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Smith et al. BMC Public Health (2023) 23:418
https://doi.org/10.1186/s12889-023-15306-6 BMC Public Health
*Correspondence:
Philip John Smith
Philip.Smith@hiv-research.org.za
Andrew Medina-Marino
andrewmedinamarino@gmail.com
Full list of author information is available at the end of the article
Abstract
Background Compared to women, South African men are less likely to know their HIV status (78% vs. 89%),
have suppressed viral loads (82% vs. 90%), or access HIV prevention services. To achieve epidemic control where
heterosexual sexual behavior drives transmission, interventions to improve the uptake of HIV testing services (HTS)
and prevention services must also target cis-gendered, heterosexual men. There is limited understanding of these
men’s needs and wants with regards to accessing pre-exposure prophylaxis (PrEP).
Methods Adult men (≥ 18 years) from a peri-urban community in Buffalo City Municipality were offered community-
based HTS. Those who received a negative HIV test result were offered community-based, same-day oral PrEP
initiation. Men initiating PrEP were invited to participate in a study exploring men’s HIV prevention needs and reasons
for initiating PrEP. An in-depth interview guide, developed using the Network-Individual-Resources model (NIRM),
explored men’s perceived HIV acquisition risk, prevention needs, and preferences for PrEP initiation. Interviews were
conducted by a trained interviewer in isiXhosa or English, audio-recorded and transcribed. Thematic analysis was
used, guided by the NIRM to generate findings.
Results Twenty-two men (age range 18–57 years) initiated PrEP and consented to study participation. Men reported
elevated HIV acquisition risk associated with alcohol use and condom-less sex with multiple partners as facilitators
driving PrEP initiation. They anticipated social support from family members, their main sexual partner and close
friends for their PrEP use, and discussed other men as important sources of support for PrEP initiation. Nearly all men
expressed positive views of people using PrEP. Participants believed HIV testing would be a barrier for men interested
in accessing PrEP. Men recommended that access to PrEP be convenient, rapid, and community-based (i.e., not
clinic-based).
Discussion Self-perceived risk for HIV acquisition was a major facilitator for men’s PrEP initiation. Although men
expressed positive perceptions of PrEP users, they noted that HIV testing may be a barrier to PrEP initiation. Finally,
men recommended convenient access points to facilitate PrEP initiation and sustained use. Gender-responsive
What motivated men to start PrEP? A cross-
section of men starting PrEP in Bualo city
municipality, South Africa
Philip John Smith1*, Joseph Daniels2, Linda-Gail Bekker1 and Andrew Medina-Marino1,3,4*
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Smith et al. BMC Public Health (2023) 23:418
Introduction
With 200,000 new HIV infections annually and the
world’s largest population of people living with HIV
(20.4% prevalence among those aged 15–49 years), South
Africa (SA) is the global epicenter of the HIV pandemic
[1]. e last National HIV prevalence for South Africans
aged 15–49 years was estimated at 15% and 26% among
men and women respectively [2]. South African men
have the highest risk of premature mortality worldwide
[3], with HIV being the second leading cause of mortality
after tuberculosis for those under 35 years [4]. Although
women bear the brunt of HIV infections, South African
men have poorer rates of HIV testing, treatment initia-
tion, viral suppression, and survival on treatment com-
pared to women [5–8]. While engaging men in the HIV
testing, care, and treatment cascade is essential to ensur-
ing optimal health outcomes, implementing effective
HIV prevention strategies for men is crucial to curbing
new HIV infections among both women and men [9].
