Date of Award

January 2023

Document Type


Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Sheela Shenoi


Background: South Africa has the highest HIV burden in the world. In KwaZulu-Natal province, 27% of adults are living with HIV and 25% of new cases are in adolescent girls and young women. High prevalence of hazardous alcohol use complicates delivery of HIV testing, care, and prevention services. Gaps exist in knowledge on alcohol use among rural women and the association with HIV outcomes. We sought to understand facilitators and barriers to HIV pre-exposure prophylaxis (PrEP) initiation in women, focusing on local alcohol venues, called shebeens.Methods: Surveys and interviews conducted among women attending shebeens assessed alcohol use, HIV risk behaviors, intimate partner violence (IPV) exposure, attendance at shebeens, and perceptions of PrEP. Multivariate logistic regression identified factors associated with interest in initiating PrEP. Semi-structured interviews explored shebeen attendance and alcohol consumption, HIV risk perception, and individual and community perceptions of oral PrEP. Results: Among 198 respondents, 44 (22.2%) reported living with HIV. Among respondents without HIV (n=154), mean age was 28.8 years (SD 7.61), 114 (74.0%) met criteria for hazardous drinking, 18 (11.7%) experienced IPV, and 58 (37.7%) had never heard of PrEP. Additionally, 135 (87.7%) women had high HIV risk, but 74 (58.7%) reported no self-perceived risk of HIV. Of 133 respondents without HIV, 108 (81.2%) reported interest in initiating PrEP. Multivariate correlates of interest in PrEP included hazardous drinking (AOR=4.76, 95% CI [1.19, 21.6]). History of physical violence from a partner was associated with decreased interest in PrEP (AOR=0.11 95% CI [0.02, 0.51]). Interview responses reinforced quantitative findings regarding high alcohol use and limited knowledge of PrEP. Perceived risk of HIV was more nuanced in interview responses, with women identifying multiple factors that influenced their risk. Most women interviewed indicated that they were interested in PrEP and would encourage their friends to take it. Comfort with disclosing use of PrEP to partners varied among respondents. Conclusion: Women in this rural population engage in high-risk behaviors including high rates of hazardous drinking and have limited knowledge of PrEP. Hazardous drinking was positively correlated with interest in PrEP while physical IPV was negatively correlated. PrEP implementation programs should aim to increase knowledge of PrEP and must consider hazardous drinking practices and IPV in expanding PrEP services. In a high prevalence setting for HIV, shebeens may offer an important access point to reach women for interventions to address HIV risk, hazardous drinking, and IPV.


This thesis is restricted to Yale network users only. It will be made publicly available on 05/10/2025