The evolution of DREAMS: using data for continuous program improvement

Abstract

The DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe) Partnership, a public-private partnership launched by the United States President's Emergency Plan for AIDS Relief (PEPFAR), represents the largest investment in comprehensive HIV prevention for adolescent girls and young women (AGYW) ever made in a single global initiative. This paper describes the evolution of programming over time using the triangulation of multiple data sources to develop and refine an impactful program, as well as to improve efficacy and resource investment. Methods of analysis used to evolve this programming include reviews of literature on behavioral, biomedical and structural interventions, and HIV vulnerability; PEPFAR program data; external implementation science and impact studies;observations from site visits; in-depth reviews of program materials; and inputs from AGYW and other stakeholders. Key program improvements made in response to this real-time data use are described, including the rationale for programmatic changes and the evidence base for continual program refinements. This review emphasizes the importance and process of implementing the most effective combination of structural and biomedical HIV prevention programming, based on the best available science, while also adapting to local context in a way that does not compromise effectiveness or violate core implementation principles. Data from research and evaluation are critical to move the HIV prevention field toward more impactful and efficient programming responsive to the lived realities of AGYW. A central tenant to using these data sources effectively is the inclusion of AGYW in decision-making throughout the planning and implementation of programming.

Modeling DREAMS impact: trends in new HIV diagnoses among women attending antenatal care clinics in DREAMS countries

“…This investment must include continuous monitoring and evaluation to determine the impact on HIV diagnoses among AGYW using multiple sources of data for timely programmatic improvements, especially given the complexities of implementing programming that combines biomedical, structural, and behavioral interventions. The analyses in this article complement others included in this supplement issue that directly speak to implementation improvements [29] and changes in secondary outcomes [30,31], and changes in incidence [31]. Our findings align with similar published modeling in Lesotho that found declines in new HIV diagnosis rates at ANC in DREAMS SNUs were greater than in non-DREAMS SNUs [32].…”

“…DREAMS has demonstrated that continuous data analyses and program course corrections based on quantitative and qualitative information can result in improvements in both implementation and outcomes. Two years ago, PEPFAR conducted a similar predictor analysis, revealing that a greater number of implementing partners, partial geographic coverage within a SNU, and implementation in urban areas was associated with smaller declines in new diagnoses [34]. In response, DREAMS guidance was revised to encourage consolidation and coordination of partner efforts and implementation across full SNUs [35].…”

Multisectoral, Combination HIV Prevention for Adolescent Girls and Young Women: A Qualitative Study of the DREAMS Implementation Trajectory in Zambia

“…Contextual interventions include community-based services that cannot necessarily be delivered discretely to DREAMS participants but can be prioritized in specific communities (e.g., with higher HIV burdens) or tailored to specific populations (e.g., male partners). 15 In Zambia, contextual interventions included community mobilization and norms-changing activities focused on violence prevention and gender equity.…”

“…IP organizations delivering individual DREAMS interventions are integrated primarily through formal referral mechanisms, whereby implementing staff must actively link (through accompaniment or individual case management) AGYW to services offered by other IP organizations within the DREAMS Partnership. 15 Individual interventions included in the primary service package are also delivered through community-based platforms called DREAMS centers or venues located within communities where AGYW congregate and participate in DREAMS-sponsored activities and services.…”

“…When delivered in combination, individual interventions included in the DREAMS core package are more accessible to AGYW, customizable and tailored to individual client's needs, and positioned to synergistically address overlapping drivers of HIV risk. 15 Combination service delivery models like DREAMS also offer promising returns on investments-by packaging individual interventions into a streamlined service delivery platform, they can magnify the expected benefits of these same interventions delivered independently, optimizing cost-effectiveness. [16][17][18] Nevertheless, relative to standalone HIV initiatives, combination HIV prevention programs like DREAMS require innovation, flexibility, and integration-characteristics that pose unprecedented challenges to intervention fidelity and sustainability.…”