In a high HIV prevalent setting, consistent condom use promotion is one of the tools to combat the spread of HIV, especially among adolescent and young adults (aged 15-24) known to have the highest rate of new infections. Our study examined the prevalence, barriers and facilitators of consistent condom use among sexually active adolescents and young adults. We found that only two-fifths of our study participants consistently used condoms in the past year, which is in line with previous studies [29, 30] among young people in South Africa. However, a study conducted reported a lower prevalence among young women in rural settings . In contrast, a study among recently circumcised males and another conducted among young people in Cape Town reported a slightly higher consistent condom use prevalence [6, 32].
Surprisingly, this study's finding is similar to previous studies in other settings with a relatively low HIV prevalence [25, 33] compared with South Africa. Even though the need to prevent STIs and unintended pregnancy is universal, we expected that the prevalence of consistent condoms use among young people would be higher in South Africa than those reported among a similar population  in a low prevalent setting, like Nigeria. Contrary to a previous study in South Africa, we did not observe any gender differences in condom use consistency. Also, the factors associated with consistent condom use are similar for both males and females, underscoring the absence of differences in condom behaviours of young men and women.
This study highlighted factors that facilitate consistent condom use, some of which have been reported in previous studies [25, 30-32]. We found that family financial support, disclosure of status to partner, HIV testing, and self-efficacy to prevent HIV status positively impact consistent condom use. While the influence and importance of condom self-efficacy are well established in the literature, our study highlights the considerable importance of family financial support, partner communication, HIV testing uptake and self-efficacy to prevent HIV/STIs. Previous studies have not explored the link between family financial support and condom use consistency. Our plausible explanation for why young people who received adequate financial support use condoms more consistently than those who did not is that they may have sufficient resources to purchase condoms than their counterparts. They could, for instance, purchase and keep their preferred condoms brands in their rooms in anticipation of sex, unlike their counterparts who may have to ration their scarce resources and advance purchase of condoms may not be among their priorities. It is worth noting that condoms are distributed on campus, but this happens infrequently and may not go far enough in solving condoms unavailability problem.
Previous studies have highlighted the importance of partner communication on protective sexual behaviours [25, 34]. We know from these studies that partners who discussed the need to use condoms and prevent unintended pregnancy are more likely to engage in protective sex. Our study further adds to the emerging evidence of the importance of partner communication for HIV/STIs and unintended pregnancy prevention. Partner communication on HIV/STIs means that couples would risk and resort to the appropriate preventive methods.
Consistent with the literature [25, 30], our study shows that HIV testing encourages protective behaviours. Those who have tested are more likely to use condoms consistently than those who never tested for HIV. The difference observed could be due to the positive impact of the counselling before and after HIV testing. Also, uptake of HIV testing is a positive health behaviour, suggesting that most people who undertook HIV testing are more concerned about preventing HIV than those who had never been tested. However, no studies have examined the influence of HIV prevention self-efficacy. Expression of high self-efficacy for HIV prevention reflects that young people are not only aware of methods of preventing HIV/STIs but also feel confident in their ability to protect themselves. Therefore, it is not surprising to see that those who expressed confidence in their ability to prevent HIV/STIs are more likely to use condoms consistently.
Based on our findings, the desire for maximum pleasure, preference for sex without condoms, unavailability of condoms, partners’ objections, alcohol use, and hormonal contraception use constitute barriers to consistent condom use. Like previous studies, our study demonstrates that young people who believe that condoms reduce sex pleasure are unlikely to use it regularly, if at all. It appears that the desire for maximum fun trumps the need to prevent HIV/STIs for many young people. Also, in line with previous studies, condom unavailability was reported as part of the factors hindering condom use consistency [25, 30]. For many, sexual intercourse is unplanned, and in such situations, condoms are not always available. Rather than wait to source for condoms, some young people often take the risk, ignoring the possibility of contracting HIV/STIs.
Trust has also been documented in the literature as one of the barriers to condom use consistency among young people. In this study, young people failed to use condoms consistently because they trust their partners to remain faithful in the relationship. The trust is based on perceived fidelity in a relationship. Since some already tested for HIV and were on hormonal contraception, they do not see the need to use condoms. For others, the trust could be described as a “blind trust” given that it was implied despite having never tested for HIV. In these relationships, unprotected sex is equated with trust and initiating a conversation about condoms could be misconstrued as distrust . Our result indicated that those who failed to use condoms at all or inconsistently because they were on hormonal contraception suggest that some young people are more concerned with pregnancy prevention than HIV/STI prevention. Our findings on the link between alcohol use and condom use consistency further add to the literature on the adverse effect of alcohol on high-risk sexual behaviours. Excessive use of alcohol could make young people inebriated, therefore, lacking agency to negotiate condom use.
In light of our study findings, there is a need to invest in multi-prongs interventions that begin with early and comprehensive sex education. This sex education should continue beyond high school and should happen in other settings outside of school to reach out of school adolescents and young adults. In addition to sexuality education, the government should continue to make condoms and other contraceptives freely available through the health department. The government initiative to make different varieties and flavours of condoms available is a positive development that could impact condom use consistency, given the complaint about pleasure concerns. Interventions need to be innovative and convenient while addressing these identified barriers to reach these adolescents and young adults. Counselling of students has historically been the standard intervention in safe sex education . However, many young people appear not to use condoms despite counselling. To address this need, innovation on behavioural interventions are critical. Social marketing campaigns on HIV are necessary to target these groups, and therefore should be implemented more rigorously. Integrating interventions into the routine standard of care in South Africa is necessary to promote behaviour change.
Study strengths and limitations
This study adds to the literature, highlighting the barriers and facilitators of condom use consistency in a high HIV prevalent setting. The use of the mixed-methods approach is a strength of this study. Nevertheless, our study is not without some limitations. Our study population is not representative of adolescents and young adults in the country, given that they are more educated, limiting the generalisability of our findings. However, our findings are consistent with previous studies among young people living in rural and urban settings [29, 30, 32], suggesting that our results may apply to other young people in the country. Even though we ensure privacy, anonymity and confidentiality throughout the study and with our use of ODK, we could not completely rule out social desirability bias, which could lead to over-estimation of the prevalence of consistent condom use.