are expected to provide services daily at two sites in the Dr Kenneth Kaunda District. However, this could not be carried out due to the lockdown restrictions, where the number of staff members was reduced to align with the COVID-19 safety measures. The participants revealed that this was a challenge because their daily targets were compromised.

“We even had to adjust ourselves to having two teams where we had to work in shifts like today the other team will come and tomorrow will be the other shift. So, that is how we were working during those times” (P2, male, 34 years old)

Sub-theme 4.2: Difficulties with locating potential service users

One of the barriers to retaining PrEP outcomes (initiation, uptake, and adherence) among service users was locating both new and old users during the pandemic. The participants said they struggled to reach service users because some provided incorrect contact details, and even their physical addresses were incorrect.

“Yeah, in terms of the challenges, I would say we have retention challenges because some of them they lose their cell phones, they give us wrong contact details, and sometimes even the physical addresses that they had provided us with they are incorrect. Remember they don’t want to be exposed to their family members because the families will know what they do for a living.” (P8, female, 33 years old)

Sub-theme 4.4: Protective clothing conveyed stigma to service users

Interestingly, as stakeholders were conducting their normal rounds, such as recruiting new service users within the community, service users were not comfortable around them because of the protective gear (masks, hand gloves, etc.) worn by the participants. The participants mentioned that as they approached service users, they assumed that the stakeholders wore such clothing because they were smelly or sick.

“In terms of PrEP services, they were also slow because, in places like taverns, where we would find them mostly, it was not easy due the restrictions like social distancing, and wearing of masks, because some of them would think otherwise, especially when one wears a mask, for instance, they will feel as if they are being judged or stigmatized because one will wear the mask, surgical gloves, and maintaining the distance between.” (P5, female, 50 years old)

As mentioned, Figure 3 illustrates the themes that emerged concerning the PrEP services provided during the post-COVID-19 lockdown period. It consists of four themes and several sub-themes.

Theme 1: Services provided post COVID-19 restrictions

This theme aims to show the significant differences between how services were impacted during the lockdown period and the current situation following the COVID-19 pandemic. The participants appear satisfied with how services are being rendered, as improvements can be seen from their records. Some of the sub-themes are discussed below.

Sub-theme 1.1: Pre-exposure prophylaxis information awareness to public and service users

The stakeholders were confident that the public and service users now knew the services rendered by TB HIV Care to the various communities. This is achieved through the visibility of their mobile clinic and the education campaigns they conduct in different settings.

“As in now, no, as much as we have cell phone challenges at least we can physically reach them at their hotspots, unlike the lockdown period. And yes, I can say now the PrEP outcomes (uptake and adherence) are much better.” (P6, female, 37 years old)

Sub-theme 1.2: Recruitment

Recruitment of new service users is one of the key responsibilities of the stakeholders, as well as connecting them with the relevant care (either PrEP or antiretroviral therapy). Participants were impressed by how they currently reach their daily targets. Also, during their recruitment drives, they educate other service providers on the benefits of taking PrEP and the side effects.

“Yes, we provide awareness campaigns where we provide them with much most information needed regarding the benefits of PrEP, we also provide them with education as well as adherence counselling” (P7, male, 30)

Theme 2: Means to promote pre-exposure prophylaxis uptake and adherence

Despite the effectiveness of PrEP in reducing HIV acquisition, particularly among women, its uptake and adherence remain lower in the sub-Saharan African countries. This second theme explores some ways in which the TB HIV Care stakeholders maintain their pool of PrEP care service users. Some of the methods used are covered in the following sub-theme:

Sub-theme 2.1: Retaining service users in care

Once the service user agrees to be placed in PrEP care, during the recruitment process, the stakeholders would collect their personal information, including contact details, which would assist with retaining them in care. The participants mentioned that one of the approaches they use is telephone follow-ups with service users to stay informed of any side effects experienced, enabling them to offer advice on how to manage such issues. Another method is psychosocial support counseling provided by a social worker, where they will explore ways to enhance PrEP uptake and adherence. One of the most significant and feasible methods is the scheduled one-on-one appointments at preferred locations, which improves PrEP outcomes.

“I can say now we are performing very well because of they are involvement in risky behaviours, whereby some will have clients that will offer them more money if they don’t use protection. So, because of these reasons, they are adherent, and we can retain them” (P8, female, 33)

Theme 3: Challenges in retaining service users in care

Irrespective of the efforts made by the stakeholders to maintain service users in PrEP care, they experience several challenges in this process, some of which are discussed in the following sub-themes.

Sub-theme 3.1: Public misconception of pre-exposure prophylaxis

The participants revealed that some of the service users are skeptical about the effectiveness of PrEP in reducing HIV transmission. Others feel that taking daily oral tablets is burdensome for them, especially when they are not sick.

“Before, it was hard because some of them would refuse to take it because they said they were not sick for them to be on treatment. So, they were saying that is better for them to be infected or to be sick and take ARV every day than PrEP.” (P3, female, 44 years old)

Sub-theme 3.2: Gender-based violence and abuse

The involvement of young women in risky behaviors like transactional sex, as well as being in relationships with abusive partners, contributes to one of the major challenges preventing them from adhering to care. Moreover, PrEP tablets are being violated for use as they contain ingredients used in the manufacturing of drugs.

