Jane Osindo

Common mental disorders (CMD) are increasing globally among young people. The DREAMS (Determined-Resilient-Empowered-AIDS-free-Mentored-Safe) multi-component intervention package, delivered during 2016–2023, aims to reduce HIV incidence among adolescent girls and young women (AGYW). We hypothesised that social, health and economic benefits of DREAMS would reduce CMD, though this was not the program’s goal. In each of two Kenyan settings (Gem and Nairobi) a randomly selected cohort of around 1000 AGYW aged 13–22 years was enrolled during 2017–2018 and followed up during 2019–2022. CMD was measured using the Shona-Symptom-Questionnaire; a score of ≥7 was classified as `experiencing CMD’. We used inverse-probability-of-treatment-weighting to control for confounding and compared 3 groups of AGYW: those invited to DREAMS by 2018 (early invitees), during 2020–2022 (later invitees), or not invited to DREAMS (non-invitees). In 2022, the proportion experiencing CMD was 45% (463/1023) in Gem, and 46% (410/889) in Nairobi. In Gem, the estimated proportions with CMD were 49%, 45%, and 38% for the counterfactual scenarios in which all AGYW were early invitees, all were later invitees, or all were non-invitees, respectively. There was evidence of an increase in CMD prevalence when comparing early invitees with non-invitees (11%; 95% CI:2%,21%). In Nairobi, the estimated proportions with CMD were 46%, 55%, and 32% for the scenarios in which all were early invitees, all were later invitees, or all were non-invitees, respectively. There was evidence of an increase in CMD prevalence when comparing early invitees to non-invitees (14.4; 95% CI:2.1%, 26.4%) and when comparing later invitees to non-invitees (23.3%; 95% CI:5.8%,41.2%). CMD was common among AGYW in both settings. The higher CMD prevalence among DREAMS invitees compared with non-invitees might be due to increased recognition of, and willingness to disclose, symptoms of mental ill-health. Specific interventions to address CMD among AGYW should be incorporated within health and HIV prevention programmes.

In Kenya, the DREAMS Partnership (“Determined, Resilient, Empowered, AIDS-free, Mentored and Safe”) aims to reduce new HIV cases among adolescent girls and young women (AGYW; aged 10–24) through a comprehensive programme of interventions. The impact of DREAMS varies across settings but reasons for this are not well understood. One potential reason is the differential implementation of DREAMS interventions due to on-the-ground adaptations made by implementers. We sought to understand if, how, and why DREAMS delivery was adapted in three Kenyan settings, so that complex interventions like DREAMS can be tailored to diverse contexts and challenges.We analysed 40 transcripts from individual and group discussions with DREAMS implementing teams. Data were collected between 2017–2019 in rural Gem and two Nairobi informal settlements. Using both FRAME and CFIR frameworks, we identified programming and contextual challenges that affected implementation, local adaptations made in response to these realities and challenges, and the goals and reasoning for adaptation. Reasons for adapting DREAMS were similar across settings yet the type of adaptation varied by context. Adaptations were made to: 1) improve programme attendance; 2) tailor content to better suit AGYW, encourage programme attendance and address community concerns; 3) support participants’ wellbeing, amidst poverty, hunger and violence; and 4) cope with insufficient programming resources. Given their close contact with participants and families, DREAMS mentors often developed unique context-specific strategies to make interventions more appealing and accessible to participants of different ages and circumstances. Understanding shared reasons for adaptation across settings can help anticipate challenges before implementation, and inform the co-design of interventions with communities. As context-specific issues inevitably arise during implementation, mentors can be instrumental in adapting DREAMS, serving as a bridge between programme implementers and beneficiaries. Supporting mentors’ ideas and ongoing commitment can ensure that those delivering programmes plan, learn, adapt and improve in partnership with communities.

Comprehensive intervention packages are recommended to address multiple sources of HIV risk for adolescent girls and young women (AGYW). DREAMS is a multi-component HIV prevention program designed to reduce HIV incidence among AGYW. We conducted a prospective cohort study among AGYW aged 13–22 years, randomly selected in rural Gem and urban Nairobi informal settlements followed from 2017/2018–2019. AGYW were classified into three groups: (1) invited to DREAMS and received a “complete” package, (2) invited and received a “partial” package, or (3) not invited to DREAMS. We defined the “complete” package as 4–5 primary interventions in Gem and 5 in Nairobi: the “partial” package as 3 specific interventions in Gem and any 3–4 interventions in Nairobi. We used propensity score-adjusted logistic regression to estimate the causal effect of DREAMS on outcomes under three counterfactual scenarios: all AGYW accessed the complete package, all accessed a partial package, or none were invited. In Nairobi, 1081 AGYW were enrolled. By 2019, 26% accessed the complete package and 32% accessed the partial package. Among those receiving the complete package, there was increase in HIV status knowledge(24.8% [95%CI:16.4,32.6]),social support(13.9% [95%CI:3.3,23.6]) and self-efficacy(10.3% [95%CI:0.5,20.4]) and a decrease in the proportion with ≥2 lifetime partners(-8.0% [95%CI:-15.9,0.0]). In Gem, 1171 AGYW were enrolled. By 2019, 24% received the complete package and 21% received the partial package. We found evidence of an increase in HIV status knowledge(10.0% [95%CI:4.5,15.2]), social support(27.2% [95%CI:19.2,35.5]) and a decrease in condomless sex(-9.1% [95%CI:-13.6,-4.1]), and the proportion with ≥2 lifetime partners(-7.6% [95%CI:-12.4,-2.2]) for the complete package. Among those receiving the partial package, there was a decrease in condomless sex(-12.2% [95%CI: -17.0,-6.4]), and an increase in self-efficacy(8.0% [95%CI:0.0,17]). A package of 4–5 primary DREAMS interventions had positive impacts on multiple HIV-related outcomes in both settings. A partial package was effective in Gem, but not in Nairobi, suggesting the need for context-specific intervention strategies.

