Worldwide, the United Nations’ Programme on HIV/AIDS (UNAIDS) reveals that at least 37.7 million people are living with human immunodeficiency virus (HIV) (UNAIDS, 2020). Furthermore, the World Health Organization (WHO) revealed that of the 1.5 million people who were newly infected with HIV, 680 000 died from acquired immunodeficiency syndrome (AIDS)-related illnesses in the same year of 2020. Countries in sub-Saharan Africa have contributed 76% of the people infected with HIV, and another 76% of those who are newly diagnosed with HIV infections. These numbers indicate that HIV infections are on the rise and are not decreasing as would be expected. A study that was conducted in sub-Saharan Africa to explore adherence of youth to the HIV preventive programs showed that HIV prevalence increased by 3.0 million between 2000 and 2017 and during the same period, people that were infected by HIV ranged from 17. 0 million to 20.1 million (Dwyer-Lindgren et al., 2019). A financial cost, an amount of R144 685 640.00 or more, is still needed in sub-Saharan Africa to implement HIV prevention programmes and to maintain Antiretroviral Therapy for those who are already on Antiretroviral Therapy (Magura et al., 2025).

In South Africa, several HIV prevention strategies have been implemented, including condom distribution for males and females, which provides up to 99% protection against HIV and other sexually transmitted infections (STIs) when used correctly and consistently. Other key interventions include voluntary medical male circumcision (VMMC), which reduces a male’s risk of acquiring HIV by approximately 60%; pre-exposure prophylaxis (PrEP), a daily or event-based oral medication taken by HIV-negative individuals to significantly reduce their risk of HIV infection; and post-exposure prophylaxis (PEP), an emergency antiretroviral treatment initiated within 72 h after potential exposure to HIV and taken for 28 days to prevent infection.

Low PrEP adherence and continuation for the youth population have been documented by studies in adolescent girls and young women (AGYW) (Dayton et al., 2023). While oral PrEP is advised by the WHO for AGYW, PrEP has been approved for use in more than 100 nations to prevent HIV. It is being expanded globally, especially in South Africa, which has the highest AGYW HIV incidence rate in the world (Dayton et al., 2023). Recently, the South African Department of Health began a state-wide rollout of PrEP in more than 1000 basic healthcare facilities. In 2019, 13 (76.5%) of the 17 PrEP demonstration and implementation initiatives in South Africa had AGYW as their primary population (Ajayi et al., 2020).

Post-exposure prophylaxis is quite successful in preventing HIV if performed appropriately and consistently, while it does not completely prevent HIV infections (Vega-Ramirez et al., 2022). Because PEP can reduce the risk of contracting HIV by more than 80%, observational evidence indicates that some study participants contracted HIV despite using PEP. Although some of these individuals reported high PEP adherence and no subsequent HIV exposures, many HIV infections among PEP users happened because of low adherence (failing to take PEP every day for 28 days) and/or continued HIV exposures (Merrick et al., 2022). If PEP is used consistently, appropriately, and according to prescription, effectiveness is probably much greater than 80% (Coppolo et al., 2022).

KwaZulu-Natal is an epicentre of HIV prevalence in South Africa (Conan et al., 2022). Programmes that aim to prevent the transmission of HIV, such as condom distribution, VMMC, PrEP and PEP, have been implemented in KwaZulu-Natal. However, there is little positive effect on preventing the transmission of HIV and stopping AIDS (Basdav et al., 2023). Ulundi is also taking part in the 95-95-95 strategy to make sure that by 2030, the spread of HIV is stopped by encouraging the youth to test for HIV every year in December. The authors conducted this study to explore youth perspectives on PrEP and PEP, as these interventions have been shown to be effective in preventing the spread of HIV when used correctly and adhered to consistently (Elliott et al., 2019). Understanding young people’s perceptions and engagement with biomedical prevention strategies such as PrEP and PEP is therefore essential to strengthening the effectiveness of these interventions. The aim of the study was therefore to investigate the youth perceptions to PrEP and PEP at the Ulundi Local Municipality.

This study used a quantitative approach with a descriptive research design. The quantitative approach has been adopted for its benefits to create a simple understanding of behaviour and/or phenomena across different populations and settings (Flynn, 2021). The quantitative approach is intended to quantify the attitudes and behaviours to correct, support, or reject the hypothesis of the specific phenomenon by contextualising the data obtained through questioning (Bruner et al., 2019).

The article is part of a larger study conducted in KwaZulu-Natal in 2020 that focused on developing a guideline to support the implementation of PrEP as a preventive measure (Moodley, 2020).

The Ulundi Local Municipality was selected as the setting for the study. It is one of the municipalities leading in HIV prevalence in KwaZulu-Natal. The Ulundi Local Municipality is located within the Zululand District Municipality on the southern boundary of northeastern KwaZulu-Natal, South Africa. It is a predominantly rural municipality that encompasses the town of Ulundi. According to the Integrated Development Plan (IDP), the population is estimated at 205 762 residents, and the municipality comprises 24 wards. Healthcare infrastructure includes two district hospitals (Enkonjeni and Ceza), one psychiatric hospital, one MDR-TB (Multidrug-Resistant Tuberculosis) hospital, 19 fixed clinics, and five police stations.

