Four decades into the HIV epidemic, adolescent girls and young women remain disproportionately affected by HIV due to family circumstances, reproductive service disruptions, gender inequalities, violence, poverty, unemployment, and lack of access to education. Recently, HSRC researchers published a report on the most prominent behavioural and structural risk factors faced by young pregnant teenage girls in South Africa. By Jessie-Lee Smith, Dr Inbarani Naidoo and Dr Nompumelelo Zungu
Photo by MarijoAH12, Wikimedia Commons (CC BY-SA 4.0)
According to UNAIDS, an estimated 1.65 million adolescents aged 10–19 years are living with HIV across the globe. South Africa remains one of the highest HIV-burdened countries, with high rates of teenage pregnancy exacerbating the risk among adolescents. The persistently high number of reported teenage pregnancies in South Africa raises several concerns about associated health risks and social factors for young girls. High teenage pregnancy rates significantly impact HIV transmission and maternal and child health, with stakeholders expressing urgency to mitigate these risks.
In November 2023, the HSRC released a summary of its completed 6th South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI). Key findings from the survey show that young women continue to be disproportionately infected with HIV. The HIV prevalence among adolescent girls and young women (AGYW) aged 15–24 years was 6.9%, compared to 3.5% among males of the same age. Additionally, just over two-thirds (68.2%) of young women aged 15–24 years living with HIV were virally suppressed.
The suppression of an individual’s HIV viral load is an important determinant of HIV transmission. When people living with HIV consistently take antiretroviral treatment, they can achieve undetectable viral loads and reduce the risk of transmitting the virus. The SABSSM VI results highlighted that a critical need remains for HIV advocacy and behaviour change interventions.
Using data from the past four SABSSM surveys (2005, 2008, 2012 and 2017), HSRC researchers recently published a report on HIV-risk-related behaviours among adolescent girls and young women living with HIV. This analysis estimated pregnancy rates, HIV prevalence, and associated risk behaviours among women of childbearing age (15–49 years), with a specific focus on AGYW (15–24 years) and adolescents (15–19 years).
Recently, Dr Nkosazana Dlamini-Zuma, the South African Minister of Women, Youth, and Persons with Disabilities, called for action to address the consequences of teenage pregnancies.
In April 2024, the South African Government News Agency cited the minister saying, “Early pregnancy in South Africa forces many girls to drop out of school and trap others in a cycle of poverty and leaves most stigmatised by society for being teenage mothers or forced into early marriages.”
These sentiments are echoed in the HSRC’s report, which links teenage pregnancy, HIV prevalence, low levels of education attainment, reliance on government grants and unemployment. About one-fifth (22.3%) of recently pregnant participants were aged 20–24 years, and 6.4% were teenagers. Among recently pregnant adolescent girls and young women, HIV prevalence was 24% in 2005, 17.3% in 2008, and 19.2% in 2017. In 2017, this prevalence translated to nearly 110,000 HIV-positive adolescent girls and young women aged 15–24 years.
Recently pregnant adolescents faced a combination of structural and behavioural factors that exacerbated their risk of contracting HIV. One of the most significant structural challenges for these adolescents was compromised economic conditions. The HSRC report found that the majority of recently pregnant adolescent girls and young women had completed some levels of secondary school. However, most had no income, and some relied on government grants. The HIV prevalence was higher among 15–24-year-old adolescent girls and young women who had completed only primary school as their highest educational attainment.
Age-disparate relationships
The report found that HIV-related risk behaviours were more prevalent among adolescent girls and young women living with HIV in South Africa. For example, these young women were more likely to participate in age-disparate relationships (with a partner that was five or more years older). Those in such relationships were more likely to be HIV positive compared to those having relationships with their peers.
According to an HSRC report on adolescents living with HIV, age-disparate relationships among adolescents increased in popularity from 39.2% in 2005 to 47.5% in 2017. The primary reason young girls entered these relationships was the financial benefit, which society seemed to accept. HSRC researchers analysed behaviours associated with age-disparate relationships and found that females were more likely to engage in these relationships if they had had their sexual debut before age 15, and if they were unemployed, lived in urban areas and had recently engaged in condomless sex.
Condom use
Inconsistent or lack of condom use among sexually active adolescent girls and young women remains a general concern for their sexual and reproductive health. In 2017, about 28% of recently pregnant adolescents reported never using a condom with their sexual partner, and 37.5% indicated only sometimes using one. These trends are mirrored in the SABSSM VI summary findings, which indicate that at last sex, less than half (43.5%) of adolescent girls and young women who had multiple partners in the previous year had used a condom.
The HSRC’s report on pregnant women also highlights that young women in unequal relationships were less likely to use condoms optimally. These relationships often diminished their agency to negotiate protected sex and to make informed decisions about their sexual health. Consistent with these risk behaviours, HIV prevalence was higher among recently pregnant women who reported sub-optimal (inconsistent or lack of) condom use.
Intimate partner violence
Intimate partner violence was a concern among adolescents. Among recently pregnant women (15–45 years), intimate partner violence was most commonly reported by adolescents. Over one-third (37.1%) of recently pregnant girls aged 15–19 reported having experienced violence from an intimate partner.
Healthcare
Teenage pregnancies remain a concern in South Africa because of the inherent relationship between unprotected sex and exposure to HIV and other sexually transmitted diseases. Pregnancy also increases the need for timely access to healthcare services to ensure the health of mother and child.
Adolescents with restricted access to healthcare were less likely to adhere to antiretroviral therapy (ART). This age group was shown to have the lowest proportion of viral load suppression (68.2%) in the country, as reported in the 2022 survey. Analyses of data collected between 2010 and 2013 showed that adolescent mothers had a lower uptake of prevention of mother-to-child-transmission interventions and a higher risk of early mother-to-child transmission compared with older mothers.
These findings suggest an ongoing need to identify and seek opportunities to address gaps in South Africa’s HIV response. Effective protocols should be sensitive to young people’s evolving needs, incorporate gender perspectives, and ensure equitable access to prevention, treatment, and care. This work points to the need for adolescent girls and young women to be provided with opportunities to understand their sexual and reproductive health rights so they can make informed decisions about protecting themselves. They also need support to attain higher education and develop skills to enhance their employment prospects.
Research contacts:
Dr Inbarani Naidoo (chief research specialist) and Dr Nompumelelo Zungu (strategic lead) in the HSRC’s Public Health, Societies and Belonging Division
