"Emotional stress is more detrimental than the virus itself": Towards an understanding of HIV testing and pre-exposure prophylaxis (PrEP) use among internal migrant men in South Africa

Introduction South Africa has one of the highest rates of internal migration on the continent, largely comprised of men seeking labor in urban centers. South African men who move within the country (internal migrants) are at higher risk than non-migrant men of acquiring HIV yet are less likely to test or use pre-exposure prophylaxis (PrEP). However, little is known about the mechanisms that link internal migration and challenges engaging in HIV services. Methods We recruited 30 internal migrant men (born outside Gauteng Province) for in-depth qualitative interviews at sites in Johannesburg (Gauteng) where migrants may gather (i.e., factories, homeless shelters). Interviewers used open-ended questions, based in the Theory of Triadic Influence, to explore experiences and challenges with HIV testing and/or PrEP. A mixed deductive inductive content analytic approach was used to review data and explain why participants may or may not use these services. Results Migrant men come to Johannesburg to find work, but their struggle to survive without reliable income causes daily stress. Stress and time constraints limit their availability to seek health services, and many men lack knowledge about the opportunity for PrEP should they test negative. In addition, migrants must also adjust to life in Johannesburg, where they may be unfamiliar with where to access HIV services and lack social support to help them do so. Migrants may also continue to travel intermittently for work or social purposes, which can make it hard to take a daily pill like PrEP. Yet Johannesburg also presents opportunities for HIV services for migrant men, especially those who perceive greater availability and anonymity of HIV information and services in the city as compared to their rural homes of origin. Conclusions Bringing HIV services to migrant men at community sites may ease the burden of accessing these services. Including PrEP counseling and services alongside HIV testing may further encourage men to test, particularly if integrated into counseling for livelihood and coping strategies, as well as support for navigating health services in Johannesburg. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work has been made possible by the generous support of the American People and the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) under the terms of Cooperative Agreement 72067419CA00004 to HE2RO. The contents are the responsibility of the authors and do not necessarily reflect the views of PEPFAR, USAID or the United States Government. https://www.state.gov/pepfar/ MFN was supported by grant number T32 AI007433 from the National Institute of Allergy and Infectious Diseases (NIAID) and the Harvard University Center for AIDS Research (CFAR) NIH/NIAID fund under grant number 5P30AI060354-18. LL was supported by the National Institute of Mental Health of the National Institutes of Health under grant number K01MH119923. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The ethics committees at the University of the Witwatersrand (M191068), Mass General Brigham (Harvard University) (2020P002251), and Boston University (H-40529) approved the study. All participants provided written informed consent. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.