While significant progress has been made in curbing the HIV epidemic across sub-Saharan Africa, new infections persist, particularly among young women. In southern Africa, three quarters of all new HIV infections are among young women and nearly one in four pregnancies are unplanned. Nevertheless, limited research exists around how young women make decisions about HIV prevention and contraceptive use.
Supported by the National Institutes of Health (NIH) and in collaboration with the Eswatini Ministry of Health, ICAP at Columbia University is implementing the Dynamics of Contraception in Eswatini study – also known as DYCE – to better understand young women’s contraception behavior, family building desires, and HIV prevention practices.
Participants in the DYCE study were recruited from the Eswatini Population-based HIV Impact Assessment (SHIMS3), having consented to future research and provided a mobile phone number. Beginning April 2024, 319 DYCE participants consented to and began two years of bi-weekly surveys about socio-demographics, pregnancy and contraception, relationships, sexual activity, and HIV risk and status.
“Collecting data frequently is rare, worldwide. Therefore, having bi-weekly data about how young women are managing their health is going to create novel insights that will lead to better public health programming,” said Abigail Greenleaf, PhD, principal investigator of the study. “We will be able to pinpoint moments of vulnerability and high-risk groups in a way that other studies have not been able to.”
While most studies on pre-exposure prophylaxis (PrEP) – an HIV prevention medication – are clinic-based or part of a randomized control trial, DYCE explored PrEP use among the general population. The study found that the young women who took PrEP rarely persisted on the medication for long periods; about 25 percent of those who used PrEP cycled on and off.
The study also inquired about young women’s interest in having children and found that the vast majority of the 18–24-year-olds expressed no desire to get pregnant over the first year of the study. However, only about half of young women were using a highly effective form of contraception. Much of the protection against undesired pregnancy was provided through abstinence.
In addition to standard questions asked every two weeks, participants were periodically asked additional questions to better understand their lived experiences, for example, their knowledge of PrEP and contraception. Eighty percent of participants correctly knew that injectable forms of contraception and implants cannot be used together. Eighty-six percent of participants correctly knew that PrEP does not prevent pregnancy, and 91 percent knew that PrEP does protect against HIV. The study showed that 92 percent of participants had some formal instruction on sexual and reproductive health. Fifty-four percent had discussed, for example, how to say “no” to sex, and 46 percent had discussed methods of birth control with a parent or close adult female. These results were shared with the Eswatini Ministry of Health to help understand reproductive health knowledge and knowledge sources among young women.
“We are capturing the evolving experiences of young women to understand their health needs,” Greenleaf added. “This will help lead to more practical and realistic solutions for young women to take control of their health and future.”
The study also demonstrated important findings around health services use. Thirty-nine percent of participants had visited a health facility or pharmacy for contraceptive services in the last 12 months, of whom, the majority had not encountered issues when seeking such services. The few who did face challenges noted that waiting rooms were too public and health facilities lacked confidentiality or privacy. Among those who visited a health facility in the past 12 months, 54 percent took public transportation and 44 percent walked. The average travel times for both was around an hour. The study showed that most participants who accessed sexual health services chose the health facility close to their home or work for convenience, emphasizing that young women value ease of access more so than a facility’s reputation and underscoring the need for all health facilities to offer youth-friendly, confidential services.
“This study shows the complexity of young women’s experiences and understanding of sexual reproductive health,” added Zandile Masangane, sexual reproductive health officer at the Eswatini Ministry of Health. “HIV prevention methods like PrEP, for instance, have been proven to be a reliable and safe, but we wanted to know how and by whom they’re being used. This information will be paramount in designing integrated sexual health programs, and more specifically, strategies for HIV prevention.”
DYCE is proposed to continue for an additional year of data collection – data that will inform not only understanding of sexual and reproductive health in Eswatini but also contribute to measurement and understanding of reproductive health overall.
Summary sheets outlining further details and findings are available here. The third summary sheet of results will be available in April 2025.
About ICAP
A major global health organization that has been improving public health in countries around the world for two decades, ICAP works to transform the health of populations through innovation, science, and global collaboration. Based at Columbia Mailman School of Public Health, ICAP has projects in more than 40 countries, working side-by-side with ministries of health and local governmental, non-governmental, academic, and community partners to confront some of the world’s greatest health challenges. Through evidence-informed programs, meaningful research, tailored technical assistance, effective training and education programs, and rigorous surveillance to measure and evaluate the impact of public health interventions, ICAP aims to realize a global vision of healthy people, empowered communities, and thriving societies. Online at icap.columbia.edu
