DISCUSSION
two‐thirds
Among South African AGYW at risk for HIV randomized to a client‐facing digital DST or standard of care counselling, approximately 95% received an initial PrEP prescription. High PrEP acceptance may reflect the limited access to and novelty of PrEP during early implementation in South Africa and the desire of two‐thirds to decide about PrEP after trying it. The high PrEP interest limited our ability to evaluate the impact of the DST on PrEP uptake although PrEP continuation at 1 month was two‐fold higher than in the standard of care arm. Given the low persistence observed in PrEP projects among African AGYW [Women's expressed interest in a trial of PrEP use underlines that PrEP decision‐making is an ongoing process. This highlights the need for ongoing decision support, as individuals decide to sample one method, and then potentially another. The non‐significant trend towards more decision conflict among those randomized to the MyPrEP DST may reflect a more deliberative weighing of decisions. Evidence from contraceptive counselling has shown that early discontinuation of a method can be influenced by inadequate counselling related to the method and unanticipated or unacceptable side effects [With new effective PrEP options becoming available, including the dapivirine vaginal ring and injectable cabotegravir, presentation of the range of PrEP options in a DST could help support women to make an initial informed choice about which PrEP formulation meets their needs and preferences, as well as assist them with decisions about switching PrEP methods. Further evaluation of the DST in the setting of expanded options, and the use of the DST to support persistence and switching of PrEP methods will be critical to understanding how the DST can be best utilized to support women's HIV prevention decision‐making.The limitations of this study are generalizability as the study was conducted among English speakers in one PHC clinic in South Africa in which the research context could have influenced the high PrEP uptake. Participant retention was low and influenced by common health systems challenges in this setting, including contraceptive stockouts, intermittent water and electricity interruption, civil unrest, as well as COVID‐19 lockdowns. Since a blood sample for tenofovir levels as an objective measure of PrEP adherence was not obtained at the month 1 visit, it is not possible to compare PrEP adherence by study arm. Our findings could have been due to chance and additional research is warranted with longer follow‐up. Despite these limitations, the study was implemented in a real‐world setting early in the rollout of the South African PrEP programme. The DST is a brief client‐level intervention which was developed with significant end‐user input and could be used in a waiting room or virtually, making it feasible to scale up in diverse settings.