Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR

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Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR
Early lessons from DREAMS
     impact evaluations
             Isolde Birdthistle | July 23, 2018
  On behalf of the BMGF-funded impact evaluation partnership
Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR
The BMGF-funded impact evaluation of DREAMS

 Part 1. Why, how, where, when will we evaluate?

 Part 2. What have we learned so far?

   After approx 1 year of DREAMS implementation…
   • What is the coverage of DREAMS: who is being reached and
      with what services?
   • What are some early effects of DREAMS?

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Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR
Part 1. The BMGF funded
         impact evaluation

                             3
Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR
Aims of the impact evaluation

As part of its contribution to the DREAMS Partnership, BMGF is supporting
impact evaluation in 4 settings, to generate lessons on:

1. What is the impact of the combined DREAMS package on HIV
   infection rates and other key outcomes among AGYW and their male
   partners? [1 urban & 1 rural Kenyan setting; 1 rural South African setting]

2. What is the impact of a DREAMS package which also includes an offer of
   oral PrEP to the highest risk AGYW? [Zimbabwe]

3. Through what pathways does DREAMS affect the health, education and
   social well-being of AGYW? [all settings]

4. What was implemented and how? With what coverage and fidelity? [all]

                                                                                 4
Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR
How and where are we evaluating DREAMS?
Through community-wide cohorts {for population-level change} and in-depth cohorts
{individual-level change among AGYW} followed over time before, during and after roll-
out of DREAMS
                                                      Building on existing large research platforms…

                                                      3 Population-based studies
                                                        Gem, Siaya, western Kenya
                                                      • The CDC/KEMRI HDSS with HIV, demographic
                                                         & behavioural surveillance and nested
                                                         DREAMS cohorts of AGYW
                                                         [Partners: LSTM & KEMRI]

                                                          Nairobi, Kenya
                                                      •   The Nairobi Urban HDSS with demographic &
                                                          behavioural surveillance and nested DREAMS
                                                          cohorts, including 10-14 yr olds
                                                          [Partner: APHRC]

                                                        uMkhanyakude, S Africa
                                                      • The HDSS in KZN with HIV, HSV2,
                                                        demographic, behavioural and phylogenetic
                                                        surveillance and nested DREAMS cohorts
                                                        [Partner: AHRI]

                                                      1 Key population study
                                                        Zimbabwe
                                                      • Evaluation of DREAMS+PrEP among most
                                                         vulnerable AGYW, using the Sisters programme
                                                         as a platform for cohorts of YWSS and HIV
                                                         testing in 2 DREAMS & 4 comparison sites
                                                                                                   5
                                                         [Partners: LSTM & CeSHHAR]
Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR
Theory of change to guide impact evaluation

                                              6
Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR
Timeline 2016 - 2019

 Year   Impact evaluation                                   Process
                                                            evaluation
 2016   Preparation, ethics approvals
        Map & analyse historical data for baseline
                                                              Ongoing
 2017   Round 1: General population & nested AGYW cohorts
        Share baseline summaries
            [PLOS One eCollection on DREAMS]

 2018   Round 2: General population & nested AGYW cohorts
        Share interim findings by Q4 2018
        •   Uptake of DREAMS interventions
        •   Secondary, HIV-related outcomes and mediators

 2019   Round 3: General population & nested AGYW cohorts
        Share end-line findings by Q4 2019/Q1 2020
        •   Secondary outcomes and mediators
        •   Primary outcome: HIV incidence

                                                                         7
Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR
Part 2. What have we
        learned so far?

    a) DREAMS reach so far

                             8
Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR
DREAMS’ reach: Sample findings to date (1)
In general populations (with representative samples), by mid-2017…

•   There is high awareness and participation in DREAMS, especially among young women,

    more so among adolescent girls (10-17y) than young women (18-22y)

•   HIV testing services and school-based prevention education are the most accessed

    interventions

•   Among those invited into DREAMS, good penetration of ‘newer’ interventions, like social

    asset building including safe spaces but not yet among a majority of beneficiaries

