Issue: In Zambia, like many sub-Saharan countries, HIV incidence continues to be high among adolescent girls and young women (AGYW). Many AGYW do not know their HIV status nor are they fully aware of the risks of contracting HIV. Yet knowing one’s status is critical to achieving the “first 95” in UNAIDS’s 95-95-95 targets: 95% of HIV-positive persons know their status.

Description: Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) is an ambitious PEPFAR initiative to reduce new HIV infections by layering services targeting AGYW between the ages of 10 and 24. This abstract explores the rates at which AGYW in the DREAMS program in Zambia access HIV testing and what prevents those who delay testing. One service, the 13-week Stepping Stones HIV education intervention, introduces AGYW to HIV-related topics and creates safe spaces for open dialogue. Mid-way through the intervention, peer mentors encourage HIV testing.

Lessons learned: By August 2020, DREAMS tested over 120,000 girls in Zambia. More than half did not know their status at the time of testing. Testing uptake was highest among 20-24 year olds among those who did not initially know their status. Being “afraid to test” or “afraid the results would be known to others” were the most commonly reported barriers to testing. Other barriers cited were lack of funds for testing, transport challenges, and being too busy.

HIV-positive case finding and linking to treatment are critical for HIV epidemic control. Of the 1,125 girls who tested positive, 60% were ages 20-24, 58% from Lusaka, and 78% did not know their status prior to testing. Comparing these results to a national estimate of number of girls who are unaware of their positive status, the program identified and .

Recommendations: These data demonstrate how the program has a positive impact on assisting girls to pursue testing, contributing to HIV epidemic control in Zambia. Implementers should continue to explore how to improve mentoring support for AGYW who are reticent to test.

Issues: In sub-Saharan Africa, 67 percent of new HIV infections in young people occur in adolescent girls and young women (AGYW). A 2015 UNAIDS report states that “some of the most powerful structural interventions for HIV risk reduction among adolescent girls across Africa are those that aim to keep girls in school.” In Tanzania, barriers to school attendance and progression among girls include lack of educational materials; knowledge, skills, and sanitary pads to manage menstruation; and pregnancy.

Description: “Determined, Resilient, Empowered, AIDS-free, Mentored and Safe” (DREAMS) programming is a comprehensive package of interventions to address HIV vulnerabilities among AGYW. This package is tailored to sub-populations of AGYW, and the in-school initiative for primary school girls includes: 1) sexual reproductive health education, 2) re-usable menstrual hygiene sanitary kits, and 3) educational subsidies (i.e. school bag, exercise books, school uniforms, etc.) This DREAMS primary package was implemented as part of the Kizazi Kipya project which aims to enable orphans and vulnerable children to utilize age-appropriate services for improved health and well-being.

Results: Using data collected in 2019 and 2020 in 8 DREAMS councils, 6,708 girls aged 11–16 years (mean = 13.3, SD = 1.6), were included in the analysis. Of these, 6% (n = 399) received the DREAMS primary package. Overall, 50.9% of the girls achieved school progression between 2019 and 2020. School progression was significantly higher among girls who received the DREAMS primary package compared to girls in the Kizazi Kipya project who did not receive the DREAMS primary package (62.4% vs. 50.2%) (p<0.001). In the multivariable analysis adjusted for demographic characteristics and other variables, girls who were reached with the DREAMS were 45% more likely to progress than those who were not (aOR = 1.45, 95% CI 1.16-1.80).

Recommendations: This DREAMS primary package is effective at improving school progression among vulnerable girls. As implementors reflect on how to scale-up these evidenced-based interventions, approaches to strengthen families to cover the material support provided (i.e. reusable menstrual hygiene kits and educational subsidies) should be considered to promote broader reach and longer-term sustainability.

Issues

In Rwanda, HIV prevalence is approximately two times greater among adolescent girls and young women (AGYW) between 15-24 compared to their male counterparts(1.2% vs 0.5%)¹. AGYW are more vulnerable to HIV infection due to structural and social determinants including early sexual debut, higher rates of gender-based violence, and lower rates of school completion. Young women aged 18-19 are ten times more likely to acquire HIV than young men of the same age².

Description

The USAID/PEPFAR funded ACHIEVE/Rwanda project aims to reduce vulnerability to HIV and HIV incidence among AGYW in two districts of Kigali City using evidence-based comprehensive packages of interventions on avoiding risks of acquiring HIV. Prior to enrollment, ACHIEVE through DREAMS mentors identifies potential beneficiaries using a standardized screening questionnaire. This tool assesses AGYW HIV related risks to determine enrollment eligibility. Screening is conducted in homes with AGYW between 10-24 using a door-to-door approach. Mentors also conduct outreach to assess the hard-to-reach AGYW employed in the hospitality sector and female sex workers.

Results

From November to December 2020, 29,546 AGYW were screened, of which 21,058 were enrolled. The most common vulnerabilities identified during screening were experience of physical/emotional violence (19%), being out of school(15%), and having experienced sexual violence(13%). The first two risk factors were dominant at enrollment(respectively 23% and 16%) followed by orphanhood(13%). AGYW with multiple risk factors were prioritized for enrollment.

A bivariate analysis using a chi-square test was done to examine the association between risk factors. For AGYW between 10-14, orphanhood is associated with ever-having sex and alcohol use. For AGYW between 15-19 years, having multiple sexual partners is associated with misusing alcohol and orphanhood with transactional sex. For AGYW between 20-24, alcohol misuse is associated with no or irregular condom use.

Recommendation

Screening enabled ACHIEVE to determine AGYW vulnerabilities and associated HIV acquisition risks and prioritizing the AGYW most at risk for enrollment. This approach can be adopted for interventions targeting AGYW and associated data used to tailor age-specific services to address the identified risk factors.

¹Rwanda Population based HIV Impact Assessment 2018-2019

²Gender Assessment of Rwanda’s National HIV Response 2013