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Participation in an HIV prevention intervention and access to and use of contraceptives among young women: A cross sectional analysis in six South African districts

  • Kim Jonas
    Correspondence
    Corresponding author.
    Affiliations
    Health Systems Research Unit, South African Medical Research Unit, Cape Town, South Africa

    Adolescent Health Research Unit, Division of Child and Adolescent Psychiatry, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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  • Carl Lombard
    Affiliations
    Biostatistics Unit, South African Medical Research Unit, Cape Town, South Africa

    Division of Epidemiology and Biostatics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
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  • Witness Chirinda
    Affiliations
    Health Systems Research Unit, South African Medical Research Unit, Cape Town, South Africa
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  • Darshini Govindasamy
    Affiliations
    Health Systems Research Unit, South African Medical Research Unit, Cape Town, South Africa

    Adolescent Health Research Unit, Division of Child and Adolescent Psychiatry, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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  • Tracy McClinton Appollis
    Affiliations
    Health Systems Research Unit, South African Medical Research Unit, Cape Town, South Africa

    Adolescent Health Research Unit, Division of Child and Adolescent Psychiatry, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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  • Caroline Kuo
    Affiliations
    Expert Consultant, Rhode Island, United States
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  • Glenda Gray
    Affiliations
    South African Medical Research Unit, Cape Town, South Africa
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  • Roxanne Beauclair
    Affiliations
    Department of Science and Innovation (DSI)–National Research Foundation (NRF) Center of Excellence in Epidemiological Modelling and Analysis, Stellenbosch University, Stellenbosch, South Africa
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  • Mireille Cheyip
    Affiliations
    Division of Global HIV and Tuberculosis, Center for Global Health, US Centers for Disease Control and Prevention, Pretoria, South Africa
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  • Catherine Mathews
    Affiliations
    Health Systems Research Unit, South African Medical Research Unit, Cape Town, South Africa

    Adolescent Health Research Unit, Division of Child and Adolescent Psychiatry, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Open AccessPublished:July 23, 2022DOI:https://doi.org/10.1016/j.contraception.2022.07.005

      Abstract

      Objective

      This study investigated whether young women's participation in a combination HIV-prevention intervention was associated with accessing and using condoms and other contraceptives.

      Study Design

      A cross-sectional household survey was conducted from 2017 to 2018 among a representative sample of young women aged 15–24 years old living in six South African districts in which the intervention was implemented. Cross-tabulations and multivariate regression analyses of weighted data were performed to examine access to and use of condoms and other contraceptives.

      Results

      In total 4399 young women participated, representing a 60.6% response rate. Of participants, 61.0% (n = 2685) reported accessing condoms and other contraceptives in the past year. Among those who ever had sex (n = 3009), 51.0% used condoms and 37.4% other contraceptives at last sex. Among 15–19 year old, participation in the combination intervention was positively associated with reporting contraceptive use other than condoms at last sex (Prevalence Ratio (PR): 1.36; 95% CI: 1.21–1.53) and reporting use of both condoms and other contraceptives at last sex (PR: 1.45; 95% CI: 1.26–1.68). No associations were observed in the age group 20–24.

      Conclusion

      Our findings suggest that combination HIV prevention interventions may lead to increased access and use of condoms and other methods of contraception among adolescent women, but this needs to be confirmed in experimental studies. We need to test different or more intensive interventions to increase contraceptive use in young women aged 20–24.

      Implications

      Participating in combination HIV prevention interventions that are delivered via multiple approaches may promote access to, and use of condoms and other methods of contraceptives among adolescent women, and thereby help reduce unintended pregnancies.

      Keywords

      1. Introduction

      The number of new HIV infections is decreasing in South Africa [
      • Williams BG
      • Gupta S
      • Wollmers M
      • Granich R.
      Progress and prospects for the control of HIV and tuberculosis in South Africa: a dynamical modelling study.
      ], but the incidence remains the highest worldwide and young women aged 15–24 years account for 30% of new infections [
      • Hubacher D
      • Mavranezouli I
      • McGinn E.
      Unintended pregnancy in sub-Saharan Africa: magnitude of the problem and potential role of contraceptive implants to alleviate it.
      ,
      • Dellar RC
      • Dlamini S
      • Karim QA.
      Adolescent girls and young women: key populations for HIV epidemic control.
      ]. AIDS is the second leading cause of death in young people aged 15–24 years in South Africa [

      Demographic SA. Health Survey (SADHS), 2016. Key indicators report 2018. Pretoria

      ]. Globally, interventions to promote safe sex have been effective in reducing HIV transmission among young people; however, adolescent pregnancy rates in developing countries are not declining as they are in the developed countries [

      UNFPA, 2015. Girlhood, Not Motherhood: Preventing Adolescent Pregnancy. UNFPA, New York. World Health Organization (WHO), 2015. Maternal, Newborn, Child and Adolescent Health. Available at: http://www.who.int/maternal_child_adolescent/topics/maternal/adolescent_pregnancy/en. (Accessed 14 April 2020).

      ]. An estimated 21 million adolescent girls aged 15–19 years become pregnant every year in the developing countries and the majority of these pregnancies are unintended. The impact of unintended pregnancies include depression and anxiety and early school dropout, which may further exacerbate the cycle of poverty [

      World Health Organization, 2021, HIV/AIDS. July Available at: https://www.who.int/news-room/fact-sheets/detail/hiv-aids (Accessed 19 July 2021).

