Table 3. Themes within the TFA construct representing prospective acceptability of oral PrEP and vaginal ring during pregnancy and breastfeeding.

Key themes	Affective attitude	Burden	Ethicality	Opportunity costs	Perceived effectiveness	Self- efficacy	Intervention coherence
representing each TFA construct	How an individual feel about the intervention	The perceived amount of effort that is required to participate in the intervention	The extent to which the intervention has a good fit with an individual’s value system	The extent to which benefits profits, or values must be given up to engage in the intervention	The extent to which the intervention is perceived to be likely to achieve its aim	The participants confidence that they can perform the behaviour(s) required to participate in the intervention	The extent to which participant understands the intervention and how it works
Oral pills	(+) Familiarity of taking oral pills	(-) Difficulties to take the daily dose of the pill	(-) Cultural norms discourage pregnant women to take medications	(+/-) Mixed perceptions whether taking the pills will interfere in women’s daily lives (e.g. Pills may cause vomiting, dizziness).	(+) The pills will protect mother and baby during pregnancy and breastfeeding from getting HIV	(-) Concerns in ability to take the pills due to size	(-) Taking pills is unsafe for the baby or the pregnancy
	(-) Dislike the size of pills	(-) Experiencing potential side effects will be burdensome			(+/-) Pills may work for some women and not others	(-) Lack of confidence in remembering to take pills daily	(-) Taking pills during breastfeeding may dry out production of milk
							(-) Questions about taking the pills
vaginal ring	(+) Discreetness of the ring once inserted	(+) Ease of setting the vaginal ring and forgetting about it for a month	(-) It’s taboo to insert things in the vaginal whilst pregnant	(+/-) Using the ring may or may not interfere with women’s’ daily lives (e.g. use may cause mental discomfort)	(+/-) Uncertainties about the effectiveness of the ring	(+) Confidence in using the ring because of its discreetness	(-) Concerns about hygiene when using the ring
	(-) Dislike the size and look of the ring				(-) Effectiveness linked to correct placement	(-) Lack of confidence in inserting and removing the ring	(-) Concerns about long term health effects of inserting a ring
							(-) fate of ring at time of delivery and harm to the baby
							(-) Questions about length of using the ring and protection the ring provides
Both PrEP methods			(+) Women should have the choice to decide what PrEP methods to use				(+) Clear understanding of routes of protection for both PrEP methods
			(+) Endorsement from healthcare professionals on taking both PrEP methods is key				(+/-) Mixed understanding about duration of using both PrEP methods
Suggested strategy to enhance acceptability		General education	Involvement of local communities & HCPs		General education	Practice and skills building General education
		• Testimonials from pregnant or breastfeeding moms	• Involve trusted sources in the intervention roll out, & implementation.		• Supplement with evidence from PMTCT studies, ongoing trials (when available)	• Provide strategies to enhance self-efficacy e.g. reminders to take pills; teach women how to insert and remove the ring (prior to dispensation)
		• Describe side effects of PrEP options	• Educate HCPs to ensure support and endorsement		• Explain mechanism of action
			• Differentiate traditional vaginal practices and ring use		• Educate about vaginal hygiene and PrEP products

Notes: * (+) indicate a positive reflection of the TFA construct (e.g. Affective attitude- familiarity of taking pills). (-) indicate a negative reflection of the TFA construct (e.g. Burden–experiencing potential side effects will be burdensome).

(+/-) indicate both a positive and negative reflection of the TFA construct (e.g. Opportunity costs- Using the ring may or may not interfere with women’s’ other life priorities).

Acronyms: HCP = health care provider, ARV = antiretroviral medications, PEP = post exposure prophylaxis, PrEP = pre-exposure prophylaxis, TFA = Theoretical framework of acceptability.