DREAM Big: How a quality improvement approach to behavior change is empowering adolescent girls and young women to stay HIV-free

Juliana Nabwire

Senior QI Advisor, USAID ASSIST Project/URC, Uganda

Current reports showing a decline in HIV/AIDS-related deaths and new HIV infections give hope that an HIV-free generation is in sight. New technology and biomedical research have resulted in better HIV prevention and treatment options. Despite these advances, adolescent girls and young women continue to contract HIV at alarming rates. Globally, adolescent girls and young women (AGYW) account for around half a million new HIV infections per year and 65% of new infections among 10-24-year-olds; therefore, they must be a focus for HIV prevention efforts. 

The DREAMS initiative is a multicounty program focused on supporting adolescent girls and young women to achieve their big dreams and stay AIDS-free. DREAMS recognizes that the vulnerability of adolescent girls and young women stems from the community, where she is influenced to become whatever society dictates that she becomes. Therefore, DREAMS empowers not only adolescent girls and young women but also those that influence her life, including her parents/caregivers and male sexual partners, to dream together and work towards an HIV-free generation. Working in four of the ten Uganda DREAMS implementing districts for over two years, I have seen first-hand the potential gains that can be made when communities work together to support girls and young women to achieve their DREAMS. 

Coaching session with Alengo-bir community QI team. Photo by Douglas Mutebi

Inherently, parents want what is best for their children, although sometimes they may not understand the consequence of some of the actions that are taken while they think they are doing the best. Take an example of a 15-year-old girl whose parents cannot afford to keep her in school - and, for that matter, at home as well - and so are encouraged to marry her off to someone who can supposedly afford to provide for her. The last thing the parents will ask of the suitor is an HIV test, as long as he can pay for basic requirements. The cycle of vulnerability for the young girl continues as she has to live off her provider for her own and her children's sake.  

The DREAMS initiative has a prescribed set of high impact interventions, but providing these services in an organized way that meets the needs of the communities is key to realizing risk reduction among the adolescent girls and young women and their communities. When we initiated this work, how the community could be engaged to participate in the HIV prevention efforts was of great concern. Rather than introduce many new ideas at once, we first interacted with the community to understand their perspective and perception of the risk factors of HIV.

We supported the formation of quality improvement teams at the village level to discuss, plan, implement, monitor and evaluate the HIV prevention efforts. These teams were comprised of representatives of the adolescent girls and young women, caregivers, and influential members of the community who were willing to support HIV prevention efforts in the community.  

Coaching with Acokora B community QI team - a member provides updates. Photo by Douglas Mutebi

By applying this quality improvement approach to a behavior change model, we were able to address barriers to behavioral change among adolescent girls and young women at high risk of HIV infection and empower community-based quality improvement (QI) teams to mobilize community resources to support AGYW to stop risky behavior.  Through these meetings, decisions were made on what next steps the community needed to take. We saw church leaders willing to act as a point of condom distribution within their communities, male sexual partners allowing their female spouses to participate in regular meetings in the community, girls and their partners testing for HIV as well as willingness to prevent and report violence. 

These were concerted efforts of individuals and communities working together for a cause and, consequentially, we have observed a reduced number of new infections among the cohort of girls we are working with. In addition, a recent study of this work showed that the proportion of adolescent girls and young women experiencing sexual and other forms of gender-based violence reduced from 49% a baseline to 19.5% at follow up due to the complementary targeting of parents and partners by QI teams.

The complexity of reducing new infections, especially among vulnerable and high-risk populations, has been navigated, but more work needs to be done to realize an HIV-free generation. Community participation is key to unlocking their potential to prevent and protect the next generation against HIV, and this is where we need to invest.

Learn more about our work using a quality improvement for behavior change model to promote HIV prevention and treatment among adolescent girls and young women.


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