1. 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

2. No conflicts of interest to disclose

3. 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 – 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.

4. 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

5. 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

6. 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

7. 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): e doi: /journal.pone

8. 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): e doi: /journal.pone ; 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.

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

10. 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): e doi: /journal.pone

11. 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.

12. 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?

13. Pulerwitz, Julie and Sanyukta Mathur. 2018
Pulerwitz, Julie and Sanyukta Mathur “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.

14. The Population Council
conducts biomedical, social science, and public health research. We deliver solutions that lead to more effective policies, programs, and technologies that improve lives around the world.
Founded in 1952; work in 50 countries; 60% of staff based in Global South / developing world