Condom-use decision making among pre-exposure prophylaxis (PrEP) users in a pharmacy-delivered PrEP project in South Africa: Qualitative insights from PPrEPP-SA

Background: Community pharmacies increasingly serve as access points for HIV pre-exposure prophylaxis (PrEP) in South Africa and understanding how PrEP users in these settings make decisions about condom-use is essential to inform effective combination prevention strategies. This study explored condom-use decision-making among PrEP users accessing pharmacy-delivered services in South Africa. Methods: This qualitative study formed part of the midline evaluation of the PPrEPP-SA project. In-depth interviews were conducted between March and May 2024. Interviews explored participants’ understanding of PrEP, sexual behaviours, perceptions of HIV/STI risk, and experiences with prevention methods. Audio-recorded interviews were transcribed verbatim and analysed thematically using Braun and Clarke’s inductive approach. Results: 69 PrEP users aged 18–59 years were recruited from 10 community pharmacies across Gauteng and the Western Cape. Participants demonstrated varied and often negotiated condom-use practices while on PrEP. While most understood PrEP as effective for HIV prevention, some held misconceptions regarding its ability to prevent STIs, contributing to reduced condom-use. Decisions to forego condoms were linked to trust in partners, relationship stability, cohabitation, and preferences for condomless physical intimacy. Condom-use was more likely in casual partnerships or when partner HIV status was unknown. Participants also expressed a strong preference for purchased condoms over free public-sector condoms, citing concerns about quality and durability. Conclusion: Condom-use among pharmacy-based PrEP users is context-dependent, shaped by relationships, risk perceptions, and understandings of PrEP. In South Africa, pharmacy-delivered PrEP programmes provide a critical opportunity to reinforce dual prevention messaging, address misconceptions, and improve access to acceptable, high-quality condoms as part of comprehensive HIV and sexual health prevention.