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


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          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.


          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.


          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.

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          Most cited references54

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          Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort.

          Intimate partner violence (IPV) is associated with HIV infection. We aimed to assess whether provision of a combination of IPV prevention and HIV services would reduce IPV and HIV incidence in individuals enrolled in the Rakai Community Cohort Study (RCCS), Rakai, Uganda.
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            Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study.

            Cross-sectional studies have shown that intimate partner violence and gender inequity in relationships are associated with increased prevalence of HIV in women. Yet temporal sequence and causality have been questioned, and few HIV prevention programmes address these issues. We assessed whether intimate partner violence and relationship power inequity increase risk of incident HIV infection in South African women. We did a longitudinal analysis of data from a previously published cluster-randomised controlled trial undertaken in the Eastern Cape province of South Africa in 2002-06. 1099 women aged 15-26 years who were HIV negative at baseline and had at least one additional HIV test over 2 years of follow-up were included in the analysis. Gender power equity and intimate partner violence were measured by a sexual relationship power scale and the WHO violence against women instrument, respectively. Incidence rate ratios (IRRs) of HIV acquisition at 2 years were derived from Poisson models, adjusted for study design and herpes simplex virus type 2 infection, and used to calculate population attributable fractions. 128 women acquired HIV during 2076 person-years of follow-up (incidence 6.2 per 100 person-years). 51 of 325 women with low relationship power equity at baseline acquired HIV (8.5 per 100 person-years) compared with 73 of 704 women with medium or high relationship power equity (5.5 per 100 person-years); adjusted multivariable Poisson model IRR 1.51, 95% CI 1.05-2.17, p=0.027. 45 of 253 women who reported more than one episode of intimate partner violence at baseline acquired HIV (9.6 per 100 person-years) compared with 83 of 846 who reported one or no episodes (5.2 per 100 person-years); adjusted multivariable Poisson model IRR 1.51, 1.04-2.21, p=0.032. The population attributable fractions were 13.9% (95% CI 2.0-22.2) for relationship power equity and 11.9% (1.4-19.3) for intimate partner violence. Relationship power inequity and intimate partner violence increase risk of incident HIV infection in young South African women. Policy, interventions, and programmes for HIV prevention must address both of these risk factors and allocate appropriate resources. National Institute of Mental Health and South African Medical Research Council. Copyright 2010 Elsevier Ltd. All rights reserved.
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              The DREAMS core package of interventions: A comprehensive approach to preventing HIV among adolescent girls and young women

              In sub-Saharan Africa, adolescent girls and young women (AGYW) are 5 to 14 times more likely to be infected with HIV than their male peers. Every day, more than 750 AGYW are infected with HIV. Many factors make girls and young women particularly vulnerable to HIV, including gender-based violence, exclusion from economic opportunities, and a lack of access to secondary school. The President’s Emergency Plan for AIDS Relief (PEPFAR) is dedicating significant resources through the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) partnership to impact the lives of women and girls based on PEPFAR’s mission to help countries achieve epidemic control of HIV/AIDS. The data show that new HIV infections must be reduced in AGYW, or the global community risks losing the extensive progress made towards reaching epidemic control. With support from PEPFAR and private sector partners—the Bill & Melinda Gates Foundation, Gilead Sciences, Girl Effect, Johnson & Johnson and ViiV Healthcare, DREAMS works together with partner governments to deliver a core package of interventions that combines evidence-based approaches that go beyond the health sector, addressing the structural drivers that directly and indirectly increase girls’ HIV risk. Not only is DREAMS an effort to reduce new HIV infections, but it aims to reduce other critical vulnerabilities such as gender-based violence. When girls and young women thrive, the effects are felt throughout their families, communities and countries.

                Author and article information

                J Int AIDS Soc
                J Int AIDS Soc
                Journal of the International AIDS Society
                John Wiley and Sons Inc. (Hoboken )
                31 August 2020
                September 2020
                : 23
                : Suppl 5 , Shifting paradigms: holistic and empowering approaches for adolescent HIV. Guest Editor: Moherndran Archary, Audrey E Pettifor, Elona Toska ( doiID: 10.1002/jia2.v23.s5 )
                : e25575
                [ 1 ] Africa Health Research Institute Mtubatuba South Africa
                [ 2 ] London School of Hygiene and Tropical Medicine London United Kingdom
                [ 3 ] Institute for Global Health University College London London United Kingdom
                [ 4 ] Harvard University Boston MA USA
                [ 5 ] University of the Witwatersrand Johannesburg South Africa
                Author notes
                [*] [* ] Corresponding author: Maryam Shahmanesh, University College London (UCL) Institute for Global Health, Mortimer Market Centre, off Capper Street, London, WC1E 6JB, United Kingdom. Tel: +44 7776185572. ( m.shahmanesh@ 123456ucl.ac.uk )

                Author information
                © 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                : 10 January 2020
                : 11 June 2020
                : 19 June 2020
                Page count
                Figures: 1, Tables: 0, Pages: 6, Words: 10560
                Funded by: People Programme (Marie Curie Actions) of the European Union’s seventh Framework Programme
                Award ID: FP7/2007‐2013
                Funded by: Bill and Melinda Gates Foundation , open-funder-registry 10.13039/100000865;
                Award ID: OPP1136774
                Funded by: National Institutes of Health , open-funder-registry 10.13039/100000002;
                Award ID: 5R01MH114560–03
                Funded by: Wellcome Trust , open-funder-registry 10.13039/100010269;
                Award ID: 082384/Z/07/Z
                Custom metadata
                September 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.8 mode:remove_FC converted:01.09.2020

                Infectious disease & Microbiology
                adolescent girls and young women,hiv,holistic,interventions,layering,implementation


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