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Introduction Tuberculosis (TB) preventive treatment (TPT) is effective in preventing TB among people living with HIV (PLHIV). Patient experiences and preferences contribute to optimising the delivery cascade for TPT among PLHIV. We describe patient-level reasons for initiation, completion, refusal and discontinuation of 3HP (high-dose rifapentine (RPT) 900 mg plus isoniazid (INH) 900 mg weekly for 3 months) and INH in Ethiopia, South Africa and Zimbabwe.Methods We conducted a total of 141 45–60 min in-depth interviews (IDIs) with adult PLHIV in Ethiopia (n=45), South Africa (n=45) Zimbabwe (n=51) between March and June 2022. Participants were attending routine HIV care in nine healthcare facilities and interviewed using a study-designed interview guide. The guide explored three categories: TB and TPT knowledge, reasons for TPT initiation and experiences of taking TPT and antiretroviral therapy (ART). Recordings were transcribed verbatim, translated and thematically analysed on MAXQDA using an abductive coding scheme incorporating the information-motivation-behavioural (IMB) skills model to understand reasons behind TPT uptake patterns.Results Of the 141 participants, 28 were still on TPT, 66 completed, 22 discontinued and 25 refused to initiate TPT. The majority were female (88%, 124/141), with an average of 36 years. IMB constructs were reflected in participants’ TPT uptake patterns, with illustrative quotes highlighting key patterns across the dataset. In relation to information, participants demonstrated knowledge of TPT and its benefits; however, there was confusion about the role of TPT in the absence of TB disease. Prior TB experiences, social support and engagements with healthcare workers were motivations for uptake. The main behaviours found included adoption of adherence strategies and use of medication reminders. Side effects, fears of pill burden and contraindications had negative outcomes for TPT uptake and completion.Conclusions The findings underscore the need to enhance the understanding of TPT through targeted interventions at clinic and community levels. Strengthening these efforts may improve TPT uptake and completion rates.