https://orcid.org/0000-0002-7950-3692
Figures
Abstract
Background
In Uganda, adolescent girls’, and young women’s (AGYW-15-24 years) current HIV prevalence is fourfold compared with their male counterparts due to compounded social, economic, and environmental factors. Using the Protective Motivation Theory (PMT), we explored HIV-acquisition risk sources and perceived protective factors from AGYW and caregivers’ perspective.
Materials and methods
During 2018, we conducted a qualitative study guided by PMT to explore factors influencing HIV acquisition among AGYW. We purposively sampled two groups of key informants, AGYW at high-risk for HIV acquisition (uninfected) and AGYW living with HIV, varied by age and place of residence (urban/rural). We conducted 34 focus group discussions with AGYW, nine with AGYW parents, and 25 key informant interviews. Data were analyzed using the framework method based on the PMT and developed from participants’ narratives.
Results
AGYW were knowledgeable about HIV, HIV acquisition risk factors, and HIV prevention interventions. Nonetheless, few AGYW knew about pre-exposure prophylaxis (PrEP). Imbalance in power relations between the genders explained inability of AGYW making safe healthy decisions, with social norms giving men power over women. Parents modelling positively influenced HIV risk behavior. Many AGYW viewed staying in school a protective factor both while at school and further for life. AGYW identified alcohol use, desire for material possessions, discounting HIV disease severity, social norms, and poverty as barriers to engaging in self-protective behaviors. Several AGYW believed that access to AGYW-focused programs would facilitate healthy sex-positive, protective behaviors.
Discussion
While PMT focuses on individual factors confirmed by our findings, we found HIV risk behavior to be influenced by complex contextual factors including poverty, gender inequality and cultural norms. Distinct HIV risk factors among AGYW require policy and comprehensive targeted interventions addressing violence, alcohol consumption, increased economic opportunities, educational opportunities, safe-sex practices, and PrEP scale-up which may prevent HIV in AGYW and facilitate HIV epidemic control.
Citation: Apondi R, Bastiaens H, Nöstlinger C, Galbraith J, Aholou TM, Medley A, et al. (2025) Community and familial dynamics influencing risk behavior for HIV acquisition among adolescent girls and young women in Uganda: Qualitative analysis using Protective Motivation Theory. PLoS ONE 20(1): e0301311. https://doi.org/10.1371/journal.pone.0301311
Editor: Martin Mbonye, Makerere University, UGANDA
Received: March 22, 2024; Accepted: September 12, 2024; Published: January 24, 2025
This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Data Availability: All relevant data are within the article and its Supporting Information files. Any additional data are available from the CDC Institutional Data Access/Ethics Committee (contact via plp3@cdc.gov) for researchers who meet the criteria for access to confidential data.
Funding: Centers for Disease Control and Prevention, Makerere University School of Public Health UG000466038.
Competing interests: I confirm that neither I nor any of co-authors have any competing interests to declare that could be perceived to bias this work.
Introduction
The most recent Uganda Population HIV Impact Assessment (UPHIA 2020) found that HIV prevalence was 2.9% among adolescent girls and young women (AGYW) aged 15–24 years compared with 0.8% among their male counterparts [1]. Poverty, gender inequality, low education level, early sexual debut, early pregnancy, gender-based violence, gender norms, inability to negotiate safer sex and sexual risk behaviors are associated with elevated HIV acquisition risk for AGYW [2–4]. One consistent protective factor for several negative health and social outcomes, including HIV, is having a positive parental relationship [5]. Additionally, creating intentional AGYW safe spaces can directly affect individual agency and ability for self-protective behaviors [4, 6]. Community engagement, like church membership or youth-friendly centers, sports facilities and spending time with family and youth leadership in programs were found to be associated with reduced HIV acquisition [7, 8]. Family and peer influences can therefore impact decisions to engage in self-protecting sexual behaviors [6].
Behavior change models recommend interventions focused on modifiable constructs with the greatest probability of increasing protective behaviors while inhibiting risky behaviors [9]. One evidence-based model, the Protection Motivation Theory (PMT), outlines four key elements: information source, threat appraisal, coping appraisal (which encompasses response efficacy and self-efficacy) and intentions to action [10]. PMT has informed the development of several adolescent HIV behavioral interventions [9, 11]. From the PMT, environmental and personal factors affect one’s choice for self-protective behaviors, considering either intrinsic (personal pleasure) or extrinsic rewards (social approval) and the perceived severity of and personal vulnerability to the threat [10].