Oral pre-exposure prophylaxis (PrEP) with emtric-
itabine (FTC)/tenofovir (TDF) has demonstrated signifi-
cant efficacy in clinical trials [10–15]. ese trials were
conducted among men who have sex with men (MSM)
[12], African women [10, 11], heterosexual men and
women [13, 15], and injection drug users [14]. PrEP dem-
onstration projects and government programs have pri-
oritized key populations, including sex workers, MSM,
and young women at high risk of HIV acquisition, how-
ever, there has been limited focus on cis-gender, het-
erosexual men’s access to PrEP outside that of studies
focused on sero-discordant relationships [16–19]. In this
study we will use the term “men” to denote heterosexual
males. South Africa’s National Strategic Plan for HIV, TB,
and STIs 2017–2022 includes the explicit aim of reducing
new HIV infections through a national rollout out PrEP
for all individuals, including heterosexual men [20, 21].
e guidelines recommend daily dosing for heterosexual
men at high risk of HIV acquisition. However, given the
lack of baseline research to understand men’s preferences
for PrEP promotion and access, their uptake of PrEP ser-
vices, and HIV prevention services in general, will con-
tinue to be limited [19, 22, 23].
Masculinity norms and social expectations impact
men’s health behaviors, and have been linked to men’s
late clinic presentation when ill and limited use of pre-
ventative health services, including HIV prevention and
PrEP initiation [24–27]. Structural barriers that further
impede men’s access to health and HIV services include
limited resources (unemployment and poverty), the lack
of male-friendly healthcare (unfriendly staff; the per-
ception of clinics being female/ maternal-child spaces;
female dominant healthcare staff), and inconvenient
clinic operating hours [22, 28, 29]. Additionally, alcohol
use and PrEP stigma may influence men’s PrEP persis-
tence. In a PrEP implementation study in Cape Town,
South Africa, young women noted that PrEP was desir-
able for HIV prevention especially in the context of
alcohol use when condoms were not used or difficult
to negotiate [30]. However, since alcohol use has been
found to be both a facilitator and a barrier to PrEP ini-
tiation and discontinuation [31], we need to understand
how alcohol impacts PrEP use in men. Lastly, the role
of PrEP stigma has been explored in other populations,
with findings suggesting PrEP stigma was associated
with lower initiation in pregnant women [32, 33]. When
provided with flexible, community-based options, men’s
uptake of health services approaches that of women [22,
34, 35]. Furthermore, growing evidence indicates that
men are interested in accessing sexual and reproductive
health services (SRHS), including PrEP, that are delivered
in community settings and cognizant of their work and
life priorities [36–40]. ese studies have emphasized
differentiation of SRHS for men in limited resources set-
tings in order to increase uptake of HIV services. Lastly,
leveraging aspects of masculine identity, such father-
hood, may further motivate and increase men’s engage-
ment with HIV prevention services [25].
Given South Africa’s recent policy change to expand
access to PrEP for non-MSM men [18], we implemented
a study that provided community-based PrEP services to
men, and investigated men’s barriers and facilitators to
PrEP initiation.
Methods
Study setting
is study was nested within the Community PrEP
Study (CPS) [41, 42]. CPS aimed to leverage commu-
nity-based platforms to increase access and adherence
to PrEP among young women in two high HIV burden
communities in the Eastern Cape Province, South Africa
(Fig.1); Eastern Cape is a research naïve province with
an estimated 15.3% HIV prevalence among the gen-
eral population [2]. Men were recruited from the peri-
urban community in which the CPS was implemented.
is community is 10km outside East London Central
Business District, Buffalo City Metro Health District
(BCM-HD).
interventions tailored to men’s needs, wants, and voices will facilitate their uptake of HIV prevention services, and help
to end the HIV epidemic.
Keywords HIV, Men, Pre-exposure Prophylaxis, South Africa
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Smith et al. BMC Public Health (2023) 23:418
Sta training
Study staff (i.e., HIV testing service (HTS) counsellors,
a fieldworker, and a study nurse) received training in the
study protocol, human subjects’ protection, HIV coun-
selling and testing protocols, good clinical practice and
qualitative research methods. e fieldworker was expe-
rienced in conducting semi-structured interviews. Addi-
tionally, the fieldworker attended training on using the
interview guides before study initiation.
