Table 2.

Using the dynamic framework to diagnose factors that influence PrEP use behaviour

(Adapted from Cislaghi and Heise [24])

Domains	Factor	Contribution to PrEP use	Embedded norms, and intersection with social and material influence
Individual	Perception and changes in perceived HIV vulnerability (partners’ risk, multiple partners, condom use, transactionalrelationships, vulnerability of young women to HIV and sexual violence)	Starting PrEP (less frequently motivated PrEP pause, restart and discontinuation)	• Men as ‘untrustworthy,’ attribution of individual risk to male partners • Limited power of young women to negotiate condom use • Expectations of condomless sex in transactional relationships • Association of condom use with infidelity • Normalization and expectation of sexual violence against women
	Fear of side effects	Delayed acceptance	• Myths/misconceptions about PrEP’s side effects i.e., PrEP causes weight gain, change in body shape, infertility, organ failure, increased vulnerability to HIV • Gendered standards of women as slim, shapely, fertile
	Experience of side effects	Intermittent use PrEP pause PrEP discontinuation	• Social pressure from family/belief that experiencing side effects indicates drug intolerance • Prioritization of school or employment over risk of side effects and poor performance
	Challenge/dislike of daily dosing	Intermittent use PrEP pause PrEP discontinuation	• Normalization of medicine as treatment for ‘sick’ people and not for healthy people
Social	Exposure to HIV/AIDS, (loosing parents or relatives to HIV/AIDS, exposure to orphanhood and poverty, experience of a friend seroconverting)	Starting PrEP	• ‘Old HIV/AIDS narratives’– association of HIV/AIDS with death, orphanhood and poverty
	Internalized or experienced stigma	PrEP pause	• Association of PrEP with ARVs i.e., use of ARVs as an indication of HIV infection • Use of PrEP or HIV prevention as an indication of ‘promiscuity’ or infidelity • Gendered practices and beliefs granting decision-making power to husbands, who may hold stigmatized notions of PrEP
	Intersection of travel and stigma, fear of unintended disclosure while travelling	Intermittent use
	Partner or husband disapproval	PrEP pause PrEP discontinuation
	Peer influence and encouragement, including reassurance about side effects	Starting and restarting PrEP	• Framing of PrEP daily dosing as ‘just like’ oral contraceptive/normalization of HIV prevention as part of routine sexual and reproductive healthcare
	Family and community support	Restarting PrEP
Institutional	Clinic service and support (retention events, drug-level feedback) and support from clinic staff (encouragement, information sharing leading to increased understanding of risk)	Starting and restarting PrEP