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Summary of PEPFAR DREAMS Guidance

PEPFAR DREAMS Guidance Updated March 2021 1 Table of Contents Why DREAMS ................................................................................................................................................ 2 What is DREAMS? ......................................................................................................................................... 2 DREAMS Program Implementation .............................................................................................................. 3 Assuring Quality Implementation ............................................................................................................... 12 Monitoring and Evaluating a DREAMS Program ......................................................................................... 14 Bibliography ................................................................................................................................................ 21 Appendix A: DREAMS Risk and Vulnerability Assessment .......................................................................... 27 Appendix B: The Core Package of Interventions – Rationale, Curriculum and Putting it all Together ....... 30 Appendix C: DREAMS Layering Completion Table Instructions, Example and Template ........................... 45 Appendix D: DREAMS Curriculum Review Process and Checklist ............................................................... 49 Appendix E: DREAMS Program Completion and Saturation ....................................................................... 50 Appendix F: DREAMS Technical Considerations and Guidance on Mentoring ........................................... 59 2 Why DREAMS Adolescent girls and young women (AGYW) face an increased vulnerability for HIV acquisition when compared to their peers. Globally, there are 20 million women living with HIV (1), and young women age 15-24 are two to 14 times as likely to acquire HIV than males of the same age, dependent on country (2)(3) Around 5,000 young women become infected with HIV each week and in sub-Saharan Africa, girls and young women account for four out of five new HIV infections among youth age 15-24 (2)(1). Additionally, data show AGYW are a priority population to target in order to reduce new infections to reach HIV epidemic control (1)(2)(3). Routine HIV prevention activities have not been effective in reaching this subpopulation. An evidence- based and comprehensive program is necessary to prevent new infections for an AIDS-free generation. What is DREAMS? In order to prioritize AGYW’s health and wellbeing, and reach HIV epidemic control, PEPFAR announced an ambitious public- private partnership, the Determined, Resilient, Empowered, AIDS-Free, Mentored and Safe (DREAMS) partnership, on World AIDS Day in 2014. DREAMS is currently implemented in 15 countries in partnership with the Bill and Melinda Gates Foundation, Girl Effect, Gilead Sciences, ViiV Healthcare, and Johnson & Johnson. DREAMS success depends on collaboration and coordination with national and local government officials and other relevant stakeholders and community partners including AGYW themselves. DREAMS targets vulnerable AGYW (10-24 years) in communities with a high burden of HIV who are at an increased risk of acquiring HIV due to various demographic, geographic, behavioral, and structural reasons. The DREAMS core package is an evidence-based/informed, age-appropriate, comprehensive package of biomedical, behavioral, and structural interventions across multiple sectors shown to mitigate the risk factors that may lead to HIV infection. Additionally, DREAMS provides contextual interventions to shift community norms and perceptions in order to create an enabling environment that supports HIV prevention. DREAMS, delivered in partnership with the country’s government and relevant stakeholders, provides a comprehensive package of core interventions to address key factors that make adolescent girls and young women particularly vulnerable to HIV. These include behavioral factors (i.e. multiple sex partners, condom-less sex), and family dynamics and structural barriers (i.e. gender-based violence, exclusion from economic opportunities, and a lack of access to secondary school). This model suggests a variety of 3 interventions in order to synergize the approach to reduce risk of HIV and mitigate the factors that lead to HIV (i.e. school drop-out, alcohol use/misuse, unprotected sex) (5) (6) (7). These specific interventions will be explored in more detail throughout this document. This document details the process for planning, implementing, monitoring and evaluating a DREAMS program, and makes reference to other documents found on PEPFAR SharePoint and/or in the appendix. It utilizes findings from literature, evidence-based best practices, and specific DREAMS studies. DREAMS Program Implementation Evidence-based decisions, government buy-in, stakeholder engagement and programming for