•   Most AGYW invited into DREAMS have accessed multiple services, including “layered”

    services (>1 category in the Core Package) in last 12 months

•   “Individual”-level interventions are often combined with “contextual” (community- / family

    level interventions)
                                                                                                 9
Early lessons from DREAMS impact evaluations - Isolde Birdthistle | July 23, 2018 - PEPFAR
DREAMS’ reach: Sample findings to date (2)

• AGYW were more likely to be invited to participate in DREAMS if they were:

    • in school, had never had sex, never married (Kenya), were never pregnant/gave birth

    • had socio-economic vulnerabilities (‘very poor’ or food insecure [Kenya] or received Govt grant

      [SA])

• Very few AGYW accessed all ‘primary interventions’ intended for their age / need

• Among older women, low usage of community- /family-level DREAMS interventions

  including parent/caregiver, violence prevention and social norms programs

• Among men, usage of DREAMS services is generally low, apart from HIV testing in

  some settings

                                                                                                   10
DREAMS’ reach: Sample findings to date (3)

In a high-risk key population, of young women who sell sex (YWSS) …

• By mid-2017, there was very low uptake of DREAMS interventions

• Few YWSS were reached by DREAMS, or referred when targets were already full

                  Examples of supporting data
                           follow…

                                                                                11
Awareness and uptake of DREAMS (Nairobi 2017)
 • In Nairobi, high awareness of DREAMS programme among AGYW
   (less so among other groups, esp/ men)
 • Half of AGYW invited to participate in DREAMS [N=10,874]
                                                      General
                                                                 General population
                  AGYW nested cohorts                 population
                                                                 males
                                                      females

                  10-14y      15-17y      18-22y      25-49y     15-29y      30-49y
                  (N=606)     (N=547)     (N=534)     (N=4426)   (N=2561)    (N=2200)

                  n     %     n     %     n     %     n     %    n     %     n     %
 Heard of a
 programme     482      80%   489   89%   414   78%   2838 64%   1044 41%    727   33%
 called DREAMS
 Invited to
 participate in
                  290   48%   322   59%   214   40%   420   9%   75    3%    56    3%
 any DREAMS
 activity

                                                                                         12
Awareness and uptake of DREAMS (Nairobi & KZN 2017)
• Awareness of DREAMS is highest among adolescent girls, versus
  young women, in both Kenya and South Africa
• Lower awareness & participation in SA relative to Kenya

                                                                         AGYW nested cohorts
                                    AGYW nested cohorts
                                                                         uMkhanyakude, South
                                         Nairobi
                                                                               Africa

                                10-14y        15-17y        18-22y        13-17y         18-22y
                               (N=606)       (N=547)       (N=534)       (N=1148)       (N=1036)

                           n       %     n       %     n       %     n       %      n      %
      Heard of a
      programme            482     80%   489     89%   414     78%   627     55%    324    31%
      called DREAMS
      Invited to
      participate in any   290     48%   322     59%   214     40%   463     40%    176    17%
      DREAMS activity

                                                                                                   13
14
15
16
Uptake of DREAMS services in a key population
•    Low among Young Women who Sell Sex in the evaluation cohort in Zimbabwe
     2017 (>1yr of implementation)
•    Re-prioritisation discussed for Year 3 of DREAMS; 2018 data now under review

                                                                              17
Part 3. What have we
        learned so far?

  a) DREAMS reach so far
  b) Early effects of DREAMS
                               18
Measuring HIV incidence: Direct observation of sero-conversions via
repeat testing in cohorts to be followed through 2019

                                                               New
                                                               infections
                                                               measured
                                                               through
                                                               2019

                                                                    19
20
Example of a secondary outcome
Young People’s Knowledge of their HIV Status
   in 2 informal settlement areas of Nairobi

                                               21
Young people’s knowledge of their HIV status
 By whether AGYW were beneficiaries of DREAMS in the past year…

  • Levels among DREAMS beneficiaries are significantly higher in both age groups
  • Larger % difference among the younger AG, 15-17yr-olds
                                                                               22
Young people’s knowledge of their HIV status
In uMkhanyakude…