A 2024 study conducted in KwaZulu-Natal reported low PrEP uptake, particularly among young men. Of the 1078 eligible young men, only 141 initiated PrEP, representing 13% uptake (Hlongwa et al., 2024). Access to PEP in communities within KwaZulu-Natal also remains limited, partly because of confusion between PrEP and PEP. Healthcare providers therefore need to conduct thorough assessments and engage clients effectively to determine the most appropriate preventive option (Pieterse, 2011). Figure 1 presents the map of Ulundi Local Municipality.

Probability sampling was used in this study. Probability sampling allowed the researcher to collect data from a representative sample of the entire population that was interested in participating in the study. The study adopted simple random sampling to select clinics from which the youth of Ulundi were drawn as respondents.

Ulundi IDP 2022/2023 confirms that 19 clinics fall under the Ulundi Local Municipality. The researcher obtained a list of these clinics from the municipality and used systematic sampling to select the study sites, selecting every third clinic from the list. A total of six clinics were selected, namely Mabedlane, Mdumezulu, Nomdiya, Zilulwane, Idlebe, and Sizana clinics. The estimated population of youth aged 18–35 years across these six clinics was approximately 2500.

After selecting the clinics, the required sample size was calculated using an online sample size calculator (calculator.net), applying a 95% confidence level and a 5% margin of error. The sample size was determined using the Yamane formula (n = 1 + N(e)2N), which produced a minimum requirement of n = 400 respondents for the study.

The development of the hardcopy, self-administered questionnaire was guided by the constructs of the Health Belief Model, with items aligned to the study objectives and research questions. The questionnaire, informed consent form, and information sheet were prepared in both English and isiZulu to ensure accessibility. As the researcher was proficient in both languages, the instruments were translated into isiZulu to accommodate participants’ language preferences. This approach ensured that all youth attending the selected clinics within the Ulundi Local Municipality had an equal opportunity to participate. Measures to ensure validity, reliability, and ethical integrity were implemented and are described next to demonstrate how they were operationalised in the study.

The data were collected from the youth who were available in the selected clinics during the data collection time. Data collection from the participating respondents took 6 months.

The data were captured by the researcher and were verified by the researcher together with the statistician and the supervisor. The researcher employed descriptive statistical analysis to identify patterns and trends in the collected data. This method minimises bias by using numerical representation to summarise findings and serves as a scientific tool to support decision-making (Sorkin et al., 2020). Data were presented using tables, charts, and graphs to clearly depict the phenomenon under investigation, enhancing interpretation and understanding (Schwabish, 2021). A statistician was consulted to ensure the appropriate statistical tools and procedures were applied.

Data were presented in a clear and organised manner to facilitate easy interpretation using established statistical formulas and tools (Shen et al., 2018). In the quantitative approach, statistical software enhances data management and visualisation. The researcher used SPSS version 29 to generate charts and graphs, ensuring accurate analysis and clear presentation of results (Scala et al., 2021). This approach improved readability and made the findings easier for readers to understand.

The quantitative approach requires measures to ensure the quality of the study through the assessment of validity and reliability (Heale & Twycross, 2015). In this study, both were applied to enhance methodological rigour and ensure accurate measurement of the intended constructs. Validity refers to the extent to which an instrument measures what it is designed to measure (Ahmed & Ishtiaq, 2021). Data validation was essential to ensure accurate measurement and meaningful interpretation of findings.

Theory-based validity was applied by ensuring alignment between the instrument items and the theoretical constructs. For example, in assessing youth adherence to HIV preventive measures, responses were expected to reflect behaviours consistent with reported attitudes. This alignment between theoretical expectations and observed responses strengthened the validity of the instrument.

Criterion validity was also considered, which evaluates how well an instrument correlates with an external criterion. It includes convergent, divergent, and predictive validity (Sürücü & Maslakçı, 2020). Predictive validity was adopted in this study to assess the instrument’s ability to predict future adherence to HIV preventive measures among youth (Hair et al., 2020).

Reliability refers to the consistency and stability of an instrument over time (Clark & Watson, 2019). It was assessed through three attributes: homogeneity, stability, and equivalence. Homogeneity (internal consistency) was evaluated using item-to-total correlations, split-half reliability, the Kuder–Richardson coefficient, and Cronbach’s alpha. Split-half reliability assessed the correlation between divided test items, with strong correlations indicating high reliability.

Stability was examined using test–retest and parallel-form methods by administering the same instrument under similar conditions at different times. Consistent results indicated stability. Equivalence was assessed through inter-rater reliability, measuring the level of agreement between different evaluators to ensure consistency in measurement.

