Effective use of oral pre-exposure prophylaxis (PrEP) by pregnant and breastfeeding women is limited despite its potential to reduce HIV incidence and vertical HIV transmission.

To understand health system barriers and facilitators to integrate PrEP into antenatal and postnatal clinic care, we explored the perspectives of managers, midwives, nurses, and counselors providing PrEP services in South Africa.

Barriers included shortages of and limited access to trained staff for PrEP delivery, coupled with limited policies to facilitate simplified PrEP provision in all clinics.

Facilitators included prioritizing task-shifting and task-sharing of PrEP delivery, treating the mother and baby as a dyad, and increasing PrEP awareness for health care workers and clients.

Antenatal and postnatal PrEP delivery should be simplified by optimizing clinic visit flow, revisiting health care worker training on PrEP, and task-shifting and task-sharing to all nurses and HIV counselors, together with using community-level strategies, including HIV self-testing, differentiated PrEP delivery, and improved PrEP messaging, to facilitate awareness of PrEP and reduce stigma.

Policymakers should consider adapting national PrEP prescription policy and policy guidelines outlining increased, pre-established HIV testing time points postpartum with comprehensive monitoring through national indicators.

Oral pre-exposure prophylaxis (PrEP) is an effective and safe option to prevent HIV acquisition and vertical HIV transmission in pregnant and breastfeeding women. Understanding health system factors influencing the integration of PrEP into care for pregnant and breastfeeding women is key to increasing access. We explored managers’ and health care workers’ (HCWs) experiences with integrating PrEP into antenatal care and postnatal care services in primary health care clinics in Cape Town, South Africa.

This exploratory qualitative study used codebook thematic analysis, where HCWs were purposively, heterogeneously sampled from an implementation science study. Semistructured individual interviews were conducted with 9 managerial-level staff, and 3 focus group discussions were conducted with HCWs (nurses, midwives, and HIV counselors) providing PrEP (6–7 HCWs per group) between November 2022 and January 2023 (N=28). Interview guides covered health system facilitators, barriers, and recommendations. The Health Systems Dynamics framework guided data analysis and presentation of results.

PrEP integration into antenatal care services was described as acceptable and feasible; however, changes to HIV testing policy and indicators in breastfeeding women are needed to integrate PrEP into postnatal clinics, together with identification of mother and baby as a dyad in visits. Results showed that supportive policies facilitated wider, simplified PrEP provision. The availability and accessibility of prescribing nurses and lay HIV counselors, PrEP (both within facilities and in communities), and information about PrEP for implementers and pregnant and breastfeeding women will be pivotal to facilitating integration.

Facilitators for PrEP integration include task-shifting PrEP education and identification of women for PrEP initiation to HIV counselors, changes to national guidelines defining who can prescribe PrEP, revision and integration of PrEP training for HCWs, community-level interventions for PrEP demand creation and stigma reduction, and provision of differentiated PrEP delivery options.

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