CONTRIBUTORS
Charity Chao Shete
Communications Officer
Elizabeth Kemigisha
Associate Research Scientist
Jane Osindo
Research Officer
In the global fight against HIV, numerous interventions have been directed towards supporting adolescent girls and young women (AGYW), who are more than twice as likely to acquire HIV as their male peers. This is due to a variety of factors, including gender inequality and unequal power dynamics,which undermine their ability to make decisions about their sexual and reproductive health. Consequently, reducing the risk of HIV infection among AGYW has been a global priority.
Programs such as the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe lives (DREAMS), backed by PEPFAR, aim to do this among AGYW in Sub-Saharan Africa by addressing structural and behavioural factors that increase their vulnerability. The African Population and Health Research Center (APHRC) conducted an impact evaluation of the DREAMS program in Korogocho and Viwandani from 2017 to 2022. The evaluation assessed the impact of DREAMS interventions in reducing HIV infections among AGYW by examining various outcomes, such as changes in HIV incidence, improvements in Sexual and Reproductive Health (SRH) knowledge, and the overall empowerment of young women while also looking at the program’s scalability.
The DREAMS program comprises a layered multi-component package of evidence-based interventions. These interventions address the biomedical, structural, and social risks of HIV acquisition by empowering AGYW and reducing their risk of infection. It also provides an opportunity to strengthen their families with social protection through programs like parent/caregiver programs, mobilize communities for change and reduce the risk of HIV among men who are likely to be sexual partners to AGYW. The interventions include: sexual and reproductive health (SRH) education, HIV prevention services, education support, social protection and economic empowerment activities like vocational training and business start-ups among others. While the focus of DREAMS is primarily on AGYW, some interventions do target young men. These include HIV testing, condom distribution, PrEP education and participation in health promotion sessions. However, the level of engagement and tangible benefits for adolescent boys and young men (ABYM) remains limited in comparison to those available to girls.
The DREAMS program reached many AGYW identified as vulnerable, offering them substantial educational support, vocational training, and resources for business start-ups. However, boys received fewer tangible interventions in comparison.. Some adolescent boys and young men (ABYM) were engaged in biomedical and behavioral interventions. However, due to the nature of the interventions they received they would only be engaged for a short period of time and their participation often waned with time. Despite the understanding that the DREAMS program was a girl-centered initiative, ABYM expressed concerns about being left out of the program. The issue raised was DREAMS being seen largely as a girls-only initiative which limited their involvement in the program. While ABYM appreciated the benefits they received from the program, they felt these services were either inadequate or fell short of addressing their broader needs. These programs have made great progress in reducing the rate of HIV incidence among AGYW but, the question that arises is: Are we leaving adolescent boys and young men behind?
It is understandable why AGYW have been the focus of most HIV interventions, yet we cannot ignore that ABYM are also vulnerable to HIV infection. There are some interventions available for ABYM such as MenEngage which engages men and encourages testing for HIV, enrollment on treatment for those who are HIV positive and adherence to treatment. Additionally, Voluntary Medical Male Circumcision (VMMC) which has proven to reduce risk of HIV acquisition in men by 60% and has been promoted widely as a core HIV prevention strategy. Interventions like this are, however, minimal compared to those for AGYW. As a result, many ABYM lack access to sexual and reproductive health education and services, creating a knowledge gap that often contributes to risky behaviors like unprotected sex, multiple sexual partners, and low condom use. This is evident in the Kenya Population-Based HIV Impact Assessment report (KENPHA 2018), which found that HIV testing services are predominantly accessed by young women, leaving many young men untested and uninformed.The consequences of this could be girls being more economically stable compared to their peers, increased HIV incidences among ABYM, resentment towards future HIV programs which will further limit ABYM’s access to prevention services and contribute to power imbalances with AGYW’s, potentially leading to relationship issues like gender-based violence, separation, divorce, and restricted access for girls to HIV prevention services.
We must realize that boys and young men without proper education and resources can be both vulnerable to infection and vectors of transmission. An example of a key challenge of HIV prevention in adolescents and young men is the resistance to or lack of understanding of VMMC. In cultures where circumcision is not traditionally practiced, it may be viewed as unnecessary or even harmful, dismissing its proven benefits in reducing HIV risk. This resistance, in addition to misinformation, leaves boys and men at a greater risk of infection. To overcome these barriers, it is essential to engage these communities with culturally sensitive education that highlights the role of VMMC in comprehensive HIV prevention strategies. Additionally, gender stereotypes that portray ABYM as less vulnerable to HIV or sexually transmitted infections (STIs) also contribute to their low uptake of services. Harmful gender norms such as initiating sexual activity early in life, having multiple sexual partners and representing themselves as knowledgeable about sexual matters and disease prevention even when they are not, discourages ABYM from accessing the information and services they need. For HIV prevention campaigns to be fully effective, they must actively address these societal barriers and create an environment where ABYM feel empowered to seek help. Without targeted interventions there is a risk that the new generation of young men will be under informed and unprepared to protect themselves and their partners from HIV.
To effectively fight against HIV, a holistic approach should be implemented that addresses the unique needs of both ABYM and AGYW. This has been proven to be possible by evidence from the DREAMS initiative which showcased the importance of education and empowerment in reducing HIV risk. Similar efforts can be made to reach ABYM which will make them more likely to make safer sexual choices reducing both their chances of contracting HIV and the likelihood of spreading the virus.
A few examples include:
- Sports-Based Programs: Initiatives that combine football tournaments with health education sessions have shown promise in reaching young men effectively. A notable example of this is Grassroot Soccer (GRS) founded in Zambia. GRS leverages soccer’s universal appeal to engage ABYM aged 12-19. The program combines evidence-based health curricula, mentorship from trained coaches, and an inclusive, fun culture to educate participants about HIV prevention and encourage behavioral change. For instance, activities like “Risk Field” use soccer drills to illustrate the consequences of risky behaviors, providing a relatable context for understanding how individual actions impact communities. Data from Zambia showed that nearly 60% of GRS participants sought HIV testing compared to 13% of the general population.
- School-Based Education: Expanding comprehensive sexual and reproductive health education in schools is crucial. Tailored curricula should emphasize the importance of HIV testing, condom use, and the role of boys in reducing HIV transmission. Peer-led initiatives in schools can create relatable and impactful messaging for ABYM, helping to normalize HIV prevention behaviors.
- Digital Outreach and Media Campaigns: Leveraging social media, gaming platforms, and apps can provide targeted and engaging content about HIV prevention. Interactive and gamified platforms are particularly more appealing to younger male audiences making learning about HIV prevention more engaging.
The progress made in protecting adolescent girls and young women from HIV is worth celebrating but it is important to recognise that ABYM are a big part of the solution. As the global community continues to fight against HIV, it is time to ensure that no one is left behind!