“And one should consider that there are various reasons/barriers why the service users are not adherent to PrEP; for instance, you will find that others are experiencing Gender-Based Violence from their partners, where they would forcefully take their PrEP medication from them. Also, others are in relationships with people from other countries like Nigeria, who are known to be selling drugs, and you know that PrEP has this element of ARV pills, so, they need this element for their drugs production” (P6, female, 37 years old)

Sub-theme 3.3: Service users changing locations and losing/selling phones

The target population of TB HIV Care stakeholders are AGYW, including female sex workers. Due to the nature of these service users’ work, they tend to change locations, which affects their PrEP uptake and adherence. Additionally, some are inclined to sell their mobile devices for quick cash or are mugged by armed robbers.

“Not most of them. Because if you can remember, our key populations don’t usually stay in the same location for the longest time. This is one of the most significant factors affecting our tracing process, leading to them defaulting to using PrEP.” (P5, female, 50 years old)

Theme 4: Recommendations

When concluding the interview sessions, the stakeholders were asked if they could assist by providing any suggestions to increase PrEP uptake and adherence. Some mentioned reducing PrEP side effects because they said that, in most cases, service users were not adherent due to potential complications. Others noted that they are working on other techniques to increase PrEP outcomes.

“Uhm…, no, what I have realized about PrEP is that some service users do take it, but some complain about its side effects, so, maybe if the PrEP manufacturers can try to reduce these experienced side effects, it will be much better.” (P7, male, 30 years old)

4. Discussion

This study aimed to explore stakeholders’ perspectives on the PrEP innovative interventions implemented during the COVID-19 lockdown period in South Africa, to understand how PrEP service continuity was maintained, and underscore the successes and challenges. In line with the findings of this study, Patel et al. [23] identified multiple innovative interventions implemented before the pandemic but rapidly adopted in the context of COVID-19, particularly for HIV prevention, including PrEP. These include the use of social media platforms, expanding services from facility to community, and the utilization of applications like WhatsApp and mobile device SMS for health-related communication [23].

In our study, social media platforms such as WhatsApp and Facebook were used as the communication medium between service users and providers. They also provided a platform to raise awareness about sexual and reproductive health services and maintain PrEP follow-ups and adherence. Moreover, moving HIV services from the facility out to the community improved service delivery, which is what the TB HIV Care stakeholders were using before the COVID-19 pandemic to increase their visibility within the communities. For daily oral PrEP to be effective in reducing both HIV transmission and acquisition, it requires stringent adherence [24]. However, this was not the case in our findings because, despite the implementation of these innovative interventions, there were challenges regarding the uptake of PrEP and its adherence.

Stakeholders highlighted challenges such as service users’ relocating to other settings, incorrect personal information, the loss of cell phones, and negative perceptions about COVID-19 protective clothing. These findings differ from a study conducted in Zimbabwe, where increased PrEP uptake was achieved among female sex workers since May 2020, due to the innovative interventions implemented [25]. However, Ware et al. [26], indicated that more PrEP users missed their clinic visits and refills, highlighting how users were less committed to the treatment. Service users’ inaccurate personal information also lowered PrEP uptake and adherence during the pandemic. This was confirmed by Duby et al. [27], where intervention implementers described how they could not retain the beneficiaries listed in their database due to their provision of incorrect telephone numbers and inaccessible physical addresses.

This study also explored how services were rendered following the COVID-19 pandemic and how the TB HIV Care stakeholders retained their PrEP users in care. One key method was the peer educator-led approach that they used to improve PrEP outcomes and to enhance the recruitment process. This approach allowed service providers to have face-to-face conversations about the PrEP benefits within the user’s social environment. The intervention significantly improved PrEP awareness and access [28]. Another intervention used by the TB HIV Care stakeholders to maintain PrEP outcomes was the provision of psychosocial support to the service users. Several psychosocial support factors have been identified as significant in shaping women’s intention to use PrEP, including the perceptions of behavioral control, subjective norms, and attitudes [29].

Furthermore, gender-based violence was found to be the major barrier in preventing consistent PrEP uptake among TB HIV Care users. Similar results were obtained in a qualitative study by Roberts et al. [30], where participants revealed that escaping their homes after a violent episode and forgetting to take their PrEP pills with them resulted in missing their dose.

5. Conclusions

The current study provides insights into disruptions during the COVID-19 pandemic, aiming to inform preparations for future pandemics. Although innovative PrEP interventions alleviated COVID-19 disruptions in some settings and improved HIV services, our stakeholders highlighted challenges such as incorrect contact details that affected PrEP uptake and adherence. Therefore, we recommend that future studies explore other novel initiatives that can be adopted to improve services in all settings, particularly during future pandemic outbreaks.

6. Strengths and Limitations

The stakeholders included were highly experienced in HIV PrEP services, and all of them had experience working with key populations before, during, and even after the COVID-19 lockdown period. The current study provided insights into several challenges that lowered the uptake and adherence to PrEP, which need to be targeted and resolved. This study was limited to only one district (i.e., Dr. Kenneth Kaunda), which consists of three sub-districts, including Matlosana, JB Marks, and Maquasi Hills. This contextual limitation restricts authors from applying the research findings to other geographical settings. However, this was addressed by providing a rich methodological explanation of the research process, which can be transferable to other areas of interest. Additionally, as a qualitative study, the current study was limited to the stakeholders’ views; we recommend that future studies include service users’ perspectives on the innovations implemented for service continuity during the lockdown period. Our study findings further add to the growing literature on the exploration of the adaptations introduced during the pandemic for health service continuation, which will assist in preparing for future pandemics.