Participants Demographics
A total of twelve participants were interviewed. All participants were in the age group 20–24 years and were in the third year of study. There were more females (67%, n = 8) than males (33%, n = 4), with the majority (92%; n = 11) being heterosexual. Only one participant (n = 1) identified as men who have sex with men (MSM).
Almost half of the participants (42%; n = 5) reported that they first heard about PrEP from a friend, a further 42% (n = 5) were informed of it by clinic nurse during a medical consultation, while 16% (n = 2) were informed of PrEP by the HIV counsellor at the campus health clinic. All participants began using PrEP in 2019.
The following four themes emerged from the study: (1) Sexual risk behavior, (2) reasons for using PrEP, (3) PrEP compliance and (4) the effect of COVID-19 on PrEP use.
Sexual risk behaviour
Two sub-themes emerged under this theme: Multiple sexual partners and inconsistent condom use.
Multiple sexual partners
Five participants (42%) indicated that they had more than one current sexual partner. They also mentioned that their partners had other sexual relationships and accepted this as normal. P9: “I didn’t see anything but it’s a norm that they have many girlfriends.”
Another participant mentioned that she did not know how many partners her boyfriend had but that PrEP would help her to remain HIV uninfected. P10: “I don’t know my partner, how many partners he has, so by using PrEP it helps me to stay negative because frankly they do have sexual activities with other people, maybe I can get affected with HIV. So, using PrEP helps me to stay negative all the time.”
Those who were in long distance relationships, were uncertain about their partners sexual activities when they were not in the same city. This led to a lack of trust in their partners. P11: “He is studying at another campus. Sometimes I feel I am taking risks because I’m here in Durban and he is not in Durban, so I don’t know whatever he is doing that side. Eh, it’s very risky and painful sometimes because when you trying to call someone and when you can’t find him and you start thinking all the bad things and all that. It’s not comfortable.” This was re-iterated by another female participant who mentioned a lack of trust in her partner. P7 “You can’t trust men. So, that’s why I chose to use PrEP to be on the safe side.”
Inconsistent condom use
Only one participant mentioned using a condom consistently at every sexual act in the previous year. There appeared to be a dislike of condom use, particularly by the males. P3: “My partner doesn’t feel good to use a condom, he feels that it disturbs the mood that we are in.”
The females also expressed difficulty in negotiating condom use. Requesting condom use, led to a lack of trust and fighting between the partners. P1: “Actually, we used to use it, but now we stopped using condoms. My boyfriend doesn’t like to use condoms. He says: ‘why do you have other partners?’ Then we fight.” Another participant re-iterated this: P12: “My boyfriend doesn’t like using condoms, he thinks I don’t trust him when I ask him to use a condom.”
In addition, once they commenced PrEP, they believed that it was no longer necessary to use condoms. P6: “I am on PrEP so I don’t see a need to use condoms.”
Reasons for using PrEP
All of the participants (n = 12) used PrEP to protect themselves from HIV infection as they realised that they were at a high risk of infection due to their sexual behaviour. P7: “I feel that PrEP is a good idea, I feel safe because it protects me from getting HIV and everyone is afraid of contracting HIV. I am very happy that there is such a drug introduced to help us stay negative.”
Half the participants (n = 6) felt that their risk of HIV was increased due to them not living in the same region as their partners. As mentioned under the section on multiple sexual partners, these long-distance relationships made it possible for their partners to cheat on them. P11: “I was in a long-distance relationship, and I had so many trust issues with my partner at that time because of some of the things that I’ve noticed about the behavior. So, I just wanted to protect myself.” P8 who was also in a long-distance relationship, revealed a lack of trust in her partner: “It’s because of my partner, my partner did not like to use protection, so I didn’t trust him that much because he lived in another location and I live in another location, so I cannot fully trust that person”
Others who were not in long distance relationships, were also uncertain if their partners had other sexual partners, as alluded by this male participant who commenced PrEP to protect himself as he was afraid of contracting HIV. P4: “Eish, you know these girls nowadays, you may never know! PrEP will keep me safe from HIV.”