Participant recruitment and measures
e HIV testing recruiters handed out invitation cards
(Fig.2) [43] to men walking within 500m of the mobile
gazebo HIV testing site. Recruitment took place between
09:30 and 15:30 on weekdays. Upon presentation, HTS
counselors offered all individuals (i.e., men and women)
an HIV test per South African National HIV testing stan-
dards [44]. Study eligibility was defined by the following
inclusion criteria: self-identified as male, aged ≥ 18, con-
firmed HIV negative test result at screening, interest in
taking PrEP, provision of written informed consent. Men
who received an HIV positive test result were immedi-
ately referred for clinical care and ART services at the
local clinic per South African National Guidelines. Men
aged ≥ 18 years, with an HIV negative test result were
invited to learn about PrEP. ose expressing interest in
PrEP were referred to the study-established community-
based PrEP services site which was co-located in the
same community.
A trained fieldworker read aloud an informed consent
form to all eligible and interested participants. After
obtaining written informed consent, the fieldworker
allocated a study ID number to the participant and then
administered a survey which included questions related
to the participant’s socio-demographics, the PrEP stigma
scale [45], and the Alcohol Use Disorders Identifica-
tion Test (AUDIT-C) [46]. e PrEP stigma scale had
13 items, requiring participants to rate how much they
agree with statements along a five-point Likert-type scale
from “strongly disagree” to “strongly agree”. e first item
on the scale is, “I would feel ashamed to take PrEP pills
in front of others”. e fieldworker then interviewed par-
ticipants using a semi-structured, in-depth interview
(IDI) guide; interviews were conducted in a participant’s
preferred language (English or isiXhosa). e IDI guide
was developed in English and was translated into Xhosa
by an isiXhosa speaking researcher trained in qualita-
tive research methods. e principal investigator and
the researcher discussed the translation and reviewed
the guide with the fieldworker for comprehensibility by
research participants. IDIs explored men’s: (1) decision
making regarding PrEP initiation; (2) perceptions of
other people taking PrEP, (3) perceptions of other men’s
barriers and facilitators regarding PrEP uptake/initiation,
and (4) preferences for uptake and access to PrEP refills.
Upon completion of the IDI, a nurse collected blood sam-
ples for creatinine (not reported) as a marker of kidney
Fig. 1 Provincial map of South Africa showing location of study community within Buffalo City Metro Health District, Eastern Cape Province
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Smith et al. BMC Public Health (2023) 23:418
functioning and STI diagnostic testing (chlamydia tra-
chomatis, gonorrhea, syphilis). STI results were used as
a clinical marker of sexual risk for HIV acquisition. Par-
ticipants who were diagnosed with an STI were informed
and referred for treatment. e nurse conducted counsel-
ling around PrEP initiation and adherence and provided
participants with one month’s supply of PrEP and R100
(~$6.60) for their time and transport costs.
Theoretical framework
e network-individual-resource model (NIRM)
informed the development of the IDI guide and result
contextualization. e NIRM takes an ecological
approach to understanding behavior [47]. e model
was developed to inform HIV prevention interven-
tions, and has been adapted for use in other contexts in
South Africa[48, 49, 50]. e NIRM articulates the role
that mental (e.g., psychosocial, cognitive, social support,
social cues, perceived or internalized stigma, perceived
or actual norms, self-perceived masculinity, mental
health, knowledge/education) and tangible (e.g., income,
physical health, access to health services, food security,
money) resources play in health behaviors, decisions, and
outcomes, and was used to understand what resources
men associate with PrEP initiation. Accordingly, PrEP
initiation will depend on the ability of men to (1) locate
and leverage tangible resources (i.e., work, access to
health services) and (2) access mental resources (i.e.,
support from family, male friends and partners) [47].
Moreover, the NIRM was used to understand how men
thought about their tangible and mental resources, and
how these resources influenced their perceived HIV
risk, prevention discussions with partners, and PrEP use
behaviors.