The PMT allows for the examination of several developmentally relevant variables (e.g., adolescent perceptions of invulnerability and changing relationships with parents and peers to gain autonomy) and accommodating economic, historical, and cultural influences in the community [12]. Describing contextual factors that influence HIV risk behaviors among AGYW through qualitative methods can provide a richer framework, given that many studies have mostly quantified the HIV risk among AGYW [11, 13]. Yet, few studies applied a systematic approach to identity factors affecting HIV risk for AGYW using the PMT. Such research was mainly conducted in the USA and no studies are available for in Eastern Africa using this theoretical model [14]. Using the PMT, we sought to explore the contextual factors influencing HIV-acquisition risk sources and perceived protective factors from AGYW and caregivers’ perspective to inform targeted high-risk AGYW HIV prevention programs. We further aimed to examine the roles of peers and parents in influencing risk behaviors of AGYW from the perspective of AGYW themselves and their parents.
Materials and methods
Study design and setting
We conducted a qualitative study with combined deductive and inductive approaches to explore familial and community factors influencing HIV acquisition among AGYW [15, 16]. Data were collected through 34 focus group discussions (FGDs) and 25 key informant interviews (KIIs) (Table 1). A total of 34 focus group discussions were held including 9 with parents/guardians of AGYW, 8 with AGYW living with HIV, and 17 with AGYW at high risk of HIV acquisition. Participants were selected from districts in the greater Masaka and Kampala areas. The districts were purposively selected based on factors associated with high HIV acquisition risk among AGYW, including higher than 7% HIV prevalence, average age of first birth, number of young women with early sexual debut (defined as sex <15 years), and percentage of women reporting first sex as coerced. The US President’s Emergency Plan for AIDS Relief (PEPFAR) DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program is implemented in districts in the greater Masaka region. DREAMS is a multipronged HIV-prevention approach for AGYW, sexual partners, families, and communities that include parenting/caregiver programs, cash transfers, educational subsidies, and HIV prevention interventions [4].
During June and July 2018, we purposively sampled two AGYW key informant groups: AGYW at high risk for HIV acquisition and AGYW living with HIV, ensuring representation by age (15–17, 18–24) and residence (urban/Kampala, rural/Greater Masaka) [17]. We used similar criteria to conduct FGDs with parents/guardians of AGYW at high risk for and living with HIV. We outline all factors considered in the purposeful sampling for the FGDs and KIIs in S1 Appendix.
Data collection
Data were collected by trained qualitative interviewers using semi-structured interview guides. The team of interviewers were half female and half male, all with experience qualitative interviewing skills, all social workers while the supervisor was a social scientist. As part of the creating a safe space, emphasizing confidentiality and trust, the team started with self-introductions, clarifying their credentials, occupation, and training.
Based on the PMT, separate guides were developed for AGYW with and without HIV and their parents/guardians and for the two data collection techniques. These guides were developed in English, translated into Luganda, back translated into English, and piloted with mock participants for accurate translation. All discussions were held in the local Luganda language and audio recorded to create a verbatim transcript for each FGD and KII.
Data analysis
We used the framework method for data analysis, which is an adequate approach for data collected in line with the overarching PMT framework. It is an excellent tool for supporting systematic managing and mapping of the data [18]. This allowed for extraction of detailed, experiential material from the data to examine in the context of the application and proposed expansion of PMT [19].
Data were coded in NVivo V1 (QSR International, Melbourne, Australia) using both deductive and inductive coding by developing themes from both the participants’ narratives using the PMT as guidance [20, 21]. A codebook was developed as outlined in Table 1. Three analysts, all behavioral scientists with experience in qualitative research (RA, TMA, AM) coded transcripts and regularly met to discuss any discrepancies allowing further transcript exploration, constant discussion of deviant cases, and agreement on recurring themes.
Ethics and consent procedures.
Ethics approval was given by the Uganda National Council of Science and Technology and Institutional Review Boards (#4443) at the Makerere School of Public Health (#509) and the US Centers for Disease Control and Prevention (CDC). Written informed consent, including audio recording, was obtained from all participants. Additionally, all participants under age 18 years provided written informed assent and caregiver consent, excepting emancipated minors. According to the “National Guidelines for Research Involving Humans as Research Participants”, published March 2007 by the Uganda National Council for Science and Technology (http://www.uncst.go.ug, excerpt attached) “…emancipated minors are individuals below the age of majority who are pregnant, married, have a child, or cater for their own livelihood” and “…and may independently provide informed consent…” (p. 33). Confidentiality assurances were given during the assent/consent process. Names and other personal identifiers were removed from transcripts before they were analyzed.
