Bottlenecks and Solutions During Implementation of the DREAMS Program for Adolescent Girls and Young Women in Namibia

Ellen W. MacLachlan; Abigail K. Korn; Alison L. Ensminger; Sharon Zambwe; Theopolina Kueyo; Rosanne Kahuure; Gena Barnabee; Josua Nghipangelwa; Juliet Mudabeti; Prisca Tambo; Agnes Mwilima; Elizabeth Muremi; Norbert Forster; Christa Fischer-Walker; Gabrielle O’Malley

doi:10.9745/GHSP-D-22-00226

Key Findings

Adolescent girls and young women (AGYW)–centered HIV prevention programs, such as DREAMS, must employ layered interventional approaches that address both AGYW health and sociobehavioral issues and must engage stakeholders across multiple sectors, increasing the potential for implementation bottlenecks that can undermine their efficiency and effectiveness.
Bottlenecks identified involved challenges with program access and enrollment, outdated and unengaging health education curriculum and lack of safe meeting spaces, stock-outs of HIV commodities, and limitations in supporting gender-based violence (GBV) cases.
Solutions include increasing the government role in identifying safe spaces for AGYW, expanding sexual and reproductive health services for AGYW within existing institutions, ensuring a continuous supply of sexual and reproductive health and HIV commodities, and decentralizing GBV care to increase access.

Key Implications

These bottlenecks highlight practical implementation issues and higher-level considerations for AGYW-centered HIV/GBV prevention programs.
The unique programming needs for HIV/GBV prevention in AGYW require multilevel collaboration and forecasting. Successful program implementation necessitates adequate preparation.

ABSTRACT

Background:

We synthesize implementation bottlenecks experienced while implementing the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program, an HIV prevention intervention for adolescent girls and young women (AGYW), in Namibia from 2017 to 2019. Bottlenecks were organized into the following 4 AGYW program components.

Program Access:

Enrollment was slowed by the time-intensive nature of screening and other baseline data collection requirements, delays in acquiring parental consent, and limited time for after-school activities. Solutions included obtaining advance consent and providing 1-stop service delivery and transportation assistance.

Health Education:

We experienced difficulty identifying safe spaces for AGYW to meet. A lack of tailored curricula also impeded activities. Governments, stakeholders, and partners can plan ahead to help DREAMS identify appropriate safe spaces. Curricula should be identified and adapted before implementation.

Health Services:

Uneven availability of government-provided commodities (e.g., condoms, preexposure prophylaxis [PrEP], family planning products) and lack of AGYW-centered PrEP delivery approaches impacted services. Better forecasting of commodity needs and government commitment to supply chain strengthening will help ensure adequate program stock.

Social Services:

The availability of only centralized care following gender-based violence (GBV) and the limited number of government social workers to manage GBV cases constrained service provision. Triaging GBV cases—i.e., referring high-risk cases to government social workers and providing DREAMS-specific social services for other cases—can ensure proper caseload management.

Conclusion:

These bottlenecks highlight practical implementation issues and higher-level considerations for AGYW-centered HIV prevention programs. The critical need for multilayered programming for HIV/GBV prevention in AGYW cannot be addressed simply with additional funds but requires multilevel collaboration and forecasting. The urgency to achieve results must be balanced with the need for adequate implementation preparedness.

Received: May 16, 2022.
Accepted: September 9, 2022.
Published: October 31, 2022.

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