Awareness and uptake of layered HIV prevention programming for young women: analysis of population-based surveys in three DREAMS settings in Kenya and South Africa

Adolescent girls and young women (AGYW) aged 15–24 years remain at high risk for HIV infection compared to their male counterparts, particularly in sub-Saharan Africa [1, 2]. The estimated 450,000 new HIV infections among AGYW globally in 2015 [1] is far from the UNAIDS goal to reduce annual new infections to below 100,000 by 2020 [1].

The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe lives) Partnership is an ambitious public-private investment, established in 2015 to reduce the rate of new HIV infections among AGYW in ten sub-Saharan African countries [3, 4]. DREAMS is based on the principle that ‘combination HIV prevention’ [5]– an approach to reduce HIV transmission through integrated behavioural, biological and structural interventions tailored to the needs of a population – is essential. In the case of DREAMS, the multiple sources of HIV risk for adolescent girls and young women are conceptualised through a theory of change model and are to be addressed through a package of ‘layered’ evidence-based interventions [6]. ‘Layering’ is defined by the President’s Emergency Fund for AIDS Relief (PEPFAR) as “at the individual level…to provide multiple interventions or services from the DREAMS core package to each DREAMS recipient (i.e. AGYW)” while “layering also takes into account contextual level interventions (i.e. those that are not delivered directly to an AGYW but from which she may benefit)” [7].

Figure 1 illustrates the key components of the DREAMS core package of interventions, grouped into categories (e.g. social protection), which in turn are organised by levels (e.g. ‘strengthen families’, which can also be described as ‘contextual level’) [6, 8, 9]. At the individual-level, interventions aim to empower AGYW and reduce their risk of HIV and violence, for example, through access to HIV testing and youth-friendly sexual and reproductive health services, or social asset building interventions such as ‘safe spaces’ where AGYW can meet with mentors and peers for social support, courses, and links to services. Contextual-level interventions are intended to strengthen families, for example, economically and through parenting support, and to mobilise communities more broadly to address social norms, including through schools. The core package also includes strategies to reduce an AGYW’s risk of acquiring HIV from a male partner, through the expansion of essential HIV and/or prevention services including HIV testing, linkage to ART and voluntary medical male circumcision (VMMC). Each country has subsequently selected a minimum package of ‘primary’ interventions from the core package, some that are intended for all AGYW and some that are for particular age groups. ‘Secondary’ interventions are based on need, rather than being intended for all AGYW, for example, post-violence care services for those who have experienced violence [7].

Complex interventions are proliferating, for example, with the ‘Sauti’ initiative in Tanzania, ‘She Conquers’ in South Africa, and ‘DREAMS-like’ AGYW programs funded by the Global Fund for AIDS, TB and Malaria [10‐12]. Investments in packages of services are also promoted to address the broader needs of adolescents, with global calls to go beyond school-based education to involve families, communities and media in adolescent development [13, 14]. To date, however, there is sparse empirical evidence that such complex adolescent interventions can be taken to scale (at district level, for example) and implemented effectively in real-world, non-trial conditions. Their effectiveness will depend on the intensity and quality with which they are delivered and whether they are accessed by young people and related target populations.

The question of how to achieve effective delivery and reach is fundamental to addressing the ‘implementation gap’ [15, 16]. It has been argued that it is now imperative to fill the gap between what we know works and what can be achieved in reality. Fauci and colleagues emphasise there should be “no more excuses” and that “we have the tools to end the HIV/AIDS pandemic”, although “from a practical standpoint, this will be difficult and will require aggressive implementation of the biomedical research advances that have been made…” [15].

As part of an independent impact evaluation of DREAMS among representative samples of AGYW in Kenya and South Africa [17], we investigate the population-level uptake of DREAMS, specifically the awareness and uptake of any and multiple (‘layered’) DREAMS interventions after the first year of implementation.

As possibly the most ambitious example of combination HIV prevention to date, we sought to evaluate the extent to which DREAMS reached AGYW and related target groups in large and representative samples in diverse settings. Our findings are among the first to demonstrate that it is possible to deliver combination HIV prevention interventions to AGYW, in real-world (non-trial) settings, addressing biological, behavioural (sexual) and social protection pathways.

