Development of a Self-administered Sexual Behavior Assessment Tool to Facilitate Self-reflection by Young Women in South Africa About HIV/STI Risk.

Abstract

Self-assessment of sexual behavior may empower adolescent girls and young women (AGYW) to reflect on HIV/STI risk and adopt prevention strategies. We developed a web-based sexual behavior self-assessment tool providing real-time feedback based on a numeric score and examined associations of scores with STI detection and HIV pre-exposure prophylaxis (PrEP) initiation among AGYW in South Africa. The tool was implemented as part of PALESA, a pilot randomized trial which followed up 55 sexually-active AGYW (16-20 years) for six months in Johannesburg between June 2023 and May 2024. Participants received monthly links to the tool, monthly oral PrEP offering and quarterly chlamydia, gonorrhea, and trichomoniasis testing. Multivariable generalized linear mixed-effects models and survival models assessed associations between participants' scores and STI detection and PrEP restart; interrupted time series analysis examined score changes around PrEP initiation. Tool completion rate was high (94.8%). Frequently reported items included older partners (38.4%), vaginal STI symptoms (26.3%), new sexual relationships (20.0%), multiple partners (18.9%) and partner distrust about STI symptom experiences (17%). Higher scores were associated with increased odds of STI detection (adjusted odds ratio: 2.61, 95% CI: 1.46-4.68) but not significantly with PrEP initiation (adjusted hazard ratio: 1.43, 95% CI: 0.56-3.63). Among participants who restarted PrEP, scores decreased by 0.47 points per month before PrEP restart (p = 0.002) and remained stable afterward (p = 0.39). Our findings demonstrate this tool as feasible to implement among AGYW with potential to support self-reflection and awareness of HIV/STI risk. Larger studies are warranted to fully evaluate its utility.