Data analysis
Audio-recorded interviews were transcribed into Eng-
lish. A bilingual researcher trained in qualitative research
methods translated the interview audio. e translations
were discussed with the PI where phraseology was clari-
fied where needed. Using thematic analysis [51, 52], the
first five transcripts were read by two researchers and
open coded to identify mental and tangible resource
influential in PrEP initiation and adherence [47]. After
review by the research team, codes were assembled into
a codebook that was applied to all transcripts. Once
coding was completed, a frequency analysis was con-
ducted to generate a range of resources from most to
less frequently discussed, which were subsequently orga-
nized into matrices to understand positive and negative
Fig. 2 Invitation flyer for the Male Community PrEP Study
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Smith et al. BMC Public Health (2023) 23:418
influences on PrEP initiation and adherence [53]. is
quantification was conducted to determine most fre-
quently cited resources, and to create a useful matrix for
organizing the analysis and interpretation. Memo writing
and causal diagrams were developed to refine prelimi-
nary themes that were presented to the research team for
discussion, informing additional analysis to generate the
final themes [24, 54].
Ethics and participant representation
In accordance with the Declaration of Helsinki (1964),
all research was conducted adhering to ethical guidelines
and the study was approved by the Human Research Eth-
ics Committee at the University of Cape Town (HREC
Ref 173/2021). Approval to conduct research in the
selected sites was provided by the Eastern Cape Pro-
vincial Department of Health, and supported with local
approval by a Community Advisory Board. Written
informed consent was obtained from all participants
before enrolling in the study. Participant quotes are rep-
resented by age and a participant ID number to ensure
confidentiality.
Results
We enrolled 22 participants’ (Median Age: 24 years;
IQR: 20–33). Participant characteristics are reported in
Table1. Most participants reported neutral levels of PrEP
stigma [45], but moderate to severe levels (86%) of haz-
ardous alcohol consumption.
While there were limited codes specific to individual
participants, these codes were not sufficient to gener-
ate new themes. Additionally, while participants tended
to frame their responses personally, some responses
presented a collective perspective denoted by “we” and
“men”. Interviews generated four key findings: (1) men’s
self-perceived HIV risk motivates their interest in PrEP;
(2) HIV testing hesitancy and clinic access are barriers
to PrEP initiation; (3) men are hearing about PrEP from
women and people in the gay, men-who-have-sex-with-
men (MSM) and transgender communities; and (4) clinic
proximity to working and living locations and friendly
staff will promote PrEP uptake.
Men’s self-perceived HIV risk motivates their interest in
PrEP
Motivating their interest in PrEP, men described risk
behaviors including: alcohol consumption; sexual behav-
iors; multiple sexual partners (MSP); and limited discus-
sion of HIV prevention practices with sexual partners.
Participants frequently linked alcohol consumption to
their desire for engaging in sex. Men further described
prioritizing sex in the moment over discussing preven-
tion, especially if condoms were not available. ey knew
that unprotected sex increased their risk for HIV acquisi-
tion, and even described being anxious about HIV infec-
tion after having unprotected sex.
Participant 6, 19 years: “I would say it is very high
[HIV risk], because they like alcohol, and we as men
we have this tendency, we are drunk, we like women,
we must have sex. So, others take that advantage
that they are drunk now, so we must have sex. So,
that is the reason I say the rate of HIV is very high,
alcohol is the inuence, because everything they do
they are not in their right minds because of alcohol,
so they do whatever they want to do.”
Participant 2, 25 years: “When we are drunk, we
are men that just do things without consideration.
Too much, because the minute you have alcohol you
think too much and end up saying that my partner
is not here and I can do this, no one is going to see
me, do you understand? So that is when we end up
taking risks.”
Participant 18, 41 years: “… when you meet with
someone and the condom is not there, then you just
decide to just continue. After the act, you just realize
that you did not use condom.”
Participant 17, 20 years: [HIV prevalence] is very
high. It is, my brother, because we talk about every-
thing and we don’t use condoms.”