impact are necessary in planning a DREAMS program. Globally accepted literature and guidance must be thoroughly understood and adapted to a country context in agreement with stakeholders, implementers and DREAMS ambassadors as AGYW representatives. By working within government structures and by prioritizing AGYW within all levels of planning and implementation, DREAMS aims to be effective and sustainable (5). This section covers stakeholder engagement, geographic and demographic prioritization and core package planning. Who needs to be involved: Working with stakeholders, governments and AGYW to build DREAMS PEPFAR resources alone will not be sufficient to permanently reduce the vulnerabilities of AGYW to achieve an AIDS-free generation. Policy, structural, and system reforms within the current local health, education, and judicial systems are necessary to ensure the sustainable impact of these interventions. PEPFAR has learned several important lessons for ensuring that DREAMS programs are poised to sustain the gains made in reducing new HIV infections. These lessons include leveraging key stakeholders, decision makers and DREAMS AGYW (i.e., program participants, ambassadors, mentors) to assure buy-in and input. Given the nature of the DREAMS core package, multi-sectoral stakeholder political will and shared responsibility are essential for success and sustainability, as this is likely dependent on integration into existing government-supported systems and structures. Government engagement and leadership in planning and management of HIV activities is essential, both at the beginning and throughout the program cycle. Multi-sector engagement, including engaging government leadership, leveraging political will and utilizing task sharing through direct commitments, is essential to the DREAMS Partnership. This extends to other key leaders and stakeholders as well. It is crucial to work directly with other donors such as Global Fund and relevant UN agencies to reach more AGYW across all platforms. Collaborative planning and decision making between the government, key stakeholders including civil society, and donors (PEPFAR, Global Fund and UN) enables governments to lead and commit vital resources to these efforts, while improving complementary programming across donors. Country team and HQ engagement with AGYW living with HIV and AGYW who are vulnerable to acquiring HIV informs our programming and makes it more responsive. A key component of DREAMS are DREAMS ambassadors. DREAMS ambassadors are current or former DREAMS participants who play a variety of roles including recruiting AGYW, providing interpersonal support of AGYW during service 4 delivery, and representing AGYW and fellow DREAMS participants in local, national, and global meetings. DREAMS ambassadors are selected by implementing partners based on leadership skills, interest in advocacy and local knowledge of the community. Beginning in COP20, country teams are required to work with partners to hire DREAMS Ambassadors as district-level coordinators to lead DREAMS coordination and promotion at the provincial, regional and/or district level (depending on context). For example, this local coordinator helps streamline communication between facility and community partners, PEPFAR and other donors, government bodies and AGYW for efficiency and overall programmatic impact. These coordination efforts are meant to empower AGYW and ensure that AGYW input remains at the center of design, implementation, and coordination of DREAMS. Policy, structural, and system reforms within the current health, education, and judicial systems are often necessary to ensure the sustainable impact of these interventions. For example, ensuring universal access to primary and secondary education for girls regardless of whether they are pregnant or have children is essential to achieving DREAMS outcomes. Additionally, advocating for accessible family planning is important since restricting access to contraception hinders DREAMS goals. Providing equitable family planning services can be leveraged as part of a partnership with local government. In the justice sector, enforcement of existing laws prohibiting child marriages, statutory rape/defilement and female genital mutilation (FGM), and ensuring that AGYW at risk for child marriage and/or FGM have legal protection, may contribute to the long term impact of programs designed to reduce HIV risk for AGYW. Prosecution of perpetrators of sexual violence is another area where the national response can enhance specific programs for post-violence care. The advocacy related to DREAMS implementation has helped shift the policy environment for PrEP accessibility for AGYW. In COP20, all 15 DREAMS countries are planning to implement PrEP for AGYW, but there is still room for improvement. The COVID-19 pandemic revealed the necessity to continue advocating for supportive PrEP policies, such as community distribution, at all levels of governance and implementation. Where will you implement: Geographic prioritization DREAMS