By Heather Kelly, senior program officer, PATH, and Erika Amaya, digital communications officer, PATH
Heather Kelly, senior program officer for the Drug Development program, and Ellen MacLachlan, senior research officer with the Reproductive Health program, recently visited with Kenya-based PATH colleagues working on the rollout and implementation of DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women), an ambitious partnership aimed at reducing HIV infections among adolescent girls and young women.* At the PATH office in the Western Kenyan city of Kisumu, Heather and Ellen had the opportunity to learn about progress on DREAMS, as well as the challenges and opportunities that lie ahead. Heather sat down with us to share highlights from the visit.
What prompted the visit to Kenya?
This was an opportunity to meet with our Kenya colleagues and discuss the multifaceted implementation of DREAMS, work that is funded through a PATH-led project called APHIAplus Western (short for AIDS, Population, and Health Integrated Assistance Zone 1). We came to this from the perspective of wanting to know what the learnings and challenges have been so far and also initiating discussions about building on DREAMS to integrate HIV prevention and reproductive health services for high-risk women and girls. We were particularly interested in learning about the rollout of oral pre-exposure prophylaxis (PrEP), which is a component of the DREAMS project. PrEP is an innovation in HIV prevention, and its use in developing countries is new. DREAMS is a great opportunity to see how PrEP works in real life with real people.
What is PATH’s role on DREAMS?
PATH is an implementing partner in two Kenyan counties—Kisumu, which is more typically urban, and adjacent Homa Bay, which is much more rural. Both places struggle with high rates of HIV prevalence, particularly among adolescent girls and young women aged 15 to 24. There are a few other organizations also serving as DREAMS implementing partners in Kenya, and we had the chance to meet with one of them, IMA World Health. Their work is concentrated in Nairobi within its unincorporated urban slums. It was interesting to hear how their experiences line up with the core DREAMS package—using the same targeted interventions, timelines, collection techniques, tools, etc., but working with slightly different populations.
What are the specific objectives and strategies behind DREAMS?
The overarching goal is HIV prevention, specifically, to reduce new infections in adolescent girls and young women between the ages of 10 and 24 by 40 percent over two years. The work of our Kenya team under DREAMS reflects a comprehensive package of interventions targeting areas such as individual behavioral change (counseling on sexual behavior and safe sex and mentoring), societal barriers to HIV prevention (school dropout rates, transactional sex, and partner violence), biomedical prevention (distributing condoms and PrEP and conducting HIV testing), and training and instruction for entrepreneurial skills and financial literacy.
What were your take-aways from meeting with colleagues working on DREAMS?
I am inspired by the work going on and the data being collected. We came away really excited about the possibilities to use the data to further illuminate obstacles to receiving HIV prevention services. For instance, of the adolescent women and young girls designated vulnerable and eligible for PrEP, how many of them will choose to start PrEP? And if they do not, why is that? Also, if an individual does begin on PrEP, how adherent are they? What are the factors influencing her adherence or decision to stop? Answering these questions could help us better understand the decision-making around PrEP uptake and adherence.
In addition to crunching the numbers, it would be great to capture qualitative data by interviewing women and girls who decided to start or not to start PrEP. Questions around sources of stigma and how it may prevent access to services, as well as whether healthcare providers adhere to guidelines set at the national level are important and warrant further investigation.
We also have questions about risk perception before and after PrEP. Does risk perception change after starting PrEP? Do people who start PrEP engage in riskier behavior? We need further study to see whether risk of sexually transmitted infections or unintended pregnancy actually goes up or not, a significant concern for many of the health care providers we spoke with. Better evidence to help answer these questions can help us respond proactively to mitigate risks.
There’s not a lot of data on how PrEP works in low- and middle-income countries, but Kenya will be a pioneer in helping us understand this new frontier for HIV prevention.
*DREAMS is a partnership between the US President’s Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences, and ViiV Healthcare aimed at delivering a core package of interventions that combine evidence-based approaches that go beyond the health sector, addressing the structural drivers that directly and indirectly increase girls’ HIV risk, including poverty, gender inequality, sexual violence, and a lack of education. Learn more at www.dreamspartnership.org.