Participants reported that MSP was common, and cor-
rectly associated MSP with increasing one’s risk for HIV
acquisition. Participants described how the practice of
MSPs resulted in confusion and a lack of trust in their
own relationships. One participant even wondered aloud
whether their partner had other partners. Being unsure
Table 1 Participant characteristics
n %
Median age years 24 IQR 20–33
18–19 4 18%
20–24 7 32%
25–29 3 14%
30–34 2 9%
35–39 4 18%
≥ 40 2 9%
PrEP Stigma* 3.1
AUDIT-C
Severe Risk : 8–12 points 5 23%
High Risk: 6–7 points 6 27%
Moderate Risk : 4–5 points 8 36%
Low Risk: 0–3 points 3 14%
STI
Chlamydia trachomatis 4 18%
Gonorrhoea 0 0%
Syphilis 0 0%
*Scale scor e ranges from 1–5, where highe r values indicate higher s tigma
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Smith et al. BMC Public Health (2023) 23:418
about trust in relationships caused the participant to
think about how to ensure his own safety and the safety
of his partner.
Participant 4, 27 years: “Bro the small number of
people I know introduce me to people’s partners
but when I come back I nd that, that person is no
longer with that person and that they are now with
someone else. at leaves me sort of confused, other-
wise I think the risk of HIV here is high.”
Participant 4: “Earlier I spoke to [the nurse] and
spoke about trust. You can trust someone but you
don’t know them fully. For instance, I was in [a
neighbouring city] and my partner is here and I
don’t remember what she [the nurse] asked me, but
my answer was I don’t know. I think she [the nurse]
asked if she [partner] doesn’t have another person
and my answer was I don’t know. So, it would really
suck to nd out that she has another person through
an HIV test, nding out that she has HIV. What
comes to my mind is her safety and mine because
I don’t 100% know her and the things she is doing
when I am not around.”
Clinic access barriers and hesitancy to test for HIV
Men were asked to describe their use of clinic-based
health services and previous awareness of PrEP. Men
stated that they avoid clinics for various reasons, includ-
ing unfriendly staff, long waits, and a lack of privacy;
some men even described leaving a clinic without being
helped. One participant described the clinic as “not safe”
because the clinic staff treated patients poorly and they
were not respectful of patients.
Participant 16, 19 years: “Clinics don’t treat peo-
ple well, as a result men don’t want to go to clinic
because it is not safe. e main problem is spending
the whole day at the clinic and you end up leaving
without getting any help.”
Participant 22, 39 years: “It’s very nice coming here
[the research site] because you won’t have to face
the community like in the clinic meeting people with
dierent problems and here it’s only based on HIV
so that is why I like it and you get less judges by the
community.”
One significant barrier to PrEP was the need to be tested
for HIV. One participant stated that men worry about
testing positive for HIV after having unprotected sex,
and that this fear factored into avoiding HIV testing.
Another participant noted that women routinely visited
clinics and were offered HIV testing and HIV prevention,
adding that men do not routinely visit clinics, and HIV
prevention was understood to be for women.
Participant 16, 19 years: “I can’t say those people [in
the community] protect themselves and men don’t go
to the clinics, it’s mostly women, and we don’t know
the statistics.”
Participant 1, 35 years: “Men are afraid to do testing
and things that are associated with HIV (illness). It
is not easy, but the way you have approached us is
one (delivering invitations), I don’t know any other
way you could have done. You have to be ready
before you decide to go and test, so it is dicult in
that way.”
Participant 11, 19 years: “We do things then get
scared of the outcomes, for example having sex with-
out a condom and then fearing taking PrEP because
you will get tested for HIV, and think what if it is
positive. We don’t want to know.”
