HIV Prevention Patterns Among a Population-Based Sample of HIV Negative Young Women in Eswatini

Adolescent girls and young women (AGYW; aged 15-24 years) in Sub-Saharan Africa have shouldered a disproportionate share of the global HIV burden for decades and currently account for 78% of incident AGYW HIV cases worldwide. Condoms remain the predominate tool for HIV protection, but antiretroviral pre-exposure prophylaxis (PrEP) is increasingly available in Southern Africa. The DYnamics of Contraception in Eswatini (DYCE) study conducts bi-weekly phone surveys about sexual and reproductive health with a nationally representative panel of AGYW. We employ sequence analysis to classify longitudinal experiences from a pattern-based perspective and to create HIV protection behavior groups, based on patterns of reported daily oral PrEP use, condom use and sexual activity. From April to September 2024 (13 fortnights i.e. two-week periods) among the 237 DYCE participants in the analysis, 70.3% of sexually active participants used a condom at least once, of whom 20.9% used a condom with every sexual act. PrEP was used for at least one fortnight by 19% of women. Over 13 fortnights, 96% discontinued PrEP use, and 24% cycled on and off PrEP at least once. 49% of ever-PrEP users used PrEP for less than one-fifth of reported fortnights. Using sequence analysis, we identified four groups with variable HIV protection patterns and characteristics. 16% of participants were in the Protection: No Sex group (not sexually active); 64% in the Medium Protection: Less Sex group (spent > 50% of the time not sexually active); 13% in the Least Time Protected group (> 50% of the time sexually active without condom use); and 7% in the Medium Protection: PrEP group (PrEP used about 50% of the time). The Medium Protection: PrEP group was characterized by not being in school, two-thirds using modern contraception, 83% parous and a quarter married. In comparison, among those in the Protection: No Sex group half were in school, there was low modern contraceptive usage, a third had children and none were married. PrEP and condom use is inconsistent and does not reflect prevention-effective adherence among young women in Eswatini. Four groups based on duration of HIV protective behaviors exhibit distinct characteristics that can be used to target HIV protection messaging.