These authors have contributed equally to this work and share senior authorship
The introduction of new pre-exposure prophylaxis (PrEP) methods presents an opportunity to expand choice and better integrate HIV prevention and broader sexual and reproductive health (SRH) services. Integrating HIV prevention services, including PrEP, and SRH services presents an opportunity to improve healthcare access and outcomes. However, implementation within real-world healthcare settings requires an understanding of both enablers and barriers from the perspective of healthcare providers (HCPs).
A qualitative descriptive study was conducted using in-depth interviews (IDIs) to describe the integration of PrEP and SRH services, drawing on the perspectives of HCPs. Thirty-four HCPs were purposively sampled and interviewed between October and November 2024 across four South African locations: eThekwini, Gqeberha, Mthatha, and Tshwane. Audio recordings were transcribed, translated, and analysed using inductive thematic analysis with NVIVO 14 software.
Key benefits of service integration expressed by HCPs included increased continuity of care with the same HCP, convenience, and a higher uptake of SRH services, such as contraception and sexually transmitted infection (STI) screening and management. Facilitators included integrated education and awareness, flexibility in alignment of appointment schedules, and positive staff attitude. Challenges and barriers included misalignment between injectable PrEP and injectable contraceptive visit schedules and infrastructural limitations within some public health facilities.
Successful integration requires adaptable systems, responsive scheduling, functional infrastructure, and positive staff attitude. To improve uptake and continuity of SRH services, health systems should be flexible and provide holistic services that align with client needs.
Despite progress in HIV prevention, critical gaps remain in meeting the intersecting sexual and reproductive health (SRH) needs of different populations, particularly adolescent girls and young women (AGYW) (
This study was conducted as part of the work of Project PrEP, an implementation science study funded by Unitaid that aims to inform HIV prevention delivery models and expand choice among AGYW in South Africa through the provision of accessible, differentiated, and integrated HIV prevention and SRH services. The project approach has been described previously for oral PrEP introduction (
This study employed a phenomenological descriptive qualitative research design to describe the perspectives of HCPs on the facilitators and barriers to service integration for PrEP and SRH, in the context of new PrEP methods introduction in South Africa. The study adhered to Consolidated Criteria for Reporting Qualitative Research (COREQ) (
HCPs were recruited through a purposive sampling approach to identify cadres actively delivering PrEP services to ensure representation of both clinical staff (professional nurses) and non-clinical staff (counsellors and client navigators). Eligible participants were required to be at least 18 years old, actively providing SRH and PrEP services at the study sites, and willing to participate in an audio-recorded interview. Thirty-six providers meeting these criteria were invited: thirty-four participated, with two declining (one unavailable, one non-response). Recruitment was done telephonically and through email by a senior researcher who is not involved in the day-to-day activities at the sites. Informed consent was obtained before participation, and demographic information was collected to provide a contextual background for the analysis.
Data were collected through single individual in-depth interviews (IDIs) between October and November 2024 with thirty-four HCPs aged 25–63 years. Among those who participated fifteen were clinical staff (professional nurses) and nineteen were non-clinical staff (counsellors and client navigators). Interviews were held in private spaces within the healthcare facilities or nearby community-based organisations (CBOs) to ensure confidentiality, while three were conducted telephonically. To help limit social desirability bias, interviews were conducted by three trained female qualitative researchers (FAC, FMM, and SD) not involved with the participants’ day-to-day work activities, and participants were assured of confidentiality and the non-evaluative nature of the study. Interviews were conducted using a semi-structured guide developed by the research team to explore experiences, perceptions, training needs, and delivery models for different PrEP products; however, the focus of this paper is on service integration. The interview guide was not piloted as it was adapted from previous similar research conducted among HCPs and eliminated the need for pretesting. All data were anonymised, stored securely on access controlled server on Microsoft teams, and accessible only to the research team. Interviews were conducted in English, isiZulu, Setswana, or isiXhosa, depending on the participants’ language preference, and lasted on average 60 min. All interviews were audio-recorded with participant consent. To compensate for their time participants received a reimbursement of R300.