Results
Participant characteristics
Table 2 shows participant characteristics by age category for the KIIs and FGDs. Among the adolescent girls aged 15–17, 38% were living with HIV compared to 42% of the young women aged 18–24. About 46% of the participants 15–17 years old reported that they attended school compared to 50% among the young women aged 18–24 years.
A. Participant characteristics of Adolescent Girls and Young Women key informant interviews. B: Participant characteristics of focus group discussions for both Adolescent Girls and Young Women and parents/guardians (N = 34).
Contextualized PMT describing the AGYW HIV risk.
Source of information. From 34 FGD with AGYW and parents and 25 AGYW key informant interviews, we identified four main sources of influence for HIV risk behaviors for AGYW: family, community, parent/guardian, and peers. Peer influences were strong motivators leading to intention and actions of AGYW (Fig 1 and Box #1). The influence of parents and guardians on HIV risk behaviors came from both guidance and role modelling (Table 3 QO2). Most AGYW felt positively about the protective behaviors recommended and learned from either their family, community, or from exposure to HIV programs.
Key: Green box = data-driven themes, Blue box = PMT, Grey/black box = Additional themes identified.
Threat appraisal pathway. The AGYW perceived ‘education’ and ‘spending time on school’ as leading to future gains, especially employability, respect, and self-confidence (Fig 1 and Box #2). These perceived gains empowered AGYW and were fundamental factors in their willingness to adopt HIV prevention behaviors. Participants’ assessment of their HIV acquisition risk, particularly those seen as more ‘extreme,’ such as perception of the severity of HIV in the community, played a major role in their willingness to engage in protective behaviors. AGYW who perceived that early sexual activity interfered with education prospects were generally highly motivated to engage in positive behaviors around abstinence, condom use, or reducing sexual partners, because these behaviors helped avert the risk of early pregnancy. Participants perceived that education helped them stay busy and avoid some high-risk behaviors that idle, out-of-school youth sometimes engaged in (e.g., alcohol use and sex with multiple partners). Social norms around virginity increasing a girl’s desirability as a marriage partner was a strong facilitator to reducing early sexual debut. Participants reported that knowledge would prevent the acquisition of diseases like HIV or sexually transmitted diseases (Table 3, Q3, Q4, Q28).
The perception of the current risk of HIV acquisition was a crucial factor for some participants to avoid risky behaviors (Fig 1 and Box #3). Data demonstrated that many parents and girls viewed teen pregnancy as a higher risk than HIV among AGYW in Uganda (Table 3 Q21). Some participants were concerned about the high proportion of AGYW at risk of HIV infection. This was influenced by the number of young girls witnessed at the health centers on adolescent days and further discussed in the media (Table 3 Q23, Q34, Q35). The perceived inability and lack of confidence of adolescent girls to protect themselves from HIV were felt to be a significant risk. Young women generally perceived an inability to negotiate protective behaviors, including condom use and knowing their partner’s HIV status (Table 3-Q29).
Many participants perceived HIV to be associated with a high risk of severe illness or death if left untreated (Fig 1 and Box #3). There were also concerns that healthcare workers may not keep their HIV status confidential, increasing their fear of experiencing HIV-related stigma. However, AGYW also recognized that HIV treatment was widely available and that they could potentially hide their HIV status from their friends and family members if needed. In contrast, AGYW were more concerned about getting pregnant, which they would not be able to hide. This fear of pregnancy appeared to be a stronger motivating factor for adopting protective behaviors than fear of acquiring HIV (Table 3 Q21). Parents also further confirmed this fear of pregnancy (Table 3 Q27).
Some AGYW cited that economic status negatively affected their ability to prevent the acquisition of HIV. Hardship in attending school was particularly singled out as a key barrier that exposed AGYW to risky behaviors leading to HIV infection. For example, the inability of families to pay school fees was the main factor that promoted AGYW to drop out of school. In addition, harmful discipline methods like corporal punishment have affected the attendance levels for AGYW (Table 3 Q21). Collectively, these factors may lead to premature school dropouts and early sexual debut, which increase the risk for HIV infection.
