As the US Global AIDS Coordinator since 2014, Ambassador-at-Large Deborah Birx leads the US Government’s international HIV/AIDS efforts, including PEPFAR’s DREAMS partnership to reduce vulnerability in adolescent girls and young women (AGYW). Here she shares with PSI’s CEO and President Karl Hofmann the latest results of this ambitious initiative and ways we can innovate to get closer to ending HIV/AIDS.
1. KH: DREAMS has had tremendous success in reducing new infections. What have we learned from the last three years about HIV prevention for AGYW? What do we want to take forward and scale up? What should we leave behind?
DB: We are extremely proud of DREAMS’ accomplishments to date. Through this initiative, we have helped drive a 25-40% decline—or greater—in new HIV diagnoses among AGYW in nearly two-thirds of the highest HIV burden communities implementing DREAMS across 10 African countries. Overall, we’ve reached more than 2.5 million AGYW with services and support through DREAMS.
DREAMS continues to be an incredible learning process. We started DREAMS quickly because the data showed that AGYW were experiencing a public health emergency. We created a core package of interventions, and continually modify as we learn from new data and implementation experiences. For instance, we originally included cash transfers in the DREAMS core package, but later removed that component when evidence for its impact on HIV acquisition became less clear.
Data from the PEPFAR-supported, CDC-led Violence Against Children Surveys show that girls’ sexual debut is usually before age 16, and that this first sexual experience is often forced or coerced. In response, we are increasing our focus on sexual violence prevention among girls 9 to 14 years of age. For young women, lack of access to jobs in the formal economy is also a challenge. We are examining how to build job skills related to market needs to help young women develop economic independence.
2. KH: How can AGYW gain greater control of their sexual health?
DB: A number of factors reduce AGYW’s control over their sexual health. Girls often bear the burden of societal expectations surrounding sex and fertility. They often engage in transactional sex to support themselves or their families, making it difficult to negotiate condom use. As noted, AGYW are experiencing startling levels of sexual violence. Frequently, AGYW’s relationship with sex becomes intertwined with violence and/or financial need.
To address these issues, we are implementing comprehensive curricula that teach girls about their bodies, build decision making and assertiveness skills to delay sexual debut, and provide information on methods of protection from HIV and early pregnancy. We are complementing this information with access to clinical services, such as contraceptives, HIV testing, and pre-exposure prophylaxis (PrEP). We are also offering socioeconomic strengthening programs, such as savings groups, to increase AGYW’s economic independence. Finally, we are helping communities and families to surround these youth with support and education.
3. KH: Can we use new technologies or more flexible approaches—like HIV self-testing—to leapfrog over problems in health systems?
DB: PEPFAR is always looking for new technologies and approaches that are data-driven and can be taken to scale. This year, our policy guidance emphasized the scale up of HIV self-testing (HIVST), PrEP, and a transition to dolutegravir-based treatment regimens. We are scaling up HIVST to reach young people who are healthy and would not typically seek care at health facilities. When appropriate, we are also offering HIVST kits to people living with HIV that they can offer, in turn, to their partners who cannot make it to a facility setting. We are also working with private sector colleagues to explore new approaches to find and reach missing populations with healthcare services. Health systems also need innovations in the supply chain and we are exploring the use of digital health technology to address challenges and improve understanding of how HIV commodities are used.
4. KH: You’ve been especially outspoken about how sexual violence creates risk for AGYW. What are you hearing from AGYW about the role of sexual violence in their lives, and what can we do to address this pervasive problem?
DB: Sexual violence is pervasive with as many as one third of AGYW reporting forced or coerced sex as their first sexual experience. These unacceptable levels of violence are also apparent in the stories we hear as we visit DREAMS sites in all of the 15 countries supported by the partnership—stories of victimization from very young ages by boyfriends, uncles, neighbors, strangers, and teachers. But they are also stories of survival and resilience. These young women want to succeed in life; they look for partners like PSI to support their forward movement. PSI can help AGYW by providing evidence-based violence prevention programming, including programming to change harmful norms and practices that can contribute to the acceptability of violence.
5. KH: How do we balance the opportunities and risks of user-controlled technologies for young people?
DB: User-controlled technologies are less risky if they are implemented carefully, and as part of a package of comprehensive prevention services that includes risk reduction education and counseling, condom promotion and provision, voluntary medical male circumcision, and structural interventions to reduce vulnerability to HIV infection.
We must respect the ability of young people to comprehend complicated medical information and use it to make critical decisions for their own health. Contraception is a case in point. For decades, AGYW have been weighing the risks and benefits of various contraceptives and making informed decisions. If we do our job by creating youth-friendly clinics, training youth-friendly providers, and providing clear information and adherence support when needed, young people will be successful at using these new user-controlled technologies.
6. KH: We’re experiencing a profound political shift in the US and Europe. What messages about HIV prevention are resonating with global leaders right now?
DB: People want to get behind success, whether they’re global leaders or community members. We’ve made such incredible gains over the past 15 years since PEPFAR was created. Many high-burden countries are approaching HIV/AIDS epidemic control because they’re bringing proven HIV prevention and treatment strategies to sufficient scale. We need to do a better job of showcasing our successes and painting a vivid picture of the future possibilities that exist if the momentum continues.
7. KH: Ten years from now, what would you love to see when it comes to the fight against HIV/AIDS? What changes to the current response could bring about this vision?
DB: We are on the cusp of something extraordinary. With the tools we already have, there’s the historic opportunity—for the first time ever—to control a pandemic without a vaccine or a cure. This will lay the groundwork for eventually eliminating HIV through future scientific breakthroughs.
Until we have a vaccine and/or a cure, the main challenge is one of implementation. We need to reach the individuals who we’ve yet to find, retain those who we’re already supporting with services, and create the conditions whereby countries can sustain the HIV/AIDS response and at a lower future cost.
