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'Guys are different': young women's views on heterosexual relationship dynamics and how they influence women's potential PrEP uptake and disclosure in Durban, South Africa

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BACKGROUND: Considerable evidence demonstrates that heterosexual relationship dynamics influence women's decisions around HIV prevention methods, but little research has been conducted among educated South African women. In the context of oral pre-exposure-prophylaxis (PrEP) becoming publicly available in South Africa (2019), we explored urban, educated young women's views on relationship dynamics with male partners, how these dynamics might impact women's use of PrEP, and how women might navigate those dynamics if they chose to use PrEP. Understanding and taking into account the realities of the lives of women is key to designing successful PrEP programs.
METHODS: This analysis utilized qualitative data from a study to develop a gender-focused PrEP information-motivation workshop to introduce young women to PrEP, in Durban, South Africa. Participants were aged 18-25, educated, and recruited from urban clinic and community settings. Six focus group discussions and eight in-depth interviews were conducted with 46 women. Data were analyzed thematically.
RESULTS: Women described men as having a different culture and set of behaviors than women and as experiencing different societal gender norms, which leads to women being at a greater risk for HIV. These differences bring complexity to women's relationships and influence their choices around PrEP use and disclosure. While acknowledging the potential benefits of PrEP, women stated that risks included: potential for anger and loss of trust in relationships, breakup, physical violence, pregnancy or other sexually transmitted infections. Despite these concerns, woman expressed desire for mutuality in relationships and shared suggestions to manage choices around PrEP use and disclosure, including willingness to end relationships.
CONCLUSIONS: These results document the challenges that even urban, educated women experience in heterosexual relationships with respect to gender dynamics and HIV prevention and add to the growing body of evidence that women's use and adherence to PrEP in Africa is shaped by male partners and women's perceptions of their male partners' reactions. For PrEP to be rolled out successfully, implementation programs need to provide women with concrete methods to improve self-agency and communication skills that address conflict. Women need these skills to navigate the complex power dynamics they experience in heterosexual relationships.