All interviews were transcribed verbatim in the original language, translated into English where necessary, and reviewed for accuracy before analysis. Translations were reviewed by bilingual team members to verify accuracy and preserve meaning. Any discrepancies were discussed and resolved before analysis to ensure cross-language validity. A thematic analysis was conducted following Braun and Clarke's six-phase steps (
Analysis was primarily conducted by FAC, FMM, and SD in discussion with the broader research team. FAC is a female researcher with a Master's degree in Research Psychology and experience in qualitative research. FMM is a female researcher with a PhD in sociology and experience in qualitative research. SD is a female researcher with a PhD in Public Health and experience in qualitative research. All three analysts have prior experience in SRH and HIV-related qualitative research, which informed familiarity with the study context. To address positionality and potential bias, the analysts engaged in reflexive practices throughout analysis, including discussing emerging interpretations with the broader research team. These discussions were used to critically reflect on how researchers’ backgrounds and assumptions might influence interpretation and to ensure findings remained grounded in participants’ accounts.
The study received ethical approval from the Human Research Ethics Committee at the University of the Witwatersrand (220604) and the World Health Organization (WHO) Ethics Research Committee (0003784). Written informed consent was obtained from all participants for both their participation and the audio recording of the interviews.
Socio-demographic characteristics of study participants.
| Socio-demographic characteristics | % | |
|---|---|---|
| Age group | ||
| 25–34 years | 21 | 61,8 |
| 35–44 years | 9 | 26,5 |
| 45 + years | 4 | 11,8 |
| Biological sex | ||
| Male | 4 | 11,8 |
| Female | 30 | 88,2 |
| Geographical area | ||
| Tshwane | 9 | 26,5 |
| Mthatha | 10 | 29,4 |
| eThekwini | 7 | 20,6 |
| Gqeberha | 8 | 23,5 |
| Staff category | ||
| Clinical staff | 15 | 44,12 |
| Non-clinical staff | 19 | 55,88 |
| Months in current job | ||
| 0–12 months | 4 | 11,8 |
| 13–24 months | 15 | 44,1 |
| 25 + months | 15 | 44,1 |
Increased continuity of care with the same healthcare provider
Continuity of care, where clients see the same provider, was mentioned as a key benefit of integrated services. HCPs reported that when clients consistently engage with the same provider for multiple services, it strengthens trust, reduces the need to explain themselves every time, and fosters a more supportive on-going provider-client relationship. This theme reflects relational consistency over time.
“… you screen the client that is on CAB-LA for STI, you check pregnancy, every time the client comes. You check if the client has an STI, and then you track accordingly if the client has it or not. So, you screen every time the client comes for pregnancy and STIs.” (Clinical staff, Mthatha)
“…you build like a better rapport and the relationship with the client, then clients would come back to say, I'm looking for that nurse and I only want to see that nurse because they know, like they don't have to re-explain themselves, like what was the issue last month.” (Clinical staff, Tshwane)
HCPs mentioned that when clients return to a familiar provider, they feel more comfortable and will return for services.
“…they get familiar with one person, if they know that this is the nurse that I'm comfortable with, then they know that they can always come back.” (Non-clinical staff, Tshwane)
Convenience
A key benefit of service integration was the creation of a “one-stop shop” where clients could access contraception, STI screening and management, and HIV prevention services in a single visit under the same roof. HCPs mentioned that this reduced the need for clients to have multiple appointments. HCPs reported that clients valued receiving multiple services in one room. This one-stop-shop model was seen as highly convenient, saving clients time and effort by eliminating the need to queue at multiple service points hence reflecting structural and logistical efficiency of service delivery. HCPs emphasized that integrated service delivery is especially beneficial for clients with limited time. Clients were reported to value the ability to plan their day around predictable and streamlined service provision, which enhances their overall healthcare experience and encourages continued engagement. Without service integration, HCPs noted, clients might be deterred from seeking care due to the time burden of visiting multiple service areas.
“… some of our clients are students and they come here after school, especially around half past two, three o'clock. And because of the integration of services that we have, they [clients] know that even though I go to the facility at three o'clock, I would always find it and then I'm going to leave at a certain time. I'm not gonna spend the whole day.” (Non-clinical staff, Tshwane)
“Mostly, there is this thing of one-stop shop. It helps that a patient must not sit in this room for contraception and go to that room for PrEP and go to that room for STI. It is good for them to do everything in one consultation to eliminate time.” (Non-clinical staff, Mthatha)
Increased uptake of SRH services
Integrating HIV prevention and SRH services encourages clients to engage with a broader range of preventive healthcare services. HCPs reported that clients who initially seek treatment for STIs or access contraception are introduced to other prevention interventions, such as PrEP, leading to increased uptake. Education during consultations helps shift perceptions, encouraging clients to take proactive steps in their sexual health. This also leads to an interest and desire to try biomedical HIV prevention products. Additionally, peer influence was also reported to play a role, with clients referring friends after receiving services and information. HCPs leveraged integration to offer comprehensive care, addressing other health concerns during the same visit.
