Youth perspectives on the diffusion of PrEP in South Africa: a qualitative study of innovation characteristics and demand creation strategies

BACKGROUND: South Africa was the first African country to roll out oral pre-exposure prophylaxis (PrEP) at scale and has made substantial progress in ensuring its availability across the public health care system. Nevertheless, PrEP uptake remains low even as HIV incidence remains high, particularly among young people. AIM: To guide the development of culturally resonant, youth-centred PrEP demand creation strategies, we explored how young people make decisions about key PrEP attributes within their social context as well as their perceptions of the opinion leaders, communication channels, and messaging approaches most likely to foster PrEP demand. METHODS: Qualitative semi-structured interviews were conducted with 35 young people aged 18 to 24 years by trained youth interviewers from the community, in line with a community-based participatory research approach. A mixed deductive and inductive thematic analytic approach, which drew from the diffusion of innovations model, was applied to the data. RESULTS: Results suggest that diffusion of PrEP has been hindered by a perceived lack of relative advantage over other HIV prevention methods, incompatibility with the social context, the perceived complexity of daily pill-taking, and the absence of visible PrEP adopters. At the same time, young people advocated for a PrEP demand creation approach that amplifies local stories, leverages community-wide events, and disseminates non-directive, destigmatising, desexualising messages through youth-friendly social media and AI-based platforms. CONCLUSION: By understanding the individual and social drivers of PrEP decision-making and youth preferences for demand generation, this study provides practical insights to inform co-created strategies for culturally sensitive PrEP demand generation among South African youth.