DISCUSSION
fatigue, HIV self‐testing
In this cluster randomized trial, CHWs, supported by clinicians, delivered a community‐based, client‐centred dynamic choice model for prevention (DCP) to persons at risk of HIV acquisition. The DCP intervention provided clients with structured choices between biomedical prevention products (PrEP or PEP), service locations (clinic or out‐of‐clinic) and HIV testing options (self‐test or rapid test) as well as the ability to switch over time. A key innovation was bringing HIV prevention services into the community by leveraging existing CHWs. The intervention increased biomedical HIV prevention coverage by 27.5% overall and 35.7% during periods of self‐reported risk. Prevention coverage was <1% in the control, highlighting that offering PrEP or PEP does not equate to uptake.Client preferences for HIV prevention have previously been explored in discrete choice experiments, providing insights on HIV self‐testing was more popular than rapid testing in this study, and participant selection of self‐testing increased over time, highlighting the importance of this option in the community setting. Self‐testing has been widely accepted to be a safe alternative to rapid testing [Our study increases the evidence of the potential for CHWs to extend HIV prevention services into the community. Previous literature has demonstrated the value of CHWs in improving other aspects of HIV care, specifically behavioural change counselling, health education, ART adherence counselling and defaulter tracing [Prior studies have shown the effectiveness of CHWs in intervention delivery is impacted by various factors, including task‐specific training and capacity building [Delivery of the DCP intervention by existing CHWs is potentially scalable, but additional research is necessary to understand effectiveness and implementation in routine practice. Since CHWs did not previously conduct HIV testing or PrEP/PEP delivery, clinician oversight was needed to ensure participant safety and intervention fidelity. In routine programmes, supervision will be required to ensure the safe delivery of HIV prevention services by CHWs but may not be as intensive as implemented in this pilot. We aim to address these and other open questions in a follow‐up, population‐level, community‐randomized trial (NCT05768763).While the community‐based DCP intervention substantially increased biomedical prevention coverage, a significant proportion of time at risk remained uncovered. This could be explained, in part, by several barriers to taking PrEP within the household setting, including stigma and fatigue associated with daily pill taking. In addition, some participants were not comfortable disclosing their HIV risk status to CHWs and tensions within the household setting prohibited some from choosing oral PrEP or PEP. We provided location choice to address these barriers. In addition, the emergence of new biomedical products such as long‐acting injectable Cabotegravir could help to counter many of these barriers and further increase biomedical prevention coverage.Our study has several limitations. First, we piloted a multi‐component intervention, which makes it challenging to parse out individual component effects. However, our results show both risk and choice change over time, suggesting the limitations of a one‐size‐fits‐all intervention and the importance of client‐centred service models. Open questions remain about the impact of each component of the intervention, as well as about its scale‐up. In particular, while choice was a core feature of our DCP model, our intervention also included other services (e.g. structured assessment of barriers). These other services, together with client‐centred choice, likely contributed to improvements in biomedical coverage, overall and during periods of risk. Ongoing qualitative and implementation science studies will help elucidate the specific impact of choice, and our follow‐up trial aims to assess scale‐up, implementation and impact of DCP at the population level. Second, our assessment of biomedical prevention coverage was by self‐report of any use of PrEP or PEP. As a result, covered time may have been over‐estimated; however, given the magnitude of the estimated effects, it is unlikely that bias due to self‐report or the survey limitations accounts for all, or even the majority, of the increases in biomedical coverage, seen overall and across key subgroups. Furthermore, 76% of participants reporting recent PrEP or PEP use had detectable tenofovir levels in their hair (