Unravelling pre-exposure prophylaxis initiation trends and patterns in KwaZulu-Natal, South Africa, 2015-2025

Pre-exposure prophylaxis (PrEP) is a key HIV prevention intervention, particularly in high-burden settings such as KwaZulu-Natal, South Africa. This study examined PrEP initiation trends and service delivery platforms using routine health system data from the District Health Information System (webDHIS) and Three Interlinked Electronic Registers (TIER. Net), covering all public-sector facilities from 2015/2016 to 2024/2025. Facilities were categorised by cumulative initiation volume: low (<500; n = 759), medium (500-1999; n = 242), and high (≥2000; n = 40). PrEP initiation increased from 18,981 in 2015/2016 to a peak of 122,466 in 2022/2023, with a temporary decline in 2020/2021 during COVID-19 disruptions, followed by a decline to 96,094 in 2024/2025. Medium-volume facilities contributed 48.9-51.4% of annual initiations, while the 40 high-volume facilities contributed 25.3-38.2% despite comprising 3.8% of facilities. PHC clinics accounted for 83.1% of cumulative initiations, while mobile clinics and HIV testing areas/non-medical sites contributed 8.3%. Rural districts accounted for 53.6% of cumulative initiations. PrEP was progressively integrated into PHC, antenatal care, HIV testing services, and community outreach platforms. Strengthening lower-volume and rural facility integration is essential for equitable HIV prevention in KwaZulu-Natal.