is not meant to be implemented country-wide, but rather in the highest burden areas where large numbers of AGYW are vulnerable to HIV acquisition. Geographic considerations based on current epidemiological data, survey findings, cultural considerations and other routine indicators must be utilized to determine priority areas. When planning a DREAMS program, use a data-based approach and start with the epidemiology. Consider the following: ● Overall HIV burden (i.e., number of PLHIV) ● Total population ● HIV incidence of 15-24 year old females (focus on areas with >1% incidence) ● Disparity in incidence between AGYW 15-24 and adolescent boys and young men (ABYM) ● Other extenuating circumstances and cultural/implementation considerations (e.g. areas with transport corridors, urban hotspots, safety concerns, high rates of adolescent pregnancy, low rates of secondary school completion, etc.) Additionally, it is important to think about the DREAMS geographical footprint when planning where to begin implementation or expansion. DREAMS is intended to be implemented in every ward or 5 neighborhood within the selected DREAMS SNUs in most cases. Yet, there is flexibility in geographical footprint if a proper epidemiological-based justification can be provided for prioritizing or excluding specific sub-SNU’s (e.g. extremely rural sub-SNUs that have a low population, all HIV concentrated in one sub-SNU). Who will you enroll: Demographic prioritization: Beyond geographic prioritization, the DREAMS program aims to reach girls who are at the greatest risk of acquiring HIV. Based on the literature on what factors increase an AGYW’s risk for acquiring HIV, a list of enrollment criteria can be found in Table 1, and additional information can be found in Appendix A. These criteria are intended to assure the most HIV-vulnerable girls within the highest burden districts are identified and enrolled in DREAMS. AGYW (18-24 years old) who sell sex or women who participate in transactional sex, defined as a sexual relationship that is based on an implicit assumption that sex will be exchanged for material support or some other benefit, are at a greater risk of HIV. For AGYW who sell sex, DREAMS programs should work with key population (KP) staff and female sex worker (FSW) programs to ensure that AGYW who have transactional sex and young women sex workers are reached and enrolled in the appropriate program. Factors to consider include: age, type of programming needed to best serve the AGYW, and IP capabilities to handle the special needs of these populations. Violence is strongly and consistently associated with sex work and transactional sex. It is critical that interventions to decrease HIV risk associated with sex work and transactional sex incorporate comprehensive violence prevention programming. Overall, DREAMS teams are responsible for assuring that screening and enrollment questions accurately capture HIV vulnerability status related to the enrollment criteria. Table 1 summarizes the enrollment criteria for each of the three DREAMS age bands. To be eligible for DREAMS, an AGYW only needs to meet one of the criteria listed (exceptions to the number of criteria can be requested with a justification sent to the AGYW ISME and SGAC country contact). Table 1: Enrollment Criteria by Age Band 10-14 Year Old Age Band 15-19 Year Old Age Band 20-24 Year Old Age Band ● Ever had sex ● History of pregnancy ● Experience of sexual violence (lifetime) ● Experience of physical or emotional violence (within the last year) ● Alcohol use ● Out of school ● Multiple sexual partners (in the last year) ● History of pregnancy ● STI (diagnosed or treated) ● No or irregular condom use ● Transactional sex (including staying in a ● Multiple sexual partners (in the last year) ● STI (diagnosed or treated) ● No or irregular condom use ● Transactional sex (including staying in a relationship for material or financial support) 6 ● Orphanhood relationship for material or financial support) ● Experience of sexual violence (lifetime) ● Alcohol misuse ● Out of school ● Orphanhood ● Experience of sexual violence (lifetime) ● Alcohol misuse What will you implement: DREAMS Core Package DREAMS employs a client-centered approach, for although there are other points of intervention (e.g., families, communities), the AGYW is always at the center. DREAMS requires the implementation of multiple interventions that target different risk factors or behaviors that may lead to HIV acquisition. In order to provide services to target the key vulnerabilities for change, different biomedical, behavioral, and structural interventions are recommended. The DREAMS country team is responsible for selecting the appropriate interventions to create their country-specific Core Package of interventions. Figure 1 details the four main categories of engagement and the group of interventions associated with each category. Figure 1: The DREAMS Core Package: DREAMS approach utilizes a theory of behavior change to target different societal, structural and individual factors that lead to an AGYW’s increased HIV risk. These risks are targeted through the strategic, layered implementation of evidence-based, culturally sensitive interventions at each level of influence. 