Psychosocial factors associated with the willingness to initiate and continue PrEP during pregnancy among PrEP-naïve persons in South Africa: the critical roles of alcohol use and HIV-related shame and blame

In South Africa (SA), women are disproportionately affected by HIV, with increased risk during the peripartum period. Despite the availability, efficacy, and safety of oral PrEP to prevent HIV, uptake and adherence rates remain low. This study assessed the association of intrapersonal, partner-related, and community-referenced psychosocial factors with willingness to use PrEP among pregnant persons in SA. PrEP-naïve pregnant persons receiving antenatal care in Cape Town were recruited. Hierarchical regression models examined the associations among willingness to (a) initiate and (b) continue PrEP with intrapersonal (PrEP awareness, depression, alcohol use, PTSD, internalized HIV-related shame/blame, perceived HIV risk), partner-related (relationship power, reproductive autonomy, dyadic trust), and community-level (social support, HIV-related community shame/blame, enacted stigma) factors. Increased willingness to initiate and continue PrEP was associated with reduced alcohol use, increased internalized HIV-related blame, increased HIV-related shame at the community level, and decreased HIV-related blame at the community level. Decreased enacted stigma increased willingness to initiate PrEP, while previous pregnancies increased willingness to continue PrEP. Attending to multi-level psychosocial factors through tailored interventions may support PrEP initiation and continuation among pregnant people in SA. Further research is needed to develop and adapt culturally meaningful interventions that address these factors within antenatal care settings.