"I will take PrEP because that's what will help me not to get infected with HIV": Barriers to and facilitators of pre-exposure prophylaxis (PrEP) and condom use amongst adolescent girls and young women enrolled in a school-based HIV prevention programme in South Africa

Kate Bergh^1,2*Kim Jonas¹Elona Toska^3,4Fareed Abdullah^5,6,7Nomtopi Blom¹Catherine Mathews^1,8Ngkatiseng Mthanti¹Nevilene Slingers⁵Nathanael Van Blydenstein⁹Zoe Duby^1,10

• ¹Health Systems Research Unit, South African Medial Research Council, Cape Town, South Africa
• ²Department of Psychology, University of Cape Town, Cape Town, South Africa
• ³Centre for Social Science Research, Department of Sociology, University of Cape Town, Cape Town, South Africa
• ⁴Department of Social Policy and Intervention, University of Oxford, Oxford, England, United Kingdom
• ⁵Office of AIDS and TB Research, South African Medical Research Council, Pretoria, South Africa
• ⁶Division of Infectious Diseases, Department of Internal Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
• ⁷Department of Public Health Medicine, University of Pretoria, Faculty of Health Sciences, Pretoria, South Africa
• ⁸School of Public Health and Family Medicine,, University of Cape Town, Cape Town, South Africa
• ⁹Networking HIV and AIDS Community of Southern Africa, Pretoria, South Africa
• ¹⁰Division of Social and Behavioural Sciences, School of Public Health, University of Cape Town, Cape Town, South Africa

The Imagine Programme is a school-based HIV prevention programme offering pre-exposure prophylaxis (PrEP), condoms and other social and structural interventions to adolescent girls and young women (AGYW) in South Africa. PrEP uptake and adherence together with the provision of condoms has not been extensively studied in the school context. We explored the barriers to and facilitators of PrEP and condom usage among Imagine Programme beneficiaries using the HIV prevention cascade framework. Sixteen AGYW aged 16-20 years who had never taken PrEP, were on PrEP or had stopped PrEP were interviewed between November 2023 and March 2024. Interviews were audio-recorded, and transcripts were deductively coded according to the HIV prevention cascade steps: 1) Knowledge, 2) Motivation, 3) Access and 4) Effective use. HIV and pregnancy risk awareness was high. For condom use, the risk of HIV transmission and pregnancy was outweighed by fear of sexual or physical violence from male partners and a desire to maintain relationships, as asking to use condoms demonstrated a lack of trust. High levels of PrEP knowledge motivated participants to use PrEP, especially if their partner refused to use condoms. Fear of side effects and daily pill taking were barriers to PrEP uptake. PrEP and condom services in school were highly acceptable, while anticipated stigma remained a challenge at the community clinic. Barriers to condom use persist in South Africa, but positive attitudes towards PrEP described in this study suggest that opinions about PrEP are still forming and can be heavily influenced by youth-friendly HIV programming in schools.