This discrete-choice experiment involving 49 FSW in Uganda suggests that combining in-person care from facility-based nurses with text message reminders improved oral PrEP adherence. The intervention was effective across different religious groups and among clients of different sexes, indicating its versatility and potential for widespread implementation among diverse groups of FSWs. The combination of facility-based care and mobile health technology (SMS reminders) offers a practical, scalable solution for improving PrEP adherence in real-world settings. This notable improvement in adherence was observed across several key subgroups, indicating the model’s broad applicability. Specifically, both AGYW and older FSW showed remarkable increases in adherence.

Decentralized and tailored care helps address the structural barriers faced by FSWs, meeting their needs for convenience, confidentiality, and stigma-free care. Our findings align with prior research that highlights the importance of tailored interventions for high-risk populations¹⁸. The addition of regular SMS reminders, alongside in-person facility-based care, appeared to address the barriers to access and continuity of care that FSWs often face. Regular text reminders serve as behavioral cues that mitigate forgetfulness and help normalize PrEP use amid competing daily priorities, stigma, and mobility common in this population. A scoping review evaluated mHealth interventions supporting PrEP use among adolescent girls and young women in sub-Saharan Africa, identifying SMS reminders, mobile applications, telecounselling, and web-based platforms as the most common tools, generally acceptable and feasible, for discreet support, reminders, and linkage to PrEP services. The review underscores the need for well-designed implementation studies that measure real-world engagement and effectiveness, and tailor digital support within youth-friendly service models.¹⁹ Coupled with the facility-based backing where trained providers offer personalized counselling, refills, and laboratory follow-up, this delivery model created a reinforcing loop of motivation, accountability, and social connection to care. This dual approach aligns with evidence that multimodal adherence support is more effective than single-component interventions in sustaining medication use among key populations. Similar results found that SMS reminders improved adherence and appointment keeping among PrEP users, while the non-judgmental facility-based services were critical to retention among FSWs.^20–22

Consistent with other studies, our model’s effectiveness was observed across different religious groups and regardless of the clients’ sex.^23–25 This broad applicability suggests that the intervention effect did not vary significantly due to these demographic factors, thereby supporting the feasibility of implementing this model across diverse populations. Similarly, the study revealed essential findings regarding specific subgroups in which the intervention had a limited impact. For example, no significant change was observed in adherence scores for participants with no formal education and those with tertiary education. This suggests that other underlying variables, such as socio-cultural contexts or individual perceptions of healthcare, may have a more profound influence on adherence behaviors, extending beyond formal educational attainment.²³ Recent evidence from sub-Saharan Africa suggests the relationship between education and PrEP adherence is inconsistent. Among Ugandan FSWs, a 2025 mixed-methods study found no independent association between education level and continuation (a proxy for sustained adherence) after adjustment, underscoring the primacy of structural and service-delivery factors over schooling alone²⁴. In contrast, a study found that higher education is consistently associated with better PrEP knowledge and more favorable attitudes, which may facilitate, but do not guarantee, adherence. For instance, social support networks and logistical considerations have been identified as critical factors impacting adherence trajectories, particularly among vulnerable populations such as AGYW.²⁵ Understanding the multifaceted interplay between internal drivers and external circumstances, such as PrEP delivery models that strengthen individual motivation and self-efficacy, enhance social support networks, and address structural barriers like stigma, access, and affordability. For instance, adherence programs could combine counselling and behavioral support (targeting internal motivation) with mobile health reminders, peer-led follow-up, and differentiated service delivery models (addressing external facilitators and constraints).

This integrated approach ensures that both personal and contextual determinants of adherence are holistically addressed, which is a crucial step in developing effective PrEP adherence strategies.^26–29 Interestingly, participants with a regular partner also showed no significant change in adherence scores. This finding suggests that relationship dynamics, including regular partnership status, did not directly influence adherence to oral PrEP in this pilot. In contrast, evidence from multiple studies indicates that partner support, communication, trust, and the nature of sexual arrangements are critical determinants of PrEP adherence outcomes.^30,31 For instance, among Ugandan HIV serodifferent couples, intimate partner violence (IPV) was negatively associated with PrEP adherence, underscoring how maladaptive relationship dynamics can undermine prevention efforts.³² Similarly, in African women with HIV Sero different relationships, those reporting economic or physical IPV had significantly lower PrEP adherence levels compared to those not experiencing abuse.³³ Conversely, supportive partnerships facilitate better adherence. In Malawi, male partners’ active involvement, including shared decision-making and emotional encouragement, was positively linked to pregnant women’s PrEP uptake and continued use.³⁴ This aligns with findings from Kenya and Uganda³⁵, where disclosure of oral PrEP use to partners and perceived partner approval improved adherence behaviors.

Perceived stigma within relationships also affects adherence. Some individuals avoid initiating or continuing PrEP due to fears that their partners may interpret its use as a sign of infidelity or promiscuity. It is possible that, for individuals in stable relationships, the perceived need for PrEP could be lower, or that other relationship-related factors, such as support or opposition, communication quality, trust, IPV, and stigma, may be impacting adherence. This observation warrants further investigation into the interplay between relationship context and PrEP adherence^36–38. Overall, this study underscores the importance of combining facility-based care with mobile health interventions, such as SMS reminders, to improve oral PrEP adherence. However, the varying responses across subgroups emphasize the need for further customization of interventions better to address the specific challenges and needs of FSW. More targeted approaches that account for factors such as education level and relationship context may be needed to maximize the impact of PrEP adherence programs. The present study, therefore, adds to a growing body of evidence supporting hybrid models that combine digital and face-to-face support to strengthen PrEP adherence and continuity of use in real-world contexts.