Most Women in Two-City Study Prefer Long-Acting Injectable PrEP Over Daily Pills, Despite Low Awareness

Most women at risk of HIV in Washington, DC, and Santo Domingo would rather receive a long-acting injectable form of pre-exposure prophylaxis (PrEP) than take a daily pill, yet very few had ever heard of either option, according to a mixed-methods study published in Frontiers in Global Women’s Health. The research, led by Deanna Kerrigan of the Rutgers School of Public Health with collaborators at Johns Hopkins University, MedStar Health, and the Instituto Dermatológico y Cirugía de Piel in the Dominican Republic, surveyed 602 women and conducted in-depth interviews with 40 women and 20 healthcare providers across the two cities.

The survey results revealed strikingly low awareness of PrEP in both settings. Only 29 percent of participants in Washington, DC, and 6 percent in the Dominican Republic had heard of daily oral PrEP, the form of the drug that has been available since the US Food and Drug Administration first approved it in 2012. Awareness of long-acting injectable PrEP, which the FDA approved in 2021 and which is not yet available in the Dominican Republic, was even lower, at under 6 percent across both sites. Actual use was rare: 3 percent of DC participants and 1 percent of Dominican participants reported having ever used PrEP. When asked why they had never used it, 62 percent of DC participants selected that they had never heard of it.

Interest in taking PrEP differed sharply between the two populations. Just 5 percent of DC participants reported definite interest in using some form of PrEP, compared with 80 percent of participants in the Dominican Republic, where all survey respondents reported sex work as one of their forms of livelihood. Thirty percent of DC participants said they definitely had no interest, versus 3 percent in the Dominican Republic. Perceived HIV risk was low in both groups despite behavioral and health histories suggesting potential benefit: 88 percent of DC participants and 53 percent of Dominican participants said it was unlikely or very unlikely they would ever acquire HIV.

Despite these differences, modality preferences were remarkably similar. Seventy-three percent of DC participants and 71 percent of Dominican participants said they preferred injectable PrEP given every two months over daily oral pills. The researchers note that this aligns with prior studies: a recent study among US women found 55 percent preferred injectable PrEP, and the team’s earlier work among female sex workers in Tanzania found 88 percent preferred the injectable form, citing convenience, confidentiality, and perceived greater effectiveness.

The qualitative interviews, conducted between November 2021 and February 2022, illuminated why the injection held such appeal. Women across both settings described PrEP as an empowerment tool that gave them control over their HIV risk in situations where they could not always control partner behavior. Women in the Dominican Republic described clients offering extra money for sex without condoms, condoms breaking, and non-consensual sex, while DC women spoke of being unable to guarantee a partner’s fidelity. Several participants said the injection would spare them from carrying pill bottles that others might identify as HIV-related medication; some Dominican participants and providers described a common practice of hiding PrEP pills in unrelated medicine containers to avoid being recognized as PrEP users.

Healthcare providers interviewed in the study expressed enthusiasm about injectable PrEP as an additional option, with one DC nurse calling it a potential game-changer, but many also reported lacking the comfort and preparation to discuss it with patients. Providers said they needed more information on medication administration protocols, side effects, and dosing before they could confidently present the option. Providers in DC observed that public messaging about PrEP was directed at men who have sex with men rather than at cisgender women, and DC women who had heard of PrEP generally saw it as a medication intended for other populations. In the Dominican Republic, word of mouth between friends and sex worker colleagues served as a trusted source of information.

Multivariate logistic regression, run separately for each site, identified both shared and distinct factors associated with preferring the injectable form. In DC, preference for injectable PrEP was significantly positively associated with a higher score on a PrEP optimization scale measuring how many considerations participants weighed in decision-making (adjusted odds ratio, 1.06), and significantly negatively associated with being bothered by injection site pain or tenderness (adjusted odds ratio, 0.54). In the Dominican Republic, prior experience with injectable medications or contraceptives (adjusted odds ratio, 2.39) and higher alcohol use (adjusted odds ratio, 1.90) were significantly associated with preferring the injection, while being bothered by injection site pain (adjusted odds ratio, 0.46), experiencing sexual partner violence (adjusted odds ratio, 0.39), and higher PrEP stigma scores (adjusted odds ratio, 0.93) were significantly negatively associated with that preference.

The interviews also surfaced practical barriers that shaped whether women could act on any preference. In the Dominican Republic, providers perceived the cost of injectable PrEP as a barrier and noted that daily oral PrEP was currently free, arguing the injection would also need to be free for women to adopt it, although some women said they would pay or borrow money to obtain it. In DC, participants and providers highlighted the need for insurance coverage and wanted to know co-payment amounts in advance. Both groups cited transportation, appointment reminders, and childcare as needed supports, with DC women noting clinic policies that barred children under 18 from the office. Most participants said a peer navigator would help them start and stay on PrEP, with 66 percent of DC and 97 percent of Dominican participants finding that useful.

The authors argue that the findings point to the need for multi-level interventions tailored to specific subgroups of women, including women-centered awareness campaigns, training and decision-making tools for healthcare providers, and conversations about PrEP that are not predicated on self-reported risk, since many women who could benefit do not perceive themselves to be at risk. They note that nearly half of DC participants and 73 percent of Dominican participants said they would feel comfortable discussing PrEP with a provider at the clinic where they were surveyed, and that DC participants most often preferred obtaining PrEP through family planning or primary care clinics, suggesting reproductive health settings offer an acceptable platform for expanding access.

The researchers caution that the study has limitations, including the cross-sectional design of both the qualitative and quantitative components, reliance on self-reported data, and timing near the FDA approval of injectable PrEP, which may have limited awareness and provider training at the time of data collection. The survey was conducted between November 2022 and July 2023, and the study was not designed to be generalizable to all women in either geographic context. Nevertheless, the authors write that the lessons may transfer to similar groups of women in the United States and to female sex workers in low- and middle-income countries, and that expanding access to both daily oral and injectable PrEP options, alongside supports addressing social and structural factors, is critical to reducing disparities in PrEP uptake among women.

Subject of Research: PrEP awareness, interest, and modality preferences among cisgender women in the Dominican Republic and the United States

Article Title: Pre-exposure prophylaxis awareness, interest, and modality preferences to prevent HIV among cisgender women in the Dominican Republic and the United States

Article References: Kerrigan, D., Davis, W., O’Rourke, A., Galai, N., Mantsios, A., Scott, R. K., Moriarty, P., Metzner, A. A., Oglesby, A., Karver, T. S., Taggart, T., Barrington, C., Uhrig Castonguay, B. J., Yonamine, K., Gomez, H., Perez, M., & Donastorg, Y. (2026). Pre-exposure prophylaxis awareness, interest, and modality preferences to prevent HIV among cisgender women in the Dominican Republic and the United States. Frontiers in Global Women's Health, 7, Article 1817411. https://doi.org/10.3389/fgwh.2026.1817411

Image Credits: AI Generated

DOI: 10.3389/fgwh.2026.1817411

Keywords: HIV, PrEP, long-acting injectable PrEP, cisgender women, Dominican Republic, Washington DC, female sex workers, healthcare providers, PrEP stigma, mixed-methods study, HIV prevention, modality preferences