Directed and target focused multi‐sectoral adolescent HIV prevention: Insights from implementation of the ‘DREAMS Partnership’ in rural South Africa

Abstract

Introduction The “DREAMS Partnership” promotes a multi‐sectoral approach to reduce adolescent girls and young women's (AGYW) vulnerability to HIV in sub‐Saharan Africa. Despite widespread calls to combine structural, behavioural and biomedical HIV prevention interventions, this has not been delivered at scale. In this commentary, we reflect on the two‐year rollout of DREAMS in a high HIV incidence, rural and poor community in northern KwaZulu‐Natal, South Africa to critically appraise the capacity for a centrally co‐ordinated and AGYW‐focused approach to combination HIV prevention to support sustainable development for adolescents. Discussion DREAMS employed a directed target‐focused approach in which local implementing partners were resourced to deliver defined packages to AGYW in selected geographical areas over two years. We argue that this approach, with high‐level oversight by government and funders, enabled the rapid roll‐out of ambitious multi‐sectoral HIV prevention for AGYW. It was most successful at delivering multiple interventions for AGYW when it built on existing infrastructure and competencies, and/or allocated resources to address existing youth development concerns of the community. The approach would have been strengthened if it had included a mechanism to solicit and then respond to the concerns of young women, for example gender‐related norms and how young women experience their sexuality, and if this listening was supported by versatility to adapt to the social context. In a context of high HIV vulnerability across all adolescents and youth, an over‐emphasis on targeting specific groups, whether geographically or by risk profile, may have hampered acceptability and reach of the intervention. Absence of meaningful engagement of AGYW in the development, delivery and leadership of the intervention was a lost opportunity to achieve sustainable development goals among young people and shift gender‐norms. Conclusions Centrally directed and target‐focused scale‐up of defined packages of HIV prevention across sectors was largely successful in reaching AGYW in this rural South African setting rapidly. However, to achieve sustainable and successful long‐term youth development and transformation of gender‐norms there is a need for greater adaptability, economic empowerment and meaningful engagement of AGYW in the development and delivery of interventions. Achieving this will require sustained commitment from government and funders.

Facilitators and barriers to HIV pre-exposure prophylaxis (PrEP) uptake through a community-based intervention strategy among adolescent girls and young women in Seme Sub-County, Kisumu, Kenya

“…A critical component to the successful implementation of PrEP Pamoja was its ability to leverage existing partnerships with key local community, health sector and government entities. This was similar to some of the findings published by Chimbindi et al and Djomand et al [ 11 , 13 , 27 ]. These studies showed that multi-sectoral collaborations in addition to strengthening existing resources and policies promoted the rapid expansion of the DREAMS Initiative, contributing to increased PrEP uptake [ 11 , 27 ].…”

Young people’s experiences of sexual and reproductive health interventions in rural KwaZulu-Natal, South Africa

“…Nevertheless, alcohol and transactional sex, as well as deep rooted negative social attitudes to female sexuality (and to a lesser degree young male sexuality) continued to be a barrier to SRH. The DREAMS intervention excluded mechanisms to respond to gender-related norms and the experience of sexuality for young women (Chimbindi et al, 2020). For young men, openness for male sexuality is acknowledged, and there is also pressure to have multiple partners and enjoy sex, also putting young men at risk.…”

“…DREAMS enhanced information and knowledge of SRH services; however, young women remained constrained by power relations between men and women and DREAMS reduced its impact by leaving out young men in curriculum-based education which also focused on dispelling gender-norms (Zuma et al, 2019). Although DREAMS implemented a cash transfers intervention to respond to some of the gender dynamics, by limiting engagement of young men, this intervention did not directly respond to the gendered nature of risks that drive HIV infection among AYP (Chimbindi et al, 2020).…”

Facilitators and barriers to Pre-Exposure Prophylaxis (PrEP) uptake among adolescent girls and young women in Seme-Sub County, Kisumu, Kenya

“…al, who published a study on the implementation of the DREAMS Initiative in South Africa (12). This study showed that multi-sectoral collaborations in addition to strengthening existing resources and policies promoted the rapid expansion of the DREAMS Initiative, contributing to PrEP uptake (12,16). The authors argue that the core tenants for successful adoption and early expansion of PrEP include key stakeholder consultations and engagement, favorable legal environment for key populations, existing PrEP treatment guidelines, HIV service provider training, existing drug procurement system, innovative demand creation activities, multiple service delivery models, and government's active ownership, which is consistent with our ndings (13,16).…”