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.