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

Joseph G. Rosen; Maurice Musheke; Drosin Mulenga; Edith S. Namukonda; Nrupa Jani; Michael T. Mbizvo; Julie Pulerwitz; Sanyukta Mathur

doi:10.9745/GHSP-D-22-00089

Key Findings

The DREAMS Partnership is a combination HIV prevention approach in sub-Saharan Africa to reduce risk in adolescent girls and young women (AGYW), but its multisectoral approach poses challenges for implementing partners.
Comprehensive coordination systems between implementing partner organizations are needed in multisectoral programming to build the necessary infrastructure for effective implementation.
Securing financial commitments, for both primary interventions directed toward AGYW and secondary interventions directed toward their male partners and parents, is important for engaging these stakeholders and addressing structural drivers of HIV risk among AGYW.
Real-time adaptation of implementation strategies helped address challenges with recruiting AGYW with the highest risk and retaining AGYW in the program.

Key Implication

To administer DREAMS sustainably and effectively, implementing partners must invest in robust implementation infrastructure, including harmonized electronic data capture systems and flexible workplans, requisite for multisectoral HIV prevention programming.

ABSTRACT

Objective:

To identify solutions to the implementation challenges with the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women) Partnership in Zambia, this study examines the rollout and evolution of the DREAMS Partnership’s implementation.

Methods:

In September–October 2018, implementing partner (IP) staff (n=15) and adolescent girls and young women (AGYW) participating in DREAMS programming (n=32) completed in-depth interviews exploring early rollout and scale-up of DREAMS, experiences with program participation, and shifting service delivery approaches in response to emerging implementation challenges. Inductive and deductive thematic analysis of 47 interviews uncovered salient service delivery facilitators and barriers in the first 2 years of DREAMS implementation, which were subsequently mapped onto the following domains: reach, effectiveness, adoption, implementation, and maintenance.

Results:

Key implementation successes identified by IP staff included using standardized recruitment and risk assessment tools across IP organizations, using a mentor model for delivering program content to AGYW, and offering centralized service delivery at venues accessible to AGYW. Implementation challenges identified early in the DREAMS Partnership’s lifecycle were rectified through adaptive service delivery strategies. Monthly in-person coordination meetings were established to resolve IP staff jurisdictional disputes over recruitment and target setting. 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. Prominent barriers to implementation fidelity included challenges recruiting the highest-risk AGYW (e.g., those out of school), limited resources to incentivize participation by young women, and inadequate planning to facilitate absorption of individual DREAMS interventions by the public sector upon project conclusion.

Conclusions:

Delivering multisectoral HIV prevention programs like DREAMS with fidelity requires a robust implementation infrastructure (e.g., adaptable workplans and harmonized record management systems), early coordination between IP organizations, and sustained financial commitments from donors.

Received: March 4, 2022.
Accepted: September 13, 2022.
Published: October 31, 2022.

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