Biomedical Prevention without Social Protection: The ethics of providing PrEP to socially vulnerable adolescent girls and young women in rural Lesotho

Background: Adolescence is a critical period for HIV prevention, yet many adolescent girls and young women (AGYW) experience this developmental transition within contexts of poverty, gender inequality, and limited social protection. As HIV pre-exposure prophylaxis (PrEP) expands across eastern and southern Africa, little attention has been paid to the ethical implications of providing PrEP within these social contexts. Methods: We conducted a qualitative study in two rural districts of Lesotho using focus group discussions with AGYW aged 16-24 years and group interviews and individual interviews with village health workers and village chiefs. Data were analysed using reflexive thematic analysis. Results: Three interconnected themes described how social vulnerability shaped young women's sexual and reproductive health (SRH) and opportunities to benefit from PrEP. First, adolescence was characterised by limited SRH support, age-disparate and transactional relationships, and multiple forms of sexual violence occurring across homes, schools, hostels, and communities. Second, early and unintended pregnancy and child marriage accelerated transitions into adult roles and responsibilities before many young women were developmentally and socially prepared. Third, families, schools, communities, and existing protection systems frequently failed to provide adequate support, leaving young women to navigate violence, pregnancy, and early marriage with limited protection or recourse. Conclusions: Providing PrEP to AGYW in contexts where social protections remain limited raises important ethical considerations. Expanding access to biomedical HIV prevention is necessary but insufficient. Ethical PrEP provision requires implementing social protection alongside biomedical prevention so that young women are supported not only to access PrEP, but also to meaningfully benefit from it.