7 This section details each component of the DREAMS core package and its justification for inclusion. Please see Appendix B for details on implementation and relevant resources (i.e. standards, evidence- based curricula, etc.). 1. Empower AGYW and reduce their risk for HIV, unintended pregnancy and violence a. Condom Promotion, Demand Creation, Provision and Adherence: i. Condoms are highly effective at preventing pregnancy and STIs, including HIV, when used correctly and consistently (8) (9) (10) (11), therefore, it is unethical to withhold condoms when intervening with high-risk populations. Research indicates that pregnancy prevention is a primary motivating factor behind many young women’s use of condoms (8) (11) (10). Condom promotion efforts can capitalize on young women’s desires to prevent unwanted pregnancy. The promotion and provision of male and female condoms is offered throughout DREAMS programming to AGYW and male sex partners to increase consistent use and availability. DREAMS facilitates a youth-friendly environment and provides education to ensure that AGYW understand the importance of consistent condom use in protecting their sexual and reproductive health and in dual method use for protection from both pregnancy and STIs (8) (9) (10) (11). b. Pre-exposure prophylaxis (PrEP) Promotion, Provision and Adherence: i. There is extensive evidence that PrEP is a highly effective intervention to reduce HIV acquisition. Initial trials estimated a greater than 90% reduction in HIV for men and women, but additional studies have shown that adherence/continuation, and therefore effectiveness, varies across priority populations (12). Meta-analysis of PrEP use with AGYW shows PrEP reduces risk by 61% given an adherence rate of 75% or more (13). Effectiveness of PrEP is linked to adherence (15) which is dependent upon different behavioral, structural and societal factors (12) (13) (14) (15) (16) (17) (18). Adherence is increased by 40% when social support is available; 38% of that can be attributed to social support from partners (16) (17). PrEP is provided in the context of receiving the full DREAMS core package of services in alignment with WHO normative guidance. Biomedical HIV prevention is an active area of research and advanced development. New ARV-based products such as long-acting injectable ARVs, implants, vaginal rings, and patches are quickly progressing through regulatory approvals. c. Linkage to post violence care, including post-exposure prophylaxis (PEP): i. Research shows a significant association between intimate partner violence (IPV), a specific form of GBV, and HIV status in women, suggesting women are up to 3x more likely to become HIV positive if they experience IPV (19). Preventing, identifying and responding to violence experienced by AGYW is an effective way to reduce risk for further violence as well as vulnerability to HIV acquisition. PEPFAR-supported sites that are able to do so should offer the WHO recommended minimum package of services for survivors of violence, including first-line support (LIVES), rapid HIV testing, provision of and counseling on PEP, STI screening and presumptive treatment, emergency contraception, and referrals to additional services such as legal support, longer term psychosocial 8 counseling, child protection and other social welfare services. DREAMS providers, mentors and Ambassadors should be trained in first response to violence, using the LIVES or similar curriculum. (19) (20) (21) (22) (23) (24). d. HIV testing services (HTS): i. This is an essential intervention to increase knowledge of serostatus among AGYW, as well as increase general HIV knowledge. Additionally, an earlier diagnosis for those living with HIV facilitates earlier linkage to care and initiation on lifesaving antiretroviral therapy (ART) (25). HTS is both a potential point of entry for DREAMS enrollment and an ongoing service for DREAMS participants (9) (26). There is some emergent data that HTS may have prevention benefits among youth (26) (27). The importance of linking to appropriate services (i.e. PrEP, PEP, etc.) from the testing platform cannot be underemphasized. DREAMS facilitates strategies, such as mobile vans, self-testing, and testing after-hours and on holidays, to ensure that AGYW and their partners are reached, and appropriately linked, with HTS, HIV prevention services or HIV treatment services at facility and community-based platforms. The acceptance of HTS should never be a condition for enrollment in DREAMS program nor should HIV- infected AGYW be turned away from the program. e. Expand and improve access to voluntary, comprehensive family planning services: i. AGYW in low-income countries experience high rates of early pregnancy which is associated with lower educational attainment and socioeconomic status (28) (29) (30), making AGYW