Assessing the Acceptability Of, and Willingness to Pay For, Event-Driven Pre-Exposure Prophylaxis Among Cisgender Men in Cape Town, South Africa

Introduction: South Africa has expanded access to pre-exposure prophylaxis (PrEP), yet men remain under-represented. Event-driven pre-exposure prophylaxis (ED-PrEP), taken around episodes of sexual activity, offers an effective non-daily option for cisgender men with intermittent sexual exposure. However, evidence on ED-PrEP in South Africa remains limited. We assessed ED-PrEP awareness and understanding, acceptability and willingness to pay (WTP) among cisgender men in Cape Town, South Africa. Methods: We conducted a cross-sectional survey among 150 cisgender men attending community-based mobile clinics in October–November 2025. Acceptability was assessed using five-point Likert items aligned with the Theoretical Framework of Acceptability (TFA). WTP was elicited using a contingent valuation bidding game. Amounts were elicited in South African rand (ZAR) and converted to United States dollars (US$). Open-text responses were coded using a predefined framework. Modified Poisson regression examined associations with acceptability and positive WTP (WTP>US$0); gamma regression examined stated maximum WTP amount among men reporting WTP>US$0. Results: Median age was 31 years (interquartile range [IQR] 26–41). Prior ED-PrEP awareness was 24.7%; among those aware (n=37), 40.5% demonstrated correct understanding. ED-PrEP was acceptable to 86.7%. The largest unadjusted TFA associations with acceptability were observed for self-efficacy (unadjusted prevalence ratio [uPR] 3.00, 95% CI 1.54–5.83) and intervention coherence (uPR 2.25, 95% CI 1.05–4.83). Among men who found ED-PrEP acceptable (n=130), 30.8% accepted the initial bid of US$16.64; 10.0% reported WTP=US$0. Median stated maximum WTP was US$5.55 (IQR: US$2.77–US$16.64). Men who did not know some or all partners' HIV status were more likely to report WTP>US$0 than men who knew all partners' HIV status (adjusted prevalence ratio [aPR] 1.17, 95% CI 1.01–1.36). Among men with WTP>US$0, those earning ≥US$554.63 monthly had an expected mean WTP amount 82% higher than those earning <US$277.32 (adjusted mean ratio [aMR] 1.82, 95% CI 1.11–2.97). Conclusions: ED-PrEP was highly acceptable despite low prior awareness and limited correct understanding. Acceptability was linked to perceived understanding and confidence in using the regimen. WTP was common but price-sensitive, and higher income was associated with higher stated maximum WTP. Implementation should combine clear dosing education with free or subsidised access.