Reaching early adolescents with a complex intervention for HIV prevention: findings from a cohort study to evaluate DREAMS in two informal settlements in Nairobi, Kenya

Adolescent girls and young women (AGYW) aged 15–24 years remain at higher risk of HIV infection compared to their male peers, especially in sub-Saharan Africa [1, 2]. Sources of HIV risk among AGYW are varied and include limited access to sexual and reproductive health services, economic pressures driving transactional sex and experiences of violence [3‐7]. A proliferating, broad evidence base around these vulnerabilities has informed the recent expansion of HIV programming for AGYW [5]. In contrast, equivalent data among early adolescent girls (EAG) aged 10–14 years are sparse, in part due to low HIV incidence [2], and HIV prevention approaches for this age group are less well understood [3, 8‐11]. However, early adolescence presents a key opportunity to intervene that can result in sustained health, education and social-economic benefits [12].

Adolescents living in informal settlements face distinct challenges as they transition to adulthood. Urban informal contexts are often characterized by food insecurity, violence, inadequate housing, and poor sanitation and infrastructure [3, 6, 13, 14]. In informal settlements in Nairobi for instance, six in ten girls aged 10–14 years have experienced violence [15]. Girls in these settings are also at high risk of dropping out of school [16]. While much has been done to document health outcomes in these contexts, EAG continue to be under-represented in research, perhaps due to perceived difficulties and ethical issues around recruiting and engaging this age group [8, 17]. Projects such as the Global Early Adolescent Study (GEAS) are creating new approaches and opportunities for conducting research with EAG, by contributing to appropriate data collection tools and methods [17, 18]. Formative studies from GEAS, including research in informal settlements, show that gender socialization occurs early in life, and that interventions encouraging the development of positive attitudes and equitable gender norms can be transformative immediately and over the life course [18].

Intervening early can also ensure that EAG are reached with prevention messages and skills that promote healthy sexual relationships and behaviours before they transition to higher risk groups, when incidence of HIV, STI and pregnancy escalate [5, 19]. Developing holistic interventions that promote learning, self-efficacy, life-skills, and positive social norms, and that involve caregivers who play a key role in shaping the attitudes of adolescents, are key to the life-long development and health trajectory of EAG [20].

Agencies are increasingly investing in early adolescence, with a focus on delivery of multi-sectoral and comprehensive programmes [16, 21‐23]. As a response to repeated calls to invest in combination interventions and accelerate HIV prevention programming, the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe girls) Partnership promotes a ‘layered’ package of evidence-based, multi-sectoral interventions to AGYW aged 10–24 years, with a primary aim of reducing HIV acquisition [5]. DREAMS was implemented in countries with high HIV burden, and targeted vulnerable AGYW in the most affected sub-national units (district-level) including urban informal settlements. DREAMS is based on the principle that HIV prevention will be most effective when it targets the myriad of behavioural, social and structural factors driving HIV risk [5]. While the value of intervening early in adolescence is recognised, there is limited documentation of whether and how complex interventions can be delivered and scaled up to the intended participants [24, 25]. A recent journal supplement on ‘data driven HIV prevention’ calls for researchers and program implementers to “learn how to best deliver combination and multi-dimensional programmes for youth” [25].

We sought to explore the awareness, reach and uptake of DREAMS interventions, and the profile of EAG reached by the programme after 3 years of implementation, in two urban informal settlements in Kenya.

We assessed the extent to which a complex, multi-sectoral intervention for HIV prevention (DREAMS) reached early adolescent girls in two urban informal settlements in Kenya, and found evidence of strong programme penetration among a representative sample of girls. Uptake of each primary intervention was high ranging from 50% (financial capability training) to 82% (school-based HIV and violence prevention) indicating that interventions for EAG can be delivered and integrated across schools and community-based settings [32‐34]. Uptake was high among DREAMS invitees for interventions that were newly introduced into this setting by DREAMS, such as financial capability training and social asset building (reaching 59 and 81% of EAG invited into DREAMS respectively), as well as interventions that existed prior to, or outside of DREAMS. High uptake of the latter, such as school-based HIV and violence prevention among non-DREAMS invitees, may reflect access through other programmes and funders.

Girls’ receipt of multiple interventions improved over time and more so among DREAMS invitees compared to non-invitees, indicating that with sustained effort over multiple years, integration of a coherent package of interventions is feasible and can be scaled up to reach a majority of EAG in environments with limited resources and infrastructure. While few studies have provided information on service uptake among early adolescents, particularly for complex interventions [32, 35, 36], previous research has shown the value of sustained investment. For example, the evaluation of the Gender Equity Movement in Schools (GEMS) program among young adolescents aged 12─14 years concluded that longer periods of programming could improve the effectiveness of the program [36]. Another study, assessing large-scale replicability of a programme training teachers to deliver HIV education to upper primary school pupils in Kenya, found that both teaching practices and learning improved with time [37], suggesting that sustained commitment to programming will improve uptake as well as outcomes.

