When women's HIV prevention becomes unstable: findings from a longitudinal qualitative study in Sierra Leone

HIV prevention among women is often described as movement from risk recognition to protective action. Structural and gender factors shape whether that movement occurs. Less clear is how these factors change over time and how these changes affect women's capacity to sustain prevention. This longitudinal qualitative study examined this temporal gap in Sierra Leone. Forty-eight interviews were conducted across Western Area Urban, Bo and Kenema. They included women who were re-interviewed 12 months after a parent study, male participants recruited through female-partner referral or HIV community networks, and community health workers. Data were analysed using thematic analysis, trajectory comparison and a typology of male partner orientations. Women who previously discussed HIV testing or negotiated protection could lose this capacity when income, relational safety or partner support deteriorated; others rebuilt it through income, osusu participation, service contact and social support. Analysis of male participants' accounts identified three male partner orientations in relation to women's HIV prevention: protective complicity, dismissive gatekeeping, and fearful avoidance. Structural instability emerged as a useful analytic lens for understanding changing enabling conditions. Prevention programmes may need to protect women's privacy, reduce economic and relationship barriers and keep services accessible, rather than assume one-time behaviour change will last.