Health system and social determinants influencing potential PrEP access among young men in rural Mpumalanga, South Africa: a qualitative analysis

Young heterosexual men face HIV risk in South Africa's generalized HIV epidemic. Although many men express interest in biomedical pre-exposure prophylaxis (PrEP), uptake of daily oral PrEP has been slow. Enhancing access to standard and alternative health care providers offering PrEP services could increase men's uptake as product options expand. We conducted in-depth interviews with 13 young men and 9 health system stakeholders in the rural Ehlanzeni District of Mpumalanga Province to explore factors shaping current or potential PrEP access, with a focus on social determinants and the health service system. We used framework analysis and identified four themes: competence, convenience, confidentiality and autonomy. In considering hypothetical PrEP access, participants identified public clinics as competent to provide PrEP despite concerns over HIV testing. While health system stakeholders endorsed community-based models as a convenient way to reach young men, men themselves raised concerns over confidentiality. Facilities considered reliable and less stigmatized such as pharmacies were identified as an additional promising approach. This study suggests multiple options for PrEP access for men in rural South Africa, including faster, more discreet services within clinics and self-directed options like self-test kits paired with vouchers for pharmacy pick up.