Building evidence to guide PrEP introduction for adolescent girls and young women

This document was developed by the Population Council, with support from the Bill & Melinda Gates Foundation, to provide DREAMS country teams with practical guidance on building evidence to guide pre-exposure prophylaxis (PrEP) introduction for adolescent girls and young women (AGYW). The primary audiences for this document are health policymakers and program planners who will be making decisions about how PrEP is introduced and the researchers who will assess AGYW’s specific needs and experiences. Our aim is to complement emerging global guidance on PrEP and ongoing work regarding delivery platforms, marketing, and policy and regulatory frameworks for PrEP introduction more generally. We focus on examining the factors that influence informed choice, demand, and use of PREP by young women and that influence client–provider interactions. Further, this document can serve as a useful guide to gather data on user, community, and provider perspectives as countries move from introduction to broad-based implementation of PrEP

Evidence to support HIV prevention for adolescent girls and young women (AGYW) and their male partners: Results from Malawi Dreams studies with AGYW, male partners of AGYW, men living with HIV, and program implementing partners

Project SOAR, led by the Population Council, in partnership with the Center of Reproductive Health at the University of Malawi College of Medicine, conducted a research portfolio to generate evidence to reduce HIV risk among adolescent girls and young women (AGYW) and their male partners. The objectives of this implementation research were to generate evidence for describing HIV-related risk factors among AGYW; assess the extent to which the overall DREAMS project contributed toward the goal of reducing HIV risk among AGYW; and understand the characteristics of male partners and how to link them to HIV services, as well as retain men living with HIV in care. (DREAMS is an initiative that aims to ensure that AGYW aged 15–24 have an opportunity to live Determined, Resilient, Empowered AIDS-free, Mentored, and Safe lives.) The findings of the study, conducted in the Zomba and Machinga districts and detailed in this report, aimed to inform HIV prevention programs and policies with the goal of improving health programming and overall well-being of AGYW and men in Malawi and other similar settings

PrEP introduction for adolescent girls and young women

The International AIDS Conference in Durban, South Africa, in July 2016, has renewed interest and momentum around HIV prevention. High and sustained HIV incidence rates—about 2 million people acquiring HIV every year for the past 5 years—highlight the need for new prevention technologies for populations at substantial risk of HIV.1 As many as 7000 new infections a week are occurring in the most vulnerable adolescent girls and young women in eastern and southern Africa. 75% of young people in sub-Saharan Africa living with HIV are adolescent girls and young women age 15–24 years; AIDS is the leading cause of death for girls age 10–19 years in Africa

DREAMS implementation science: Round 2 Data, Malawi

The Population Council is the research partner to DREAMS—a global partnership to reduce HIV infections among adolescent girls and young women (AGYW) in 10 sub-Saharan African countries. DREAMS aims to reduce HIV infections among adolescent girls and young women. This dataset is Round 2 data collection with young Malawian women (aged 15–24 years at Round 1) enrolled in DREAMS programming. All respondents also participated in the Round 1 survey. These data are from a Population Council-led implementation science study to assess the reach and effectiveness of DREAMS programming in two catchment areas

DREAMS implementation science: All Round 1 Data, Malawi

The Population Council is the research partner to DREAMS—a global partnership to reduce HIV infections among adolescent girls and young women (AGYW) in 10 sub-Saharan African countries. DREAMS aims to reduce HIV infections among adolescent girls and young women. This dataset is Round 1 data collection with young Malawian women (aged 15–24 years) enrolled in DREAMS programming. These data are from a Population Council-led implementation science study to assess the reach and effectiveness of DREAMS programming in two catchment areas

Relationship dynamics and anticipated stigma: Key considerations for PrEP use among Tanzanian adolescent girls and young women and male partners

Objectives: We examined key gender, interpersonal and community dynamics influencing PrEP acceptability among adolescent girls and young women (AGYW) and their male partners. Methods: We administered 12 in-depth interviews (IDI) to partnered, or married AGYW aged 15-24 years living without HIV, and 16 IDIs to male partners living without HIV aged 18 or older, partnered or married to an AGYW in Tanzania. Card sorting, a participatory qualitative method for facilitating systematic discussion, was used to identify attitudes, values, and desires that would influence PrEP acceptability. Results: Relationship distrust, partner communication about HIV risk, and need to control HIV risk were highly influential considerations for PrEP use. AGYW and male partners both wanted to discuss PrEP use amidst relationship distrust, while most male partners encouraged AGYW PrEP use for shared protective benefit. Anticipated stigma of being perceived as a person living with HIV, as a result of PrEP use, was a deterrent for both AGYW and male partners while AGYW also feared additional stigma of being considered sexually promiscuous. Conclusions: Couples counseling for PrEP uptake and adherence might be a well-placed strategy for couples who are living without HIV to educate one another about the relationship benefits of using PrEP, thereby increasing its acceptance and adherence, addressing unequal power dynamics, and reducing associated relationship distrust. Community awareness and education about PrEP can help curb persistent PrEP stigma, including intersectional stigma

Hearing from men living with HIV: Experiences with HIV testing, treatment, and viral load suppression in four high-prevalence countries in sub-Saharan Africa

