Background Between 2016–2018 a targeted roll-out of pre-exposure prophylaxis (PrEP) for 15–24-year-old female-sex-workers (FSW) was conducted in a sub-district of rural KwaZulu-Natal, South Africa where antenatal HIV-prevalence is 40%. We use an HIV-prevention cascade framework to understand how implementation impacted the first two steps at a population-level, i.e. demand for, access to and community members’ attitudes towards PrEP.

Methods We conducted participatory community mapping of four purposively sampled communities and enrolled a representative nested cohort of adolescent girls and young women (AGYW) aged 13–22 in 2017–2018. We conducted group discussions (14), key-informant interviews (9), in-depth interviews (94) and participatory observations (4). All interviews were recorded, transcribed and analysed using thematic content analysis.

Results Among n=2184 AGYW in the nested cohort, n=965 reported being sexually active, of whom 13.4% reported transactional-sex and 10.6% sex-for-money (therefore PrEP-eligible). PrEP awareness significantly increased from 2% in 2017 to 9% in 2018 (p<0.001). Among PrEP-eligible AGYWs (n=194), 11.3% were aware of, and <1% had used PrEP. Interview respondents were generally unaware of PrEP but imagined it would benefit young people, discordant couples and those with long-distance partners. Condoms were described by young people as undesirable, ‘killing your babies’ or ‘eating sweets in a wrapper’, in contrast to PrEP which ‘…will be in their system’ so not act as a barrier. Teachers and healthcare providers were apprehensive: while acknowledging PrEP’s effectiveness, they worried it would lower personal responsibility for sexual health (e.g., abstinence, condoms). Targeting FSWs was portrayed as further stigmatizing PrEP, already tarnished by association with HIV.

Conclusion The narrow focus of public-sector PrEP contributed to implementation challenges in this high HIV-prevalence setting. PrEP reach was low, even amongst self-identifying eligible FSW. Community-based approaches to PrEP education and provision, including engagement of youth and key stakeholders, may help improve demand for, access to, and optimise the PrEP cascade.

Disclosure No significant relationships.