We found high levels of awareness and uptake of DREAMS among AGYW after 1 year of implementation in Kenyan and South African, urban and rural, settings, with the highest levels in Nairobi (where DREAMS had been implemented longest). In Gem, lower awareness reflected the earlier phase of DREAMS implementation at the time these data were collected. In contrast, awareness and uptake was low among other population groups, e.g. adult women and young men targeted for ‘contextual’ interventions in the DREAMS package.

The majority of AGYW beneficiaries accessed multiple categories of the core package, typically 2–3, which often included both individual and contextual-level interventions. This evidence of ‘layering’ indicates that programmatic integration across sectors is feasible. Findings from other studies in similar settings have also indicated that it is feasible and acceptable, though challenging, to deliver combination HIV prevention packages to AGYW, though these packages have usually combined either “health service”, or social, or behavioural interventions, rather than all three together. Examples of such initiatives include delivery of a prevention package including universal HIV testing and treatment to young people within the context of the PopART trial in Zambia [31]; and combination of microfinance, gender/HIV training and community mobilisation for women through the IMAGE trial in South Africa [32]. The EMPOWER trial in Tanzania and South Africa also offers useful insights by demonstrating the feasibility and acceptability of combining a wider array of interventions for AGYW, e.g. integrating gender-based violence screening with HIV testing services, delivering PrEP alongside sexual and reproductive health interventions, counselling, community/partner mobilisation, and empowerment clubs [33]. Our analyses extend these findings to non-trial settings and to ‘layering’ a comprehensive combination of biological, behavioural, and social interventions to AGYW and their partners/families. They also complement findings emerging from parallel research conducted by the Population Council on the effectiveness of efforts to recruit vulnerable AGYW to DREAMS, in a range of different communities [34‐37]. However, detailed findings on awareness and ‘layering’ of the DREAMS core package and primary interventions have not been reported and there are methodological differences compared to our evaluation. Our study design leverages long-standing population-based demographic surveillance platforms, allowing for robust comparison groups (those not reached by DREAMS) and for analyses of uptake of relevant DREAMS interventions in the community.

Although we found evidence of ‘layering’, the intention of the DREAMS Partnership is to ‘layer’ more interventions than we observed, e.g., between 3 and 7 interventions in the primary intervention packages defined by age group. More time may be required to achieve greater ‘layering’, given the primary interventions were specified in the second year of DREAMS implementation (circa July 2017), and because roll-out of interventions was typically staggered until the full package became available [20]. In particular, interventions that were new to an area, e.g., ‘safe spaces’ and social asset building, or social protection interventions, took longer to implement than pre-existing interventions that were expanded with DREAMS funding, e.g., HIV testing services and school-based HIV education. This is reflected in the relatively lower uptake and ‘layering’ of the new interventions, in comparison to more established services.

In both Nairobi and uMkhanyakude, uptake of individual and ‘layered’ interventions was highest among younger women (particularly those aged 13/15–17 years) compared to 18–22 years. This indicates that DREAMS offers a model for reaching adolescents early, prior to entering a high risk window (e.g., before age 15/16, when HIV incidence starts to rise rapidly among girls [1]), and before most young women access health services for the first time (often with their first pregnancy). This was reinforced in Nairobi with the high receipt of DREAMS interventions, including multiple interventions, among 10–14 year olds – a stage dubbed the ‘window of opportunity’ by UNICEF [38]. On the other hand, the program was relatively less effective at reaching young women entering the period of ‘peak’ HIV risk (typically early/mid-twenties in high-burden settings [1]), which may impede its impact on HIV incidence, particularly over a short timeframe.