All the female participants (67%; n = 8) revealed a lack of trust with their partners and felt insecure in their relationships, which motivated them to access PrEP. P3: “The truth ma’am is, I don’t trust his word. Taking PrEP makes me feel in control of my own health and I can stay HIV negative.” This lack of trust in the sexual partner was echoed by P6 “I was like scared and wanted to protect myself because I was not sure what my partner was doing on the other side so I just told myself that I cannot have HIV, I’m very scared of that disease.”
One participant reported commencing with PrEP when she perceived herself at risk of HIV infection. P10: “In 2019 after I found out some stuff about my partner. I wanted to protect myself. I tested for HIV and I was negative, so I wanted to stay negative.” The high HIV risk perception for the participant who identified as MSM, was a strong motivator to use PrEP due to potential exposure to HIV as he was aware that condoms were not always effective. P8: “I am gay sister. Sometimes, I feel much safer because condoms are not 100%, as I said before it is not 100% guarantee that they will protect us.”
PrEP Compliance
In the first year of taking PrEP (2019), 67% (n = 8) of participants were compliant on treatment. Four participants (33%) reported defaulting treatment intermittently. Travelling over weekends and rushing to university in the morning often led to forgetting to take the PrEP medication.
P1: “I sometimes forget to take my PrEP medication sister, when traveling over weekends and rushing to go to university in the mornings.” This was re-iterated by P2, who also travelled home over the weekends: “I live in another town sister, so sometimes I forget to pack my pills for the weekend when I’m going home, but I start them on Monday when I return to my residence.” Those living in the same town as the university, but who required public transport, had to rush in the mornings, which often led to forgetting to take the medication. P3: “In the mornings I am rushing to get ready and be on time to catch the bus to campus and I often skip breakfast and my pills.”
Side effects of PrEP, when commencing it led to another participant defaulting on the medication. However, once the side effects subsided after a few days, she then re-commenced with the treatment. P9: “Nausea and vomiting for the first few days but it stopped after a while and restarted taking it.”
In contrast, those participants who were regular in taking the medication used reminders so that PrEP was taken daily; for instance, these participants established a routine to help them remember to take medication, by setting an alarm. P6 “I already take my contraceptive at 8 o’ clock at night, and my alarm is always on, so I was taking them at the same time.” Another participant set an alarm specifically to remind her to take PrEP. She was aware that intermittently missing a dosage may render the PrEP ineffective. P9 “I’m very particular about it, so it’s for my safety. With PrEP you should not skip a day. So, I had an alarm on my cell phone and at seven every night I would take my PrEP.”
Effect of COVID-19 on compliance to PrEP
After the first year on PrEP, compliance decreased largely due to the COVID19 pandemic and nationwide lockdown which commenced in March 2020. This had a detrimental effect on students accessing PrEP treatment at the campus health clinic as universities were shut down. P8: “It was very hard to collect the PrEP because school was closed for few months. During the lock down, it was very difficult for me to collect medication”
Some participants reported continuing with PrEP, once they managed to source it from other clinics. P6: “The clinic was closed sister, so I stopped, and we were sent home. There was no transport. I went to my local mobile clinic and started PrEP again.” The clinic in their hometown tested participants for HIV prior to recommencing PrEP. P1: “During the lockdown, I stopped taking my tablets because the clinic was closed. I went to my home clinic, they did HIV test and started me on treatment again.” Participant 8 re-iterated: “During the lockdown everything was closed, my medication got finished and there was no transport. So, I went to a public hospital, they did my HIV test and started me on PrEP again”
However, many primary health care clinics were offering limited services, which did not include PrEP, as indicated by P7: “Campus clinic was closed, and my medication got finished. We were sent back home. My home clinic did not have PrEP medication.”
Due to the COVID19 nationwide lockdown, there was no public transport available in some areas. As a result, students had no transport to fetch their PrEP medication from clinics which were not within walking distance of their place of residence. P3: “There was no transport to go to clinic to get medication.” This sentiment was echoed by P17: “I stopped taking treatment, the president locked the country and there was no transport to go to the clinic, Sister”