Risk Perception and Its Influence on Pre-Exposure Prophylaxis (PrEP) Uptake and Adherence Among Pharmacy-Based PrEP Users in South Africa: A Qualitative Study.

BackgroundPre-exposure prophylaxis (PrEP) is highly effective in preventing human immunodeficiency virus (HIV) transmission, particularly for individuals at increased risk. However, uptake and long-term adherence remain challenging, with limited data on pharmacies beyond pilot studies. This study explored how psychological, social, and structural factors shape perceptions of HIV risk and influence PrEP adherence, using the Tripartite Risk Perception (TRIRISK) model, Protection Motivation Theory, and the Theory of Planned Behavior.MethodsA qualitative design using in-depth interviews (IDIs) was conducted pre-implementation (May 2023) and during implementation (April-July 2024) of pharmacy-based PrEP services. Participants were adults (18+years) accessing pharmacy-based PrEP services in Gauteng and the Western Cape, South Africa. Data were analyzed thematically using Excel and MAXQDA, guided by the integrated behavioral frameworks.ResultsA total of 99 IDIs were conducted, 30 in 2023, 69 in 2024. Through the TRIRISK model, this study found that decisions to start or continue PrEP were shaped by perceived vulnerability to HIV, awareness of risky sexual behaviors, mistrust of partners, and emotional experiences like fear and trauma. The PMT further highlighted how emotional triggers, along with perceived severity and coping efficacy, affected motivation to initiate or continue PrEP. The TPB helped explain how subjective norms, such as stigma and social judgment, and perceived behavioral control, shaped by access, convenience, and privacy, impacted adherence.ConclusionIntegrated behavioral frameworks offer critical insights into PrEP-related decision making. Interventions, including pharmacy-based PrEP models, should address emotional barriers, such as stigma-sensitive messaging, strengthening social support, and reducing structural inequalities.