Project Summary
Our overarching goal is to arrest the HIV epidemic and its negative impact on young people in sub Saharan
African (SSA) through improving the uptake, retention and adherence of multi-level combination HIV
prevention by AGYW and male partners. South Africa has an estimated 6.3 million people living with HIV –
the highest in the world. Despite having the largest HIV treatment program in the world, HIV incidence in
Adolescent Girls and Young Women (AGYW aged 15-24) remains extremely high. Whilst there have been
significant innovations in combination HIV prevention, e.g. universal test and treat (UTT) and Pre-exposure
prophylaxis (PrEP), this has far outpaced the ability to deliver them. To control the HIV epidemic here is an
urgent to significantly improve uptake and retention of HIV prevention by AGYW and male partners, alongside
UTT of those testing positive. In this project we have a unique opportunity to leverage a key time-sensitive
events in a poor and rural hyperendemic area of KwaZulu-Natal: The roll out of eight new youth-focused multi-
level HIV prevention interventions for AGYW and their male partners by PEPFAR’s Determined, Resilient,
Empowered, AIDS free, Mentored, and Safe (DREAMS) program in the context of a state of the art
demographic and health surveillance, where data on individual HIV biomarkers, sexual behaviors, HIV
prevention and ART exposure are linked to public-sector clinical records for HIV and other care. We will
achieve this through three interlinked aims: Specific aim 1: Quantify how multiple levels of social dynamics
interact to predict uptake of DREAMS components. Approach: We will use hierarchical analysis of population
surveillance data to evaluate how community, household and interpersonal-level exposures predict uptake of
each intervention, and two composite outcome measures: 1) Exposure to community-level DREAMS
interventions, 2) uptake of the individual-level HIV care and prevention. Specific aim 2: Elucidate how
individuals’ life-course transitions and exposure to DREAMS affect retention and adherence to HIV care and
prevention. Approach: We will use both survival analysis of the population surveillance data and in-depth
qualitative interviews to evaluate how specific life-course events affect HIV prevention and care cascade
trajectories and how community-level DREAMS exposures moderate the impact of life-course transitions on
adherence and retention. Specific aim 3: Ascertain whether family- and peer-network strategies improve
uptake and adherence to combination prevention interventions by young people. Approach: we will work with
youth to adapt existing models of community and peer-support to develop an intervention informed by aims 1
and 2. We will pilot the acceptability and feasibility of this approach on improving AGYW and male peers
uptake and retention of HIV care and prevention. Our multidisciplinary team includes HIV epidemiologists, a
biostatistician, social scientists, psychologist and intervention development expertise from the Africa Health
Research Institute, University College London, Southampton and the London School of Hygiene and Tropical
Medicine. Moving forward, this will provide answers to an NIH priority area: Can using peer, family and
community-level networks harness the full mortality and HIV incidence reducing potential of multi-level HIV
prevention for adolescents and young people in rural SSA?