Creating a combination HIV and pregnancy prevention cascade to measure condom and contraception use among adolescent girls and young women in South African schools

In South Africa, HIV incidence and unintended pregnancy among adolescent girls and young women (AGYW) remain high, driven by a range of shared biological, behavioural, and structural factors. This study aimed to investigate AGYW’s uptake of and adherence to non-barrier contraceptives and dual condom and contraception use to identify associated barriers and facilitators and inform programming. We analysed baseline data collected between July and September 2022 for the evaluation of a combination HIV and pregnancy prevention programme in 14 South African schools. Building on the theory-driven HIV prevention cascade, a cascade describing (1) Knowledge (2) Motivation (3) Access and (4) Effective use of condoms, contraceptives and dual methods was constructed among AGYW who reported having sex in the past six months, not living with HIV and not planning to become pregnant. For contraceptives and dual methods, the relationship between cascade steps was explored using path analysis and the barriers to and facilitators of motivation, access and effective use were investigated using generalised linear models. For contraceptives, perceived access was high (71%), but motivation to use (50%) and effective use (11%) were low. For dual methods, perceived access to (54%), motivation to use (35%) and effective use (3%) was even lower. For contraceptives, knowledge was associated with all other steps of the cascade (p ≤ 0.031) and motivation was associated with effective use (PR = 2.33; 95% CI: 1.22─4.48; p = 0.015). Being older in age (PR = 1.11; 95% CI: 1.04─1.19; p = 0.005) and having ever been offered contraceptives (PR = 1.38; 95% CI: 1.23─1.54; p < 0.001) was associated with contraceptive access. Believing that contraceptives prevent pregnancy was associated with contraceptive motivation (PR = 1.88; 95% CI: 1.22─2.9; p = 0.008). Having parents who had spoken to AGYW about contraceptives was associated with the last three cascade steps for contraceptives (p < 0.05). There are major gaps in motivation and effective use of contraceptives and dual methods among AGYW in South Africa. Providing convenient, youth-friendly access to these prevention methods, for example, through school-based Safe Spaces such as those implemented by the Imagine Programme, could improve access; however, our findings highlight the added value of engaging parents to strengthen uptake and adherence. In South Africa, levels of HIV and unintended pregnancy among young women remain high, driven by a range of shared factors. This study aimed to investigate young women’s use of contraceptives and dual condom and contraception use and identify associated barriers among young women who reported having sex in the past six months, not living with HIV and not planning to become pregnant, recruited from 14 South African schools. Our analysis was guided by the HIV prevention cascade which has the following four steps: 1) Knowledge 2) Motivation 3) Access and 4) Consistent use. For contraceptives, perceived access was high, but motivation to use and consistent use were low. For dual methods, perceived access, motivation and consistent use were even lower. For contraceptives, knowledge was associated with the other cascade steps, and motivation was associated with consistent use. Being older in age and having ever been offered contraceptives was associated with contraceptive access. Believing that contraceptives prevent pregnancy was associated with contraceptive motivation. Having parents who had spoken to them about contraceptives was associated with the last three cascade steps for contraceptives. There are major gaps in motivation and consistent use of contraceptives and dual methods among young women in South Africa. Safe Spaces in schools have been found to be an acceptable environment in which to provide sex education and services to school-going young women, but our findings highlight the added value of engaging parents to strengthen use.