Engaging men in HIV services remains a challenge across sub-Saharan Africa. There is a critical need to better understand facilitators of men\u27s successful engagement with HIV services and assess if there are similarities across contexts. We conducted in-depth interviews and focus group discussions with 92 men living with HIV (MLHIV) across Malawi, Uganda, South Africa, and Eswatini, most of whom had been diagnosed with HIV within the last 5 years. We coded interviews for themes using a constant-comparative approach. We contextualized our findings within a socioecological framework. HIV testing was primarily motivated by illness (individual level), though illness was sometimes accompanied by prompting and support from healthcare providers and/or intimate partners. Once diagnosed, nearly all participants reported immediate linkage to care, initiation of antiretroviral therapy (ART), and subsequent ART adherence. ART initiation and adherence were facilitated by men\u27s sense of agency and ownership over their health (individual level), social support from intimate partners, friends, and family (interpersonal/network level), supportive-directive counseling from healthcare providers (institutional/health systems level), and male-friendly services, i.e., rapid, respectful, private (institutional/health systems level). Health literacy regarding viral suppression (individual level), strengthened by patient-provider communication (institutional/health systems level), was highest in Uganda, where most men could discuss viral load testing experiences, report their viral load status (most reported suppressed), and demonstrate an understanding of treatment as prevention. Elsewhere, few participants understood what viral load suppression was and even fewer knew their viral load status. Our findings reveal socioecological-level facilitators of men\u27s progress across the HIV-care continuum. Programs may want to leverage facilitators of ART initiation and adherence that span socioecological levels—e.g., healthcare ownership and agency, social support, supportive-directive counseling—and apply them to each end of the continuum to encourage early HIV testing/diagnosis and improve health literacy to help men understand and achieve viral load suppression

Challenges to and opportunities for the adoption and routine use of early warning indicators to monitor pediatric HIV drug resistance in Kenya

Abstract Background Pediatric non-adherence to antiretroviral therapy (ART), loss to follow-up, and HIV drug resistance (HIVDR) are challenges to achieving UNAIDS’ targets of 90% of those diagnosed HIV-positive receiving treatment, and 90% of those receiving treatment achieving viral suppression. In Kenya, the pediatric population represents 8% of total HIV infections and pediatric virological failure is estimated at 33%. The monitoring of early warning indicators (EWIs) for HIVDR can help to identify and correct gaps in ART program functioning to improve HIV care and treatment outcomes. However, EWIs have not been integrated into health systems. We assessed challenges to the use of EWIs and solutions to challenges identified by frontline health administrators. Methods We conducted key informant interviews with health administrators who were fully knowledgeable of the ART program at 23 pediatric ART sites in 18 counties across Kenya from May to June 2015. Thematic content analysis identified themes for three EWIs: on-time pill pick-up, retention in care, and virological suppression. Results Nine themes—six at the facility level and three at the patient level—emerged as major challenges to EWI monitoring. At the facility level, themes centered on system issues (e.g., slow return of viral load results), staff shortages and inadequate adherence counseling skills, lack of effective patient tracking and linkage systems, and lack of support for health personnel. At the patient level, themes focused on stigma, non-disclosure of HIV status to children who are age eligible, and little engagement of guardians in the children’s care. Practical solutions identified included the use of lay health workers (e.g., peer educators, community health workers) to implement a variety of care and treatment tasks, whole facility approaches to adherence counseling, adolescent peer support groups, and working with children directly as soon as they are age eligible. Discussion The monitoring of EWIs has not been routine in health facilities in Kenya due to several challenges. However, facilities have implemented novel strategies to address some of these barriers. Future work is needed to assess whether scale-up of some of these approaches can aid in the effective use of EWIs and improving HIV care outcomes among the pediatric population

Girl-only clubs’ influence on SRH knowledge, HIV risk reduction, and negative SRH outcomes among very young adolescent girls in rural Malawi

Background: Early adolescence is an important period to lay the foundation for positive sexual health development that can overcome sexual and reproductive health (SRH) challenges faced by very young adolescents (VYAs) as they reach puberty and sexual debut. In this study, we explored the following questions: first, what are the experiences of VYA girls on DREAMS’ Go Girl club participation? Second, how does club participation influence the VYAs SRH knowledge to reduce their risk for HIV and negative sexual health outcomes? Methods: This was a qualitative study in which twenty-three in-depth interviews were conducted with VYA girls aged 12–14 years. These girls were enrolled in girl-only clubs in two rural southern districts in Malawi. The clubs were a part of larger comprehensive HIV prevention project called DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) which provided an evidence-based core package of interventions to VYAs to prevent HIV. Interventions included improved access to key health services, education support, social skills, asset building, and economic strengthening. Narrative inquiry was used to generate first-hand accounts of the girls’ experiences with club participation. Thematic analysis was used to generate themes from the transcribed stories. Results: Six main themes were generated: 1) reasons for joining the clubs with desire to learn about SRH as a motivation for joining the clubs.; 2) influence on gender norms and roles whereby participants described a change of gender roles and norms at home; 3) influence on child abuse practices whereby participants reported a decline in child abusive practices at home;4) influence on life skills and social networks whereby participants described learning about networking; 5) support to go back to school whereby out-of-school girls described how economic empowerment of their guardians facilitated their return to school; and 6) influence of clubs on SRH knowledge acquisition and behaviours whereby participants described acquiring knowledge on sexual health issues. Conclusion: Girls-only HIV and SRH programs coupled with economic empowerment for their families can be effective in keeping VYA girls in school and improving SRH knowledge and health seeking behavior

DREAMS implementation science: All Round 1 Data, Kenya

The Population Council is the research partner to DREAMS— a global partnership to reduce HIV infections among adolescent girls and young women (AGYW) in 10 sub-Saharan African countries. DREAMS aims to reduce HIV infections among AGYW. This dataset is Round 1 data collection with young women (ages 15–24 years) from Kisumu county, Kenya from a Population Council-led implementation science study to assess the reach and effectiveness of DREAMS programming in two catchment areas in Kisumu county, Kenya. This cross-sectional data includes data from AGYW enrolled in DREAMS programming and AGYW who lived in the catchment area but were not enrolled in DREAMS