Many participants presented peer pressure as a significant influence on the behavior of AGYW. Peer pressure was coupled with admiration of property and personal items that the girls could not afford. This desire for material possessions made them vulnerable to sexual exploitation by an older sex partner or to entering the sex trade, which increased their risk for HIV acquisition (Table 3, Q9, Q11, Q12).
Lastly, the effects of alcohol consumption among AGYW were identified as a key negative attribute, and there was some concern about the effect on mental well-being. Participants recounted several examples of girls engaging in high-risk sexual behavior while under the influence of alcohol. Alcohol use by young women was further associated with putting girls at risk for sexual abuse, and assault and domestic violence by partners and family members (Table 3, Q18). Alcohol was perceived as easily accessible with no restrictions to minors and inexpensive, making it dangerous for the daily wellbeing of AGYW, and a barrier to HIV prevention.
Coping and appraisal pathway. Most participants knew how to use condoms and understood their importance as a tool for preventing both pregnancy and HIV acquisition (Fig 1 and Box #4). However, few reported using condoms consistently, including AGYW living with HIV who reported partner refusal as a barrier, that they did not use condoms with partners who were either HIV-negative or of unknown status. Hence, the main factor hindering condom use was a perceived inability to negotiate condom use with their male partners (Table 3, Q42).
Some participants also feared that condom use would be perceived by their partners and families as an indicator of their promiscuity, also confirmed by discussions with parents (Table 3, Q27, Q34, Q37). In addition, AGYW cited negative attitudes of healthcare workers as a barrier to health seeking behaviors of young girls (Table 3, Q35). Most participants were knowledgeable about their partner’s HIV status with many reporting they had tested together.
While most AGYW were unaware of PrEP (pre-exposure prophylaxis), a few did mention PrEP as another HIV prevention strategy. One of the participants was currently receiving PrEP and was able to explain how it worked and the importance of using PrEP to prevent HIV infection. She emphasized her belief that PrEP was particularly important for people who were unaware of their partner’s HIV status and/or were unable to use condoms. Some AGYW also appeared to confuse PrEP with post-exposure prophylaxis.
Several costs were perceived by AGYW that hindered their ability to adopt HIV protective behaviors. Many AGYW expressed fear of accessing health services due to healthcare worker attitudes that stigmatized young girls attempting to access sexual and reproductive health services (Fig 1 and Box #5). While HIV treatment services are free in Uganda, AGYW often pay a small fee to access family planning and other sexual and reproductive health services. This payment can act as a barrier to accessing these services. AGYW also face difficulty affording the transport costs to seek facility services. Inconvenient clinic hours were a barrier, with some AGYW mentioning school vacation times as the only time they had available to access health services.
Intentions and action: Reported behavior of AGYW in relation to HIV prevention. Some participants were aware of programs that could support AGYW and reinforce positive behaviors to prevent HIV acquisition. This includes the DREAMS program, which was available in the rural community. In addition, participants described the ability to receive an HIV test and life skills education as part of the DREAMS program (Fig 1 and Box #6).
Access to HIV prevention programs for AGYW was an important factor in how feasible it was for AGYW to access HIV testing and condoms for protection. AGYW generally perceived these programs as attractive for the added advantage of skill building for self-development. Some AGYW worried about health worker attitude and HIV status disclosure from attending health facilities, citing stigma and concerns about healthcare workers potentially violating confidentiality (Table 3 Q33, Q35). Despite the high knowledge of condom use and access, very low or inconsistent condom use was reported among HIV-infected and un-infected AGYW. Most girls associated trust and love with non-condom use (Fig 1 and Box #7), irrespective of partner’s HIV status (Table 3, Q42).
Constructs outside the PMT. We identified themes relevant for protective behavior among young women which were not part of the original PMT. One such theme depicting gender imbalance and power relations (Fig 1 and Box #0) explained AGYW’s reported inability making safe healthy decisions by themselves, driven by a norm that gave men power over women as illustrated in Table 3, QO1.
Secondly, the importance of parenting and role modeling through perceived effectiveness of behaviors was communicated through knowledge and the willingness to perform the behaviors. (Fig 1 and Box#0) Parents and guardians further reinforced their influence in modelling the protective behavior that would be important for young women to learn from them (Table 3, QO2).
Lastly, the effect of social norms affected motivation to engage in certain behaviors. The view that girls and men having children before marriage related to HIV acquisition risk, with varied range of perspectives on when a girl should be ready to have children.