Empowerment is key to person-centered HIV prevention. This study aims to evaluate the extent to which the Determined, Resilient, Empowered, AIDS-free, Mentored, Safe (DREAMS) Partnership promotes empowerment of adolescent girls and young women (AGYW) in Kenya. We conducted a mixed-methods study to examine DREAMS influence on empowerment precursors (resources, agency, institutional structures) and outcomes, guided by Kabeer’s framework for women’s empowerment. With representative cohorts of AGYW aged 13–22, followed since 2017/18, we estimated the impact of DREAMS on social support and self-efficacy by 2022. With a nested sample of cohort participants in 2022, we conducted qualitative inquiry through in-depth interviews and participatory action learning with DREAMS participants, implementers, and community members, for evidence of mechanisms, achievement and contextual influences on AGYW empowerment. We found statistical evidence of a causal impact of DREAMS on social support and self-efficacy among adolescent girls. Qualitatively, DREAMS enhanced AGYW’s access to and control of resources, including coveted material assets like educational subsidies, hygiene products, and business support, which reportedly reduced transactional sex through economic autonomy and bodily integrity. DREAMS enhanced intangible resources like HIV knowledge and financial skills. Greater confidence, courage, and critical consciousness enabled some AGYW to act on health choices, assume leadership roles, and continue education. In mentor-led activities, AGYW demonstrated collective action and solidarity and group saving skills for financial autonomy. DREAMS aimed to engage the broader community including leaders, parents, and young men, but social structures, dominant gender norms, gender-based violence, and widespread poverty mitigated its empowering impact for AGYW. We found compelling evidence that DREAMS strengthened many young women’s access to and control of resources and their intrinsic and collective agency. These are important precursors to empowerment but insufficient for the transformation of power relations without supportive institutional structures, including gender-equitable norms and viable livelihood strategies.

The DREAMS partnership aims to deliver a comprehensive package to reduce HIV incidence among adolescent girls and young women (AGYW), including through shifting gender norms. We evaluate DREAMS’ effect on attitudes towards gender norms in two Kenyan settings. AGYW aged 15–22 in Nairobi (n = 852) and Gem (n = 761) were randomly selected for cohort enrolment in 2017–18 and followed-up to 2019. We described the proportion of AGYW and their male peers with equitable attitudes towards gender norms, using an adapted version of the GEM scale. We estimated the association between self-reported invitation to DREAMS (in 2017–18) and AGYW’s attitudes towards two dimensions of gender norms, and then applied a causal inference framework to estimate the difference in the proportion of AGYW with equitable attitudes under the counterfactual scenarios that all versus none were DREAMS beneficiaries. We estimated that overall, 90.2% versus 87.1% of AGYW would have equitable norms around sexual and reproductive health decision-making in Nairobi if all versus none were DREAMS beneficiaries (+3.1; 95%CI:-2.5, +9.0). In Gem, we estimated a risk difference of +1.0 (89.6% vs 88.6%, 95%CI: -3.6,+5.6). There was no evidence for an effect of DREAMS on attitudes towards violence-related norms (Nairobi: 82.7% vs 82.2%, +0.5; 95%CI: -5.3,+6.5; Gem: 44.3% vs 48.2%, -3.9; 95%CI: -11.7,+3.0). We found no evidence of an impact of DREAMS invitation on individual attitudes towards gender norms. In some cases, equitable attitudes at enrolment left limited scope for improvement, and additional effort may be required to shift inequitable violence attitudes among both AGYW and their male peers.

Mental health issues are a predisposing factor for HIV acquisition. We examined the association between depressive symptoms and patterns of sexual experience among girls aged 10–14 years living in Korogocho and Viwandani slums in Nairobi, Kenya. We analysed data collected in 2017 from a random sample of 606 girls. Using Latent Class Analysis, we modelled patterns of sexual experiences and used multivariable regression analysis to determine the association between self-reported depressive symptoms and sexual experiences. Seven in ten girls reported at least one symptom of self-reported depression in the past 12 months. About 13% of girls had had a sexual experience, resulting in two patterns of sexual experience – naïve and experienced. Girls reporting depressive symptoms were more likely to be sexually experienced. Sexual and reproductive health programs targeting adolescent girls should consider including intervention packages that address mental health conditions such as depression.

Across the world, Community Health Volunteers (CHVs) are recognised as first line health care providers. Overtime, the Kenyan government has acknowledged CHVs as an integral component in provision of first line health care services at the community level. This paper uses data from four group discussions with CHVs and two key informant interviews with sub-County Community Strategy Coordinators to examine the lived experiences of CHVs. The findings show that meaningful engagement of CHVs is hampered by lack of logistical support, recognition, insecurity, and inadequate resources. Despite the bottlenecks, voluntarism is their greatest driving force. They noted that their work could be enhanced through logistical support from the government involving training, provision of equipment, remuneration and recognition in the community. The findings suggest that there is need for close coordination between the national government and the community units for CHVs to contribute to improved health outcomes at the local level