A scoping review of pre-exposure prophylaxis awareness, acceptability, uptake, adherence, and HIV-related risk behaviors among university students in South Africa.

BACKGROUND: Pre-exposure prophylaxis is an effective biomedical intervention for preventing HIV infection, yet evidence on its awareness, acceptability, uptake and adherence among South African university students remains fragmented. OBJECTIVE: To map and synthesize the available evidence on pre-exposure prophylaxis awareness, acceptability, uptake, adherence, and HIV-related risk behaviors among university students in South Africa. METHODS: A scoping review was conducted using Joanna Briggs Institute methodology and reported according to PRISMA-ScR. Studies published between 2014 and 2026 were searched in PubMed/MEDLINE, Scopus, ScienceDirect, CINAHL, African Journals Online and ProQuest Dissertations and Theses/grey literature. Two reviewers independently screened studies and charted data using a predefined extraction tool. Findings were synthesized thematically. RESULTS: Sixteen studies were included, of which 68.75% (n = 11) were quantitative and 31.25% (n = 5) qualitative. Evidence was concentrated in KwaZulu-Natal, Gauteng, Limpopo and the Western Cape, with most studies published from 2019 onwards. Six themes emerged: (1) Individual Level: individual perceptions, knowledge and appraisal of HIV and PrEP; (2) Interpersonal Level: interpersonal relationships and social influence on PrEP decision-making; (3) Institutional Level: accessibility, acceptability and responsiveness of PrEP services; (4) Community/social Level: stigma, misconceptions and social norms surrounding PrEP; (5) Structural Level: socioeconomic and health-system conditions shaping PrEP utilization; and (6) HIV Risk Behaviors: patterns of sexual risk and their relationship to PrEP need. Awareness and willingness to use PrEP were generally favorable, but uptake and sustained use were constrained by knowledge gaps, low perceived risk, stigma, side-effect concerns, cost, accessibility and service-related barriers. Risk behaviors included multiple partnerships, inconsistent condom use, substance-associated sexual behavior and socioeconomic pressures. CONCLUSION: PrEP utilization is shaped by interacting individual, social, institutional and structural factors. Integrated, youth-friendly services and targeted education addressing HIV risk, stigma and access are needed to strengthen informed PrEP decision-making and prevention.