“…you find out that the adolescent girls and young women are only coming for contraception, they do not know anything about PrEP. So, when you talk to them about PrEP methods, you will see that they are interested in taking PrEP.” (Non-clinical staff, Gqeberha)
“… they [clients] come for STI and they're not even aware that they're at the risk of HIV. But then, when they get here, because we are integrating services, they get to learn about PrEP, and then someone would now realize I’m at risk of getting HIV.” (Non-clinical staff, Mthatha)
Education and awareness
An important facilitator of the successful integration of new PrEP methods and SRH services was comprehensive, integrated education and awareness. HCPs emphasized the need to inform clients about available SRH services, including contraception and STI screening, HIV testing, and HIV prevention options, in an integrated manner. HCPs highlighted that young people often avoid coming to the clinic; therefore, when they do visit, it is crucial to provide all services holistically to prevent missed opportunities.
“…So, we need to understand that they [young people] don't want to come to the clinic, so we need to try, when they are here, to do everything that they need. So, we check what they came here for, you provide all the services that we have, all the products for PrEP. Now you also check the contraceptive. So, we need to look at everything holistically. We don't look at one thing because they won't come back.” (Clinical staff, Mthatha)
“Because when the client comes to the clinic, they [nurses] provide them with information on these products and SRH services. So, a client gets a lot. The client goes home having received contraceptives and knowing her HIV status.” (Non-clinical staff, Mthatha)
“Mostly it’s the education… They might have come in not for PrEP, but for something else. And while sitting in the waiting room, they have a client navigator speaking to them about PrEP. Then they come to your PrEP line. That’s how they end up there.” (Clinical staff, eThekwini)
Flexibility in alignment of appointment dates
To reduce the number of times clients must come to the clinic, HCPs need to be flexible and problem-solve ways PrEP and contraception visits can be aligned. The schedules for contraception and PrEP method were not always well aligned. A key strategy was aligning PrEP and contraceptive appointments, particularly for those using the injectable contraception methods, to enable clients to receive both services in a single visit. This not only improved convenience but also reduced transport costs and time burdens for clients. This client-centred problem-solving approach facilitated integrated service delivery, enhanced access to PrEP, and supported continuity of care.
“..So, the client was saying, how about I miss coming to my contraception and wait until my PrEP date? …she wanted her clinic dates to be aligned [so that] when she comes for contraception, she can also take CAB-LA.” (Clinical staff, Gqeberha)
“…now we can align the dates for those who are on contraceptives. So then, at least we can align their dates. When they come for contraception, they're also coming for the PrEP.” (Clinical staff, Tshwane)
HCPs reported that flexibility and problem-solving were helpful, for example, where oral contraceptives were used as a bridge to align the client's PrEP method and injectable contraceptive appointments. HCPs noted that alignment of oral contraceptives with DVR was easier than for CAB-LA, whereas schedule alignment posed greater challenges with CAB-LA, making this a key barrier to integration.
“Oral contraceptives, so that next month when she comes for the second injection, [CAB-LA] we offer both the injectable contraceptive and PrEP. So that we can align the dates. Oral contraceptives are aligned better, and with DVR, they don't have a problem. You can align it with any contraceptive.” (Clinical staff, Mthatha)
For clients initiating PrEP for the first time, careful scheduling was required to ensure alignment with contraception appointments. HCPs reported that they adjusted follow-up appointments to ensure that new PrEP users could gradually transition to aligned dates by adjusting the scripting of the oral PrEP or contraceptive methods. Additionally, HCPs mentioned that misaligned visit schedules also influenced clients’ decision-making around contraception, with some women switching or choosing specific contraceptive methods to better align with their PrEP appointments and reduce the need for frequent clinic visits.
