MAKING DREAMS A REALITY (PDF)

MAKING DREAMS A REALITY: SUPPORTING DETERMINED, RESILIENT, EMPOWERED, AIDS-FREE, MENTORED AND SAFE GIRLS In eastern and southern Africa, HIV/AIDS is the leading cause of death among adolescent girls and young women (AGYW), ages 15-19. In sub- Saharan Africa, girls account for 71 percent of new annual HIV infections among adolescents,1 and adolescent girls are twice as likely to be living with HIV as adolescent boys of the same age. While significant achievements have been made overall in expanding HIV services, including prevention of mother-to-child transmission and linkage to and uptake of antiretroviral treatment (ART), improvements are still needed to decrease HIV risk for AGYW. HIV prevention efforts for this population must address the wide range of overlapping vulnerabilities that AGYW face, including social isolation, economic disadvantage, discriminatory cultural norms, orphan status, and high rates of school drop out. AGYW are also vulnerable to gender-based violence (GBV), which greatly contributes to their risk of HIV. According to the Violence Against Children Surveys (VACS) supported by the U.S. Centers for Disease Control and Prevention (CDC) in Kenya, Tanzania, Swaziland, and Zimbabwe, one in three adolescent girls reports experiencing some form of sexual violence during childhood. The Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) initiative is a public-private partnership supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), which consists of a core package of evidence-based interventions that address the many overlapping vulnerabilities for AGYW. DREAMS is being implemented in 15 countries: Botswana, Cote d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. DREAMS is aiming to achieve a 40 percent reduction in new HIV infections among AGYW in these 15 countries. CDC and its implementing partners receive funding to implement the following components of the core package: • Empowering Girls and Young Women – HIV testing and counseling, and sexual and reproductive health services, including contraceptives, post-violence care, including post-exposure prophylaxis (PEP), access to condoms, and pre-exposure prophylaxis (PrEP) • Mobilizing Communities – School-based HIV and violence prevention programs and programs to strengthen communities and change behavior • Strengthening Families – Parent and caregiver programs, educational subsidies, and socio-economic approaches • Decreasing Risk in Male Sex Partners – Voluntary medical male circumcision (VMMC) and HIV treatment for men, with supplemental funding provided to the CDC country offices to support these services The layering of different interventions in targeted communities is critical to the success of DREAMS and is the cornerstone of the initiative’s innovation. Evidence shows that girls can reach their full potential when they have access to multiple interventions. Therefore, the core package of interventions offered through DREAMS is not implemented at a national level but instead is layered and concentrated within specific provinces, districts, and communities where the burden of HIV is highest. The following are examples of CDC’s programmatic support for DREAMS. • CDC supports implementation of the Families Matter! Program (FMP), a parent and caregiver training component of DREAMS, in Kenya, South Africa, Zambia, Zimbabwe, Botswana, Rwanda, Namibia, Malawi, and Haiti. FMP is an evidence-based, parent-focused intervention designed to promote positive parenting and effective parent-child communication about sexuality and sexual risk reduction – including risk of child sexual abuse and gender-based violence – for parents or caregivers of 9 to 19 year old children and youth in Africa. • CDC has completed the development of a new intervention, Teachers Matter, for use in DREAMS countries. Teachers Matter will use key components from the Families Matter! Program curriculum to help teachers overcome barriers to delivering sex education, 1 http://www.pepfar.gov/partnerships/ppp/dreams/index.htm O V E R V I E W C D C ‘ S R O L E  develop knowledge and skills related to discussing sensitive sex-related topics, and ensure that teachers feel prepared to deliver the UNESCO and other comprehensive sexuality education curricula. • CDC is analyzing VACS data to characterize AGYW’s male sex partners. These analyses include the relationship of the sex partners to the AGYW and the age difference between AGYWs and their sex partners and are used to help countries identify men who need to be targeted and reached with HIV testing and counseling, VMMC, and treatment services. • CDC has supported the implementation of PrEP for HIV-negative AGYW in 12 countries as part of PEPFAR programming or demonstration projects. Successes and lessons learned from PrEP implementation in Kenya and South Africa were highlighted for the PEPFAR solutions platform as AGYW present distinct challenges. In addition, PrEP was first implemented within PEPFAR through the DREAMS initiative; lessons learned informed expansion of PrEP use beyond AGYW. • CDC conducted a policy review of PrEP for AGYW, and developed a comprehensive brief of the policies in three countries: Kenya, Uganda, and South Africa. The policy review was expanded to all DREAMS countries with the intention of understanding gaps in policies that support PrEP use among AGYW and to increase attention, awareness, and allocation of resources among governments and other stakeholders. • DREAMS supported the implementation of recent HIV-infection surveillance in two pilot countries, Kenya and Malawi. This effort will help programs identify clusters of new HIV infection and help inform efforts to prevent further HIV transmission. The experience in these pilot countries informed rapid scale-up of recent HIV-infection surveillance, using a rapid recency test developed at CDC in 14 countries. • DREAMS works to empower young women and advance gender equality across many sectors of global health, education and economic growth. In order to address the structural inequalities (i.e., unequal division of power and resources between women and men) that affect girls’ vulnerabilities to HIV, DREAMS partners with community, faith-based, and non-governmental organizations to mobilize volunteers. These organizations are uniquely positioned to work with young women and their families where they live, in ways that few other groups can. One of these organizations, Raising Voices, implements the community mobilization program SASA!, which raises awareness of violence against women and HIV/AIDS and engages the community to rethink and reshape social norms. • In 