DREAMS Heather Watts M.D. Senior Technical Advisor Office of the US Global AIDS Coordinator US Department of State
Key Populations Vary by Location Young women are the major key population in Sub-Saharan Africa Source: UNAIDS, 2014
Disparity in new infections among young people New HIV Infections in Sub-Saharan Africa by Age & Sex, 2013 Source: UNAIDS 2014
More than 1/3 new HIV infections globally occur among young women in Africa Estimated number of new HIV infections per week among young women aged 15-24 years in East and Southern Africa, 2012 Data source: UNAIDS 2013 South Africa Uganda Mozambique Tanzania Kenya Zimbabwe Malawi Zambia Lesotho Swaziland Ethiopia Botswana Namibia Rwanda 287 262 185 110 79 64 54 42 25 570 494 491 468 Over 5,000 new HIV infections every week among young women in these 14 countries alone 2363 0 500 1000 1500 2000 2500 Number per week
HIV in pregnant women in rural South Africa (2001-2013), N=4,818 HIV Prevalence 60.00% 50.00% 49.50% 51.90% 40.00% 30.00% 20.00% 10.00% 11.50% 21.30% 30.40% 39.40% 0.00% 16 17-18 19-20 21-22 23-24 >25 Age Group (years) Source: Abdool Karim Q, 2014
The DREAMS Partnership $210M partnership to reduce new HIV infections in AGYW in up to 10 countries. Determined, Resilient, Empowered, AIDS-free, Mentored and Safe lives. Based on a core package of evidence-based interventions HIV risk behaviors, HIV transmission, Gender-based violence
How will we address the stark disparity in HIV incidence among young women vs. men? Right Things Core package of interventions to prevent HIV infection and address comprehensive needs of girls and young women Right Places Focus on finding the most vulnerable in the highest burden areas Right Time The population of AGYW growing rapidly NOW is the time to intervene so that we do not see an increase in these already alarming numbers Prevent at the right time in people s lives for women that means targeting prevention when they are young, before the peak age of prevalence
Determined Resilient Empowered AIDS-free Mentored Safe DREAMS Eligible Countries: Kenya Lesotho Malawi Mozambique South Africa Swaziland Tanzania Uganda Zambia Zimbabwe
Communities What makes DREAMS Different? Sexual Partners Families 9
12.0 10.0 How is DREAMS Different? The Importance of Layering Interventions 10.4 FEMALES: % PROBABILITY OF INCIDENCE OF TRANSACTIONAL SEX (modeled percentage probabilities using multivariate logistic regression coefficients) 8.0 6.0 4.0 5.1 4.6 2.0 2.2 0.0 No intervention Child grant Free school Both interventions Cluver, Orkin, Yakubovich
The Core Package Community Mobilization & Norms Change Mobilize Communities for change School-Based Interventions Parenting/ caregiver Programs Reduce Risk of Sex Partners Characterization of male partners to target highly effective interventions (ART, VMMC) Youth-friendly sexual and reproductive health care (Condoms, HTC, PrEP, Contraceptive Mix, Post-violence care) Empower Girls & Young Women and reduce risk Social Asset Building Strengthen Families Social Protection (Cash Transfers, Education Subsidies, Combination Socio-Economic Approaches)
Determining the Core Package Prudent Practice Impact on Violence Rigorous Evaluation Biological Outcomes
Example of Evidence Evaluation for DREAMS Core Package
The Core Package I Condoms Increasing contraceptive method mix Violence prevention and postviolence care Building agency and social capital Empowering Girls and Young Women PrEP HTC Referrals and linkages Increasing school completion Economic strengthening
Access to Sexual and Reproductive Health Services Crucial to Empowering Young Women
The Core Package II School-based HIV prevention Strengthening the Community Community Mobilization/ Norms Change
Violence Against Children Survey Results
The Core Package III Parenting/Caregiver Programs Educational subsidy Strengthening the Family Cash transfers, either uncondition al or with schooling conditions Combination socioeconomic approaches
Links between Cash Transfers and HIV Risk Lutz and Small 2014
HIV Prevalence and Inequality as Measured by the Gini Co-efficient From Piot, Greener, and Russell 2007. See Cash Transfers and HIV Transmission UNDP discussion paper by Lutz and Small, 2014.