Most of the DREAMS interventions accessed were at the individual level, with combinations of individual and contextual-level interventions less common. This is because EAG participation in parenting and community mobilization interventions was relatively low (compared to individual-level interventions) and more can be done to expand access. A related study reported low uptake of DREAMS’ parenting and community programs among older AGYW aged 15–22 years, as well as older women and men in the community [38, 39]. Given the important role of parents, male partners and the broader community in shaping adolescent health and development, low uptake of contextual interventions is likely to limit the effectiveness of DREAMS, and is an important area for improvement.

For curriculum-based interventions, we found that few EAG attended the total number of sessions provided, although half of the participants accessed at least ≥3 sessions for school-based HIV and violence prevention and financial capability training. Sessions on parenting programs were attended less frequently. This shows that it may be more feasible to engage EAG and parents in shorter, intense programmes rather than longer ones. This finding is echoed in our related qualitative research with IPs, where sustained engagement of beneficiaries was a challenge, especially for the longest programmes, e.g., participation in 10–12 sessions, due to mobility, family and caregiving obligations, and hunger [26]. Among parents and broader community members, time constraints, competing priorities, and logistical challenges limit their participation in contextual-level interventions (51). Much has been learned about the barriers in engaging, recruiting and retaining parents/caregivers [39, 40], to help improve their participation going forward.

We found few differences in the socio-demographic and socio-economic profiles between the girls invited to participate in DREAMS and those not invited. Related to this, the fact that high proportions of EAG were invited to DREAMS by 2018 (77%) indicates that many EAG met the targeting criteria. In part, this reflects the high vulnerability of young people in these settings [15]. The Girl Roster tool used to identify participants found many ‘eligible’ girls and IPs supplemented the Roster with other methods (e.g., consulting community-based organisations) to identify girls with greatest need for DREAMS. It was clear that many, if not most of the girls in these informal settlement areas could benefit from DREAMS interventions, posing a challenge for targeting (with limited resources) and a tension with communities promoting social justice and inclusion over exclusivity. A goal in such high-burden settings may be to offer the primary (priority) interventions universally while targeting specific groups of EAG for the secondary interventions like HIV testing.

Sustained participation in DREAMS interventions was not always equitable. We found that EAG who had experienced verbal violence (although the evidence was weak), or ever been in relationships (although numbers were relatively low) accessed fewer primary interventions than their fellow participants. There remains scope to strengthen EAG participation in the primary interventions through active involvement and engagement of DREAMS beneficiaries, and through continued use of dedicated mentors [41]. Also, findings from qualitative research with DREAMS mentors shows that many of the girls were hungry during their time in safe spaces (social asset building), and this could have impacted their participation, particularly in the longer-term curriculum-based interventions as noted above [42]. It is imperative that programs targeting highly vulnerable EAG, especially in the context of social vulnerabilities like food insecurity, identify mechanisms to counter these challenges and support girls’ continued participation. Provision of food and beverages could facilitate ongoing and active participation and enjoyment of the programme.

One key strength of this study was the high cohort retention rate, limiting the introduction of selection bias over time. Interview questions captured components of each DREAMS intervention allowing for detailed assessment of combinations of interventions among EAG. We utilised self-reported invitation to participate in DREAMS as a marker of who was a DREAMS beneficiary. This may have resulted in misclassification of some of the participants in cases where some EAG did not know whether they had been invited to DREAMS. However, using data across multiple years strengthened this measure, in that responses in each year were complemented by responses in subsequent years. Our definition of uptake as participation in at least one session may have over-estimated exposure to interventions comprised of multiple sessions. However, only few of the interventions were offered as a curriculum of multiple sessions, so it is unlikely to largely inflate exposure to DREAMS. In addition, half of the girls participated in three or more of the intended sessions (except for parenting programs), and so we expect them to have benefited from this exposure, in comparison to those who were never invited to DREAMS.

As DREAMS investments continue and expand to new districts and countries, with a particular focus on early adolescent girls, it is important to understand whether and how such a complex intervention can reach the youngest adolescents. We found that it is possible to deliver, scale up, and sustain an ambitious multi-sectoral intervention among EAG in challenging urban contexts, with uptake and layering improving over time. Provision of a coherent primary package of integrated interventions reached the majority of EAG in two informal settlement areas of Nairobi. Many girls also accessed secondary interventions, although longer-term engagement of the most vulnerable EAG and their families can be enhanced with support like food provision. There also remains a need to expand access to contextual, community-based programs so that parents, partners and communities can support the healthy development of EAG. Given the importance of engaging early adolescents in interventions for HIV prevention, and the limited evidence on programming among EAG, findings from this study can help programme implementers and funders to strengthen the implementation and reach of complex interventions like DREAMS.