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

OBJECTIVE: We investigated the coverage of contraception services (excluding condoms) to prevent unintended pregnancy among young women and girls aged 15-24 years who were beneficiaries of one of the two largest combination HIV and pregnancy prevention programme in South Africa.

STUDY DESIGN: We invited 2,160 randomly sampled beneficiaries who were living in six of the 12 programme districts across six provinces to participate in a telephone survey. We created pregnancy prevention coverage cascades and conducted univariate and multivariable analyses using Poisson regression 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 had sex in the six 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. Respondents aged 20-24 years were 88.0% more likely to effectively use contraceptives compared to the younger age group (95% CI: 1.19-2.96).

CONCLUSION: Most respondents had access to and were motivated to use contraceptives other than condoms but were not effectively using them. We found that having been offered contraceptives facilitated better access, while distance to the services was associated with poorer access, suggesting the importance of improving supply-side interventions such as increasing the number and accessibility of spaces where SHR services are offered. We recommend longitudinal behavioural counselling 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 towards universal access to contraception services and to identify barriers that need to be addressed to achieve effective use of contraceptives.