Multisectoral, Combination HIV Prevention for Adolescent Girls and Young Women: A Qualitative Study of the DREAMS Implementation Trajectory in Zambia

"The DREAMS Partnership offers valuable learning opportunities through the novel, multisectoral approach to implementation of a combination of HIV prevention interventions that have historically been delivered in a siloed fashion."

There is concern about the gendered dynamics of HIV transmission in Zambia, whose annual HIV incidence in adolescent girls and young women (AGYW) is 13 times higher than in similarly aged men. To address the social and structural dimensions of AGYW's HIV risk, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) launched the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women) Partnership in 2014. DREAMS is a combination HIV prevention approach in 15 sub-Saharan African countries to reduce AGYW's vulnerability to HIV by strengthening families, mobilising communities for change, and reducing risk of sexual partners. This qualitative study examines the DREAMS implementation trajectory in Zambia. It is nested in a larger portfolio of implementation science research of the DREAMS Partnership in 7 countries.

As the article outlines, DREAMS programming was first introduced in Zambia in 2016; by 2022, more than 800,000 AGYW in that country had received at least some component(s) of the DREAMS primary service package. A hallmark of DREAMS is "layering", a client-centred approach involving the assessment of AGYW's HIV risk to determine the appropriate combination of services that should be offered to them. Depending on the particular participant, DREAMS in Zambia offers:

• Primary service package: a social-asset-building curriculum (i.e., age-appropriate "safe space" sessions focused on HIV prevention-related topics), condom promotion and distribution, HIV testing services, combination socioeconomic support (i.e., financial literacy, training, and education support), and school-based HIV and violence prevention education.
• Secondary interventions for eligible AGYW: adolescent-friendly family planning services, preexposure prophylaxis (PrEP) for HIV prevention, postviolence care, education subsidies, and parenting/caregiver programmes.
• Contextual interventions: community mobilisation and norms-changing activities focused on violence prevention and gender equity.

This study was conducted in 2 urban districts with ongoing DREAMS implementation: Lusaka (Lusaka Province) and Ndola (Copperbelt Province). AGYW in these districts are disproportionately affected by numerous health and development challenges, including high HIV prevalence and high proportion of teenagers who have begun childbearing. In September-October 2018, implementing partner (IP) staff (n=15) and AGYW participating in DREAMS programming (n=32) completed in-depth interviews exploring early rollout and scale-up of DREAMS, experiences with programme participation, and shifting service delivery approaches in response to emerging implementation challenges.

The research conceptual framework, RE-AIM, conceptualises the public health impact of an intervention as a product of the interaction between 5 factors, around which the article organises emerging themes and insights from AGYW and IP staff interviews:

1. Reach (intervention coverage): A key recruitment strategy was using a standardised risk assessment tool to identify the appropriate combination of DREAMS interventions that should be offered to newly enrolled AGYW.
2. Effectiveness (achievement of expected/desired outcomes): AGYW and IP staff shared mixed perspectives on whether DREAMS programming achieved its intended impacts. On the positive side, IP staff shared observations of improved healthcare access and positive shifts in health behaviour, describing increased HIV testing, heightened demand for modern contraception, and reductions in adolescent pregnancies - all of which they attributed at least partially to DREAMS programming. However, IP staff identified challenges with condom promotion messaging, which they suggested was insufficient for building the capacity of AGYW, especially married young women, to negotiate condom use with male partners.
3. Adoption (acceptability and uptake of intervention): AGYW, especially younger girls, embraced the DREAMS centres because they felt welcome and comfortable discussing salient issues regarding sex and sexuality. These venues offer accessible spaces in AGYW's communities to engage meaningfully with similarly aged girls and safely share perspectives on sensitive topics. AGYW also spoke highly of DREAMS mentors, women who are responsible for a range of activities. Interventions meant to reach secondary programme audiences - specifically, AGYW's male partners and parents - were plagued by recruitment challenges and suboptimal attendance.
4. Implementation (intervention effectiveness or adherence to service delivery strategies like layering): Key implementation successes identified by IP staff included using standardised recruitment and risk assessment tools across IP organisations, using a mentor model for delivering programme content to AGYW, and offering centralised service delivery at venues accessible to AGYW. Implementation challenges identified early in the DREAMS Partnership's lifecycle were rectified through adaptive service delivery strategies. For example, to address high participant attrition, IP staff adopted a cohort approach to sequentially recruit AGYW who enrolled together and provided social support to one another to sustain involvement in DREAMS programming.
5. Maintenance (sustainability of programme impact and implementation): Prominent barriers to implementation fidelity included challenges recruiting the highest-risk AGYW (e.g., those out of school), limited resources to incentivise participation by young women, and inadequate planning to facilitate absorption of individual DREAMS interventions by the public sector upon project conclusion.

A key finding of this study was the necessary leadership of site-level staff (i.e., mentors, connectors, and site coordinators) in real-time modification of DREAMS implementation strategies. These staff not only played key roles in AGYW recruitment and day-to-day operations but were also critical to adapting DREAMS service delivery approaches. The high staff turnover described by IP staff can be attributed, in part, to poor compensation and excess psychosocial demands.

The researchers cite emerging evidence showing that DREAMS has not accelerated HIV incidence declines in Kenya or South Africa, "casting doubt on the effectiveness of the DREAMS Partnership's approach. Donors should increase their financial commitments to DREAMS," because, as the present study illustrates, "implementation gaps - rather than the DREAMS model itself - may be to blame for discouraging evaluation findings reported elsewhere."

In conclusion: "To reach ambitious program coverage targets without deprioritizing fidelity and effectiveness,... findings underscore the importance of early investment in coordination infrastructure, agile implementation workplans, and resource mobilization for transition planning....Centering the voices of AGYW in the design of DREAMS programming and engaging IP staff more proactively in the target-setting process can help secure buy-in from AGYW and support IP staff in meeting ambitious, albeit realistic, recruitment goals."