PC DREAMS Priority IS Slides Emerging evidence on AGYW HIV risk and prevention from the DREAMS partnership: the role of gender Julie Pulerwitz, ScD and Sanyukta Mathur, DrPH MHS Girl uninterrupted: Evidence, implementation and agency 24 July 2018

No conflicts of interest to disclose

Context Should address the context in which AGYW live, to improve health & development outcomes Gender-based power dynamics underpins many relationships Power in sexual relationships* linked with violence, condom use, HIV incidence, untreated STIs, etc High HIV risk and incidence rates among AGYW (esp. Southern and Eastern Africa) ICPD – 1994 - Egypt *Pulerwitz, J, Gortmaker, SL, & DeJong, W. (2000) Measuring relationship power in HIV/STD Research. Sex Roles. 42(7/8); McMahon, JM, Volpe, EM, Klostermann, K, Trabold, N, & Xue, Y. (2015) A Systematic Review of the Psychometric Properties of the Sexual Relationship Power Scale in HIV/AIDS Research. Arch Sex Behav; 44(2): 267–294.

DREAMS partnership as case study Mobilize Communities for change Empower Adolescent Girls & Young Women (AGYW) and reduce risk Reduce risk of Male sexual partners Strengthen Families Adapted from: Preventing HIV in Adolescent Girls and Young Women: Guidance for PEPFAR Country Teams on the DREAMS Partnership, March 2015

Generating evidence around DREAMS Population Council 11/16/2018 Generating evidence around DREAMS 3 cross-cutting themes—focused on unique features; country priorities Assessing reach and effectiveness of community-based girl-centered programming Characterizing male partners of adolescent girls and young women, and use of HIV services 10 studies in 7 DREAMS countries Introducing oral PrEP among adolescent girls and young women

Population Council 11/16/2018 Vulnerability profiles of out-of school AGYW, Kisumu, Kenya Preliminary findings from latent class analysis (15-24yrs, n=1,014) Double orphans Sometimes hungry Not connected to adult in HH Sexual debut ≤14 Limited HIV knowledge Acknowledge inequitable gender norms LOWER VULNERABILITY 71% of sample HIGHER VULNERABILTY 29% of sample

AGYW’s relationship power in Kenya PC DREAMS Priority IS Slides AGYW’s relationship power in Kenya My partners has more say about important decisions that affect us – 50% agree, but still higher when older. Limited power in general, with older reporting less power *p < 0.05 Pulerwitz, Mathur, and Woznica. (2018) How empowered are girls/young women in their sexual relationships?: relationship power, HIV risk, and partner violence in Kenya. PLoS ONE. 13(7): e0199733.doi:10.1371/journal.pone.0199733

Relationship power, sexual violence & HIV risk Sexual violence experience in the last 12 months From partners (n=597) From non-intimate partners (n=1,778) 19% 21% Having relationship power strongly associated with: Less sexual and physical violence More condom use at last sex More knowledge of partner’s HIV status AGYW who experienced sexual violence were 2x as likely to report an STI symptom, and anxiety and depression Pulerwitz, Mathur, and Woznica. (2018) How empowered are girls/young women in their sexual relationships?: relationship power, HIV risk, and partner violence in Kenya. PLoS ONE. 13(7): e0199733. doi: 10.1371/journal.pone.0199733; Mathur, Okal, Musheke, et al. Forthcoming (PLoS ONE). High rates of sexual violence by both intimate and non-intimate partners experienced by adolescent girls and young women in Kenya and Zambia: Findings around violence and other negative health outcomes.

Conflict & miscommunication characterize relationships PC DREAMS Priority IS Slides Conflict & miscommunication characterize relationships Study site: Uganda (n=94 IDIs with male partners of AGYW)

PrEP power dynamics in the health care setting Factors associated with providers’ willingness to prescribe PrEP (n=316) “Some of us are very critical and judgmental. We just judge someone, “Ooh you came again? Last time you had gonorrhea, did you do it again?” —Service provider, age 32 Adj. IRR1 (95% CI) Negative attitudes toward AGYW sexuality 0.81 (0.66–0.99)* Behavioral Disinhibition scale 0.89 (0.79–0.99)* 1Adjusted for provider demographics, prior PrEP knowledge, other facility factors (e.g., stockouts) *p<0.05 Pilgrim, N. et al. (2018) Provider perspectives on PrEP for adolescent girls and young women in Tanzania: The role of provider biases and quality of care. PLoS ONE 13(4): e0196280. doi: 10.1371/journal.pone.0196280.

PC DREAMS Priority IS Slides Framework for PrEP introduction to AGYW Mathur, S, Pilgrim N, and Pulerwitz, J. (2016) PrEP introduction for adolescent girls & young women. The Lancet HIV 3(9): e406-e408.

Implications/next steps Gender-related dynamics accentuate HIV risk and inhibit service use Unpacking these relationships can provides useful insights for strengthening program/policy Should be more consistently measured in programs Phase 2 DREAMS Implementation Science will explore program effects What worked, when, for whom, and why?

Pulerwitz, Julie and Sanyukta Mathur. 2018 Pulerwitz, Julie and Sanyukta Mathur. 2018. “Addressing adolescent girl and young women’s risk and empowerment: Emerging lessons from the DREAMS Partnership.” Presented at 22nd International AIDS Conference (AIDS 2018), Amsterdam, The Netherlands, 24 July.

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