Ethical clearance to conduct this study was obtained from the University of Zululand Research Ethics Committee on 26 June 2024. The ethical clearance number is UZ-REC 0691-008 PGM 2024/10. Ethical considerations assert honesty and integrity that are always expected to be observed by all researchers when they are conducting empirical studies, regardless of whether a researcher is an expert or not. Honesty is required to protect and respect the rights of human subjects. To deal with vulnerability, the researcher requested a safe and conducive place for the respondents when filling out the questionnaires so that nobody was able to see what was happening; the line for collecting PrEP and for collecting ART was the same. Lastly, all the respondents were taken from the waiting area, where they were all mixed in one place. Therefore, it was very hard to tell if a respondent was HIV-positive or HIV-negative. Furthermore, to ensure that the study upheld the ethical standards, the following principles were observed: (1) right to anonymity, (2) self-determination, (3) informed consent, and (4) confidentiality (Barrow et al., 2022). Whenever respondents are promised confidentiality, it means the information they share is not going to be publicised in any form that may lead to their identification (Brall et al., 2019).

The researcher adopted the use of data encryption and encrypted predictive techniques to secure the storage of the data, which are important components of privacy-preserving analytics. These techniques help to protect sensitive data and ensure that predictive algorithms can be run on encrypted data without compromising privacy; therefore, no unauthorised person can tamper with data (Olatosi et al., 2019).

Respondents of the study were informed about the study’s aim. The researcher made sure that the respondents understood the study and signed the informed consent form after receiving the information about the study. This study was approved by the University of Zululand Ethics Committee.

The right to withdraw from the study at any point was granted to the respondents. There would be no consequences for doing so.

Respondents’ names were kept anonymous to protect them. Thus, no information that could identify the participants was collected. Furthermore, if the researcher decides to publish the findings of the study, the participants’ identities and names will not be disclosed to the public.

Respondents were assured that no harm would come after participating in the study, whether physical or social, because no information was taken that might link them with the study.

Informed written consent was obtained, and only those youth members who voluntarily signed up were included in the sample. The researcher did not force anyone to participate in the study, as the rights of the youths were observed (Mehraeen et al., 2022).

Participants (N = 400) were asked whether using PrEP reduces the risk of acquiring HIV. Of the respondents, 20.8% (N = 83) strongly agreed and 15.5% (N = 62) agreed, reflecting a moderate level of understanding. A smaller proportion was neutral at 8.8% (N = 35), while 1.8% (N = 7) disagreed and 2.5% (N = 10) strongly disagreed, indicating limited understanding among some participants. Notably, 50.7% (N = 203) indicated that the statement was not applicable to them (Figure 5).

Participants (N = 400) were asked about their utilisation of PEP after potential exposure to HIV. Among the respondents, 29% (N = 116) strongly agreed that they would use PEP, while 4% (N = 16) agreed. A further 8.5% (N = 34) were neutral regarding PEP use. In contrast, 14.5% (N = 58) expressed disagreement or strong disagreement, with 4.5% (N = 18) specifically indicating disagreement. Notably, 39.5% (N = 158) selected ‘not applicable’, suggesting that they were either not at risk or were already living with HIV.

The frequency bar chart illustrates that a considerable minority (18%) held negative views towards PEP use, underscoring the need for targeted education and awareness initiatives. Based on the study’s findings and supporting literature, prompt medical attention after potential HIV exposure is essential. Individuals who suspect exposure should seek immediate guidance from healthcare professionals or visit a clinic to obtain appropriate advice and timely access to PEP as part of comprehensive HIV prevention (see Figure 6).

Participants were asked whether they would opt for PEP for 1 month to reduce the risk of HIV infection after potential exposure. The findings indicate a limited understanding of appropriate PEP use following risky sexual behaviour.

Among the respondents (N = 400), 19.3% (N = 77) strongly agreed, and 8.0% (N = 32) agreed that PEP can prevent HIV infection after exposure, reflecting moderate awareness. A proportion of 14.8% (N = 59) remained neutral. In contrast, 1.5% (N = 6) disagreed, and 4.0% (N = 16) strongly disagreed, indicating low levels of understanding regarding PEP use. Notably, more than half of the participants, 52.5% (N = 210), selected ‘not applicable’.

The bar chart demonstrates that a substantial proportion of respondents lacked clear knowledge about the role of PEP following HIV exposure, highlighting the need for strengthened education and awareness interventions to improve understanding of timely PEP initiation and its preventive benefits (see Figure 7).

Recommendations for nursing education, practice and research are as follows:

Several limitations were identified. The study was conducted in a rural and semi-rural setting where populations are geographically dispersed, which may have limited the ability to obtain a fully representative sample and affected generalisability. Although the questionnaire was translated into isiZulu, responses were self-reported and may have been influenced by social desirability bias, stigma, or misunderstanding of questions. Data collection occurred at selected healthcare facilities within specific times, and financial or logistical constraints may have limited participation. Additionally, resource constraints within rural healthcare settings, including staffing and infrastructure challenges, may have influenced data collection.

The study also had several strengths that enhanced its credibility and relevance. The study was guided by a theoretical framework and used a structured questionnaire translated into isiZulu to improve accessibility and comprehension. Data were collected directly from the target population, enhancing relevance and contextual validity. Appropriate statistical software was used to ensure accurate analysis. By focusing on a rural municipality with limited existing research on PrEP and PEP uptake, the study provides context-specific evidence that can inform local practice and policy.