Factors associated with condomless sex among sexually active adolescent girls and young women (AGYW) in Zimbabwe: a cross-sectional respondent driven sampling survey

Abstract Introduction In Zimbabwe and other sub-Saharan African countries, understanding the factors associated with low condom use is essential for identifying adolescent girls and young women (AGYW) at increased risk of HIV. We aimed to identify characteristics associated with inconsistent condom use among sexually active AGYW. Methods We analysed cross-sectional respondent-driven sampling survey data collected from sexually active AGYW aged 15–24 years in six urban and peri-urban districts of Zimbabwe (May–July 2023). Logistic regression models estimated unadjusted and age- and sociodemographic-adjusted associations with two outcomes: (i) condomless sex and (ii) condomless sex with multiple partners. Results Among 867 participants, 66.6% (RDS-adjusted) reported condomless sex and 16.6% condomless sex with multiple partners in the previous 3 months. Older age (age- and sociodemographic-adjusted odds ratio; aOR per year: 1.16, 95% CI: 1.08–1.25), religion, and in particular being of apostolic faith compared to Pentecostal (aOR: 1.71, 95% CI: 1.01–2.88), monthly heavy drinking (aOR: 1.91, 95% CI: 1.15–3.16), cohabiting with a partner (aOR: 3.92, 95% CI: 2.23–6.90) or having a steady non-cohabiting partner (OR: 2.44, 95% CI: 1.44–4.15) compared to having no partner, and identifying as a sex worker (aOR: 1.84, 95% CI: 1.03–3.29) were associated with condomless sex. Condomless sex with multiple partners was associated with being an orphan (both parents) (aOR: 2.08, 95%CI:1.17–3.70), food insecurity (aOR: 2.47, 95% CI: 1.56–4.24), weekly (aOR: 4.781, 95% CI: 2.08–10.99) and monthly heavy drinking (aOR: 2.69, 95% CI: 1.61–4.52) compared to no drinking, substance use compared to no substance use (aOR: 3.21, 95% CI: 1.88–5.49), cohabitation status, in particular having a steady partner but not cohabiting (aOR: 2.13, 95%CI: 0.94–4.81), common mental health disorder (aOR: 2.30, 95% CI: 1.36–3.88), sexual abuse in the past 12 months (aOR: 2.19, 95% CI: 1.31–3.65), identifying as a sex worker (aOR: 6.59, 95% CI: 3.80–11.43) and discussing sex only with similarly aged female peers compared to only talking with one’s mother (aOR: 3.89, 95% CI: 0.99–15.25). Conclusion Condomless sex was common among sexually active AGYW, less common condomless sex with multiple partners (around 1 in 6). The latter was strongly associated with several factors of vulnerability, such as being an orphan, food insecurity, alcohol and substance use, mental health issues and sex work. This should inform targeted HIV prevention interventions. Further research is needed to understand the socioeconomic drivers of condomless sex and attitudes towards condom use.