Beyond Efficacy: The Access, Delivery Systems, Acceptability, Persistence, and Transition Management "ADAPT"...

Long-acting injectable pre-exposure prophylaxis (LA-PrEP) is a major biomedical advance for HIV prevention, but efficacy alone does not deliver population-level impact. Oral PrEP performed well in trials yet persisted poorly in practice, including among young women in KwaZulu-Natal, South Africa. LA-PrEP reduces daily pill burden and improves discretion, but introduces implementation demands that oral PrEP did not: appointment-based adherence, product-specific delivery needs, workforce and task-shifting limits, financing vulnerability, HIV testing requirements and pharmacokinetic-tail management.

This paper develops the Access, Delivery Systems, Acceptability, Persistence and Transition Management (ADAPT) framework as a conceptual, practice-oriented model for LA-PrEP implementation in sub-Saharan Africa.

ADAPT was developed through structured narrative synthesis of peer-reviewed and grey literature on oral PrEP scale-up, cabotegravir long-acting (CAB-LA) and lenacapavir (LEN) efficacy, HIV service delivery, task shifting and implementation frameworks, combined with non-research program experience from facility-facing implementation support in Uganda and Sierra Leone. The model is not empirically validated and should be tested through Delphi consensus, stakeholder consultation, prospective implementation studies and program evaluation.

ADAPT complements CFIR, RE-AIM, BLUPrInt and WHO guidance. Its contribution is product awareness, planner orientation and explicit recognition of Transition Management as a safety domain. It asks planners to align regulatory access, procurement and affordability; product-specific delivery systems; choice-based acceptability; appointment persistence; and protocols for stopping, switching and restarting.

For sub-Saharan Africa, safer and more equitable LA-PrEP rollout requires deliberate design across financing, service delivery, community governance, persistence systems and transition protocols. ADAPT offers a testable organizing model for this work.