Condom literacy, self-efficacy, and HIV-risk behaviors: a cross-sectional analysis of adolescent girls in northwestern Botswana.

Introduction: Despite global reductions in HIV incidence, adolescent girls in Sub-Saharan Africa remain disproportionately burdened. Methods: This study used cross-sectional data collected from 306 school-going girls ages 14-19 in northwestern Botswana in 2021 to identify behavioral and attitudinal factors associated with knowledge of correct condom use and the intention to use condoms consistently. Data were collected through self-administered, tablet-based surveys containing questions relating to HIV and condom knowledge, condom use, and relationship norms. All data were self-reported. Bivariate and multivariate analyses examined correlations with two outcome variables: reported knowledge of correct condom use and perceived ability to insist on condoms in every sexual encounter. Results: Most participants were 15-16 years old. Only 15% reported having had sexual intercourse. Few reported engaging in activities generally associated with HIV-risk behaviors, such as smoking (1.3%), alcohol use (7.2%), or substance use (4.6%). Girls who reported they had not had sexual intercourse or who did not feel they could insist on condom use had 70 and 80% lower odds, respectively, of reporting they knew how to use condoms correctly compared to more experienced or confident peers. Girls who knew there was no cure for AIDS had 2.7 times greater odds of reporting they knew how to use condoms correctly. Participants who were unaware of their HIV status had approximately 80% lower odds of reporting they could insist on condoms compared to their status-aware peers. Knowledge of correct condom use and attitudes about relationships were not significant correlates of perceived ability to insist on condoms when controlling for other covariates. Several indicators of condom-use self-efficacy, including confidence in suggesting condoms or refusing condom-less sex and communication with one's sexual partner were significant correlates of perceived ability to insist on condom use. Discussion: Most understanding of factors contributing to adolescent HIV-risk behaviors is based on studies of males and females combined or older, more sexually active young adults. Results from this study, which focused exclusively on adolescent girls, the majority of whom were not yet sexually active, point to potential targets of opportunity to reduce the likelihood of unprotected sexual initiation in this particularly vulnerable group.