Bottlenecks and Solutions During Implementation of the DREAMS Program for Adolescent Girls and Young Women in Namibia

"Effective HIV/GBV prevention programs for AGYW are multicomponent, layered programs that respond to the multidimensionality of localized influences on AGYW health-related behaviors."

In response to calls from the public health community to accelerate HIV/AIDS prevention for adolescent girls and young women (AGYW), the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) programme is being implemented in 15 countries, including Namibia. DREAMS combines multisectoral, layered, evidence-based interventions for AGYW, their sex partners, parents, and the community. These interventions include HIV and gender-based violence (GBV) education, health and social services, efforts to change male gender norms, and community mobilisation. The programme's inherent complexities increase the possibility of bottlenecks in implementation. Focusing on the period of 2017-2019, this article looks at these bottlenecks and how they were addressed in 2 high-HIV-prevalence regions of Namibia (Khomas and Zambezi).

DREAMS in Namibia used a safe space model for programme and service delivery, where AGYW aged 9-24 years met in a supportive, judgment-free, safe, and private location. All AGYW received basic HIV/GBV prevention education and health and social services, while eligible AGYW received secondary interventions based on need. The programme employed 105 full-time staff and over 200 part-time staff.

Within 18 months, DREAMS enrolled 20,150 participants, approximately 26% of the AGYW population living in the Khomas and Zambezi regions according to the 2011 national census. The programme provided HIV prevention services to 84% of participating AGYW (16,926); 75% of AGYW (15,113) received both health and social services. These results "show the substantial reach of the DREAMS program in Namibia and the significant demand for AGYW-specific services."

Bottlenecks were organised into the following 4 AGYW programme components:

1. Programme access: Enrollment was slowed by the time-intensive nature of screening and other baseline data collection requirements, delays in acquiring parental consent, and limited time for after-school activities. Solutions included obtaining advance consent and providing 1-stop service delivery and transportation assistance.
2. Health education: lthough there were Government of Namibia (GoN)-approved curricula available for HIV/GBV prevention for 9- to 14-year-olds and 15- to 19-year-olds, neither curriculum had been updated for at least 5 years. AGYW aged 15-19 years and their peer mentors reported that the didactic format of their curriculum was dull and unengaging, which may have contributed to low attendance. In addition, even though all peer mentors were fully trained to deliver the education sessions, their skill and competence varied widely. Furthermore, organisers experienced difficulty identifying safe spaces for AGYW to meet. In relation to the latter bottleneck, a key solution was to conduct advance strategic planning with ministries, the private sector, nongovernmental organisations, churches, and local authorities to identify safe spaces for DREAMS meetings. Also, a future consideration: Curricula should be identified and adapted before implementation.
3. Health services: Uneven availability of GoN-provided commodities (e.g., condoms, preexposure prophylaxis [PrEP], family planning products) and lack of AGYW-centred PrEP delivery approaches impacted services. Among the recommendations: DREAMS and other similar programmes for AGYW should consider different models for delivering PrEP to AGYW and organise strong support for selected models before launching the service. All DREAMS stakeholders, especially ministries of education, need to understand and communicate support for DREAMS services.
4. Social services: The availability of only centralised care following GBV, the limited number of GoN social workers to manage GBV cases, and the lack of private, confidential spaces to provide in-depth psychological counseling to many AGYW constrained service provision. Triaging GBV cases - i.e., referring high-risk cases to government social workers and providing DREAMS-specific social services for other cases - can ensure proper caseload management. Multisectoral involvement and coordination is essential to create awareness of and appropriately plan for the expected increase in demand for GBV services under DREAMS.

In conclusion: "Given the complex nature of AGYW programs, a variety of implementation bottlenecks are inevitable. These challenges can be overcome with iterative innovation and flexibility and by planning well in advance for contingencies related to probable future difficulties. Programs for AGYW should continue to document implementation challenges and bottlenecks so lessons learned can be widely shared."