HIV Risk Perception & PrEP Uptake Risk Perception and Its Influence on PrEP Uptake and Adherence Among High-Risk Individuals in South Africa: A Qualitative Study

Abstract

This thesis explores how individuals at risk of human immunodeficiency virus(HIV) infection in South Africa perceive their vulnerability and make decisions regarding the initiation, continuation, or discontinuation of pre-exposure prophylaxis (PrEP) when offered through pharmacy-based delivery models. Although South Africa has the highest number of people living with HIV globally, uptake of PrEP remains limited despite its availability across public health facilities and private pharmacies. Pharmacy-based PrEP delivery has been proposed as a means to increase access, reduce stigma, and offer greater convenience. However, there is limited evidence on how individuals engage with these services and make prevention-related decisions in such settings. The study employed a qualitative research design and was nested within the PPrEPP-SA implementation project. In-depth interviews were conducted with 30 participants at baseline and 69 at midline, across pharmacies in Gauteng and the Western Cape. A novel theoretical framework was developed by integrating three behavioural theories: Risk Perception, Protection Motivation Theory, and the Theory of Planned Behaviour. The framework enabled a comprehensive analysis of how individuals cognitively and emotionally interpret HIV risk, assess their capacity to respond, and navigate social norms related to PrEP. Findings indicate that HIV risk perception is shaped by a combination of rational assessment, emotional reactions, and personal or community experiences. Trust in partners, prior testing, and relationship dynamics strongly influenced decisions to start or delay PrEP. While many participants viewed PrEP positively and trusted its effectiveness, adherence was often disrupted by forgetfulness, life changes, and structural barriers such as transport or financial constraints. Pharmacy-based delivery was appreciated for its privacy, accessibility, and discretion. Yet, anticipated judgment from partners and misconceptions equating PrEP with HIV treatment continued to discourage open use and disclosure. The study concludes that risk perception is not simply about knowing risk but involves how risk is felt and lived. Pharmacy-based models offer significant promise for expanding access, but must be accompanied by stigma-sensitive communication strategies, flexible delivery systems, and public messaging that frames PrEP as a routine part of self-care rather than a response to deviance or disease.