Using prevention cascades to investigate coverage of contraception services among young women enrolled in a large-scale combination HIV prevention program in South Africa.

OBJECTIVES: We investigated the coverage of contraception services (excluding condoms) to prevent unintended pregnancy among young women and girls aged 15 to 24 years who were beneficiaries of one of the two largest combination HIV and pregnancy prevention program in South Africa. STUDY DESIGN: We invited 2160 randomly sampled beneficiaries who were living in six of the 12 program districts across six provinces to participate in a telephone survey. We created pregnancy prevention coverage cascades and conducted univariate and multivariable analyses to identify key barriers and facilitators associated with each step of the cascade. RESULTS: We achieved a response rate of 23.8%, resulting in 515 respondents, of whom 303 had sex in the 6 months before the survey. Of this subsample, 80.4% had access to contraception services, 60.6% had access and motivation to use contraceptives, and 21.9% had access to, motivation to use, and effectively used contraceptives. Distance to travel to services and not ever being offered contraceptives by health workers were access barriers, while low pregnancy risk perception was a barrier to motivation. CONCLUSIONS: Most respondents had access to and were motivated to use contraceptives other than condoms but were not effectively using them. Having been offered contraceptives facilitated better access, while distance to the services was a barrier, suggesting the importance of improving supply-side interventions, such as increasing the number and accessibility of spaces where Sexual and Reproductive Health (SRH) services are offered. We recommend longitudinal behavioral counseling for young people, especially adolescents, as well as risk reduction and information-tailored interventions. IMPLICATIONS: Pregnancy prevention cascades are a promising tool to monitor progress toward universal access to contraception services and to identify barriers that need to be addressed to achieve the effective use of contraceptives.

Adaptation and Resilience: Lessons Learned From Implementing a Combination Health and Education Intervention for Adolescent Girls and Young Women in South Africa During the COVID-19 Pandemic.

The COVID-19 pandemic has been associated with reduced access to health services and worsening health outcomes for HIV and sexual and reproductive health (SRH). Through the analysis of data from an evaluation study of a combination intervention for adolescent girls and young women (AGYW) in South Africa, we sought to examine the way in which implementation and service provision were impacted by the COVID-19 pandemic and related restrictions, describing the adaptation implementers made to respond to this context. The intervention was implemented from 2019 in South African districts identified as high priority, given the high rates of HIV and teenage pregnancy amongst AGYW. The South African government introduced the first COVID-19 lockdown in March 2020. We conducted in-depth interviews with 38 intervention implementers in the period from November 2020 to March 2021. Respondents described various ways in which the COVID-19 pandemic and related restrictions had limited their ability to implement the intervention and provide services as planned. As a result, AGYW intervention beneficiary access to SRH and psychosocial services was disrupted. Implementers described several ways in which they attempted to adapt to the pandemic context, such as offering services remotely or door-to-door. Despite attempts to respond to the context and adapt services, overall COVID-19 negatively affected implementation and service provision, and heightened issues around community acceptability of the programs. Our findings can help to inform efforts to reduce health service disruption, increase health system resilience, and ensure continuous SRH service provision to AGYW in times of pandemics and other crises.