What shapes women’s preference for a dual prevention pill in South Africa and Zimbabwe

A pill that combines pregnancy and HIV prevention in a single product appeals to women in southern Africa, but the reasons they prefer it differ sharply between countries, according to a secondary analysis published in Contraception and Reproductive Medicine. The research examined behavioral, interpersonal, social and structural correlates of preference for an over-encapsulated dual prevention pill, or DPP, among women and adolescent girls in South Africa and Zimbabwe, with the aim of informing how the product is introduced and counseled once it becomes available.

The DPP studied is a proxy for a co-formulated product still in development and testing, which would combine an oral contraceptive pill and an oral HIV pre-exposure prophylaxis, or PrEP, pill in one dose. The analysis drew on two clinical crossover trials that compared the acceptability, adherence and preference of the over-encapsulated DPP against taking two separate pills. Participants were HIV-negative, non-pregnant cisgender women enrolled in Johannesburg, South Africa, where 96 women aged 18 to 40 took part, and in Harare, Zimbabwe, where 30 participants aged 16 to 24 were enrolled.

Participants were randomized one to one to use either the DPP or two separate pills for three 28-day cycles, after which they switched to the other regimen. Preferences were measured at the end of the crossover period and through exit in-depth interviews. The mean age was 27 years in the South African cohort and 19 years in the Zimbabwean cohort. Most participants had completed secondary school, and childbearing experience was more common in Zimbabwe, where 97 percent of participants had children, compared with 74 percent in South Africa.

Pregnancy prevention was highly valued at both sites, with roughly 90 percent of participants rating it as important. However, Zimbabwean participants voiced greater concern about HIV. Overall, preference for the DPP was higher in Zimbabwe, where 62 percent of participants favored it, than in South Africa, where 39 percent did.

In South Africa, bivariate analysis showed that DPP preference was associated with several behavioral factors, including no anal sex experience, ever having experienced sexual violence, relationship conflict, and transactional relationships or sex, as well as with product characteristics such as ease of use and side effects. When these variables were entered into a multivariable model, only anal sex experience and relationship control remained statistically significant.

In Zimbabwe, the pattern of associations looked different. Concern about HIV acquisition was associated with DPP preference, but in the opposite direction than might be expected. Interpersonal power and structural factors also appeared in the bivariate results, with more food insecurity and less housing insecurity associated with preference, alongside ease of use. Because of the small sample size in Zimbabwe, no multivariable analysis was possible, so these associations could not be adjusted for one another.

The qualitative exit interviews added context to the quantitative findings. Participants highlighted the DPP’s simplicity as a key advantage over taking two separate pills, a benefit that resonated with the quantitative finding that ease of use was associated with preference in both sites. At the same time, participants expressed clear desires for product improvements: they wanted a smaller pill and more discreet packaging, which they said would reduce stigma and make the product easier to use.

The authors conclude that while women in both countries value integrated HIV and pregnancy prevention, distinct behavioral and social factors, along with product attributes, influence DPP preference. They suggest that tailoring DPP introduction and support strategies to address specific challenges, such as relationship dynamics and product usability, may support acceptability and informed choice of dual prevention strategies.

Several limitations should be kept in mind when interpreting these findings. The analysis used data from two small crossover trials with a combined 126 participants, and the over-encapsulated DPP was studied as a stand-in for a co-formulated product that is still under development, so preferences may differ for the final product. No multivariable analysis was possible in the Zimbabwean cohort, and the associations reported there come only from bivariate comparisons. The trials were registered on ClinicalTrials.gov as NCT04778514 for Zimbabwe and NCT04778527 for South Africa, both registered on 25 February 2021. The published version is an accepted manuscript shared early, and is subject to further edits before the final version of record.

Subject of Research: Factors associated with women's preferences for an over-encapsulated dual prevention pill for HIV and pregnancy prevention in South Africa and Zimbabwe

Article Title: Factors associated with women’s preference for an over-encapsulated dual prevention pill: findings from South Africa and Zimbabwe

Article References: Mathur, S., Plagianos, M. G., Friedland, B. A., Bruce, I. V., Burnett-Zieman, J. B., Dandadzi, A., Musara, P., Ndlovu, N., Sedze, N., Tenza, S., Reddy, K., Zulu, S. K., Haddad, L. B., Murombedzi, C., Mgodi, N. M., & Palanee-Phillips, T. (2026). Factors associated with women’s preference for an over-encapsulated dual prevention pill: findings from South Africa and Zimbabwe. Contraception and Reproductive Medicine. https://doi.org/10.1186/s40834-026-00487-3

Image Credits: AI Generated

DOI: 10.1186/s40834-026-00487-3

Keywords: dual prevention pill, PrEP, oral contraceptives, HIV prevention, pregnancy prevention, South Africa, Zimbabwe, acceptability, crossover trial, women's health, product preference, stigma