•   Differences by DREAMS are also evident but not as great as Kenya (HIV testing not delivered
    as systematically as Nairobi, where enrolment includes an offer of HIV testing?)
•   And they are only significant among the younger AG (13-17y), not the older YW (18-22y)
•   Levels remain sub-optimal but promising signs that DREAMS can reach adolescent girls 23
Young people’s knowledge of their HIV status

Reflections so far

• Knowledge of HIV status is the gateway to HIV prevention and treatment
  services, but typically low among young people (big gap to 95:95:95)

• DREAMS is helping to quickly increase young women’s knowledge of their HIV
  status:
    •   especially in Kenya, where DREAMS enrolment was usually accompanied by an HIV
        test
    •   but also in KwaZulu-Natal, SA, where levels were low pre-DREAMS
    •   in both settings, DREAMS is boosting knowledge of status among adolescent girls
        13-17yrs (more so than young women 18+), showing that adolescent girls can be
        reached before ANC / pregnancy-related services.

• The DREAMS model can be expanded to reach young males, whose
  knowledge of their status remains very low in most settings, over time and
  relative to females (see Annex).

                                                                                          24
CONCLUSIONS (so far)
•   DREAMS has mobilised communities and governments to deliver a complex program
    across sectors introducing new services (e.g., social asset building, PrEP) and new ways
    of working
•   DREAMS offers a model that – with commitment and resources – can be adapted to diverse
    contexts, with these lessons so far:

    For impact on HIV incidence?
                                                                                           25
    It is too soon to say. We will observe sero-conversions through 2019.
Related talk at AIDS2018 this week…

HIV incidence trends among the general population in Eastern and Southern
Africa 2000-2014
Emma Slaymaker, London School of Hygiene & Tropical Medicine, United Kingdom

 Session:        “Forging new pathways towards HIV elimination”
 Code:           TUAC01
 Session Type:   Oral Abstract Session Track C – Epidemiology and prevention research
 Venue:          Elicium 1
 Date Time:      14:30 Tuesday 24 July, 14:30 – 16:00

                                                                                        26
In memory of our colleague and
     co-Investigator Basia Zaba

Thank You
Annex

        28
Baseline HIV incidence                                                  Trend pre-DREAMS:
                                                                    Persistently high incidence in
      - pre-DREAMS in uMkhanyakude, KZN                              10 years prior to DREAMS;
                                                                        no evidence of rise or
                                                                     decline. A steady baseline.
 Females aged 15-24 years (2006-2015)
    Age group     Calendar period    New HIV     Person-years    Incidence rate /        Rate ratio
                                    infections                  100 person-years         (95% CI)

    15–19 years     2006–2010          254          5395        4.71 (4.10 -5.41 )           1

                    2011–2015          197          4330        4.54 (3.89 -5.30 )   0.97 (0.78 -1.19 )

    20–24 years     2006–2010          340          4462        7.62 (6.71 -8.65 )           1

                    2011–2015          289          3881        7.45 (6.51 -8.51 )   0.98 (0.81 -1.18 )

 Males aged 20-29 years (2006-2015)
    Age group     Calendar period    New HIV     Person-years    Incidence rate /        Rate ratio
                                    infections                  100 person-years         (95% CI)

                    2006–2010          103           3430       2.99 (2.38 -3.77 )            1
    20–24 years
                    2011–2015           76           2876       2.62 (2.01 -3.42     0.85 (0.59 -1.23 )

                    2006–2010           59           1299       4.54 (3.32 -6.21 )            1
    25–29 years
                    2011–2015           66           1592       4.16 (3.12 -5.56 )   0.92 (0.59 -1.42 )
Young people’s knowledge of their HIV status

  By age and sex, among random samples of young people in Nairobi 2017…

   • Levels among females are quite high (>75%), and increase with age
   • Lower levels among male peers, in both 15-19y and 20-22yr groups

                                                                          30
Comparison with uMkhanyakude, KZN, S Africa
By age and sex, among representative samples of young people

  •   Knowledge of HIV status is much lower overall than seen in Nairobi (reflecting a history of
      relatively few HIV prevention programs targeting young people in this area)
  •   Again, higher levels among females than males (15-19y): 54% v 21%
  •   Among females, it’s higher (double) among older YW than younger AG                        31
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