Faith Magut

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.

Introduction: South Africa is experiencing a significant shift in its disease burden from high HIV and tuberculosis (TB) mortality to increased burden of non-communicable diseases (NCDs). Despite this, screening, treatment and control for NCDs remain limited. Community health fairs are often used to identify and refer individuals with chronic diseases in underserved areas, but their impact on morbidity and mortality is unclear. Methods: From 2018 to 2020, individuals aged 15+ in the Africa Health Research Institute’s demographic surveillance area in rural KwaZulu-Natal were invited to Vukuzazi, a community health fair programme offering screening and referrals for HIV, TB, hypertension and diabetes. All residents were followed through regular household surveillance to identify deaths. We used inverse probability of treatment weighting survival analysis to estimate the effect of attendance on all-cause mortality and logistic regression to assess whether any difference in mortality may be explained by increased access to care. Results: Of those eligible, 18 041 (50.0%) participated in Vukuzazi. Individuals were observed after the health fairs for a median of 4.0 years (IQR 3.7–4.2 years) comprising a total of 127 625 person years. Vukuzazi health fair attendance was associated with a 25% relative reduction in the hazard of all-cause mortality (HR=0.75, 95% CI 0.67 to 0.84), corresponding to a 1.5% absolute reduction in mortality over 5 years. In the 3 months post health fair, attenders had 13% increased odds of clinic attendance (OR=1.13, 95% CI 1.10 to 1.17), but no change in clinic attendance among non-attenders (OR=1.02, 95% CI 0.98 to 1.06). Conclusion: Participation in a community-based health fair was associated with a reduction in 5-year all-cause mortality in rural South Africa. The reduced mortality in those attending corresponded to an increase in primary healthcare engagement following the health fairs. The integration of health fairs with a paired referral system may be an effective strategy to improve health outcomes in the region.

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.

We investigate the relationship between hope and risky behaviour and the role of migration among young people in northern KwaZulu-Natal, South Africa. We use data from a cohort of n = 5248 adolescents and young adults (AYA) aged 13-35 recruited and followed up in 2017-2019. We conducted a structured quantitative survey to assess levels of hope among AYA using a validated tool/scale. 44% of participants were aged 13-17 years, 63% were still in school, 66% were from rural areas, and 26% were from food insecure households. The mean hope total score was 31.7. The mean hope score was lower for females compared to males -0.43(95%CI; -0.64, -0.21) and lower for those out of school and not matriculated compared to those in school -0.72(95%CI; -1.1, -0.32). Young people who had experienced violence had a lower mean hope score than those who had not -0.28(95%CI: -0.50, -0.06). Those out of school, matriculated and unemployed were more likely to migrate than those in school (aOR = 1.60, 95%CI; 1.25, 2.05). AYA who were food insecure were also more likely to migrate (aOR = 1.23, 95%CI; 1.05, 1.43). Our findings suggest a need for structural interventions that address employment and education needs and harmful gender norms for older AYA.