Awareness and uptake of layered HIV prevention programming for young women: analysis of population-based surveys in three DREAMS settings in Kenya and South Africa

Abstract

Background: The DREAMS Partnership is an ambitious effort to deliver combinations of biomedical, behavioural and structural interventions to reduce HIV incidence among adolescent girls and young women (AGYW). To inform multi-sectoral programming at scale, across diverse settings in Kenya and South Africa, we identified who the programme is reaching, with which interventions and in what combinations.

Methods: Randomly-selected cohorts of 606 AGYW aged 10-14 years and 1081 aged 15-22 years in Nairobi and 2184 AGYW aged 13-22 years in uMkhanyakude, KwaZulu-Natal, were enrolled in 2017, after ~ 1 year of DREAMS implementation. In Gem, western Kenya, population-wide cross-sectional survey data were collected during roll-out in 2016 (n = 1365 AGYW 15-22 years). We summarised awareness and invitation to participate in DREAMS, uptake of interventions categorised by the DREAMS core package, and uptake of a subset of 'primary' interventions. We stratified by age-group and setting, and compared across AGYW characteristics.

Results: Awareness of DREAMS was higher among younger women (Nairobi: 89%v78%, aged 15-17v18-22 years; uMkhanyakude: 56%v31%, aged 13-17v18-22; and Gem: 28%v25%, aged 15-17v18-22, respectively). HIV testing was the most accessed intervention in Nairobi and Gem (77% and 85%, respectively), and school-based HIV prevention in uMkhanyakude (60%). Among those invited, participation in social asset building was > 50%; > 60% accessed ≥2 core package categories, but few accessed all primary interventions intended for their age-group. Parenting programmes and community mobilisation, including those intended for male partners, were accessed infrequently. In Nairobi and uMkhanyakude, AGYW were more likely to be invited to participate and accessed more categories if they were: aged < 18 years, in school and experienced socio-economic vulnerabilities. Those who had had sex, or a pregnancy, were less likely to be invited to participate but accessed more categories.

Conclusions: In representative population-based samples, awareness and uptake of DREAMS were high after 1 year of implementation. Evidence of 'layering' (receiving multiple interventions from the DREAMS core package), particularly among more socio-economically vulnerable AGYW, indicate that intervention packages can be implemented at scale, for intended recipients, in real-world contexts. Challenges remain for higher coverage and greater 'layering', including among older, out-of-school AGYW, and community-based programmes for families and men.

Keywords: Adolescent girls; Complex intervention; Evaluation; HIV prevention; Implementation.

Fig. 1

Framework for DREAMS core package of interventions

Fig. 2

Uptake* of DREAMS core package** in three settings by: a age; b DREAMS invitation. Footnote:*uMkhanyakude and Nairobi: Participated in the last 12 months (datasets from 2017); Gem: ever participated (dataset from 2016); Uptake regardless whether or not the intervention was identified as a ‘DREAMS programme’ **Interventions aligned with PEPFAR Core Package outlined to countries in 2015

Fig. 3

Uptake* of DREAMS core package** in Nairobi, 10–14 year-olds: a overall, b by DREAMS invitation. Footnote: *Participated in the last 12 months (dataset from 2017); Uptake regardless whether or not the intervention was identified as a ‘DREAMS programme’ **Interventions aligned with PEPFAR Core Package outlined to countries in 2015

Fig. 4

Layering of interventions across DREAMS core package levels in Nairobi and uMkhanyakude. Footnote: Numbers indicate those AGYW aged 15–22 in Nairobi and 13–22 in uMkhanyakude who used any intervention within each DREAMS core package intervention level in the last 12 months

Fig. 5

Number of primary interventions accessed, overall, and among those invited to DREAMS, by age, Nairobi. Footnote: Primary interventions in Kenya: HIV Testing Services, HIV and violence prevention, contraceptive method mix education, condom education and demonstration, financial capability training, entrepreneurship training, social asset building (PrEP excluded from the analysis - not asked on the 2017 Nairobi enrolment survey)

Fig. 6

Number of primary interventions accessed, overall, and among those invited to DREAMS, by age, uMkhanyakude. Footnote: Primary interventions in South Africa: School-based HIV & violence prevention, social assets building (applicable to Non-sexually active and sexually active aged 10–19 years), Condoms, HIV testing and Sexual & reproductive health (applicable to sexually active only)