“…choice counselling has influenced the client to choose their contraception accordingly. …remember when the client comes, we align the appointment days. …with CAB-LA because it’s a two-monthly injection, first one month first, then two monthly. So, it also has contributed to clients changing their contraceptive methods just to make sure that, they are aligned because they don't want to come to the facility now and then. (Clinical staff, Tshwane)
“…you need to align all of that because you would have a new PrEP initiation, never been on contraception come to you for PrEP services. You initiate them on PrEP, offer contraception, and they want to go on the oral contraceptive. …You review them in a month’s time and give them one month of PrEP and one month of contraception… So, that is how you align the two. If it’s an injectable method, the client is coming on a two monthly injectable method, you do an initiation, you give them the two monthly injectable method. In a month’s time you recall them for PrEP for month one follow-up. But then again, you give them another month so that they come back just to align it with their two monthly methods [contraception] so that moving forward they only get two monthly PrEP and two monthly injectable [contraception] method so that you align them to ensure that the two appointments are being done in a one stop shop manner.” (Clinical staff, eThekwini)
HCPs described proactively working with clients to align visit schedules, sometimes even recommending adjustments to contraception methods to better align with PrEP follow-ups.
“…we tell them take this type of contraception so that next time when you come the dates will match. So, we integrate contraception mostly because most of them come for contraception than PrEP.” (Clinical staff, Tshwane)
Positive staff attitude
HCPs noted that the provision of integrated services must be grounded in quality of care, with staff attitude playing a central role in facilitating interpersonal interaction quality. A positive, respectful, and non-judgmental approach was reported as essential for creating a welcoming environment that supports integration. One HCP reported that simple gestures such as smiling, speaking politely, and avoiding harsh tones contributed to a positive clinic experience and encouraged clients to return for follow-up visits.
“…if the client has been treated the right way at the clinic, they will be happy. Then the client will come back. I also think a positive attitude is important to the client. Because if the client did not get a positive attitude, she would leave and never come back… Even when you talk to them [clients], you mustn’t shout; they don’t want that. Always smile when you talk to them, and they’ll come back.” (Non-clinical staff, Mthatha)
Aligning three-monthly injectable contraceptives and CAB-LA
HCPs reported that a major challenge in integrating CAB-LA with the client's current contraception method is the misalignment of visit schedules. Since CAB-LA follows an initial one-month injection followed by two monthly injections, it does not align with the three-monthly schedule of injectable contraceptives like depot medroxyprogesterone acetate (DMPA). This results in additional clinic visits for clients, which can be inconvenient, particularly for those with financial constraints, busy school/work schedules or transportation difficulties. HCPs mentioned that they attempted to align schedules by discussing with clients the option to switch to contraceptive methods that align with CAB-LA's dosing schedule. However, HCPs reported that many clients preferred their current contraceptive method due to personal experiences, such as side effects with alternative options. HCPs reported that some clients expressed frustration over needing multiple clinic visits, while others were willing to adjust. Despite the challenge, HCPs focused on clear communication to help clients understand the scheduling implications and potential alternatives.
“…make them understand that maybe some dates are not going to be the same, and then we talk to the client and inform the client that we would love to align their visit dates. And now that is starting the CAB-LA, because they have to take the CAB-LA for one month, firstly, and then two monthly, if the client is on two months injectable [contraception]. We would suggest that the client take one-month oral PrEP” (Clinical staff, Mthatha)
“…sometimes you find out that integration is not going to work based on what the client wants. Because when the client is on DMPA that injectable is three months injectable but if the client is also on CAB-LA, it cannot integrate. We cannot integrate CAB-LA and DMPA, because there will always be that one month that overlaps you, see? So, it depends on which product the client is on because sometimes we try to change the client’s minds to say, for you to be able to integrate this, you maybe have to change from using this one to this one..” (Clinical staff, Mthatha)
“…if the client comes and the client is using maybe the two-month contraceptives, and they want CAB-LA, remember the CAB-LA, you start with one month, and then she’s here for two months injection. So, the dates are not going to align. So that was a challenge for me to convince the client to switch the contraceptive methods..” (Clinical staff, Tshwane)
Healthcare facility infrastructure constraints
Integration needs a supportive health system. Constraints due to infrastructural problems were reported to create barriers to both the quality of care and efforts to integrate services. HCPs explained that in many facilities, pregnancy testing is conducted at designated service points within the facility rather than being integrated into all service areas. Another key issue is the lack of infrastructure within certain clinics, such as running water or functioning toilets, which prevent on-site urine pregnancy testing. Clients are sometimes required to go to other areas of the clinic for urine testing or return home if a pregnancy test cannot be done on-site. This fragments the service, often leading to missed follow-up visits and delays in accessing PrEP and contraception. Mobile services provide a more streamlined approach, offering pregnancy testing within a single setting.