DREAMS was effective at reaching AGYW with socio-economic vulnerabilities, in both Kenya and South Africa, although less so for AGYW who were out of school than those in school. Invitation to participate was also lower among AGYW who had ever had sex or ever been pregnant, i.e., those at potentially higher sexual risk, although ‘layering’ was more common among these AGYW (which may reflect engagement in pre-existing antenatal care and reproductive health services). Research conducted by Population Council in Zambia and Kenya has also found under-representation of out-of-school and sexually active AGYW among DREAMS beneficiaries and, more generally, defined the majority of an out-of-school AGYW sample in Kenya as ‘lower’ vulnerability [34, 39].

These findings show that, while feasible to deliver multiple interventions for ‘layered’ HIV prevention, among large proportions of the general population of AGYW, challenges remained for higher coverage and greater ‘layering’ of DREAMS, including increasing coverage among older, out-of-school AGYW, and community-based programmes to reach families and men, if DREAMS is to impact on HIV incidence. These findings reflect that achieving scale-up of such a complex intervention, as fully intended, takes time, and suggest that phased implementation can allow time for reprioritisation, where required [24]. Some interventions - like community-based norms interventions and parenting programmes - were newly introduced in these settings, without programme infrastructure to build from. They therefore required intensive training of implementing partners and took longer to roll-out and scale-up than services with a pre-existing infrastructure [24]. Related qualitative research in South Africa has also revealed that conflicts with home priorities and logistical issues such as transport have contributed to challenges with recruiting and retaining AGYW and caregivers into DREAMS parenting programmes (who ideally participate together, at least in some sessions, but are often unable to do so in practice) [40]. Future rounds of our evaluation research will continue to track uptake by intervention type and sub-group, to assess changes over time.

Strengths of the study include the large, representative samples which enable accurate, population-level estimates of DREAMS’ reach among AGYW as well as important related target groups, across diverse settings. Harmonised research tools, with questions on all interventions in the core package, allowed for detailed assessment of combinations of interventions and comparable summaries across settings. Still, measuring uptake of such a complex programme with so many components is challenging. We relied on self-reported information on invitation to participate in DREAMS, as a marker of who was intended to benefit from, as well as who actually accessed, the programme. This may have underestimated participation, if some AGYW did not know they had been ‘invited to DREAMS’, or that interventions were DREAMS-funded. Going forward, linkages with individual-level programme data may improve our classification of which AGYW were DREAMS beneficiaries. Differences in the data available in the 2016 Gem survey, compared to data collected in 2017 in Nairobi and uMkhanyakude, limited some of the comparisons that could be made. For example, invitation to participate in DREAMS was not captured explicitly in Gem and participation was measured as ‘ever participated’, compared to participation within the last 12 months in the other two settings (although DREAMS was introduced in 2016, so participation in DREAMS-specific interventions in Gem should have reflected participation within the prior 12 months only). Furthermore, the heterogeneity of DREAMS implementation across settings limited the comparability of some measures, though we strove to standardise using common frameworks like the core package and primary intervention packages, as defined by PEPFAR [6]. The STROBE reporting guidelines were also used to guide synthesis and standardise reporting of our findings across settings [30] (Additional file 2). This evaluation focussed on selected DREAMS sites (justified in Birdthistle et al. [17]) and our findings may not be generalisable to all other DREAMS intervention sites.

This study contributes detailed evidence to a relatively sparse body of research on the feasibility of scaling-up combination HIV prevention in non-trial conditions. Such evidence is important for understanding how to bridge the ‘implementation gap’ [15, 16]. Our findings reveal that it is possible to deliver multiple interventions at scale, among target populations of AGYW, including socio-economically vulnerable individuals, in varied settings. However, we showed that maximising ‘layering’ with the full range of intended interventions takes time, especially when interventions are being delivered in an area, or to a population, for the first time. This is particularly true among key sub-groups such as older and out-of-school AGYW, while efforts to reach male partners and families with community-level programmes also need to be intensified. Specifically, lessons here can inform programming that aims to maximise the impact of HIV prevention among young women, especially in the context of current expansion of DREAMS, ‘DREAMS-like’ programmes, and other multi-sectoral programming. Moreover, we will continue to track uptake over time as two further years of data collection (2018–2019), combined with ongoing process evaluation, will offer longer-term lessons about scale-up and sustainability, as well as impact.