Discussion
Our findings highlight complex multidimensional pathways including poverty, gender inequality, parental behavior and social norms affecting HIV acquisition. AGYW were knowledgeable about most HIV prevention interventions though less familiar with PrEP. Many AGYW thought access to these programs would help facilitate healthy, sex-positive, protective behaviors. Alcohol use, desire for material possession, incorrect perception of HIV disease severity, social norms, and poverty were barriers to self-protective behaviors. While condom knowledge and access were high, usage remained low, resulting from structural barriers, negative community perceptions, and associations with promiscuity [22]. Conservative perceptions around condom use and promiscuity have long hindered and increased stigma around condom use while the scientific literature demonstrates overwhelmingly that social conservatives’ promiscuity argument on sex education is false [23]. From large-scale systematic reviews from the 1970s to the 1990s evidence consistently indicate the value of sex education with no links to increased sexual activity in young people. Further, understanding the socio-economic complexities driving sex, for basic needs, improved social status and material expressions of love need to be accommodated to best design successful prevention programs [24, 25]. Additionally, some AGYW and parents showed higher risk perception for pregnancy than HIV seemingly generated from cultural and social norms. This is essential for programs to address. Studies generally indicate that young people, especially adolescents, are more inclined to worry about the current and immediately visible impact of unprotected sexual behavior, such as unplanned pregnancies, rather than the behavior’s long-term consequences [26]. Low HIV risk perception may additionally be explained by existing HIV treatment optimism (i.e. confidence into the availability and effectiveness of HIV treatment), although evidence on this causal explanation seems to be inconclusive [26–28]. With sexual debut for Uganda reported at about 33–40% below age 19, this underscores the importance of addressing challenges faced by young people. This calls for comprehensive interventions for the broader HIV prevention and Sexual and Reproductive Health (SRH) rights context [29]. Our analysis corroborates other study findings on condom-use gaps among HIV-infected and non-infected AGYW associating non-use with “trust/love,” meriting creative, intentional condom messaging for boys and couples that targets the ability of girls to negotiate condom use [22, 30, 31]. Deliberate strategies that improve risk perception of both female and male condoms while responding to access and acceptability concerns around the female condoms would be key for condom-use uptake [32].
Many AGYW viewed staying in school as an important protective factor regarding preventing risky behaviors during schooling and later in life. Education is further critical for accurate risk perception of HIV among AGYW [33]. Furthermore, schools can lead to the economic empowerment of AGYW, an important factor associated with protecting AGYW against HIV acquisition [34, 35]. Programs should strive to work with communities to ensure that AGYW are educated, offering educational subsidies appropriately and job training to empower them to make their own choices and negotiate safe sex [4, 36]
Evidence [26, 28] does show that materialism, including a desire for glamour and luxury can become an important motivation to engage in sexual relationship for adolescent girls and young women in the sub-Saharan African region. Having certain material goods may be deemed essential to avoid social exclusion especially for adolescent girls and young women, for whom belonging to and being acknowledged by the peer group is important for their social status [26]. This way, forming a socially acceptable identity may be intricately intertwined with their self–esteem, which in itself can be linked with vulnerability to sexual risk [28].
Research evidence suggests that this phenomenon is particularly prevalent in adolescence, therefore reducing transactional sex during this developmental phase is particularly important for HIV prevention [37].
Socio-cultural norms restricting sexuality communication impede open discussion of SRH matters between adolescents and young people and their parents [38]. Adolescent sexuality is often viewed as something that needs to be controlled and repressed, and thus sexuality communication between parents and adolescents in the sub-Saharan African region tends to be punitive, focusing on abstinence, rather than information about contraceptives and/or condoms [39]. This is particularly relevant in countries such as Uganda that have had a history of conservative SRH programming based on abstinence. However, recent sexuality education policies and guidelines in Uganda have started to recognize the need to act on unintended consequences of sexual behavior, such as unplanned pregnancies, thus being a step in the right direction. The socially driven norms around condom use perception related to promiscuity would require intentional targeted messaging at different levels.
