Translating DREAMS into practice: Early lessons from implementation in six settings

Abstract

BackgroundThe ‘DREAMS Partnership’ promotes a multi-sectoral approach to reduce adolescent girls and young women’s (AGYW) vulnerability through a core package of interventions targeting multiple sources of HIV risk–to promote Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) lives. Implementation of such multi-sectoral programmes is complex and requires adaptation to national and local contexts. We describe the early implementation of DREAMS in diverse settings, to identify lessons for the scale-up and replication of combination programmes for young people.MethodsAs part of evaluations underway in six DREAMS sites in three countries (Kenya, South Africa and Zimbabwe), we draw on process evaluation data collected from focus group discussions, key informant interviews, and in-depth interviews with beneficiaries, parents/caregivers, programme managers and opinion leaders. Additionally, structured observations were conducted and Gantt charts completed upon consultation with implementers. We concurrently reviewed documentation available on DREAMS and held cross-site discussions to interpret findings.FindingsAll sites sought to implement all components of the DREAMS core package, but how and when they were implemented varied by context. Models of delivery differed, with either multiple or single partners responsible for some or all interventions. Key challenges included the urgent and ambitious expectations of DREAMS; ‘layering’ multiple interventions across different sectors (health, education, social welfare); supporting individuals’ journeys between services to improve uptake and retention; engaging communities beyond direct beneficiaries; avoiding perceived/actual exclusivity; and ensuring continuity of commitment and funding for DREAMS. Despite significant challenges, DREAMS was well-received in the communities and perceived by both beneficiaries and implementers to empower AGYW to remain HIV negative. Structures, protocols and tools were introduced to strengthen referrals and deliver services targeted to the age and circumstances of young people.ConclusionsThe benefits of combinations or integrated ‘packages’ of interventions are increasingly recognised. Early implementation of DREAMS provides useful lessons for improving coordination across multiple partners using a phased, systematic approach, regular adaptions to each unique context, and ensuring community ownership.

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“…Adolescent girls and young women (AGYW) (ages [15][16][17][18][19][20][21][22][23][24] remain disproportionately affected by HIV, comprising 11% of the global population and 20% of new HIV diagnoses [1]. In sub-Saharan Africa (SSA), where 80% of AGYW living with HIV reside, AGYW become infected five to seven years earlier than their male counterparts [2,3].…”

The Political, Research, Programmatic, and Social Responses to Adolescent Sexual and Reproductive Health and Rights in the 25 Years Since the International Conference on Population and Development

“…The DREAMS initiative supports the application of a core package of evidence-based interventions addressing adolescent girls and young women, their sexual partners, their families, and their wider communities to address HIV risk behaviors, socioeconomic vulnerabilities, and gender-based violence (GBV). Impact evaluation activities are ongoing, but important implementation lessons are emerging [76,77].…”

“…Beyond these adolescent-specific issues, the road to improved HIV programming for young people has been beset by the tensions affecting the broader population, such as balances between prevention and treatment and competition between the HIV and SRH fields. In addition, programming improvements have been further hindered by challenges in achieving and sustaining coordinated actions by multiple sectors [77].…”

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