      ,

      Darroch JE, Woog V, Bankole A, Ashford LS, Points K. Costs and benefits of meeting the contraceptive needs of adolescents. Guttmacher Institute. 2016.

      ]. Unintended pregnancies among HIV-positive young women are a major contributor to mother-to child-transmission of HIV [

      World Health Organization, 2021, HIV/AIDS. July Available at: https://www.who.int/news-room/fact-sheets/detail/hiv-aids (Accessed 19 July 2021).

      ].
      Access to, and use of, contraceptives are key to preventing unintended pregnancies. However, the prevalence of contraceptive use among young women is suboptimal despite contraceptives being available free of charge in South Africa. In 2016, 19% of all sexually active women of reproductive age in South Africa reported an unmet need for contraception, with an even higher unmet need among adolescent girls aged 15–19 years (31%) and among young women aged 20–24 years (28%) [

      Demographic SA. Health Survey (SADHS), 2016. Key indicators report 2018. Pretoria

      ].
      To expand and enhance HIV prevention and improve access to sexual and reproductive health (SRH) services including contraception, a South African combination HIV-prevention intervention for adolescent girls and young women aged 10–24 years, funded by the Global fund, was implemented by governmental and non-governmental organizations in 10 high-burden districts of South Africa from 2016 to 2019 [
      • Mathews C.
      • Lombard C.
      • Puren A.
      • Cheyip M.
      • Ayalew K.
      • Jonas K.
      • et al.
      Evaluation of a South African combination HIV prevention programme for adolescent girls and young women: HERStory Study.
      ]. The combination intervention promoted access to contraceptives through linkages to SRH services and commodities aiming to reduce unintended pregnancies. A detailed description of the intervention components, including the SRH components examined in this paper, are presented in Box 1.
      The main aim of these analyses was to investigate whether participation in the combination intervention was associated with accessing and using condoms and other methods of contraceptives among young women aged 15–24 years old.

      2. Methods

      2.1 Study design and sampling

      We conducted secondary analysis using data from a cross-sectional, representative household survey of young women living in six of the 10 districts in which the combination HIV prevention intervention was implemented [
      • Mathews C.
      • Lombard C.
      • Puren A.
      • Cheyip M.
      • Ayalew K.
      • Jonas K.
      • et al.
      Evaluation of a South African combination HIV prevention programme for adolescent girls and young women: HERStory Study.
      ]. South Africa is divided into 9 provinces that consist of 53 districts an area within a province demarcated for administrative purposes [
      • Sartorius K
      • Sartorius B.
      Service delivery inequality in South African municipal areas: a new way to account for inter-jurisdictional differences.
      ]. The survey was conducted between 2017 and 2018 among young women aged 15–24 years old and used a stratified sampling design comprised of a three staged sampling approach. Detailed description of the methods has been documented in the HERStory report and published elsewhere [
      • Mathews C.
      • Lombard C.
      • Puren A.
      • Cheyip M.
      • Ayalew K.
      • Jonas K.
      • et al.
      Evaluation of a South African combination HIV prevention programme for adolescent girls and young women: HERStory Study.
      ,
      • Mathews C
      • Cheyip M
      • Beauclair R
      • Puren A
      • Lombard C
      • Jonas K
      • et al.
      HIV care coverage among HIV-positive adolescent girls and young women in South Africa: Results from the HERStory Study.
      ].
      Permission to conduct the study was obtained from the South African Medical Research Council's Ethics Committee. For participants under 18 years of age, parental or caregiver consent was obtained before getting consent from the adolescent girl. Participants were reimbursed with a gift (for example, earphones) and voucher to the value of R75 (US $5). Details about the procedure have been published [
      • Mathews C.
      • Lombard C.
      • Puren A.
      • Cheyip M.
      • Ayalew K.
      • Jonas K.
      • et al.
      Evaluation of a South African combination HIV prevention programme for adolescent girls and young women: HERStory Study.
      ,
      • Mathews C
      • Cheyip M
      • Beauclair R
      • Puren A
      • Lombard C
      • Jonas K
      • et al.
      HIV care coverage among HIV-positive adolescent girls and young women in South Africa: Results from the HERStory Study.
      ].

      2.2 Measures

      The primary outcomes were (1) accessing condoms, defined as having accessed a male condom and/or a female condom in the past year, (2) accessing contraceptives, defined as having accessed another method of contraceptives other than condoms in the past year. For the purposes of this study, other methods of contraceptives were defined as: oral contraceptives (the pill), injectable contraceptives, emergency contraceptives (morning after pill), the implant, and intrauterine device (IUD), (3) contraceptive use other than condoms at last sex, defined as use of one of the above-mentioned contraceptive methods other than condoms at last sexual intercourse, (4) Dual contraception at last sex, defined as use of condoms plus another method of contraceptives at last sex.
      The primary exposure was participation in the key components of the combination intervention, defined as reporting ever having attended or being a member of Soul Buddyz Clubs, Rise Clubs, Women of Worth Clubs, or the Keeping Girls in School Programme.
      Other variables included age, currently in school, relationship status, socioeconomic status (SES), ever had sex, transactional relationship, transactional sex, having accessed SRH related websites, having had social support from parents, having experienced intimate partner violence (IPV) and/or sexual violence in the past 12 months, and pregnancy history. The measures are described in Mathews et al (2021) [
      • Mathews C
      • Cheyip M
      • Beauclair R
      • Puren A
      • Lombard C
      • Jonas K
      • et al.
      HIV care coverage among HIV-positive adolescent girls and young women in South Africa: Results from the HERStory Study.
      ].