2018, PEPFAR expanded its HIV-prevention focus to increase support for youth, ages 9-14 years. This support includes preventing sexual violence and any form of coercive/forced/non-consensual sex in the community, preventing early sexual debut, supporting healthy choices, and helping communities and families to surround youth with support and education. CDC will be supporting the IMpower rape prevention program through No Means No worldwide and with in-country implementing partners. IMpower is a 12- hour, dual-gender course for youth, ages 10-20, that has been proven to reduce the incidence of rape by half. • CDC, along with its implementing partner Jhpiego, led the development of a GBV quality assurance tool to ensure PEPFAR-supported health facilities provide the highest quality post-violence care services possible. The tool is endorsed by the World Health Organization (WHO) and is being rolled out in six PEPFAR-supported countries in 2019. • In order to understand GBV laws in countries with high HIV prevalence, given the known association between GBV and HIV acquisition, CDC conducted a comprehensive review of laws and regulations related to GBV from 10 east and southern African countries participating in the PEPFAR DREAMS initiative. The review focused on the following items: 1) constitutional provisions, 2) definition of GBV, 3) child marriage, 4) rape (including marital rape), 5) reporting, 6) response, 7) access to justice, and 8) enforcement. An increased understanding of GBV laws and their respective gaps can help lead to countries strengthening their legal environments for improved GBV prevention and response. AGYW are an important group that would benefit from strengthened GBV laws and implementation. • In an effort to empower girls and young women, DREAMS partners implement a variety of social asset building activities. For example, in Uganda, youth clubs such as Girls First Clubs and Peer Educator Clubs have been formed and are being led by DREAMS participants. Stepping Stones and SASA! programs are being conducted to build sustainable protective assets such as self-esteem, problem-solving abilities, confidence, and social networks. These programs are often linked with community savings and loans groups and health services, including HIV testing, counseling and family planning. Safe Spaces can be found throughout the community as temporary spaces near community centers, in green spaces, and in churches. AGYW benefit from life skills training and from gathering in spaces where they can talk freely and openly with peer educators and facilitators about their lives, fears, problems, and life goals. • In Zimbabwe, DREAMS funding supported the implementation of a violence against children survey. The PEPFAR team is currently conducting data to action workshops with DREAMS implementing partners in Zimbabwe to share the results of the survey and identify ways to adjust their program to respond to the data. For the first time in 2017, PEPFAR data shows significant declines in new HIV diagnoses among AGYW. In the original 10 African DREAMS countries, the majority of the highest HIV-burden communities or districts, achieved decreases of 25–40 percent or more in new HIV diagnoses among young women. Significantly, new diagnoses declined in nearly all DREAMS intervention districts. Through DREAMS, notable increases have been recorded in men who have been tested and treated, and VMMCs performed in DREAMS supported districts in three countries. Overall, in DREAMS-supported districts, there was an increased uptake in testing and treatment services A C C O M P L I S H M E N T S / R E S U L T S  for men, ages 15-49 years, compared to other similar districts; these data suggest that DREAMS contributes to PEPFAR’s efforts to achieve epidemic control. CDC’s technical experts will assist PEPFAR country teams in looking critically at how DREAMS has progressed, in order to prepare for integrating DREAMS activities into 2019 Country Operational Plans. Experiences from the DREAMS programs also inform gender and youth program improvements in countries beyond the 15 countries with DREAMS programs in place, as best practices are being generated and replicated across numerous CDC-supported programs worldwide. DREAMS is also working closely with the PEPFAR Orphans and Vulnerable Children programs to align support for the most vulnerable AGYW. As part of the DREAMS monitoring and evaluation framework, 12 indicators are being monitored on a quarterly, semi-annual, or annual basis. These indicators will help experts understand whether or not the right interventions are being delivered to the intended sub-populations of AGYW, their parents, and male sexual partners. If gaps are identified – for example, some components of DREAMS are not being successfully implemented – course corrections will be made in program delivery or in the DREAMS activities themselves. In 2018, PEPFAR introduced a new indicator to measure how many AGYW are being served in the DREAMS program and whether all AGYW in DREAMS have received the intended layered services and interventions to ensure that they remain HIV-free. For additional countries where AGYW shoulder a significant burden of HIV infection or girls and young women are not yet adequately reached with HIV services, CDC will continue to help country teams to adopt relevant components of DREAMS. In addition to programmatic activities, CDC conducted a formative assessment of AGYW in DREAMS districts in Uganda in order to understand how best to deliver HIV-prevention services to this vulnerable population. This study will provide insights about the individual, family, and community risk factors that are most relevant for AGYW and that will further inform programming over the coming years. The struggles of AGYW in DREAMS-supported countries are not unlike the struggles of young women in impoverished communities in the U.S. Lessons learned from DREAMS may be applicable to AGYW in the U.S., particularly those who are affected by both HIV and violence. Knowledge gained on how to reach young adult men and male sexual partners of AGYW may generate new insights into HIV and violence prevention in the U.S. The benefits of knowledge sharing between CDC’s work in the U.S. and in sub-Saharan Africa are bi-directional. Some of the programs being implemented in DREAMS countries – for instance, the Families Matter! Program – have been adapted from programs first developed in the U.S. As a result, CDC staff who work on HIV prevention continue to look for ways to share knowledge between domestic and global programs. B E N E F I T S O F O U R W O R K F U T U R E E F F O R T S