more vulnerable to transactional sex, gender-based violence, and potentially HIV (24) (31) (32). HIV incidence significantly increases during pregnancy and the post-partum period. (33). Additionally, high rates of pregnancy are sometimes due to unmet need for voluntary FP, which increases risks for pregnancy-related morbidity and mortality (34). Sexual violence can lead to unplanned pregnancy. Although PEPFAR does not purchase FP commodities, DREAMS provides counseling and education about the mix of available contraceptive methods as a means to prevent both HIV and pregnancy, with an emphasis on dual method use (35) (36) (37) (38) (39) (40) (41)). f. Social asset building: i. The AGYW at highest risk of HIV often lack strong social networks, including relationships with peers, mentors and adults who can offer emotional support as well as information and material assistance. Interventions that build social capital, both the necessary skills and actual network, have been shown to increase agency and empowerment among AGYW. Although social asset building has not been linked directly to decreases in HIV acquisition, interventions that build social capital have been shown to increase agency and empowerment among AGYW (42) (43) (44). In order to assist AGYW in making important connections, DREAMS promotes the practice of holding small, female mentor-led group meetings in safe, public or pre-determined private spaces on a regular basis. “Safe Spaces” or “Girls Clubs,” work to address AGYW’s multiple vulnerabilities by enabling AGYW to build social networks and linking AGYW to additional DREAMS interventions and services. Multiple DREAMS curricula are 9 often delivered in these spaces. Literature suggests that social empowerment- interventions should include discussion groups on gender-based violence/intimate partner violence (GBV/IPV) and couples communication (56) (60), mentoring (60) (61), and comprehensive, evidence-based HIV prevention (54) (56) (58) (60) (61) (62) (63) (64). Thus, social asset building is the structure in which curriculum-based interventions are delivered and are critical in the DREAMS layering process. g. Economic-strengthening: i. Economic disparity related to gender inequality is an ongoing and complex driver of HIV. Implementing robust and evidence-based economic strengthening (ES) interventions is a priority for DREAMS in order to decrease AGYW’s reliance on transactional sex and strengthen AGYW’s self-efficacy and decision-making power in relationships. Stand-alone economic empowerment interventions demonstrate variable effectiveness (50) (51) (52) (52) (53). Combining economic and social empowerment interventions have demonstrated more consistent effects on both behavioral and violence outcomes (54) (55) (56) (57) (58) (59), an approach that is consistent with DREAMS implementation of the primary package. ES experts and the literature recommend two pathways to economic independence – self-employment/entrepreneurship and wage employment. Enhanced economic strengthening is intended for DREAMS participants at highest risk of HIV who would benefit the most from learning marketable skills and finding suitable jobs. Enhanced economic strengthening is offered after basic financial literacy and additional DREAMS interventions have been completed. 2. Strengthen the family a. Parenting/caregiver programs: i. Having positive relationships with parents, caregivers or other caring adults is a consistent protective factor for AGYW against a variety of negative health and social outcomes (49). DREAMS facilitates parent/caregiver programs that increase caregivers’ knowledge, skills and comfort with talking to their children about sexual health, HIV, GBV, violence prevention and response, as well as guides on how to best monitor their children’s activities and increase positive parenting practices. Some of these interventions have shown preliminary promise to influence high-risk sexual behavioral patterns among youth (65) (66) (67). Beyond improving relationships between AGYW and parents/caregivers, an informed and educated parent/caregiver can be engaged to help promote other activities within DREAMS. b. Educational subsidies and material support for transitioning and completing secondary school: i. Female students are especially vulnerable to school dropout and are more likely than boys to never attend school at all (65) (68) (69). Educational subsidies are an effective intervention for keeping girls in school (74) (75) and are correlated with higher rates of HIV testing, and decrease in high-risk sexual behaviors, 10 likelihood of early marriage (72), school dropout rates and other negative outcomes among female adolescents (70) (71) (72) (73) (74) (75). Additional research suggests a correlation between secondary schooling and HIV negative status, and that additional secondary schooling may be nearly as cost-effective for HIV prevention as PrEP (74) (76). 