Evaluating the impact of the DREAMS partnership to reduce HIV incidence among adolescent girls and young women in four settings: a study protocol

Abstract

Background: HIV risk remains unacceptably high among adolescent girls and young women (AGYW) in southern

and eastern Africa, reflecting structural and social inequities that drive new infections. In 2015, PEPFAR (the United

States President’s Emergency Plan for AIDS Relief) with private-sector partners launched the DREAMS Partnership, an

ambitious package of interventions in 10 sub-Saharan African countries. DREAMS aims to reduce HIV incidence by

40% among AGYW over two years by addressing multiple causes of AGYW vulnerability. This protocol outlines an

impact evaluation of DREAMS in four settings.

Methods: To achieve an impact evaluation that is credible and timely, we describe a mix of methods that build on

longitudinal data available in existing surveillance sites prior to DREAMS roll-out. In three long-running surveillance

sites (in rural and urban Kenya and rural South Africa), the evaluation will measure: (1) population-level changes

over time in HIV incidence and socio-economic, behavioural and health outcomes among AGYW and young men

(before, during, after DREAMS); and (2) causal pathways linking uptake of DREAMS interventions to ‘mediators’ of

change such as empowerment, through to behavioural and health outcomes, using nested cohort studies with

samples of ~ 1000–1500 AGYW selected randomly from the general population and followed for two years. In

Zimbabwe, where DREAMS includes an offer of pre-exposure HIV prophylaxis (PrEP), cohorts of young women who

sell sex will be followed for two years to measure the impact of ‘DREAMS+PrEP’ on HIV incidence among young

women at highest risk of HIV. In all four settings, process evaluation and qualitative studies will monitor the delivery

and context of DREAMS implementation. The primary evaluation outcome is HIV incidence, and secondary

outcomes include indicators of sexual behavior change, and social and biological protection.

Discussion: DREAMS is, to date, the most ambitious effort to scale-up combinations or ‘packages’ of multi-sectoral

interventions for HIV prevention. Evidence of its effectiveness in reducing HIV incidence among AGYW, and

demonstrating which aspects of the lives of AGYW were changed, will offer valuable lessons for replication.

Keywords: HIV prevention, Adolescent health, Complex intervention, Impact evaluation, Gender equity, Kenya,

South Africa, Zimbabwe