      2.3 Analysis

      We incorporated sample weights into the analyses as we aimed to generalize our results to the broader population of young women across all the 6 districts [
      • Mathews C
      • Cheyip M
      • Beauclair R
      • Puren A
      • Lombard C
      • Jonas K
      • et al.
      HIV care coverage among HIV-positive adolescent girls and young women in South Africa: Results from the HERStory Study.
      ]. In the bivariate analyses, we included all participants, while in the multivariate analyses, we included only participants who reported ever having had sex, who also responded to the questions that comprised the primary outcomes. We conducted cross-tabulations to explore the factors associated with contraceptive access in the past year and use of contraceptive at last sex.
      We performed 2 survey-based binomial generalized linear regression models using a log link function to determine: (1) the association firstly between intervention participation and use of contraceptives other than condom at last sex; (2) the association between intervention participation and use of dual contraception last sex (condoms plus another method of contraceptives). We assessed whether age moderated the associations. We assessed the interaction between age, and the intervention effect by incorporating the interaction term in the model. Variables were chosen based on how they performed on the bivariate analyses initially, and then based on evidence regarding factors that affect intervention participation. We adjusted the model for potential confounders (being in a relationship, having had a boyfriend in the past 12 months, having had transactional sex, having had transactional relationship, having had social support from parents, having used a condom at last sex as a method of contraception, and had experienced IPV and/or sexual violence in the past year) all a priori.
      All fractions, adjusted prevalence ratio (aPRs) and 95% confidence intervals (95% CIs) were estimated using survey-based analysis. The significance level was set at a p-value of equal to, or less than 0.05 (p ≤ 0.05). We used Stata version 14 to perform the analyses [

      StataCorp, Stata Statistical Software: Release 14. 2015 College Station, TX: StataCorp LP.

      ].

      3. Results

      3.1 Description of the participants

      We included 4399 young women, a survey response rate of 60.6%. Of these, 3009 (68.4%) reported they had ever had sex and therefore met the inclusion criteria for the multivariate analyses. Among these, 2884 (95.8%) met the inclusion criteria for complete case analysis. The mean age of participants was 19.1 (standard deviation (SD) 2.7). Slightly more than half (56.2%) of the total sample were currently in school. Among the participants who reported they had ever had sex (n = 3009), 52.1% reported they had ever been pregnant (Table 1).
      Table 1Socio-demographic characteristics of young women included in the
      Evaluation of a South African combination HIV prevention intervention for adolescent girls and young women: HERStory Study.
      HERStory Study, South Africa, 2018−2019
      Variablen (%)
      Age group
      15−192515 (56.7)
      20−241884 (43.3)
      Currently in school
      Yes2518 (56.2)
      No1881 (43.8)
      Socioeconomic status
      Relatively high SES792 (20.3)
      Relatively low SES3607 (79.7)
      In a relationship
      Yes2775 (62.0)
      No1624 (38.0)
      Had a boyfriend in the past 12 months
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months”, 1.2% (n = 35) were excluded for the variable “ever pregnant”, 1.1% (n = 18) for abortion, 3.4% (n = 54) for first pregnancy intended].
      Yes2953 (67.3)
      No1387 (31.4)
      Ever had sex
      Yes3009 (68.4)
      No1390 (31.6)
      Accessed SRH related websites (BeWise, MomConnect, iLoveLife, Chommy, & Rise)
      Yes739 (17.5)
      No3660 (82.5)
      Has had transactional relationship
      Yes481 (10.7)
      No3918 (89.3)
      Has had transactional sex
      Yes424 (9.5)
      No3975 (90.5)
      Ever pregnant
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months”, 1.2% (n = 35) were excluded for the variable “ever pregnant”, 1.1% (n = 18) for abortion, 3.4% (n = 54) for first pregnancy intended].
      Only asked for those who reported to have ever had sex.
      Yes1680 (52.1)
      No1412 (46.3)
      Pregnant more than once
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months”, 1.2% (n = 35) were excluded for the variable “ever pregnant”, 1.1% (n = 18) for abortion, 3.4% (n = 54) for first pregnancy intended].
      .
      Only asked for those who reported to have ever been pregnant.
      Yes453 (26.7)
      No1213 (72.4)
      First pregnancy before the age of 18 years old
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months”, 1.2% (n = 35) were excluded for the variable “ever pregnant”, 1.1% (n = 18) for abortion, 3.4% (n = 54) for first pregnancy intended].
      Only asked for those who reported to have ever been pregnant.
      Yes583 (36.2)
      No990 (63.8)
      First pregnancy intended
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months”, 1.2% (n = 35) were excluded for the variable “ever pregnant”, 1.1% (n = 18) for abortion, 3.4% (n = 54) for first pregnancy intended].
      Only asked for those who reported to have ever been pregnant.
      Yes408 (26.6)
      No1218 (70.1)
      Ever chosen abortion
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months”, 1.2% (n = 35) were excluded for the variable “ever pregnant”, 1.1% (n = 18) for abortion, 3.4% (n = 54) for first pregnancy intended].
      Only asked for those who reported to have ever been pregnant.
      Yes123 (7.8)
      No1538 (91.0)
      HIV status
      Negative3829 (87.6)
      Positive568 (12.4)
      Participated in the intervention
      Yes2103 (48.4)
      No2296 (51.6)
      Social support from parents
      High support2730 (61.9)
      Moderate support1207 (27.8)
      Low support462 (10.3)
      Experienced IPV and/or sexual violence in the past 12 months
      Yes1263 (29.6)
      No3136 (70.4)
      a Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months”, 1.2% (n = 35) were excluded for the variable “ever pregnant”, 1.1% (n = 18) for abortion, 3.4% (n = 54) for first pregnancy intended].
      b Only asked for those who reported to have ever had sex.
      c Only asked for those who reported to have ever been pregnant.
      d Evaluation of a South African combination HIV prevention intervention for adolescent girls and young women: HERStory Study.