3. Mobilize communities for change a. School-based HIV and violence prevention programs: i. The DREAMS Partnership delivers school based HIV and violence prevention in order to provide scientifically accurate information, referrals to health centers for services not provided in school, and to build prevention skills among large numbers of young people in a community. Comprehensive HIV/AIDS and sex education curricula may lower sexual risk behaviors (77) (78) (34). However, a recent review claims that sex education programs alone may not suffice for reducing HIV among AGYW (19). The most effective interventions are often multifaceted and interactive with multiple sessions. Furthermore, sexuality education curricula that address gender and power dynamics are associated with better behavioral outcomes, including significantly lower rates of STIs and unintended pregnancy (79) (80) (81) (82). The DREAMS program does not allow abstinence only HIV/AIDS and sex education programs. Please note that violence prevention programs for the 10-14 year old age band became mandatory in COP19. b. Community mobilization/norms change programs: i. Community mobilization programming should be widely and strategically implemented, as this provides an essential support framework for HIV prevention programs (83) and serves to engage boys, men, community leaders, and the broader community in addressing and impacting social norms that increase HIV risk for AGYW (84) (85). Community mobilization efforts in related areas, like GBV prevention, have shown a significant impact on norms change, a decrease in violent victimization and perpetration (83) (85) and an increase in empowerment (84). Community mobilization and norms change interventions in DREAMS engage all community members with a focus on men and opinion leaders in community conversations about HIV, gender norms, sexuality, relationships, violence prevention and response, joint decision-making and alcohol use. DREAMS implements curricula with a participatory learning component focused on building skills and a community-level awareness and ownership of HIV risk reduction. 4. Reduce risk of sexual partners of AGYW a. Characterizing potential male sexual partners and linkage to other PEPFAR services: i. When first planning comprehensive programming for AGYW, it is important to consider reaching male sex partners as an HIV reduction strategy. Biomedical services for men are highly effective in reducing HIV acquisition and reducing HIV transmission to sexual partners (27) (86) (87) (88) (89) (90) (91). VMMC is a 11 highly effective intervention for reducing the likelihood of HIV acquisition among men and boys as well as protecting their female sex partners (86) (87) (88) (89) (90) (91). ART for men living with HIV is a highly effective intervention to prevent transmission to their sexual partners (27). However, men are reluctant to be tested (90) and linked to care (91) (92). DREAMS teams should use information about the characteristics of male sexual partners of AGYW to engage with other PEPFAR services on targeting men with those characteristics for HTS, VMMC, and ART. How will you implement: Layering Layering, or the provision of multiple evidence-based services from the DREAMS core package to each active DREAMS participant, is a core principle of DREAMS as outcome evaluations show that a layered approach is more effective at mitigating HIV risk than a single intervention (5). Additionally, this approach helps to assure that AGYW are surrounded with critical support to keep them safe from HIV and other risks (3) (4). Each DREAMS country is responsible for designating its own primary, secondary, and contextual packages of services/interventions for each DREAMS AGYW age band (10-14, 15-19, 20-24) based on the country specific context and epidemiological nuances. Emerging evidence suggests that tailoring DREAMS programming around country specific considerations yields stronger results (106). Appendix B, Table 1 has a list of approved curricula for country team consideration. If a country team wants to adapt an intervention or select a different program to meet the goals of the core package, these country or IP- specific curricula require consideration. See Appendix D for more information. The selection of interventions forms the country-specific DREAMS Layering Table and accompanying DREAMS Intervention Completion Table (Appendix C). All DREAMS countries are required to submit these tables on an annual basis for S/GAC and AGYW ISME approval. Please note, “layering” services does not necessarily mandate that these services must be received concurrently. The following definitions should guide the development of OU-specific Layering Tables: ● Primary Services/Interventions: Interventions that ALL AGYW in an age group should receive if they are DREAMS participants. ● Secondary Services/Interventions: Needs-based interventions that are part of the DREAMS core package but may not be received by all AGYW in that age group (i.e. only AGYW who earn an income should participate in a savings group). ● Contextual Services/Interventions: Interventions that are part of the DREAMS core package but cannot be linked to an individual AGYW (i.e. community mobilization) ● Service/Intervention Completion: This is country-specific criteria for determining the completion of each service/intervention in their DREAMS core package. Service completion definitions should be based on normative guidance and instructions from program developers where available. A service should not count towards an AGYW’s DREAMS program completion until it has met the service completion definition. 