“…in this facility, we struggle a lot there are times when there’s no water and we cannot do pregnancy test, for instance. We cannot do urine testing… So, if we could maybe have a working station that’s gonna have toilets it would help us a lot because when the toilets in the facility are not working, we'll be able to do pregnancy test because sometimes when a client comes in for PrEP, maybe it’s their follow up date, but they are behind with contraception we have to send them where they have [water] or to go home.” (Non-clinical staff, Gqeberha)
“With the mobile it’s much easier because everything happens in the mobile..They know that everything is just in one place. And it’s much quicker that side. With the facility, some of the things we are assisted by the DOH. So, it means we work hand in hand with them. Certain things can delay. Let’s say the likes of urine testing, they need to go to do it that side with the mobile, you have the toilet inside with the facility, you need to travel a certain distance for you to go there…” (Non-clinical staff, Tshwane)
This study describes HCPs’ perspectives on integrating new PrEP methods and SRH services, shedding light on both the operational and relational elements that shape successful integration in real-world settings. Three key domains emerged: the benefits of service integration, facilitators that enable it, and the challenges and barriers that must be addressed. HCPs highlighted how integration improves continuity of care by enabling clients to see the same provider across multiple services, which builds trust, reduces the need for repeated explanations, and improves client comfort, particularly for sensitive issues such as HIV prevention and contraception. PrEP integration was described as a critical component of responsive SRH services. HCPs emphasized that offering PrEP alongside contraception, HIV testing, and STI management allows clients to consider prevention holistically rather than as separate decisions. They noted that counselling on multiple PrEP and contraception methods could be complex, as clients’ choices for one method sometimes influenced the other. At these service points injectables, oral contraceptives, and implants are offered, and uptake of injectable contraceptive methods is high making alignment of CAB-LA and injectable visits of relevance. This service integration not only reduces missed opportunities for initiation but also fosters continuity. Such integration reduces repetition of explanations from the client, aligns appointment schedules, and promotes more efficient use of clinic resources. These findings align with existing literature, which supports that integrated models strengthen client engagement and reduce service fragmentation (
Our findings may not be generalizable to different settings, as we only described the views of HCPs in settings where integration was implemented. We acknowledge the potential for social desirability bias in this study, as data were collected through IDIs with healthcare providers working at the project sites. Given their role within the healthcare system, participants may have provided responses that aligned with institutional expectations or perceived best practices. While our main project focuses on AGYW, integration approaches should consider the perspectives of key populations to determine if similarly integrated models may address their specific preferences and needs.
The findings presented in this paper offer novel insights into the integration of PrEP and SRH services, particularly in the context of introducing multiple PrEP methods and as longer-acting PrEP methods are introduced. Successful integration of HIV prevention and SRH services requires a holistic, client-centred approach supported by flexible systems, positive provider attitudes, and functional infrastructure. Education and awareness remain key to introducing new biomedical interventions, while flexibility in appointment scheduling enables alignment of product visits and continuity of care. Health systems should plan for the complexity of integrating products with differing clinical requirements and ensure services can be provided efficiently in a single visit.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The studies involving humans were approved by Human Research Ethics Committee at the University of the Witwatersrand (220604) and the World Health Organization (WHO) Ethics Research Committee (0003784). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.
FM: Writing – review & editing, Methodology, Writing – original draft, Data curation, Project administration, Formal analysis. SD: Formal analysis, Data curation, Writing – review & editing, Project administration. FC: Project administration, Data curation, Formal analysis, Writing – review & editing. MP: Writing – review & editing. ML: Writing – review & editing. SA: Writing – review & editing. AK: Writing – review & editing. CM: Writing – review & editing, Funding acquisition, Supervision, Conceptualization, Project administration. SM: Project administration, Conceptualization, Funding acquisition, Writing – review & editing.
The authors wish to thank the Project PrEP site staff who took their time to participate in this study and shared their perspectives, and the Department of Health for their support and collaboration.
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The author(s) declared that generative AI was not used in the creation of this manuscript.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
The Supplementary Material for this article can be found online at:
Edited by:
Reviewed by: