Barriers and facilitators to pre-exposure prophylaxis uptake among high-risk women and men who have sex with men in Georgia: A pre-implementation mixed-methods study using nominal group technique and the COM-B model.

While pre-exposure prophylaxis (PrEP) research predominantly focuses on men who have sex with men (MSM), PrEP uptake among women who use drugs (WWUD), female sex workers (FSWs), and female partners of people who inject drugs (PWID) is limited. This study fills a critical gap in the literature by examining the unique barriers and facilitators to PrEP uptake among these under-researched female populations, relative to MSM. This pre-implementation study employed a human-centered design approach guided by the Capability, Opportunity, and Motivation-Behavior (COM-B) model. Five focus group sessions using nominal group technique (NGT) were conducted with 66 participants from key populations (MSM, WWUD, FSWs, and female partners of PWID) across three cities (Tbilisi, Kutaisi, and Batumi) to systematically generate and prioritize barriers and facilitators. This study applied the Behavior Change Wheel (BCW) framework to map identified barriers and facilitators to specific intervention functions, highlighting actionable strategies to improve PrEP uptake. Semi-structured interviews with healthcare providers were conducted to contextualize system-level factors. Participants prioritized 15 distinct barriers, with clear differences between groups. MSM most often identified opportunity-related barriers, such as rigid clinic hours, confidentiality concerns, and prior negative healthcare experiences. In contrast, women primarily reported informational and social barriers, including lack of accurate information about PrEP and eligibility, anticipated stigma, and fear of being seen at AIDS centers. Other top barriers included low perceived HIV risk and fear of social stigma. Key facilitators included providing PrEP in neutral, non-stigmatizing delivery settings (i.e., separate from AIDS centers or MSM-specific venues) and offering tele-PrEP and injectable options. Provider insights aligned with participant findings. Findings highlight the need for better access to information and alternative PrEP delivery strategies that decouple PrEP from AIDS centers and MSM-identified venues, including neutral access points, tele-PrEP models, pharmacy or primary care delivery to improve acceptability and reach among at-risk women.