12 Only services provided by PEPFAR should be included in the DREAMS Layering Table. However, if PEPFAR implementing partners are making active referrals to a service provided by a non-PEPFAR entity, the active referral may be counted as a DREAMS service. If this is the case, your Layering Table should specify this (e.g. “facilitating access to government education subsidies” instead of just “education subsidies”). Teams may include services/interventions in their layering tables that are paid for with other PEPFAR funding (e.g. supplementary OVC support); please note this in the layering table. To learn more about the curriculum review and approval process, please see Appendix D. How will you implement: What should not be included in DREAMS: When implementing DREAMS, it is equally important to understand the data on interventions that are NOT likely to have a significant impact on reducing HIV incidence among females 10-24 years of age so these can be avoided or removed from PEPFAR AGYW programming. Interventions that will NOT likely have a significant impact on reducing HIV incidence or are not appropriate for this comprehensive package are found in Appendix B, Table 2. The activities and interventions listed in this table were selected because evaluations of their effectiveness are either non-existent or showed little-to-no-to- negative impact, or the intervention is not sustainable with PEPFAR funds. Treatment for schistosomiasis may be worth evaluating further but should not be associated with DREAMS at this time. Abstinence- only or sexual risk avoidance education has been extensively studied and has shown to have a negative impact on HIV risk. Therefore, DREAMS programming on HIV and sexual health should be comprehensive, providing abstinence as a method to avoid HIV along with other methods such as condoms. It should not be presented as the only method or the preferred method. These interventions should not be included in a package focused on reducing HIV incidence in AGYW. Additionally, there are activities/interventions that should not be implemented using DREAMS funding because these interventions may be specific priorities for other COP funding. Appendix B, Table 2 identifies these activities/interventions which include the purchasing of ARV drugs for: PMTCT for young mothers, AGYW testing positive in HTC programs, male partners of AGYW testing positive and VMMC. For treatment, these individuals should be referred to PEPFAR-supported or other programs. Assuring Quality Implementation The DREAMS core package specifies what evidence-based programs and services should be implemented for each component of the package, but how these interventions are implemented is also critically important. This section will cover the importance of implementing services with fidelity, differential service delivery, training DREAMS implementers and utilizing mentor and tenants of mentorship for impact. Country teams are encouraged to implement each intervention based on normative guidance (e.g., guidelines for clinical interventions), or aligned with the delivery methods used when the intervention was originally developed and evaluated (e.g. consistent with curriculum core principles and implementation guidelines). Interventions delivered as part of DREAMS are a combination of mentor-led, facilitator-led, health-care-worker-led, individual, participatory, small groups and large groups. Therefore, it is essential to fully understand the targeted intervention requirements in order to assess implementation with fidelity. For more information, please see Appendix F. DREAMS is implemented by facility and community partners, in community safe spaces, in school settings, and at health facilities. A safe space refers to both the physical location and a supportive, non- 13 judgmental environment. Findings from evaluations of community-based girl groups, also known as safe spaces, provide preliminary, yet promising results, about the positive impact a safe space structure has on AGYW-level outcomes (5) (45) (93) (49). An additional safe space for girls can be schools. Keeping girls in school is a key tenant of the DREAMS program, as school matriculation is a protective factor from a confluence of factors and risk behaviors that may lead to HIV, pregnancy and poor economic and health outcomes (72) (73) (76) (75) (75). Some interventions may be exclusively available or more convenient at a healthcare facility. In order to reduce the number of incomplete services, DREAMS community partners are to provide active referrals from