HIV-blocking prophylactic antivirals in vaginal-ring and injectable form are not only longer-acting than daily pills, they’re also more discreet.

7 March 2025 by Pascalinah Kabi

Est. Read Time: 7 min

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When 30-year-old Ithabeleng Mosele (not her real name) discovered that her husband was having an extramarital affair about a year ago, the fear of being infected with HIV shattered her.

“That is when I started to feel uncomfortable and unsafe,” Mosele told VaccinesWork in a recent interview.

Mosele comes from Lesotho – a country with the second-highest HIV prevalence rate in the world. According to the UNAIDS report in 2022, the HIV prevalence rate among adults aged 15 to 49 was 19.3%, meaning nearly one in five people in this age group were living with HIV that year.

This statistic, combined with the discovery of her husband’s infidelity, led Mosele to initiate an uncomfortable conversation with him.

She suggested that they both start taking pre-exposure prophylaxis (PrEP) tablets – a medication that significantly lowers the risk of getting HIV through sex.

In relationships, some partners may not approve of their partner using PrEP. As a result, many women face challenges with taking oral PrEP. While they understand the need for it, they often struggle to use it at home due to these social pressures.

– Dr Nthuseng Marake, HIV Treatment and Care Officer at Lesotho’s Ministry of Health.

PrEP is designed for people who do not have HIV, but are at risk of exposure to the virus – people like Mosele, who often worries about whether her husband uses protection with the other woman.

“He refused. He took it as an indication that I do not trust him to a point where I want us to use PreP,” Mosele explained.

Undeterred by her husband’s negative response, Mosele shared how she secretly travelled to Scott Hospital, about 44 kilometres from Lesotho’s capital, Maseru, to start taking PrEP pills over a year ago.

However, she acknowledged that keeping the use of the medication a secret was often challenging, leading to occasional lapses in taking it. “That used to trigger more fear that I am not completely protected if I keep missing my dose on some days,” Mosele explained.

Longer-acting alternatives

While PrEP is a prophylactic, it’s not a vaccine. Where vaccines prompt the immune system to generate its own antibodies to defend against a given pathogen – functionally teaching the body how to win a battle it hasn’t necessarily fought before –  PrEP is an antiviral drug that that attacks the HIV virus directly: it has to be present in the blood stream in high enough to concentrations at exposure to effectively stop the HIV virus replicating, and prevent an infection from taking hold.

There are many reasons that at-risk people like Mosele might find it hard to keep to the regular, consistent daily regimen that can keep them safe. In light of those challenges, new HIV prevention approaches are being explored.

Catalysing Access to New Prevention Products to Stop HIV (CATALYST) is a research project that is aimed at understanding how to effectively introduce and deliver new HIV prevention technologies to the people. A CATALYST pilot study was conducted in Lesotho, South Africa, Uganda, Kenya and Zimbabwe from 2023, and, in Lesotho, looked at two alternative PrEP delivery systems among women: long-acting injectable PrEP, and the vaginal ring, which slowly releases the antiviral drug over the course of a month.

Mosele said she first learned about injectable PrEP, which is administered every other month after the first two injections, which are given at a month’s interval, in a Facebook post. When it was time for her next PrEP refill, she asked about the injection, believing it would be more suitable for her – a married woman who was secretly taking PrEP pills without her husband’s knowledge.

“I was taken through the whole process of how the injection works and where it is currently found. So, in August [2024], I started using the PrEP injection,” Mosele said. 

She added: “My only reason for remaining anonymous is that I have not disclosed to my husband that I am on PrEP.”    

Sensitive medicine

Dr Nthuseng Marake is the HIV Treatment and Care Officer at Lesotho’s Ministry of Health. She explained to VaccinesWork that the PrEP ring and injectable PrEP offer users increased discretion, helping them maintain privacy and confidence when necessary.

“When a girl takes oral PrEP while living with her parents, it can be interpreted as though she is revealing that she is sexually active, which sometimes creates tension within families,” Dr Marake said.

She added, “In relationships, some partners may not approve of their partner using PrEP. As a result, many women face challenges with taking oral PrEP. While they understand the need for it, they often struggle to use it at home due to these social pressures.” She said this can also lead to intimate partner violence. 

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Discretion is key: Dr Marake explained that no one needs to know if a woman has had an injection, or inserted a ring, unless she chooses to disclose it. According to studies, it is rare for men to feel the PrEP ring during intercourse, she added.

As such, the new delivery methods, “also help prevent potential intimate partner violence or gender-based violence, which can arise when an insecure partner starts questioning trust because of the use of PrEP,” Dr Marake said.

She added, “Another burden that has been alleviated is the challenge of having to remember to take oral pills daily, especially for those who are constantly at risk of acquiring HIV. With daily pills, some people forget to take them. When there is no adherence to the prescribed regimen, the risk of HIV transmission increases.”

One drop in the ocean

Dr Marake said before a full-scale implementation, Lesotho’s Ministry of Health decided to embark on a pilot study to assess the acceptability of PrEP ring and the injectable PrEP among women in Lesotho.

“We wanted to evaluate the intake of these new products, particularly since the uptake of oral PrEP has been low in Lesotho and other countries.”

The pilot, conducted at Scott Hospital and community sites at Sefika and Berea, began in June 2023. It involves 850 participants and is focused on monitoring how women transition between the different available PrEP products – the ring, injection, and oral pills.

By June 2024, the study had enrolled 158 women on the vaginal ring and 135 on the injectable PrEP. Dr Marake explained that statistics from July 2024 up to date cannot be released until an official publication has been made.

While 850 women are currently targeted participants in this pilot study, it remains clear that this number is a small fraction of the need.

Women like 35-year-old Lerato (not her real name), who lives in Mokhotlong district, are eager to access discreet PrEP products. Yet, according to Dr Marake, the study is being piloted at in Maseru district at Scott Hospital and Sefika Resource Centre as well as the Berea Resource Centre in Berea district.

“I have heard about the ring and the injection, but I was not sure where I can get them and whether they were free or not,” Lerato said.

She added: “I would really prefer a PrEP injection but since I have some chronic illnesses, I will first consult to find out whether they may have any side effects due to my chronic illnesses.”

A nurse in Morija, speaking anonymously to protect client confidentiality, recalled an emotional encounter with a woman who “could not stop crying after testing HIV-negative.

“She was crying because her husband repeatedly refused to use protection, despite having multiple partners. Every two months, she comes here for PreP injection and can’t stop thanking us for giving her the power to protect herself,” the nurse shared.

Moreover, studies have indicated that the PrEP injection may be more effective at preventing HIV than oral PrEP. However, cautioned Dr Marake, the PrEP ring only prevents HIV transmission through vaginal sex, not anal sex.

“I am sure you are aware that some women prefer anal sex, which means they would not be protected by the ring, as it only provides protection during vaginal intercourse,” Dr Marake explained, adding that the injectable PrEP offers broader protection.

This story was originally produced and published by VaccinesWork.