Adolescent girls and young women needed more than a moment—they needed a movement. That is why PEPFAR and our private sector partners launched the DREAMS Partnership in December 2014: to address the ongoing HIV crisis that saw adolescent girls and young women (AGYW) experiencing HIV rates two-to-three1 times higher than boys their same age.
PEPFAR rapidly formed an interagency task force and, guided by community inputs, created the layered DREAMS core package of interventions. This core package reached full scale in all 10 original countries implementing DREAMS by late 2016. At that time, overall HIV incidence was already declining in all 10 of these countries, but AGYW were lagging behind in this progress and contributing disproportionately to new infections.2 Almost four years later, we have made significant progress and continue to strengthen our understanding of what AGYW face, need, and how we can best support them to become Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe women.
AGYW still confront a range of biological and social challenges that elevate their risk for HIV acquisition. AGYW too often learn that they are not worth educating, that they are most valuable inside their parents’ or husband’s home, that violence is a part of life to be expected and silently endured, that sex is a taboo topic even when one is young and pregnant, and that most jobs in most industries are for men.
These deeply entrenched and often intractable norms are significant barriers to AGYW staying HIV negative. PEPFAR has sought to address them through a combination of biomedical, behavioral, and structural interventions to continue driving down HIV incidence and help close the gap between AGYW and their male peers, working in close coordination with other PEPFAR programs and partners.
In partnership with PEPFAR, the Bill & Melinda Gates Foundation funded the Population Council (PC) to conduct implementation science research on DREAMS and the London School of Hygiene and Tropical Medicine (LSHTM) to evaluate its impact. PEPFAR has also conducted modeling with Imperial College London that shows a greater than 25 percent reduction in new HIV diagnoses in antenatal care settings in nearly all DREAMS implementation districts (68/81) over four years.3
Data recently presented at the 23rd International AIDS conference by LSHTM and PC showed that DREAMS has successfully reached a large proportion of AGYW with comprehensive HIV prevention services and has positively impacted several other HIV-related outcomes. In evaluating 3 of 81 districts implementing DREAMS, LSHTM found there was no evidence in these settings that DREAMS had specifically reduced HIV incidence in AGYW by the partnership’s original, ambitious target of an additional ≥ 40% decline within two years.4 However, in one setting in rural Kenya, large additional declines in HIV incidence after DREAMS rollout are plausible but must be confirmed through longer-term follow-up.
In evaluating DREAMS, PEPFAR looks across all data sources to understand the direct impact on HIV incidence and the impacts on secondary outcomes that contribute to lower HIV vulnerability. From both PC and LSHTM’s work, we know that DREAMS is contributing to the 90-90-90 goals by increasing AGYW’s knowledge of their HIV status.5 Among AGYW in Kenya and South Africa, LSHTM also found an increase in social support through exposure to DREAMS. Young women selling sex in Zimbabwe who participated in DREAMS were more likely than those who did not to have ever taken pre-exposure prophylaxis (PrEP) and to have the ability to negotiate condom use with their partners.6 In some contexts, DREAMS contributed to reductions in recent pregnancies, number of lifetime sex partners, condom-less sex, and unmet need for contraception. In Kenya, Malawi, and Zambia, PC found that DREAMS helped significantly improve young women’s HIV knowledge and lower their experience of violence from both partners and non-partners over time.7 PEPFAR remains committed to examining all sources of data to continually optimize DREAMS for greater impact in all of its complexity.
We are regularly making real-time, data-based improvements to DREAMS. Through site visits, PEPFAR program data, and early data from PC8, it became clear that some DREAMS programs were struggling to reach the AGYW who were most vulnerable to acquiring HIV and that the layering of DREAMS services was not always occurring as intended. PEPFAR tracked these data, and through technical assistance and evolved guidance, made course corrections. We created a new program indicator to track layering, which requires the use of unique identifiers to monitor receipt of a comprehensive package of services for each AGYW in DREAMS. Recently, we introduced vulnerability criteria requirements to assist implementing partners in finding and serving the AGYW who need DREAMS the most. Data from PC and LSHTM show that both the recruitment of the most vulnerable AGYW and the delivery of layered services has improved over time as DREAMS implementation has matured.9
Additionally, through PC’s research, our DREAMS site visits in communities, and outside research, we learned that transactional sex—which is associated with increased HIV risk among women—is common for AGYW in DREAMS countries.10 We are currently addressing economic systems that revolve around transactional sex by reducing AGYW’s financial dependence on men through improved economic strengthening programming. By focusing on financial literacy, entrepreneurship training, and connecting AGYW to internships and jobs, DREAMS aims to remove economic necessity from AGYW’s sexual decision-making.
Given the recent findings on HIV incidence from LSHTM, PEPFAR will continue to scale up PrEP for AGYW to accelerate incidence reduction. PEPFAR is continually listening to and learning from our partners, our program data, and most importantly the AGYW themselves, including DREAMS beneficiaries and DREAMS Ambassadors. Young women’s voices are critical in standing up for themselves and each other. From its inception, DREAMS has required meaningful AGYW involvement in meetings with implementing partners, government representatives, and PEPFAR staff. DREAMS is helping cultivate a generation of young women leaders who educate us and their own country leadership on how to prevent HIV in AGYW.
DREAMS is already far more than a moment and together we are still building the movement. While the road to transforming how communities value AGYW and make changes to reduce their risk of contracting HIV is not always easy, PEPFAR is deeply committed to the destination: an AIDS-free future for girls.
1 UNAIDS. Women and Girls and HIV. 2018,
2 Saul, Janet, et al. “The DREAMS Core Package of Interventions: A Comprehensive Approach to Preventing HIV
among Adolescent Girls and Young Women.” PLOS ONE, Public Library of Science, 2018,
3 PEPFAR. PEPFAR Latest Global Results. 2019, www.state.gov/wp-content/uploads/2019/11/PEPFAR-Latest-
4 Kwaro, Daniel. “An Independent Impact Evaluation of DREAMS: Key Findings to Date.” International AIDS Society
Conference 2020. International AIDS Society Conference 2020, 2020.
5 Ibid and Mathur, Sanyukta. “Reducing HIV Risk for Adolescent Girls and Young Women & Their Male Partners: Highlights from the DREAMS Implementation Science Research Portfolio.” International AIDS Society Conference 2020. International AIDS Society Conference 2020, 2020.
6 Kwaro, Daniel.
7 Mathur, Sanyukta.
8 Population Council. Reducing HIV Risk Among Young Women and Their Partners. June 2020,
9 UNAIDS. 2020 Global AIDS Update – Seizing the Moment. 2020,
10 Wamoyi, Joyce, et al. “Transactional Sex and Risk for HIV Infection in Sub-Saharan Africa: a Systematic Review
and Meta-Analysis.” Journal of the International AIDS Society, U.S. National Library of Medicine, 2016,