the community to the facility, mirroring the program implementation for the HIV clinical cascade in COP guidance. Similarly, clinical partners are to provide active referrals from the facility to the community, especially from HTS, ANC, FP, and GBV response service delivery points. Unlike passive referrals where a client might be told about the availability of a relevant service, active referrals are made to a specific staff person at an organization and are tailored to clients’ needs. Active referrals are an integral part of PEPFAR programming and are proven to increase people living with HIV (PLHIV) linkage to care (99). Active referrals for routine reproductive health services, not just linkage to HIV care and treatment, are an essential trademark of the DREAMS program. This is to ensure the AGYW receives her intended service, builds relationships with youth friendly nurses and reduces the potential stress of attending the facility. Additionally, PEPFAR encourages partners, adolescent friendly health service (AFHS) hubs and adolescent friendly health care workers (HCW) to bring clinical services to the community through dynamic and innovative models. Such models may include mobile units, hybrid models and adolescent- friendly provider outreach services. Providing clinical services in community spaces helps normalize the services in the eyes of community members (94), integrates routine health services into an AGYW’s life, keeps the service client-centered and reduces stigma around seeking health care services. Integrating routine sexual and reproductive health services into HIV prevention services shows higher acceptance of HIV services. Differential service delivery may increase accessibility of services, as long as confidentiality is ensured and upheld throughout service delivery (94) (95). Note this does not suggest AFHS at facilities should be replaced by community-only modules and that AFHSs should align with relevant in-country standards. Another way that DREAMS supports quality implementation is through the training of implementers to assure that each curriculum is delivered with fidelity. In addition to training on the content and delivery of specific programs, trainings are offered on how to successfully engage and approach AGYW. Examples include training on how to provide non-judgmental, adolescent-friendly clinical services. Training for teachers is also being supported through collaborations with Ministries of Education and Health to ensure that teachers are comfortable and confident delivering HIV prevention curricula. DREAMS mentors, hired by DREAMS implementing partners, are a critical aspect of DREAMS implementation and provide ongoing support and individual follow-up with cohorts of DREAMS participants. Mentors often serve as confidants to DREAMS participants, assist them in building positive relationships within their support networks and each other, and provide active linkages to services in the community and facility (49) (95). Results about the role of mentorship in improving reproductive health outcomes for AGYW are preliminary, but promising. One meta-analysis of 19 peer-reviewed articles shows that frequent, long-term, group-based mentorship, as part of a comprehensive 14 prevention program, directly improves protective factors for AGYW (49). See Appendix F for more information about PEPFAR findings that will inform how DREAMS participants are provided with high- quality, evidenced-informed mentorship to improve the overall impact of DREAMS. DREAMS is intended to be delivered in person to the AGYW. Yet, a few, very specific situations may arise where individual and group remote support (such as SMS, phone call or WhatsApp dependent on country context) may be necessary. Some of these situations may include movement restrictions due to disease spread, natural disasters, or community/political unrest. Contact should focus on keeping participants engaged with mentors and peers and providing referrals for time-sensitive clinical services (e.g. GBV response, FP, and PrEP). Program delivery should follow the continuum in Figure 2. Figure 2: Continuum of Virtual DREAMS Content Delivery Finally, AGYW, government and stakeholder engagement does not start and end in the planning phase, it is a core principle throughout the program cycle. In order to stay informed, coordinated and employ an iterative process, a working group must be formed and continually utilized for program adaptations, routine program management and program standardization. Meeting structures are up to the consideration of country teams, and national and local governing bodies. Monitoring and Evaluating a DREAMS Program The DREAMS logic model guides how programs should be planned, implemented, monitored, and evaluated. The model lays out the epidemiological context that puts AGYW at additional risk of HIV infection, the interventions proposed to address these contextual factors, the expected outputs and outcomes of these programs, and the anticipated overall impact of those outcomes in combination.