Motivations and Barriers to Sustained PrEP Use Among Men in Buffalo City Metro, South Africa: A Qualitative Study

Abstract Men in sub-Saharan Africa experience disproportionately poor HIV outcomes, yet their engagement with HIV prevention services remains limited. Although oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy, relatively little research has examined the factors that support men’s sustained use of PrEP after initiation. We conducted a qualitative sub-study among men who initiated PrEP through a community-based HIV prevention program in Buffalo City Metro, South Africa. Men who returned for their three-month PrEP refill were invited to complete an in-depth interview. Thematic analysis was guided by the Network–Individual–Resource Model. Twelve of 22 men who initiated PrEP returned for their three-month follow-up visit and participated in interviews. Men described several interconnected factors supporting continued PrEP use. Awareness of sexual risk and confidence in PrEP’s protective benefits motivated continued use, while encouragement from partners and trusted male peers reinforced adherence. Participants also described developing daily routines that helped integrate PrEP into their lives. Structural conditions further shaped engagement: men preferred convenient community-based PrEP services, while anxiety surrounding routine HIV testing was described as discouraging for men more broadly, although many participants reported that their own concerns diminished with repeated testing. Men’s sustained PrEP use was shaped by networked mental and tangible resources, including risk awareness, social support, adherence routines, and accessible service delivery environments. Community-based PrEP delivery models that leverage men’s social networks may help improve sustained PrEP engagement among men in high HIV burden settings.