Men are hearing about PrEP from women and people in
the gay, MSM and transgender community
Most men were not completely ignorant about PrEP,
stating that they had heard about PrEP from a partner
or a family member, or overheard people talking about
it. Men specifically noted that their knowledge of PrEP
was obtained through women or the gay-bisexual-MSM-
transgender community. However, men thought PrEP
was only for ‘certain individuals’ (i.e., women and men
who have sex with men), and not them.
Participant 4, 27 years: “Now that you mention, my
girlfriend, she once told me about it but she told me
about its side eects, how she felt when she took it.
Uhm she was not alright, she felt like she was going
to vomit and dizzy.”
Participant 14, 34 years: “I overheard people talk-
ing about it and in most cases it’s gays. What were
they saying, uhm, in a way people that are sexually
active, they are, or should I say we are, using a con-
dom is, I don’t want to say is the last thing on our
minds, it’s not the rst thing on our minds… so they
say a lot of things to each other and I hear them
talking about that, and maybe they are talking and
saying PrEP is available and so on, things like that.”
Participant 4: “Transgenders have female minds
and say a lot to each other. So, I heard them talk-
ing, saying that we will not die from AIDS while
PrEP is there. So, that is how I heard about it, but
for someone telling me about PrEP clearly, it is [the
recruiter].”
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Smith et al. BMC Public Health (2023) 23:418
Some men heard messaging that they shouldn’t take PrEP.
One participant mentioned that people in his community
have discouraged the use of medication, and when asked
about barriers to PrEP initiation, one participant stated,
“there are people that are discouraging the use of other
things like the [COVID19] vaccine.” Consequently, men
who are exposed to skepticism may experience this as a
barrier to PrEP initiation if skepticism is normative.
Participants expressed a positive perception towards
those who choose to use PrEP. Specifically, men under-
stood that people took PrEP to minimize their HIV risk,
and universally described those individuals as being
responsible. Such perceptions may be a facilitating fac-
tor for men’s own PrEP initiation and use. However, they
also acknowledged the existence of PrEP-related stigma,
which may be related to the perception that PrEP is a
treatment for HIV.
Participant 10, 32 years: “I think it is being respon-
sible, I don’t look at them as wanting to be loose but
being responsible. At the end of the day, even if they
don’t take PrEP, if they decide to have multiple part-
ners, they will do that, so rather they be safe.”
Participant 6, 19 years: “at’s a great thing that
they are doing. ey are protecting themselves and
their partners.”
Participant 11, 19 years: “ey don’t want to be HIV
infected, and they are taking responsibility for their
lives. ey want to be safe.”
PrEP access close to their living and working locations
that is administered by relatable individuals will ensure
initiation
Quick access to PrEP services was a significant factor
influencing PrEP uptake. Men discussed how the con-
venience of community-based HIV testing and PrEP
services, both in terms of duration of visit and location,
influenced their uptake of these services. Men frequently
noted the importance of a PrEP service location being
close to where they lived, or accessing PrEP through
delivery or pharmacy pickup due their work hours. e
study’s community-based location, compared to clinic-
based services, was also seen as a benefit because it did
not entail having to see people or explain the reason for
one’s visit to a clinic.
Participant 1, 35 years: “I don’t have to go to town
for other things because they are here. And also this
PrEP thing, I don’t need to go and look for it far.”
Participant 22, 39 years: [quotation used previously]
“It’s very nice coming here [the research site]…
Participant 1, 35 years: “I have spoken with one of
these men and he said, he would prefer it to be deliv-
ered or get prescription so that he can get it at the
chemist because of work.”
Participants did not express strong preferences for male
or female clinic staff, but mentioned that it was impor-
tant for staff to be relatable and professional.
Interviewer: “Alright, when accessing PrEP, would
you like a man or a lady on your pick- ups?
Participant 9, 22 years: I would say both [male and
female sta] if they are professional, I would [go] to
either but only if they are professional.”
Participant 17, 20 years: “From both [male and
female]. ere is no dierence, you came for the
treatment.”
