Shades of Contemplation: HIV Pre-Exposure Prophylaxis Decision-Making among Young Women in South Africa

Expanding women's awareness of and access to HIV pre-exposure prophylaxis (PrEP) is key to enhancing its uptake, yet young women face difficulties in deciding whether to initiate any form of PrEP. Understanding factors that shape decision-making to initiate PrEP can support uptake and continuation. The Masibambane ("Let us work together") pilot in eThekwini (Durban), South Africa, compared a gender-enhanced (GE) online group workshop (N = 50) to an "individual access" (IA) control condition (N = 50) for women (ages 18-25 years). Both conditions aimed to increase knowledge and motivation to initiate oral PrEP. This study used 3-month follow-up qualitative interviews from 40 women (20 per condition). The Transtheoretical Model of Health Behavior Change guided interviews and a framework analysis was used to understand stages of and influences on PrEP decision-making. Underscoring that PrEP uptake is not a straightforward or singular decision, most respondents, regardless of condition, conveyed shades of contemplation for initiating PrEP; only a few stated they currently were using or were uninterested in PrEP. Many viewed PrEP as an effective woman-controlled method and believed their partners placed them at risk of HIV. Other considerations included relationship status, pill modality, daily adherence, and side effects. For those who prepared to use PrEP, logistical barriers were frequent. Peers were perceived as sources of encouragement for adopting PrEP. Given these findings, HIV prevention efforts need to include interventions to support PrEP decision-making, recognizing that the process is continuous, multifaceted, and changes over time. This study elucidated relevant factors for supporting young women's PrEP decision-making in South Africa.