HIV incidence and associated risk factors in adolescent girls and young women in South Africa: A population-based cohort study

BACKGROUND: In sub-Saharan Africa, high HIV incidence rates in adolescent girls and young women (AGYW) persist despite extensive HIV prevention efforts. METHODS: A prospective cohort of 2,710 HIV-negative AGYW (15–24 years) in KwaZulu-Natal, South Africa were interviewed at baseline and followed-up approximately 18 months later (2014–2017). Associations between HIV seroconversion and socio-demographic and behavioural variables measured at baseline and follow-up were examined using Cox regression and a proximate determinants framework. Inter-relationships between determinants were measured using logistic regression. Separate models were built for 15–19 and 20-24-year-olds. RESULTS: Weighted HIV incidence was 3.92 per 100 person-years (95% confidence interval: 3.27–4.69; 163 seroconversions over 4,016 person-years). Among 15-19-year-olds, absence of family support (adjusted hazards ratio (aHR): 3.82 (1.89–7.72)), having a circumcised partner (aHR: 0.5 (0.27–0.94)) or one who was HIV-positive and not on antiretroviral therapy (ART) (aHR: 6.21 (2.56–15.06)) were associated with HIV incidence. Those reporting an absence of family support were also more likely to report >1 partner during follow-up (odds ratio (OR): 2.7(1.11–6.57)). Among 20-24-year-olds, failure to complete secondary school (aHR: 1.89 (1.11–3.21)), inconsistent condom use (aHR: 3.01 (1.14–7.96)) and reporting partner(s) who were HIV-positive and not on ART (aHR: 7.75 (3.06–19.66)) were associated with HIV incidence. Failure to complete secondary school among 20-24-year-olds was associated with inconsistent condom use (OR: 1.82 (1.20–2.77)) and reporting an HIV-positive partner not on ART (OR: 3.53(1.59–7.82)) or an uncircumcised partner (OR: 1.39 (1.08–1.82). CONCLUSION: Absence of family support and incomplete schooling are associated with risky sexual behaviours and HIV acquisition in AGYW. In addition, partner-level prevention—condom use, medical circumcision, and viral suppression–continue to play an important role in reducing HIV risk in AGYW. These findings support the use of combination HIV prevention programs that consider structural as well as biological and behavioural HIV risk factors in their design.