      3.2 Access to condoms and other methods of contraception in the past year

      Of the 4399 participants, 52.3% (n = 2257) had accessed condoms and 40.6% (n = 1777) accessed other methods of contraceptives in the past year. Among the 3009 participants who ever had sex, 52.7% (n = 1599) had accessed condoms and 64.7% (n = 1938) had accessed other methods of contraceptives in the past year. Table 2 shows factors associated with accessing condoms and other methods of contraception in the past year for all 4399 participants. Almost all variables were associated with access to condoms and other methods of contraception except for SES for both outcomes and participation in the intervention for the contraceptives other than condoms outcome.
      Table 2Factors associated with accessing condoms and other methods of contraceptives among young women, by age group (n = 4399),
      Evaluation of a South African combination HIV prevention intervention for adolescent girls and young women: HERStory Study.
      HERStory Study, South Africa, 2018−2019
      Accessed condoms in the past yearAccessed other methods of contraceptives in the past year
      VariableYes n (%)No n (%)p-valueYes n (%)No n (%)p-value
      Currently in school
      Yes1019 (41.3)1499 (58.7)<0.01753 (30.3)1765 (69.7)<0.01
      No1238 (66.3)643 (33.7)1024 (53.8)857 (46.2)
      Socioeconomic status
      Relatively high SES411 (52.4)381 (47.6)0.90315 (39.3)477 (60.7)0.32
      Relatively low SES1846 (52.2)1761 (47.8)1462 (41.0)2145 (59.0)
      In a relationship
      Yes1687 (61.8)1088 (38.2)<0.011394 (50.7)1381 (49.3)<0.01
      No570 (36.7)1054 (63.3)383 (24.3)1241 (75.7)
      Had a boyfriend in the past 12 months
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months” and 1.6% (n = 49) were excluded for the variable “ever pregnant”].
      Yes1682 (57.9)1271 (42.1)<0.011359 (46.1)1594 (53.9)<0.01
      No547 (40.5)840 (59.5)397 (29.2)990 (70.8)
      Accessed SRH related websites (BeWise, MomConnect, iLoveLife, Chommy, & Rise)
      Yes623 (72.3)239 (27.7)<0.01487 (55.6)375 (44.4)<0.01
      No1634 (47.1)1903 (52.9)1290 (36.8)2247 (63.2)
      Has had transactional relationship
      Yes337 (69.4)144 (30.6)<0.01280 (57.8)201 (42.2)<0.01
      No1920 (50.2)1998 (49.8)1497 (38.6)2421 (61.4)
      Has had transactional sex
      Yes300 (71.3)124 (28.7)<0.01247 (58.4)177 (41.6)<0.01
      No1957 (50.3)2018 (49.7)1530 (38.8)2445 (61.2)
      Ever pregnant
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months” and 1.6% (n = 49) were excluded for the variable “ever pregnant”].
      Only asked for those who reported to have ever had sex.
      Yes1170 (69.8)510 (30.2)<0.011084 (63.8)596 (36.2)<0.01
      No803 (57.7)609 (42.3)548 (39.6)864 (60.4)
      HIV status
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months” and 1.6% (n = 49) were excluded for the variable “ever pregnant”].
      Positive388 (69.7)180 (30.3)<0.01312 (54.0)256 (46.0)<0.01
      Negative1868 (49.8)1961 (50.2)1465 (38.8)2364 (61.2)
      Participated in the intervention
      Yes1146 (55.7)957 (44.3)<0.01826 (39.6)1277 (60.4)0.11
      No1111 (49.0)1185 (51.0)951 (41.6)1345 (58.4)
      Social support from parents
      High support1355 (50.5)1375 (49.5)0.011066 (39.3)1664 (60.7)<0.01
      Moderate support625 (53.3)582 (46.7)489 (40.5)718 (59.5)
      Low support277 (59.8)185 (40.2)222 (48.8)240 (51.2)
      Experienced IPV and/or sexual violence in the past 12 months
      Yes815 (65.0)448 (35.0)<0.01667 (53.0)596 (47.0)<0.01
      No1442 (46.9)1694 (53.1)1110 (35.4)2026 (64.6)
      Bold= p-value for the difference between those who participated in the intervention and factors associated with participation
      a Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months” and 1.6% (n = 49) were excluded for the variable “ever pregnant”].
      b Only asked for those who reported to have ever had sex.
      c Evaluation of a South African combination HIV prevention intervention for adolescent girls and young women: HERStory Study.
      Among those who participated in the intervention, 55.7% (n = 1146) accessed condoms compared to 49.0% (n = 1111) who did not participate in the intervention. Of those who participated in the intervention, 39.6% (n = 826) had accessed other methods of contraceptives in the past year compared to 41.6% (n = 951) who did not participate in the intervention (Table 2).

