Abstract
OBJECTIVE: This study explores the decentralisation of PrEP services through primary health care (PHC) re-engineering structures such as schools, pharmacies, youth zones, community halls, and mobile clinics to improve PrEP uptake and adherence among adolescents and young adults (AYAs) in KwaZulu-Natal, South Africa. METHODS: In-depth interviews were conducted from August 2021 to July 2023 with 48 purposively selected participants from a cohort of 2,772 newly diagnosed HIV-negative, sexually active, high-risk individuals. These included 36 adolescent girls and young women aged 15–24 years and adolescent boys and young men aged 15–35 years who initiated PrEP within one month at various service delivery points, including clinics, schools, and community-based services. An additional 12 participants who had not initiated PrEP were also included. Data were analysed thematically using a comprehensive codebook developed to guide the coding process. All transcripts and audio recordings were validated for completeness and accuracy before coding. FINDINGS: The study identifies critical factors that support successful PrEP implementation and expansion among high-risk, sexually active AYAs. The PHC re-engineering programme emerged as a crucial strategy for increasing both PrEP uptake and adherence. Participants expressed a strong preference for decentralised service models, including community-based facilities, outreach teams, and home delivery systems. These models were most appealing to AYAs compared to traditional healthcare facilities. They effectively addressed common barriers such as long waiting times, unfriendly healthcare professionals, overcrowding, stigma, and transportation challenges. Some participants noted that home delivery of PrEP saved both time and money, contributing to better adherence. CONCLUSION: Decentralised, community-based approaches play a vital role in improving PrEP uptake, adherence, and continuation among AYAs in South Africa. The findings underscore the importance of addressing key barriers such as distance, stigma, and accessibility. By decentralizing PrEP services and embedding them within familiar, youth-friendly spaces at community level, this study demonstrates how HIV prevention can be made more accessible and acceptable to AYAs. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12889-025-25698-2.