Introduction: The Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) Partnership aimed to influence psychosocial processes that promote empowerment among adolescent girls and young women (AGYW), and reduce HIV incidence. We estimated the impact of DREAMS on aspects of AGYW's collective and individual agency (specifically, social support and self-efficacy), in three settings where DREAMS was implemented from 2016 until at least end 2018.
Methods: Research cohorts of ~1500 AGYW aged 13-22 were randomly selected from demographic platforms in Kenya (Nairobi; Gem) and South Africa (uMkhanyakude) and followed up from 2017 to 2019. Social support was based on questions about female networks and access to safe places to meet with peers; general self-efficacy was measured using a scale previously validated in other settings. We conducted multivariable logistic regression, and estimated the causal effect of invitation to DREAMS on each outcome in 2018 and 2019 by comparing counter-factual scenarios in which all, vs no, AGYW were DREAMS invitees.
Results: In Nairobi, Gem and uMkhanyakude, respectively, 74%, 57% and 53% were invited to DREAMS by 2018. Social support was higher among DREAMS invitees versus non-invitees (eg, adjusted OR 2.0 (95% CI 1.6 to 2.6), Gem, 2018). In 2018, DREAMS increased social support in all settings and age groups, for example, from 28% if none were DREAMS invitees to 43% if all were invitees (+15% (95% CI 10% to 20%)) in Gem. Effects were strongest in Kenya, but weakened in 2019, particularly among older AGYW. In uMkhanyakude, DREAMS invitees had greater self-efficacy compared with non-invitees in 2018 (+9% (95% CI 3% to 13%), 2018) but less so in 2019. In Kenyan settings, there was weak evidence for impact on self-efficacy among younger AGYW in Gem (+6% (95% CI 0% to 13%)) and older AGYW in Nairobi (+9% (95% CI -3% to +20%)) in 2019.
Conclusions: DREAMS impacted on social support and, less consistently, on self-efficacy. Weakening effects over time may reflect changes in access to safe spaces and social networks as AGYW age and change circumstances, and withdrawal of DREAMS from uMkhanyakude in 2018, highlighting the importance of programme sustainability and improving programming for older participants.
Keywords: HIV; cohort study; epidemiology; health systems evaluation; prevention strategies.
© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.