1. Home
  2. Uptake and Use of long-acting injectable Cabotegravir offered as alternative HIV Pre-Exposure Prophylaxis to clients of outreach clinics in sex work hotspots in Malawi

Uptake and Use of long-acting injectable Cabotegravir offered as alternative HIV Pre-Exposure Prophylaxis to clients of outreach clinics in sex work hotspots in Malawi

Wednesday 19 August 2026 - Updated on Friday 18 September 2026
Retour à la liste des projets
Malawi
HIV
On-going
Period:
2025
-
2026

Study design

Mixed quantitative and qualitative study

Context

New HIV prevention strategies, including Pre-Exposure Prophylaxis (PrEP), are crucial for achieving a significant reduction in HIV infections. PrEP involves using antiretroviral drugs to prevent infection. In 2022, the WHO recommended long-acting injectable cabotegravir (CAB-LA) as a new PrEP option. Cabotegravir, an antiviral medication from the drug class of integrase strand-transfer inhibitors (INSTI), and analogue of dolutegravir, offers an alternative to daily oral PrEP with two-monthly injections, particularly benefiting population groups who face challenges to control their access and use of HIV combination prevention such as people who engage in sex work. 

In 2024, Malawi's Ministry of Health (MoH) updated its national PrEP guidelines to include oral and injectable PrEP options. Starting in March 2024, CAB-LA PrEP has been available through the MoH in 36 prescription sites, including drop-in-centers (implementation project), and mainly in Lilongwe and Blantyre (two major cities). Following these guidelines, MSF started to roll out in January 2025 injectable CAB-LA as an alternative PrEP option to sex workers through existing MSF, MoH and sex workers’ associations-supported sexual and reproductive health outreach clinics in sex work hotspots in Dedza and Neno districts, which includes provision in rural, remote areas in with cross-border influx of sex workers and customers. There is a lack of real-world evidence on the acceptability, uptake, and sustained use of PrEP, particularly among vulnerabilized populations like sex workers, as well as on the feasibility of delivering CAB-LA through community-based service models. 

This mixed-method operational research aims to evaluate how injectable CAB-LA, as an alternative HIV PrEP option, influences acceptability, uptake, preferences, and continued use of PrEP (both oral and injectable). Additionally, it seeks to generate practical insights into the feasibility of offering PrEP choices through community-based outreach clinics in sex work hotspots. 

Our role

Coordination

Partners

  • Ministry of health, Malawi

Primary objectives 

  • P1. To assess uptake, choices, patterns, and persistence (adherence) of PrEP use (oral PrEP or injectable CAB-LA). 
  • P2. To explore and describe barriers and enablers of PrEP uptake, preferences, persistence or discontinuation (oral PrEP or injectable CAB-LA). 
  • P3. To describe the PrEP service delivery model. 
  • P4. To assess the feasibility and acceptability of providing PrEP (oral or injectable CAB-LA) to clients accessing MSF/MOH/CBO-supported outreach SRH+R clinics in sex work hotspots. 

Methodology

18-month observational mixed-methods study in Dedza and Neno districts, Malawi. Since January 2025, Médecins Sans Frontières, Malawi Ministry of Health, and female sex worker-led community organizations have provided CAB-LA alongside oral PrEP through mobile clinics in sex work hotspots, with CAB-LA initially limited to 300 initiations. The results used routine data analyzed descriptively and through multistate modelling, complemented by qualitative interviews and group discussions with clinic clients and stakeholders. 

Results for the first 14 months

Among 1,393 clients offered PrEP, 742 (53%) initiated PrEP; 59% started CAB-LA and 41% oral PrEP. Notably, 70% preferred CAB-LA, but could not receive it immediately due to limited availability. Continued use was mainly with CAB-LA, while most oral PrEP users switched to CAB-LA or disengaged early. Discontinuation occurred mainly after second or third visit, largely due to loss-tofollow-up. Estimated oral PrEP use declined from 41.4% (95% CI 37.9–45.1) at initiation to 2.9% (1.4–5.9) at 12 months, versus 58.6% (55.2–62.3) to 32.0% (27.4– 37.2) for CAB-LA. Overall, 48.6% (44.4–53.3) were lost to follow-up by 12 months. Mobility, stigma, violence associated with oral PrEP use, injection site pain, and lack of peer support were identified as barriers for uptake and persistence. 

Conclusion 

CAB-LA has potential to improve PrEP uptake and persistence and was preferred over oral PrEP in mobile outreach clinics. However, overall PrEP uptake was moderate with substantial and early loss to follow-up, highlighting the need for strengthening of counselling, peer support and community sensitization. Continuous CAB-LA supply for marginalized populations remains a priority.

Video
Légende
Real-World evidence on uptake and persistent use of long-acting injectable Cabotegravir (CAB-LA) offered as HIV prevention alternative in female sex work hotspots, Malawi | Caoimhe O’Regan

For more information, contact

Référence profils
Photo
Birgit Schramm
Birgit Schramm
Titre du poste
Epidemiologist
Contact by mail
Photo
G.r Martinez Perez
Guillermo Z. Martinez Perez
Titre du poste
Epidemiologist, mixed-methods
Contact by mail