Discussion
Daily PrEP has been recommended by the South Afri-
can Department of Health for populations at risk of HIV
acquisition, including heterosexual men [20, 21]. How-
ever, few studies have reported on cis-gender, non-MSM
men’s preferences for access to PrEP and PrEP services or
the mental and tangible resources this population would
use to initiate PrEP and sustain use. Our study reports
that men did not think that PrEP was for or available
to them, as they had heard about PrEP from women in
their lives (partners or family), or overheard gay, MSM
or transgender community members discussing PrEP.
ough participants were unaware that PrEP was for
them, risk perception was a key mental resource that
motivated of their interest in and initiation of PrEP. How-
ever, men reported that HIV testing would likely be a
major barrier to PrEP uptake for other men. Finally, con-
venience was a tangible resource for participants, given
that men recommended that PrEP services be close to
home or work commute, have accessible timing, and have
rapid consultations.
While men were generally aware of PrEP through part-
ners, family members, or by overhearing conversations
in their community, it was not commonly understood
to be an option for them. Even so, men expressed little
stigma towards other PrEP users. In fact, their perception
of those taking PrEP was positive, stating that PrEP users
were being responsible and protecting their own health
and that of their partner(s). Such low stigma and posi-
tive attributes likely served as mental resources for their
own decisions to use PrEP. Since men noted that they had
heard about PrEP from their familial or social networks,
community-based PrEP champions may serve as impor-
tant role models for initiating and continuing PrEP use
[55].
Participants became aware that PrEP was initially tar-
geted to MSM, adolescent girls and young women. Now
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Smith et al. BMC Public Health (2023) 23:418
that PrEP was being targeted to them, they felt it critical
to ensure that access to PrEP services also spoke to their
needs. Specifically, men discussed how and why commu-
nity-based services and locations appealed to their needs,
and how clinic-based services were sub-optimal due to
poor staff attitudes, perceived female spaces and long
wait times. However, even with optimized access to PrEP
services, HIV testing was seen as a major deterrent and
barrier to accessing PrEP, as men feared receiving an HIV
positive test result. Since the interview was also designed
to explore barriers that may limit other men from access-
ing PrEP. Participants noted that HIV testing may be a
barrier for other men to initiate PrEP. In the interviews,
exploring the barriers was designed to explore what
other men may perceive to limit or prevent PrEP access.
To reduce this barrier, HIV testing messaging should
emphasize the benefits of testing, and the services avail-
able to men when they know their HIV status [43, 56].
Tailored and convenient services and tailored messaging
were tangible resources that would support PrEP uptake.
Moreover, messaging that addresses fears around HIV
testing would mentally support men by relieving anxiety
associated with HIV testing.
Given men’s mental/ knowledge resource of the asso-
ciation between alcohol use, MSP and HIV acquisition,
incorporating messages about how PrEP may protect
them even when they engage in these behaviors may
improve their mental model of how to protect themselves
against HIV and promote PrEP initiation. Furthermore,
acknowledging risk associated with alcohol use may be
an important mental resource for communicating the
benefits of PrEP. Consequently, disseminating PrEP pro-
motion messaging within bars, taverns and shebeens may
allow for targeting those men with these specific risks
[57]. Non-venue-based community information cam-
paigns can incorporate the specific risk factors identified
by men as reasons for PrEP use, as well as the benefits of
PrEP articulated by men. Finally, given that men initially
heard about PrEP via their social networks or overheard
conversations in their communities, leveraging social and
community networks (tangible and mental resources)
and gorilla marketing-style campaigns should be consid-
ered [58].
