Layered programs key to preventing HIV infections for adolescent girls

WASHINGTON — Adolescent girls and young women in sub-Saharan Africa are more than twice as likely to contract HIV than their male peers, and assessing efforts to address the challenge and chart a new way forward was a key focus of discussions at the International AIDS Conference.

While individual interventions have shown promise in addressing certain aspects of risk, no single intervention dramatically reduced new infections, according to a UNAIDS report released last week. What has shown promise is a multisectoral approach, including through a flagship effort of the U.S. President’s Emergency Plan for AIDS Relief, the DREAMS — Determined, Resilient, Empowered, AIDS-free, Mentored and Safe — partnership.

New HIV diagnoses among adolescent girls and young women have declined by 25% or more in nearly all the geographic regions where DREAMS is implemented, with studies showing stronger uptake of HIV testing and improved knowledge in HIV status.

“You can tell a girl in the DREAMS program by her posture,” said Beirne Roose-Snyder, director of public policy at the Center for Health and Gender Equity, or CHANGE, which has conducted DREAMS research across several countries. “The goal is to build protective measures around AGYW and you really can see it happening.”

Part of the UNAIDS fast-track strategy to get to epidemic control by 2030 was an accelerated agenda for children, including a goal of less than 100,000 infections for adolescent girls and young women.

Efforts by PEPFAR and the Global Fund to Fights AIDS, Tuberculosis and Malaria in nearly 30 countries have been “extraordinary” and led to a realization that to reduce infection rates among adolescent girls and young women “we needed a comprehensive approach and layered approach to reduce their multiple vulnerabilities,” said Dr. Chewe Luo, the chief of the HIV/AIDS Section at UNICEF.

“We haven’t unraveled the whole story but we’re starting to learn this approach is the way to go,” Luo said.

Evaluating progress

A growing amount of research is showing what does and doesn’t work in programs targeting adolescent girls and young women, including robust studies focused on the DREAMS program.

To date, DREAMS has invested more than $900 million in 15 countries and continues to expand its geographic reach, coordinating with the Global Fund to “ensure every single thing is coordinated and maximum programming is available to every young woman in the most vulnerable areas of sub-Saharan Africa and Haiti,” PEPFAR chief Deborah Birx, said at a conference session.

While incidence rates have dropped by between 25% and 40% in most DREAMS districts, and participation generally increases HIV knowledge and testing rates, it isn’t always reducing or shifting high-risk behaviors, according to DREAMS implementation research carried out by the Population Council.

One challenge with the program has been that in some cases vulnerable girls are being left out, particularly if they are LGBTQ, engage in transactional sex, or have disabilities, said Bergen Cooper, director of policy research at CHANGE.

Identifying the most at-risk adolescent girls has been a key challenge for DREAMS, particularly early on, said Sanyukta Mathur, who has led Population Council’s DREAMS implementation science research. In many places there was no census information or a good way to determine vulnerability. But when research in 2017 found that programs were often missing girls who were out of school, and who were also more likely to be exposed to higher risk behaviors, the data was fed back into the program, and outreach strategies were changed and have continued to adapt, she said.

Regions where coordination challenges emerged, particularly those where different partners tackled each aspect of the program, often struggled to achieve target results, with research showing that communications and coordination systems were essential, Mathur said.

For example, DREAMS has struggled in providing preexposure prophylaxis — medication that can be used to prevent transmission — which has been part of DREAMS from the beginning but it is one of the components of the program that has had the slowest uptake, Mathur said. It’s been slow in part because it hadn't been approved in every country, the approval processes have moved slowly and there were questions about community acceptance, Mathur said.

Accelerating PrEP is a priority for DREAMS now and it has been working to ramp up access even during the challenges of COVID-19, Birx said at the conference.

Where to go from here

With momentum generated and some proof of success, one of the key questions among researchers and implementers is where DREAMS and similar programs should go next and how they can be scaled and expanded.

One point where there seemed to be particular agreement was that the girls and young women needed to be at the center of the efforts.

“This has to be a movement that is driven by girls themselves,” Luo said.  “Country after country we do realize these things have to be peer led and we need to be sure we continue to do that empowerment.”

Juliet Murindi, a DREAMS ambassador, shared her thoughts at the conference, suggesting that the program go beyond secondary education support, and help girls with tertiary education costs as often girls are more vulnerable in that transition.

DREAMS should also expand to other districts and consider helping to improve access to affordable sanitary products. Murindi was nearly forced to drop out of school because she couldn’t afford sanitary products and it could have led her to engage in risky activities including selling sex for money, she said.

U.S. and global efforts to address transmission challenges need to be centered around what young women and girls say they want, Roose-Snyder said.

Girls and young women from diverse backgrounds should be engaged now, even if they haven’t always been, because they know what they want and “they will save us a ton of money because they will tell us what our dumb ideas are off the bat and they will be experts in their own lives and wants and needs and risks,” she said.

That will need to happen even as the DREAMS partnership has been incorporated into the broader country operating plan process at PEPFAR, after being a standalone program. While that may help solidify the longevity of the program, there is the potential that expertise will be lost, that the implementation in the original layered approach will falter, that it may get less attention, and could lead to funding cuts for girls and young women in other areas even though DREAMS funding is earmarked, she said.

Global efforts, including DREAMS, need to be a part of the discussion following the AIDS conference to determine future action, Luo said. Those engaged in the work need to sit down “as a community to look at the elements” and figure out how to match needs in different areas and accelerate and scale interventions with good coordination structure, she said.

As UNAIDS works to develop a new strategy, it is important that it includes a continued focus on adolescent girls and young women, and thus far, Winnie Byanyima, the UNAIDS chief, has taken the issue very seriously, Luo said.

Coordination will be needed going forward, including between health and other sectors, including education, and among governments and civil society, she added.