Our previous research and other studies show that parents can be powerful protectors against adolescent risk behavior through mentoring, communication, and modeling [40]. Parents can provide guidance and model desired behavior. Youth cited parental influences as a key factor that can improve AGYW behavioral intentions. Parents also acknowledged the importance of serving as role models for their children regarding respectful behavior towards their spouse and safe, consensual sex. In addition, parents felt that being knowledgeable about the effectiveness of prevention interventions was important for them to make informed decisions about their children’s uptake of interventions. The PEPFAR DREAMS program promotes parenting programs, and Uganda implements Sinovuyu (teen parenting program) and other evidence-based programs like Families Matter! [4, 41] These programs educate parents about prevention interventions for AGYW and how to be positive role models to impact behavioral intentions among their children.
Gender and economic inequality emerged as a critical HIV risk factor for AGYW, with unequal power dynamics in sexual relationships and social expectations that obligate AGYW to provide sex in return for resources. This finding does not fit very well with the PMT and is thus worth considering as an important addition. Gender inequality negatively affects condom negotiation and self-efficacy, limits educational advancement, thereby affecting agency, limits gainful employment, and encourages violence within relationships [42]. Further, as is evidenced in research with young people in sub-Saharan Africa, the relation between gender roles and sexual agency is complex [43] Gendered community norms result in expectations around women’s autonomy, ideal or actual sexual network structures (e.g. concurrency or serial monogamy), gender power and material exchanges within relationships [44]. However, despite cultural shifts in gender-norms, the sexual agency of adolescent girls and young women in much of the African continent remains constrained by inequitable gendered power dynamics [45].
Targeted interventions addressing cultural and structural barriers to women’s advancement, including education, discrimination, harmful gender roles coupled with partner violence, could be developed to improve AGYW health.
Our findings identify alcohol as a barrier that accentuates risk for AGYW with limited programs focused on the impact of alcohol use [46]. Alcohol use during the transition from adolescence to young adulthood could reflect normative behavioral intentions from the young person’s lens. However, for many young people, drinking negatively affects their ability to control sexual and protection behavior [47]. Programs investing in understanding how alcohol use fits in young people’s lives, and how to build a stronger foundation to counter alcohol risk factors may avert the negative consequences. Too often, these factors affect mental health trajectories resulting from heavy drinking and other adverse socioeconomic effects on the social determinants of health for the current and future generations [46]. Understanding the impact of alcohol on a country’s burden of mortality as well as an economic, physical, and emotional disability could help increase investment in this area which is currently very minimal. Investments in substance use treatment for youth and structural interventions limiting alcohol availability may be worthwhile.
For HIV prevention among AGYW, the discussion among families and communities on the implications of short-term aspirations can be a cornerstone for success. Our data showed that ‘wanting of material things’ increases the risk of AGYW by negatively impacting safe sexual behavior and future HIV prevention efforts [48]. Programs could capitalize on interventions that focus on AGYW’s aspirations when addressing their sexual and reproductive health risks by finding innovative ways of engaging AGYW to focus on long-term goals for financial success [49, 50]. Working with AGYW and their community on intentional messaging could help address this behavior.
Limitations
Our study uses self-reported data, with the potential for social desirability bias as participants tend to supply information thought to be more favorable or socially acceptable as opposed to being fully reflective of actual feelings or thoughts [33]. Data collected through FGDs may be overrepresented by some youths and underrepresented by others, although the trained facilitators encouraged all youth to give their opinions and emphasized that their opinion counted. Additionally, we did not interview male partners of AGYW due to concerns around possible inadvertent HIV status disclosure and other harms. Despite these limitations, the study brings several strengths, including theory-guided design, rigorous methods, and rich data, which produced important information for HIV prevention activities for AGYW and their male sexual partners. The degree to which the findings are not transferable to other groups of AGYW was attenuated by the diverse and purposively collected sample.
Conclusions
AGYW have distinct HIV risk factors that suggest the need for policy and gender and economic equality improvement interventions, education opportunities, agency, and safe sex practices. While the PMT focuses on individual factors to promote behavior, our study findings reveal that HIV risk behavior is influenced by complex contextual factors like poverty, gender inequality and cultural norms. When applying individually centered theoretic behavioral models especially in low-income countries, they could benefit if contextualized through integrating locally appropriate structural constructs. Targeted adolescent-focused HIV interventions addressing violence, alcohol consumption, material wealth aspirations, health worker stigma, educational opportunities, and safe-sex practices and PrEP scale-up may prevent HIV in AGYW and facilitate HIV epidemic control.
Supporting information
S1 Appendix. Detailed characteristics of key informant interviews and focus group discussions.
https://doi.org/10.1371/journal.pone.0301311.s001
(DOCX)
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