Limitations
While this study aimed to understand men’s prefer-
ences for PrEP initiation, only men who elected to be
tested for HIV and initiated PrEP were included. Given
participant’s comments about HIV testing being a bar-
rier for other men, the lack of voice of those men limits
our understanding of how best to engage men in PrEP
services. Some of the descriptions provided by partici-
pants reported on their perception of other mens’ barri-
ers to testing and PrEP uptake. While illuminating, these
descriptions should be considered secondary findings
with lower validity. Towards this, future studies should
seek to identify men interested in PrEP, but for whom
HIV testing is a barrier. Moreover, our findings are based
on interviews conducted at PrEP initiation. However,
motivations for sustaining PrEP use may change over
time. is limitation may be addressed in future studies
by serial interviews comparing the initial assumptions
about motivations to use PrEP versus what they actually
found influenced their sustained PrEP use. It is impor-
tant to note that while men’s awareness of their alcohol
related risk motivated uptake in this study, excessive
alcohol use is ordinarily associated with reduced health
behaviour. Even though it may be beneficial to consider
the recommendation to market PrEP at taverns and she-
beens, our interview guide did not investigate the poten-
tial effect of alcohol use on sustained PrEP use. e
study did not track participation rate among those who
were approached, or reasons for declining to participate.
Recording declination and reasons may be informative
in future studies. Following on, the study was conducted
during work hours, which may have prevented those who
work during these times from participating. Finally, given
that our sample size was small and recruitment was not
random, caution should be employed when transferring
findings beyond the study. e study targeted a high HIV
disease burden community in the Eastern Cape. While
participants from this location may have shared similari-
ties with men from other communities, including more
locations in future investigations may provide better
transferability of the findings. Although the sample size
may have been a limitation, there were no additional
themes generated in the final interviews. Specifically,
there were codes that were unique to individual inter-
views, but these were not sufficient to create new themes.
is may indicate that thematic saturation was reached.
Conclusion
Although men in this study exhibited interest in PrEP
uptake, there are significant barriers to their healthcare
access where PrEP is currently available. Some common
barriers included the need to test for HIV and reticence
towards visiting a conventional healthcare facility. Fur-
thermore, while alcohol use was not noted as a barrier
to PrEP uptake, excessive alcohol use is associated with
reduced health-seeking behavior [17, 57]. Future studies
need to investigate the utility of counselling men about
common barriers and pathways to accessing healthcare.
Additionally, interventions would greatly benefit men by
including education around mental models for overcom-
ing barriers and attaining desirable outcomes.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 10
Smith et al. BMC Public Health (2023) 23:418
Acknowledgements
This publication was made possible in part by a grant from Carnegie
Corporation of New York. The statements made and views expressed are solely
the responsibility of the author.
Author contributions
AMM, LGB, PS obtained funding. PS, JD, LG and AMM designed the study. PS,
JD, AMM designed the interview guides, which were approved by all authors.
PS led study implementation. PS, JD and AMM conducted analysis. PS wrote
the manuscript. PS prepared Fig. 1. AMM prepared Fig. 2. PS, JD, LG and AMM
critically reviewed the findings and the approved final manuscript.
Funding
This project was supported by the U.S. National Institutes of Health (NIH)
through award R01MH114648 to AMM and LGB. Additional funding and
support to PJS was provided by the U.S. NIH Office of Behavioral and Social
Sciences Research and the Fogarty International Center under award number
D43TW009343 to the University of California Global Health Institute (UCGHI).
The content of this manuscript is solely the responsibility of the authors and
does not necessarily represent the official views of the NIH or UCGHI.
Data availability
The data generated and analysed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The current study was approved by the University of Cape Town Human
Research Ethics Committee and participants’ informed consent was obtained
prior to enrolment in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no conflict of interest and no financial interest.
Author details
1The Desmond Tutu HIV Centre, University of Cape Town, Observatory,
Cape Town, South Africa
2Edson College of Nursing and Health Innovation, Arizona State
University, Phoenix, AZ, USA
3Perelman School of Medicine, University of Pennsylvania, Philadelphia,
PA, USA
4Research Unit, Foundation for Professional Development, Eastern Cape
Province, 10 Rochester Rd, Vincent, East, London, Buffalo City Metro,
South Africa
Received: 9 September 2022 / Accepted: 21 February 2023
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