Background: Perceived risk of HIV may motivate use of pre-exposure prophylaxis (PrEP) but is dynamic and challenging to elicit and measure. Existing methodological approaches are often constrained by social desirability bias. We tested a novel approach to identifying when young women perceive ''seasons of risk'' and therefore when PrEP could offer significant HIV protection.
Methods: HPTN 082 was an open label study of PrEP uptake and adherence in 16-25 year-old HIV-uninfected women in Cape Town and Johannesburg, South Africa and Harare, Zimbabwe. In a qualitative sub-study, we used a visual method with 24 participants to obtain information about their past and current sexual relationships and perceived exposure to HIV. Participants sketched relationship ''timelines'', and an interviewer probed about condom use, relationship power, substance use, intimate partner violence (IPV), concurrent relationships, sexually transmitted infections (STIs), and pregnancies associated with each relationship. Participants assigned a “risk score” to each relationship, based on a weighing up of factors they identified as associated with HIV risk. Interviews were audio-recorded and transcripts were analysed using NVivo 11.
Results: Early sexual debut, having an older partner, sex while intoxicated, and transactional sex were highly prevalent, but women seldom considered those factors in rating relationships as ''high risk''. Women rated relationships ''low risk'' if they were casual, if condoms were used consistently, or if sex was infrequent. Risk assessment was also based on their trust and confidence in the relationship; loving partners were rated ''low risk'' and unhappy relationships involving conflict rated ''high risk'', regardless of other risk factors. Women indicated that creating the timelines revealed and encouraged new reflections on aspects of their HIV risk in relationships.
Conclusions: Self-assessment of risk is challenging when reflecting on intimate relationships. The “visual storytelling” approach using sexual history timelines facilitated discussions and recalibration of personal risk among young African women, who use different parameters than public health professionals to assess risk. This approach is relevant both for researchers seeking to understand the relationship between risk perception and PrEP use, and potentially for providers as a tool to support young women to assess their risk and adopt protective behaviours, including PrEP.

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