Reducing HIV Infection Among Adolescent Girls and Young Women in Africa
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Efforts to combat and address the threat HIV poses to the health and safety of people globally have been ongoing for decades, and significant progress has been made through the tireless efforts of organizations and activists. Yet, there is still more work to be done—in 2020, there were 37.7 million people in the world living with HIV, and 680,000 people died from AIDS-related illnesses.
Programs to deliver services and reduce transmission often focus on the communities and countries most struggling with high rates of infection. As such, the US has pioneered a program, “Determined, Resilient, Empowered, AIDS-free, Mentored and Safe” (DREAMS), to address structural and behavioral drivers of HIV infections, specifically among adolescent girls and young women in Sub-Saharan Africa. This program works to address the root cause of vulnerability to HIV, including poverty, social isolation, and limited access to schooling, and continued support and additional funding is critical to achieving these goals.
DREAMS is a private-public partnership dedicated to reducing HIV rates among young women in Sub-Saharan Africa, where rates of transmission are high—this goal is rooted in the understanding that young women are particularly at risk for HIV. In fact, adolescent girls and young women account for 74% of new HIV infections in adolescents, and adolescent girls are twice as likely to have HIV than adolescent boys in the region.
Young women and girls in Sub-Saharan Africa are more likely to experience social isolation, economic vulnerabilities, gender-based violence, absence of parental and community support, and lack of vocational training—all factors that increase their vulnerability to HIV. In an effort to empower young women and equip them with the knowledge and resources they need, as well as offer supports to strengthen families and communities, the DREAMS program aims to deliver layers of evidence-based health, educational and social services.
This includes, at the individual level, HIV education, health treatment, pre-exposure prophylaxis (PrEP), violence care, and pregnancy management. The program also provides education subsidies, economic and social supports, and violence reduction training. At the community level, the interventions target parenting and caregiver issues, foster community mobilization and social norms change, with specific activities on community-based HIV and violence prevention, parenting programs on adolescent sexual risk behaviors and protection from violence. In addition, the DREAMS program focuses on school-based HIV prevention, targeting adolescents with violence and gender-related messaging.
Over the past seven years, the DREAMS partnership has been implemented, at least in part, in sixteen countries across Sub-Saharan Africa, and substantive progress is being made. One study suggested that lack of social activities and mentorship among older adolescent girls and young women (19-23 years) living in urban settings are important factors to sexual risk behaviors. Another study in Kenya and South Africa found that the DREAMS program was able to increase awareness of HIV services and encourage their use. In Nairobi, after one year of implementation, 82% of young women became aware of the DREAMS program. The results of that study indicated that HIV testing in Kenya and school-based HIV and violence prevention in South Africa were the most accessed intervention categories by all participants.
In addition, a study of the impact of the DREAMS partnership in Zimbabwe compared HIV rates between cities with the DREAMS program and cities without. The results from the study indicated that the uptake of and access to clinical services were twice as high in DREAMS cities, and DREAMS cities saw higher attendance to community mobilization activities and reporting of the use of PrEP was about 47-times higher. Insights from the implementation of the DREAMS Partnerships in rural South Africa also indicated that the DREAMS program strengthened existing infrastructure as local communities embraced youth development to change gender-norms in South Africa.
It is true that the layering of health services and social and financial support to socio-economically disadvantaged young women and girls is a positive and evidence-based approach to reducing HIV transmission. At the community level, the program fosters the mobilization of communities for change by increasing caregiver support, school-based HIV and violence prevention, and improving health and economic outcomes for families. However, the DREAMS program is limited in that it does not typically offer HIV testing—an essential component in addressing HIV transmission and supporting the program’s ongoing progress.
Along with continued support for the existing program, additional funding is needed to:
- Support increasing testing at the community level, where DREAMS does not promote HIV testing. This could help address the problem of stigmatization.
- Allow local educators, health institutions and relevant advocacy groups to scale up their existing programs to combine sex education, HIV prevention and testing in the school’s curriculum and to provide an opportunity to reduce the rates of infection and get tested.
- Empower local health institutions and relevant stakeholders to reach out to those who tested positive for HIV either for a confirmation test, counseling or to direct them toward available social, medical and financial services at the community level.
The DREAMS partnership provides adolescent girls and young women in Sub-Saharan Africa needed health services and social and financial interventions to foster the reduction of the incidence of HIV, empower young women in their personal development and their decision to have safe and protected sex with their partners. HIV testing at both the individual and community levels will further contribute to reducing HIV incidence and stigmatization among young women and girls, and more funding is needed desperately to achieve these goals.
This research was supported by grants from The Environmental and Occupational Safety & Health (ENVOSH) and the National Institute on Minority Health and Health Disparities (NIMHD) Minority Health and Health Disparities Research Training Program, the Global Alliance for Training in Health Equity T37MD01425. The funders or sponsors did not participate in the work. Contents are the authors’ sole responsibility and do not represent official ENVOSH and National Institutes of Health or NIMHD views.
Special thanks to Drs. Gina Lovasi and Alex Ezeh from Drexel University, Urban Health Collaborative in the Dornsife School of Public Health, and Dr. Abdhalah Ziraba from the African Population and Health Research Center (APHRC) in Kenya.
This brief is based on ongoing research by Macceau Médozile.