“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 and condom use among adolescent girls and young women enrolled in a school-based HIV prevention program in South Africa

Introduction: The Imagine programme is a school-based HIV prevention program offering preexposure 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. Methods: 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. Results: 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. Discussion: Barriers to condom use persist in South Africa, but positive attitudes toward PrEP described in this study suggest that opinions about PrEP are still forming and can be strongly influenced by youth-friendly HIV programming in schools.