Evaluating the Effect of Schooling and Comprehensive Sexuality Education on HIV Prevalence, Pregnancy and Risky Sexual Behaviour Amongst Adolescents in South Africa

Background: Comprehensive sexuality education (CSE) seeks to reduce risky sexual behaviour and subsequent incidence of unintended pregnancy and HIV among school going adolescents. This study evaluates differences between in and out of school adolescent girls and the effect of exposure to CSE on key biomedical and behavioural indicators in South Africa. Methods: Data were collected from a household-based representative sample of adolescent girls (between the ages 12–18 years) in four high HIV prevalence DREAMS implementation districts in South Africa. Independent variables included school attendance and exposure to CSE, with outcome variables measuring prevalence of HIV, pregnancy and sexual behaviour, including condom use, incidence of age disparate relationships and transactional sex. Findings Attending school is associated with reduced adjusted odds of having engaged in sexual activity (AOR: 0·58, 95% CI: 0·48-0·70, p < 0·001); using condoms inconsistently in the previous 12 months (AOR: 0·48, 95% CI: 0·34-0·65, p <0·001); having 2 or more sex partners in the previous 12 months (AOR: 0·72, 95% CI: 0·57-0·92, p < 0·05); and having ever been pregnant (AOR: 0·41, 95% CI: 0·32-0·52, p <0·001). Adolescent girls in school and who had attended CSE in the previous 12 months were associated with reduced adjusted odds of being HIV positive (Full sample: AOR: 0·76, 95% CI: 0·61-0·95, p < 0·05; sexually active sample: AOR: 0·62, 95% CI: 0·40-0·96, p < 0·05). Interpretation This study shows that schooling reduces risky sexual behaviours, whilst additional exposure CSE has a protective effect against HIV acquisition. Exposure to CSE has also resulted in increased access to HIV testing for adolescent girls both in and out of school. Keeping adolescent girls in school produces the greatest positive sexual behavioural effect, this coupled with the delivery of quality CSE, is a key strategy for reducing HIV risk. Funding Information: This project has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of the cooperative agreement of NU2GGH000372–05-08 formally 5U2GGH000372–05. Declaration of Interests: We declare no competing interests. Ethics Approval Statement: Written consent was obtained from all individuals 18 years old and parental or guardian consent and individual written assent was obtained from all individuals who were younger than 18 years. The study was approved by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BFC 198/16) and the Provincial Department of Health in both KZN and GP.