Temporal shifts in HIV-related risk factors among cohorts of adolescent girls and young women enrolled in DREAMS programming: evidence from Kenya, Malawi and Zambia

OBJECTIVES: To assess temporal shifts in HIV risk factors among adolescent girls (AG, aged 15–19 years) and young women (YW, aged 20–24 years) in Kenya, Malawi and Zambia. DESIGN: Prospective cohorts with two time points (Kenya: 2016/2017, 2018; Malawi: 2017, 2018; Zambia: 2016/2017, 2018) SETTING: Community-based programming. PARTICIPANTS: 1247 AG (Kenya: 389, Malawi: 371, Zambia: 487) and 1628 YW (Kenya: 347, Malawi: 883, Zambia: 398) INTERVENTION: Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS), a multisectoral approach to reduce AGYW’s HIV vulnerability by delivering a package of tailored, multilayered activities and services. Primary and secondary outcome measures: HIV testing, sexually transmitted infection (STI) symptom experience, number of sexual partners, condom use (consistently, at last sex), transactional sex, experience of physical violence (from intimate partners) and sexual violence (from intimate partners and strangers/non-partners). RESULTS: Changes in HIV-related risk behaviours among DREAMS participants varied by age group and country. Among AG, HIV testing increased (Kenya and Zambia) and sexual violence from partners (in Kenya and Malawi) and non-partners (in Malawi) decreased. Among YW, HIV testing increased and STI experience decreased in Malawi; consistent condom use decreased in Kenya; transactional sex increased in Kenya and Zambia; and physical violence (in Malawi) and sexual violence from partners (in Kenya and Malawi) and non-partners (all three countries) decreased over time. CONCLUSIONS: Improvements in HIV testing and reductions in experiences of sexual violence were coupled with variable shifts in HIV-related risk behaviours among DREAMS participants in Kenya, Malawi and Zambia. Additional consideration of AGYW’s risk circumstances during key life transitions may be needed to address the risk heterogeneity among AG and YW across different contexts.