OVC Programming Across the Lifespan: Reducing Vulnerability and Supporting the Clinical Cascade Prenatal to birth 0-4 years Positive parenting skills Promotion of EID and confirmatory Positive Parenting / Caregiver HIV testing within early childhood skills-building to ensure early development (ECD) programs and attachment with newborn institutionalized care Child survival services Integrating ECD into health services for children under five 5-9 / 10-14 years Community groups respond to abuse, assist girls with post-rape counseling and make referrals to clinic Keeping girls in school reduces their chance of infection and promotes life chances Cash transfers reduce risky sexual behavior and thus infection rates for girls Child protection/ GBV prevention and response interventions help reduce cases and long term effects of abuse Savings Groups increase income of caregivers and ability to access key services, including HIV services Integrating adherence assessment, counselling and support into routine household support Promoting psychosocial health among children and their caregivers through group-based and relationship based activities Delivery of Nutrition and food security programs 10-14/ 15-18 years School block grants and scholarships bolster educational outcomes and keep girls in school through secondary, reducing their chances of infection Cash transfers reduce risky sexual behavior and infection rates for girls Peer Support Groups strengthen positive social development Child protection/ GBV prevention and response interventions help reduce cases and long term effects of abuse Positive parenting skills building including topics on adolescent risk, HIV disclosure, child health & development knowledge Facilitating uptake of and monitoring completion of referrals for ALHIV for SRH and FH services, including AYFS Community programs reduce stigma and promote adherence of caregiver Household Economic Strengthening reduces barriers to access for health/clinic & education Treatment for adult caregiver maintains overall health and productivity Socio-economic programs Linkages to Treatment & Prevention programs
The Core Package IV Reducing Risk in Sex Partners Characterizing male sex partners Characterizing male sexual partners Linking the right men to ART Linking the right men to VMMC
Making a Difference: DREAMS Outputs, Outcomes & Impacts Program Outputs Improve AGYW Health Services # receiving condoms # receiving HTC # linked to service # initiated on PrEP # receiving post violence care # FP sites with expanded method mix Improve AGYW & family assets # AGYW or families receiving cash transfer or education subsidies Improve male sex partner participation in ART/VMMC # of males on ART/provided with VMMC who fit sexual network partner profile Improve Family / Community Support # receiving parenting intervention # receiving school-based HIV / violence prevention and gender sensitization # receiving community-based HIV & violence interventions Program Outcomes AGYW aged 15-24 Decrease sexual risk Reduce # of pregnant 15-24 with HIV + status Reduce maternal mortality Decreased unplanned pregnancy Reduce rates of violence victimization Increase empowerment/agency Increased assets for AGYW & their families Increased access to money in an emergency Increased educational attainment for girls Male Partners Increased favorable attitudes toward gender equity Reduce rates of violence perpetration Family/Community Improved family interactions Increased community mobilization/commitment to prevent HIV in AGYW Improved gender & violence-related norms Improve health and economic outcomes for families Program Impact Reduce New HIV Infections
DREAMS requires a multi-sectoral approach Psycho- Social Education Economic Health Community/ Civil Society
Focusing Programs in the Right Places Highest burden countries Prevalence & number of PLHIV Countries with greatest unmet need for services Among general population Among specific neglected populations Sub-national regions/districts with highest burden Analyzing data to target programming geographically & among neglected populations Highest volume facilities Analyzing site-level data to prioritize support to facilities and communities with greatest need
SNU Choices Province District HIV Prevalence in ANC Other school-based interventions GBV platform HDSS platform PrEP activities (WHO/Gates) Gaza Xai-Xai 27.6% Yes No No No Gaza Cidade De Xai-Xai 26.2% Yes Yes* No Yes Gaza Chokwe 23.5% Yes Yes* Yes Yes Zambezia Cidade de Quelimane 23.4% No Yes No No Sofala Cidade da Beira 21.3% Yes Yes No No Zambezia Namacurra 20.2% Yes Yes No No Zambezia Nicoadala 21.6% No Yes No No Sofala Dondo 16.4% Yes Yes* No No Prioritization based on HIV prevalence, PEPFAR prioritization, early childbearing rates, feasibility based on existing platforms, contiguity of districts. Zambezia Sofala Childbearing in 15-19 yo: Gaza 35.4%, Zambezia 41%, Sofala 28.5% Gaza Maputo
Multilaterals and DREAMS The UNAIDS Secretariat through the Eastern and Southern Africa Regional Support Team has assisted with convening UNAIDS Country Directors around the DREAMS Initiative and elevated the priority of reducing new HIV infections among adolescent girls and young women. Plan development in-country is able to tap into the strength and expertise of the UNAIDS Joint Programme Cosponsors through inclusion of relevant Cosponsors in planning processes. WHO is engaged in developing and updating existing guidance on interventions affecting this population. The Global Fund is interested in supporting the alignment of forthcoming Concept Notes for DREAMS Countries with interventions to reduce new HIV infections among the target population.
What is the Role of the Bill & Melinda Gates Foundation in DREAMS? The Foundation will provide up to $25 million to: Resource select interventions based on data showing what 1) will have the highest impact, and 2) is aligned with the foundation s existing HIV, family planning, and financial services strategies. Possible examples: Family planning services Pre-exposure prophylaxis to prevent HIV infection Cash transfers and subsidies Co-develop M&E framework Co-develop targets Finance and leverage existing investments to support agreed country strategies Provide technical expertise to inform programing and delivery Finance implementation research and an impact evaluation
What is the role of the Nike Foundation in DREAMS? Experience in branding and communications Innovative approaches to shifting social norms and building demand Global communications and advocacy support Experience in girl engagement acquired from the Girl Effect
THANK YOU