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

BACKGROUND

CAB-LA, the first long-acting injectable HIV pre-exposure prophylaxis (PrEP), may improve prevention by overcoming adherence challenges of daily oral PrEP. Real-world evidence remains limited. We evaluated uptake, persistence, and factors influencing CAB-LA use in female sex work hotspots in Malawi.

METHODS

We conducted an 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. We report findings from the first 14 months using routine data analyzed descriptively and through multistate modelling, complemented by qualitative interviews and group discussions with clinic clients and stakeholders.

RESULTS

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-to-follow-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.