      3.3 Use of contraceptives other than condoms at last sex among young women who had ever had sex

      Table 3 shows factors associated use of contraceptives other than condoms at last sex among participants who had ever had sex. The factors associated with the increased prevalence of use of contraceptives other than condoms include having participated in the intervention, having been in an intimate relationship, having had a transactional relationship, having had transactional sex, and ever having been pregnant. Condom use at last sex was associated with slightly decreased use of other contraceptives at last sex. About a third (36.7%, n = 560) of those who used a condom at last sex reported using another method of contraceptives at last sex compared to 38.9% (n = 500) of those who reported not to use condom at last sex (Table 3).
      Table 3Factors associated with the use of contraceptives other than condoms at last sex among young women who had ever had sex, by age groups (n=2884),
      Evaluation of a South African combination HIV prevention intervention for adolescent girls and young women: HERStory Study.
      HERStory Study, South Africa, 2018−2019
      15−19 years n = 123720−24 years n = 1647Total N = 2884
      Used contraceptives at last sexUsed contraceptives at last sexUsed contraceptives at last sex
      VariableYes n (%)No n (%)p-valueYes n (%)No n (%)p-valueYes n (%)No n (%)p-value
      Currently in school
      Yes279 (31.1)625 (68.9)0.02161 (42.5)216 (57.5)0.33440 (34.4)841 (65.6)0.01
      No121 (37.1)212 (62.9)511 (40.4)759 (59.6)632 (39.7)971 (60.3)
      Socioeconomic status
      Relatively high SES58 (27.8)146 (72.2)0.06132 (39.9)193 (60.1)0.62190 (35.2)339 (64.8)0.18
      Relatively low SES342 (33.8)691 (66.2)540 (41.1)782 (58.9)882 (37.9)1473 (69.1)
      In a relationship
      Yes328 (35.4)618 (64.6)<0.01566 (42.8)771 (57.2)0.01894 (39.7)1389 (60.3)<0.01
      No72 (24.6)219 (75.4)106 (33.3)204 (66.7)178 (29.2)423 (70.8)
      Had a boyfriend in the past 12 months
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months” and 1.6% (n = 49) were excluded for the variable “ever pregnant”].
      Yes326 (33.2)674 (66.8)0.61532 (41.4)761 (58.6)0.31858 (37.8)1435 (62.2)0.26
      No70 (30.8)156 (69.2)133 (38.5)208 (61.5)203 (35.40364 (64.6)
      Accessed SRH related websites (BeWise, MomConnect, iLoveLife, Chommy, & Rise)
      Yes119 (42.5)162 (57.5)<0.01166 (42.8)208 (57.2)0.38245 (43.4)318 (56.6)0.01
      No281 (29.9)675 (70.1)506 (40.2)767 (59.8)827 (35.8)1494 (64.2)
      Used condom at last sex
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months” and 1.6% (n = 49) were excluded for the variable “ever pregnant”].
      Yes227 (32.1)488 (67.9)0.06333 (40.8)486 (59.2)0.16560 (36.7)974 (63.3)0.01
      No166 (34.7)320 (65.3)334 (41.4)477 (58.6)500 (38.9)797 (61.1)
      Have transactional relationship
      Yes72 (45.7)92 (54.3)0.01128 (51.8)124 (48.2)<0.01200 (49.4)216 (50.6)<0.01
      No328 (30.8)745 (69.2)544 (39.0)851 (61.0)827 (35.4)1596 (64.6)
      Have transactional sex
      Yes66 (48.3)75 (51.7)<0.01113 (50.8)110 (49.2)0.01179 (49.9)185 (50.1)<0.01
      No334 (30.8)762 (69.2)559 (39.4)865 (60.6)893 (35.6)1627 (64.4)
      Ever pregnant
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months” and 1.6% (n = 49) were excluded for the variable “ever pregnant”].
      Only asked for those who reported to have ever had sex.
      Yes171 (38.0)277 (62.0)0.01502 (43.6)635 (56.4)0.01673 (42.1)912 (57.9)<0.01
      No226 (30.1)552 (69.9)165 (34.9)331 (65.1)391 (31.9)883 (68.1)
      HIV status
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months” and 1.6% (n = 49) were excluded for the variable “ever pregnant”].
      Positive55 (43.6)74 (56.4)0.01147 (41.9)199 (58.1)0.58202 (42.4)273 (57.6)0.01
      Negative345 (31.6)763 (68.4)525 (40.6)775 (59.4)870 (36.4)1538 (63.6)
      Participated in the intervention
      Yes248 (37.1)429 (62.9)<0.01265 (40.4)380 (59.6)0.75513 (38.8)809 (61.2)0.09
      No152 (27.5)408 (72.5)407 (41.1)595 (58.9)559 (36.1)1003 (63.9)
      Social support from parents
      High support228 (31.5)489 (68.5)0.03403 (39.4)622 (60.6)0.08631 (36.1)1111 (63.9)0.08
      Moderate support130 (36.5)246 (63.5)184 (42.1)248 (57.9)314 (39.5)494 (60.5)
      Low support42 (29.2)102 (70.8)85 (46.0)105 (54.0)127 (38.6)207 (61.4)
      Experienced IPV and/or sexual violence in the past 12 months
      Yes154 (37.6)268 (62.4)0.01266 (42.7)360 (57.3)0.18420 (40.6)628 (59.4)0.01
      No246 (30.2)569 (69.8)406 (39.7)615 (60.3)652 (35.4)1184 (64.6)
      a Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. [1.3% (n = 59) were excluded for the variable “had a boyfriend in the past 12 months” and 1.6% (n = 49) were excluded for the variable “ever pregnant”].
      b Only asked for those who reported to have ever had sex.
      c Evaluation of a South African combination HIV prevention intervention for adolescent girls and young women: HERStory Study.
      When stratified by age, in the 15–19 year age subgroup, having participated in the intervention, having been in an intimate relationship, having had a transactional relationship, having had transactional sex, and ever having been pregnant were associated with an increased likelihood of using contraceptives other than condoms at last sex; while in the 20–24 years age subgroup, having been in an intimate relationship, having had a transactional relationship, having had transactional sex, and having ever been pregnant, were associated with an increased likelihood (Table 3).

      3. 4. Association between intervention participation and use of contraceptives other than condoms, and dual contraception at last sex

      Table 4 shows the association between participation in key components of the combination HIV prevention intervention and the use of contraceptives other than condoms at last sex among participants who had ever had sex, adjusted for potential confounders. The intervention effect was significantly modified by age (PR: 0.74; 95% CI: 0.63–0.86). Adolescent women aged 15–19 who participated in the intervention were more likely to report use of contraceptives other than condoms at last sex, compared with those who did not participate in the intervention (PR: 1.36; 95% CI: 1.21–1.53) but there was no such association among the participants of the 20–24 year old group (PR=1.00; 95% CI 0.90–1.12).
      Table 4Results of the binomial generalized linear regression model showing the association of intervention participation and the use of contraceptives other than condoms at last sex among young women who had ever had sex, by age-groups (n = 2884),
      Evaluation of a South African combination HIV prevention intervention for adolescent girls and young women: HERStory Study
      HERStory Study, South Africa, 2018−2019
      VariableAdjusted Prevalence Ratios (aPR)p-value 95% Confidence Interval lower upper
      Intervention
      No (ref)
      Yes1.36< 0.001 1.21 1.53
      Age Category
      15–19 (ref)--
      20–241.33< 0.001 1.20 1.49
      Intervention with interaction term
      Yes (15–19 years old, ref)-
      Yes (20–24 years old)0.74< 0.001 0.63 0.86
      Currently in school
      No (ref)-
      Yes0.970.49 0.89 1.06
      Socioeconomic status
      Relatively low SES (ref)-
      Relatively high SES0.950.37 0.85 1.06
      Ever been pregnant
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. Age specific intervention effects estimated from the model adjusted for the covariates in the model. Age 15-19; PR=1.36; 95% CI 1.21−1.53, p < 0.001. Age 20-24; PR=1.00; 95% CI 0.90−1.12, p < 0.001.
      No (ref)--
      Yes1.26< 0.001 1.15 1.37
      HIV status-
      Positive (ref)-
      Negative0.920.09 0.83 1.01
      Bold = significance.
      a Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. Age specific intervention effects estimated from the model adjusted for the covariates in the model. Age 15-19; PR=1.36; 95% CI 1.21−1.53, p < 0.001. Age 20-24; PR=1.00; 95% CI 0.90−1.12, p < 0.001.
      b Evaluation of a South African combination HIV prevention intervention for adolescent girls and young women: HERStory Study
      Table 5 shows the association between participation in key components of the intervention and the use of dual contraception (condom plus another form of contraception) at last sex among participants who had ever had sex, adjusted for potential confounders. There is a significant interaction with age and intervention, p < 0.001. Young women aged 15–19 who participated in the intervention were more likely to report dual contraception at last sex, than those who did not participate in the intervention (PR: 1.46; 95% CI: 1.26–1.68) but there was no such association in the 20–24 year age group (PR: 1.04;95% CI: 0.92–1.16). Table 6
      Table 5Results of the binomial generalized linear regression model showing the association of intervention participation and the use of dual contraception (condoms plus another form of contraception) at last sex among young women who had ever had sex, by age-groups (n = 2884),
      Evaluation of a South African combination HIV prevention intervention for adolescent girls and young women: HERStory Study.
      HERStory Study, South Africa, 2018−2019
      VariableAdjusted Prevalence Ratios (aPR)p-value 95% Confidence Interval lower upper
      Intervention
      No (ref)
      Yes1.45< 0.001 1.26 1.68
      Age Category
      15–19 (ref)--
      20–241.28< 0.001 1.12 1.49
      Intervention with interaction term
      Yes (15–19 years old, ref)-
      Yes (20–24 years old)0.71< 0.001 0.59 0.86
      Currently in school
      No (ref)-
      Yes1.010.80 0.92 1.12
      Socioeconomic status
      Relatively low SES (ref)-
      Relatively high SES1.010.88 0.90 1.13
      Ever been pregnant
      Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. Age specific intervention effects estimated from the model adjusted for the covariates in the model. Age 15-19; PR=1.46; 95% CI 1.26−1.68, p < 0.001. Age 20-24; PR=1.04; 95% CI 0.92−1.16, p < 0.01.
      No (ref)--
      Yes1.070.14 0.97 1.18
      HIV status-
      Positive (ref)
      Negative0.870.01 0.78 0.97
      Bold = significance.
      a Participants were given the response option “prefer not to answer” as well, which we did not included in this table as a very small percentage chose this option. Age specific intervention effects estimated from the model adjusted for the covariates in the model. Age 15-19; PR=1.46; 95% CI 1.26−1.68, p < 0.001. Age 20-24; PR=1.04; 95% CI 0.92−1.16, p < 0.01.
      b Evaluation of a South African combination HIV prevention intervention for adolescent girls and young women: HERStory Study.
      Table 6Description of the combination HIV prevention intervention components for the adolescent girls and young women implemented in 10 South African districts, 2016−2019
      NameDescriptionIntervention components
      Soul-Buddyz ClubAn in-school peer-education/youth club model in primary schools for children struggling academically, affected by HIV or with signs of neglect. Clubs were facilitated by educators, who attended annual training, and used age-appropriate materialsBiomedical Linkage and referral to health and other services Behavioral SRH education and peer support Structural Promote access to grants Promote an environment for ongoing learning Social cohesion
      Keeping Girls In-schoolA high school-based intervention for adolescent girls at risk of dropping out of school including those affected by HIV, with caregiving responsibilities or with signs of neglect. It aimed to identify and support female learners who were at risk of dropping out of school prematurely. It included a peer education program facilitated by Peer Group Trainers or Health EducatorsBiomedical HIV testing; TB, STI and GBV screening; Linkage and referral to services Behavioral SRH education; peer support; home visits to encourage school attendance Structural Career guidance; homework support; Promote an environment for ongoing learning
      RISE Clubs (In-school)The Rise clubs were constituted by 15-20 young women from a school, who meet regularly to discuss issues that affect them. The clubs also linked young women to career guidance through career jamborees and homework support. The curriculum is contained in Rise magazinesBiomedical Linkage and referral to health services including HCT, PMTCTE, ART, SRH Behavioral SRH education; caregiving support; peer support; build self-efficacy and resilience Structural Social cohesion Community activism Career guidance
      RISE Clubs (Out-of- school)The clubs were constituted by 15-20 young women from a community, who met regularly to discuss issues that affect them. The clubs also linked young women to educational and economic opportunities and local microenterprise development organizationsBiomedical Linkage and referral to health services including HTS, PMTCT, ART, SRH services Behavioral SRH education; caregiving support; peer support; build self-efficacy and resilience Structural Social cohesion Economic strengthening Community activism
      Health and welfare jamboreesThese events were held in school or community venues and brought health, social and other services to communities to facilitate access for adolescent girls and young women and their communitiesBiomedical HTS; TB, STI and GBV screening; linkage and referral to health services Behavioral SRH education Structural Career opportunities; social grants; birth registrations
      Community dialoguesTargeted at men and women 14 years of age and above living in the areas of the adolescent girl and young women intervention. Trained facilitators used promotional materials to guide dialogues in school or community venues. They promoted gender equity, prosocial male norms, and the uptake of men's SRH servicesBiomedical Linkage and referral to health services Behavioral SRH education Structural GBV prevention
      ART, antiretroviral therapy; GBV, gender-based violence; HTS, HIV testing services; STI, sexually transmitted infections; PMTCT, prevention of mother-to-child transmission; SRH, sexual and reproductive health; TB, tuberculosis.

      4. Discussion

      We examined associations between participating in a combination HIV prevention intervention, and accessing and using condoms and/or other methods of contraceptives among young women living in 6 South African districts. Adolescent girls who had participated in the intervention were more likely at last sex to have used contraceptives other than condoms, and to have used both condoms and another form of contraception, compared with those who did not participate in the intervention. However, there was no association between intervention participation and these outcomes among participants aged 20–24 years. These findings suggest that combination HIV prevention interventions have the potential to increase access and use of condoms and other methods of contraception among adolescent girls, and reduce unintended pregnancies. However, this needs to be confirmed in experimental studies. They also suggest that we need further research to explore the specific barriers to contraceptive access and use experienced by women aged 20–24 years, to inform the age-tailored re-design of combination interventions to overcome such barriers.
      Among those who had ever had sex, fewer than half of the participants used contraceptive methods other than condoms at last sex (in both age groups), even if they had participated in the intervention. This highlights the importance of finding more effective approaches to increase contraception coverage among adolescent girls and young women, even in the context of combination HIV prevention programs. Low uptake of contraceptives and high rates of unintended pregnancies among young women in this study, is similar to findings reported from other countries in the sub-Saharan Africa region and a cause for concern [
      • Jonas K
      • Duby Z
      • Maruping K
      • Dietrich J
      • Slingers N
      • Harries J
      • et al.
      Perceptions of contraception services among recipients of a combination HIV-prevention interventions for adolescent girls and young women in South Africa: a qualitative study.
      ,
      • Makola L
      • Mlangeni L
      • Mabaso M
      • Chibi B
      • Sokhela Z
      • Silimfe Z
      • et al.
      Predictors of contraceptive use among adolescent girls and young women (AGYW) aged 15 to 24 years in South Africa: results from the 2012 national population-based household survey.
      ,
      • Hagan JE
      • Buxton C.
      Contraceptive knowledge, perceptions and use among adolescents in selected senior high schools in the central region of Ghana.
      ,
      • Charles JM
      • Rycroft-Malone J
      • Hendry M
      • Pasterfield D
      • Whitaker R.
      Reducing repeat pregnancies in adolescence: applying realist principles as part of a mixed-methods systematic review to explore what works, for whom, how and under what circumstances.
      ]. Our findings concur with previous research in the country and in other LIMCs where low use of contraceptives among adolescents was reported [
      • Jonas K
      • Duby Z
      • Maruping K
      • Dietrich J
      • Slingers N
      • Harries J
      • et al.
      Perceptions of contraception services among recipients of a combination HIV-prevention interventions for adolescent girls and young women in South Africa: a qualitative study.
      ,
      • Makola L
      • Mlangeni L
      • Mabaso M
      • Chibi B
      • Sokhela Z
      • Silimfe Z
      • et al.
      Predictors of contraceptive use among adolescent girls and young women (AGYW) aged 15 to 24 years in South Africa: results from the 2012 national population-based household survey.
      ,
      • Hagan JE
      • Buxton C.
      Contraceptive knowledge, perceptions and use among adolescents in selected senior high schools in the central region of Ghana.
      ,
      • Charles JM
      • Rycroft-Malone J
      • Hendry M
      • Pasterfield D
      • Whitaker R.
      Reducing repeat pregnancies in adolescence: applying realist principles as part of a mixed-methods systematic review to explore what works, for whom, how and under what circumstances.
      ].
      Use of other methods of contraceptives other than condoms at last sex among the younger women (15–19 years old) who are currently in school was lower than those not in school. This finding corroborates the slowly declining pregnancy rates among school going adolescent girls, as well as the high burden of HIV infection rates in this subpopulation [

      World Health Organization, 2021, HIV/AIDS. July Available at: https://www.who.int/news-room/fact-sheets/detail/hiv-aids (Accessed 19 July 2021).

      ].
      HIV positive young women in our study were more likely to report use of contraceptives other than condoms and dual contraception at last sex than the HIV negative young women. This is encouraging as unintended pregnancies among HIV positive women increase the risk for MTCT, and consequently high risks for maternal and child morbidity and mortality rates [

      World Health Organization, 2021, HIV/AIDS. July Available at: https://www.who.int/news-room/fact-sheets/detail/hiv-aids (Accessed 19 July 2021).

      ]. This is likely attributed to the integration of the HIV program and family planning services in primary health care. Young women who reported to have ever a had a pregnancy were also more likely to report use of contraceptives other than condoms at last sex. This is also positive as it shows that young women are being offered family planning services after delivery of the baby or at post-natal care services. Promoting access and use of contraceptives for both HIV positive and for HIV negative young women, as well as for those who had had a pregnancy and those who had not yet have a pregnancy is essential. This would help reduce the maternal and child morbidity and mortality rates that are attributed by this sub population, and help improve contraceptive use among all young women.
      Combination interventions, like the 1 used for this study, can be considered in all SRH programming as they have shown potential to improve access and use of contraceptives, and improve other indicators of SRH. In other settings, community-based combination HIV prevention interventions showed promising results in reducing HIV incidence among pregnancy and postpartum women in the country [
      • Fatti G
      • Shaikh N
      • Jackson D
      • Goga A
      • Nachega JB
      • Eley B
      • et al.
      Low HIV incidence in pregnant and postpartum women receiving a community-based combination HIV prevention intervention in a high HIV incidence setting in South Africa.
      ], and significant reductions in HIV incidence and had an impact on the HIV care continuum outcomes among female sex workers in Tanzania [
      • Kerrigan D
      • Mbwambo J
      • Likindikoki S
      • Davis W
      • Mantsios A
      • Beckham SW
      • et al.
      Project Shikamana: community empowerment-based combination HIV prevention significantly impacts HIV incidence and care continuum outcomes among female sex workers in Iringa, Tanzania.
      ].
      Limitations of this study include its cross-sectional design (we were not able to determine causality), the response rate, the difficulty of measuring intervention participation comprehensively given that some components of the intervention were not branded, and that the survey was conducted during the second and third years of intervention implementation, and the intervention may not have had time to demonstrate impact on access and use of SRH services.

      Acknowledgment

      We would like to acknowledge and thank the adolescent girls and young women who agreed to make themselves available to take part in this research, and share their views, opinions and experiences with us.

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