Abstract
Despite increasing availability of Pre-Exposure Prophylaxis (PrEP), many Adolescents and
Young People (AYP) in Southern Africa discontinue PrEP within six months, even when their
HIV risk remains high. Poor service quality contributes to suboptimal HIV prevention
outcomes. Addressing these challenges is critical for improving PrEP retention and achieving
the goal of ending AIDS by 2030. This study assessed the mediating role of self-efficacy in
the relationship between service quality and PrEP retention among AYP in South Africa. By
focusing on this, the study proposes interventions to enhance service quality at PrEP PPs
and improve PrEP retention among this unique group. A quantitative study was conducted
among 275 AYP aged between 18-24 years accessing PrEP services through a purposively
selected community-based organisation (CBO). Systematic sampling was used to select
participants from the CBO’s PrEP register. Data were collected using a structured
questionnaire, analysed using SPSS for descriptive statistics, and Structural Equation
Modeling (SEM) with SmartPLS4 to test each path in the model. Key variables explored
include service quality, self-efficacy, and PrEP retention. Most participants perceived that
PrEP PPs offered satisfactory service quality, although they reported gaps in accessibility
and waiting areas. The majority expressed confidence in adhering to PrEP, reflecting strong
perceived self-efficacy. However, this perception contrasted with broader literature showing
high discontinuation rates among AYP. Regarding PrEP retention, the majority consistently
attended scheduled appointments, although only a few reported taking PrEP as prescribed,
revealing a gap between perceptions and behavior. Importantly, findings confirmed that selfefficacy
partially mediates the relationship between service quality and PrEP retention,
particularly along the reliability path (β = -0.039, T = 2.075, p = 0.038). However, self-efficacy
functions as a link that translates positive service quality experiences into sustained PrEP
retention. Without self-efficacy, service quality alone may be insufficient to achieve long-term
PrEP retention among AYP. Theoretically, this study extends the SERVQUAL model into
behavioral health by linking service perceptions to self-efficacy and retention behaviours.
Practically, it highlights that improving service quality and self-efficacy can enhance PrEP
retention, supporting South Africa’s progress toward the 95-95-95 UNAIDS targets and
Sustainable Development Goal 3 to end AIDS by 2030.