Stakeholders’ Perspectives Towards Pharmacy Based Delivery of Injectable Pre-Exposure Prophylaxis to Key Populations, Adolescent Girls And Young Women in Kampala, Uganda

Abstract

Background: In Uganda, key populations (KP) and adolescent girls and young women (AGYW) (15–24 years) face high HIV incidence, with 5,900 infections in 2023. Oral PrEP is hindered by adherence, stigma, and access. Long-acting injectable PrEP (LAI-PrEP) offers an alternative, and pharmacies could serve as decentralized delivery points.

Methodology: A mixed-methods study in Kampala surveyed 119 AGYW, 119 KP, 150 pharmacy staff, and 9 key informants (KI). Pharmacy readiness was assessed with Proctor framework, factors with consolidated framework for implementation research (CFIR), KI data thematically analysed, and quantitative data analysed in STATA 14.

Results: Category 1 (KP and AGYW): Among the 238 AGYW and KP (77.7% female), 33.5% (77/230) reported no condom use in the past month, 88.4% (199/225) had ≥2 partners, and 27.7% (64/230) knew their partner’s HIV status. PrEP Knowledge and Awareness: PrEP knowledge was 79.8% (186/233), mainly from health workers (81.2%; 151/186). Awareness was reported as oral only in 90.5% (172/190) of participants, LAI only in 1.6% (3/190), and both oral and LAI in 7.9% (15/190). PrEP use willingness: Willingness to use PrEP was 79.2% (183/231), with 65.6% (120/183) preferring LAI-PrEP; 85.3% (102/120) favoured lenacapavir over cabotegravir. KP were more willing than AGYW (PR=10.32, 95% CI: 5.656–18.824, p<0.001), and HIV status-aware participants were more willing (PR=2.26, 95% CI: 1.04–4.94, p=0.039). Over half (54.3%; 115/212) were willing to receive LAI-PrEP at pharmacies, citing accessibility (57.7%) and fast service (31.5%). About 49.8% (112/225) believed pharmacies could administer it, and 65.9% (151/229) were willing to pay (<$1: 34.5%; $1-$2: 31.8%; $2-$14: 31.8%). Category 2 (Pharmacy staff): Pharmacy staff (n=150): mean age 27, 59.3% male, 79.7% diploma holders. Two (1.3%) routinely administered injections. Most (90.0%; 135) had customers ask about PrEP, mainly oral (89.7%; 122/136). While 60.7% (85/140) had PrEP training, 99.3% were willing to train in both forms. Pharmacy readiness: Mean acceptability, appropriateness and feasibility scores were 3.9, 3.9, and 3.8 (out of 5). Recommended preparations included staff training/education (29.1%), policy changes (17.5%), and infrastructure (7.8%). Category 3 (Key Informants): Qualitative findings showed benefits of better access, less stigma, and service integration. Challenges were staffing gaps, lack of infrastructure, unclear policies, and stigma. Enablers were training, policy changes, and health system linkages.

Conclusion: Pharmacy-based LAI-PrEP delivery is feasible and acceptable for KP and AGYW in Kampala. Willingness to receive LAI-PrEP from pharmacies was high, especially among KP, driven by access and privacy. Pharmacies demonstrated moderate–high readiness despite limited injection experience. Stakeholders supported the model, citing policy, training, infrastructure, and financing as key requirements for implementation.