國際戰(zhàn)略研究中心-如何解決艾滋病毒、兩性不平等和衛(wèi)生安全等交叉危機(jī)（英文）-2021.5-47正式版

May2021

FiveYearsof

DREAMSand

WhatLiesAhead

HowtoAddresstheIntersectingCrisesofHIV,GenderInequality,andHealthSecurity

Author

JanetFleischman

Areportofthe

CSISGlobalHealthPolicyCenter

MAY2021

FiveYearsofDREAMSandWhatLiesAhead

HowtoAddresstheIntersectingCrisesofHIV,GenderInequality,andHealthSecurity

AUTHOR

JanetFleischman

AreportoftheCSISGlobalHealthPolicyCenter

fiveyearsofDREAMSandwhatliesahead/fleischman

ACKNOWLEDGMENTS

ThisreportwaswrittenbyJanetFleischman,seniorassociate,CSISGlobalHealthPolicyCenter,withresearchsupportfromMichaelRendelman,researchassociate,andMaggieMcCarten-Gibbs,formerprogrammanager.Wegratefullyacknowledgethemanyadolescentgirlsandyoungwomen,implementingpartners,experts,civilsociety,nationalgovernmentandmultilateralofficials,andU.S.governmentrepresentativeswhosharedtheirinsights,experience,andinputwithus.ThisworkwasmadepossiblewiththegeneroussupportofViiVHealthcare.

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fiveyearsofDREAMSandwhatliesahead/fleischman

ABOUTCSIS

TheCenterforStrategicandInternationalStudies(CSIS)isabipartisan,nonprofitpolicyresearchorganizationdedicatedtoadvancingpracticalideastoaddresstheworld’sgreatestchallenges.

ThomasJ.PritzkerwasnamedchairmanoftheCSISBoardofTrusteesin2015,succeedingformerU.S.senatorSamNunn(D-GA).Foundedin1962,CSISisledbyJohnJ.Hamre,whohasservedaspresidentandchiefexecutiveofficersince2000.

CSIS’spurposeistodefinethefutureofnationalsecurity.Weareguidedbyadistinctsetofvalues—nonpartisanship,independentthought,innovativethinking,cross-disciplinaryscholarship,integrityandprofessionalism,andtalentdevelopment.CSIS’svaluesworkinconcerttowardthegoalofmakingreal-worldimpact.

CSISscholarsbringtheirpolicyexpertise,judgment,androbustnetworkstotheirresearch,analysis,andrecommendations.Weorganizeconferences,publish,lecture,andmakemediaappearancesthataimtoincreasetheknowledge,awareness,andsalienceofpolicyissueswithrelevantstakeholdersandtheinterestedpublic.

CSIShasimpactwhenourresearchhelpstoinformthe

decisionmakingofkeypolicymakersandthethinking

ofkeyinfluencers.Weworktowardavisionofasafer

andmoreprosperousworld.

CSISdoesnottakespecificpolicypositions;accordingly,allviewsexpressedhereinshouldbeunderstoodtobesolelythoseoftheauthor(s).

?2021bytheCenterforStrategicandInternationalStudies.Allrightsreserved.

CenterforStrategic&InternationalStudies

1616RhodeIslandAvenue,NW

Washington,DC20036

202-887-0200|

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fiveyearsofDREAMSandwhatliesahead/fleischman

CONTENTS

Introduction

1

KeyRecommendationsfortheU.S.GovernmentonDREAMS

4

Background:WhyAGYWRiskFactorsRequireaMultisectoralResponse

6

TheLaunchofDREAMS

8

AMultisectoral“Layered”Approach

11

ExamplesandEvidencearoundDifferentLayers

16

ModesofImplementation:CountryExamples

19

ImpactofCovid-19onAGYWPrograms

26

Multilateral,Regional,andNationalResponsesonAGYWandHIV

28

ChallengesforDREAMS

30

ImplicationsforU.S.Policy

33

AbouttheAuthor

35

IV

fiveyearsofDREAMSandwhatliesahead/fleischman

Introduction

“IdecidedtorunawayfromhomeduetotheabusethatIwasreceiving.IranawayfromhomewithmyboyfriendbecauseIdidn’thaveelsewheretogoto.Afterrunningtomyboyfriend’shouse,Ifellpregnant.HechasedmeoutofhishouseandIdidn’thaveanywheretogo.Iwassodisturbed...Ididn’tknowwhattodo.NoonecouldhelpmeoutuntilImetDREAMS.Theyreallyhelpedme.”

—GraceNjobvu,a23-year-oldparticipantinDREAMS,Lusaka,Zambia.1

OnDecember1,2014—WorldAIDSDay—theU.S.globalAIDScoordinatoratthetime,AmbassadorDeborahBirx,soundedthealarmonHIVinfectionsinadolescentgirlsandyoungwomen

(AGYW)andlaunchedaboldinitiativecalledDREAMS—Determined,Resilient,Empowered,AIDS-free,Mentored,andSafe.ThegoalwastosignificantlyreducenewHIVincidenceamonggirlsandyoungwomeninthehighest-burdencountriesinsub-SaharanAfricaandinHaiti,wheretheyfaceafarhigherriskfornewHIVinfection—2to14timeshigher—thantheirmalepeers.2DespitetheurgencyofreducingHIVinthispopulationtoreachglobalgoalsforepidemiccontrol,Covid-19andnewglobaleffortsaroundhealthsecuritythreatentodivertthefocusonthiscriticalpopulation.DREAMSisnowataninflectionpoint,facingtheriskthatitsprogressongirlsandyoungwomenwillbereversed,alongwithdecadesofhealthanddevelopmentgainsforwomenandgirls.

LedbytheU.S.President’sEmergencyPlanforAIDSRelief(PEPFAR),DREAMSisaninnovativeandambitioushealthprogramthatfocusesonacombinationofstructural,behavioral,andbiomedicalinterventionstopreventHIVamongAGYW,includinggender-basedviolence(GBV)preventionandresponse,economicstrengthening,reproductivehealth,andeducationsupportin15countries.3Bycombininghealthwithprotectionandempowerment,DREAMSrepresentsamultifacetedapproachtoaddressingHIVprevention,genderinequality,andhealthsecuritybasedonlocalized,community-centeredprograms.Itwascreatedasapublic-privatepartnershipwiththeBill&MelindaGatesFoundation,GileadSciences,GirlEffect,Johnson&Johnson,andViiVHealthcare.

Afterfiveyearsandover$1billioninvested,thisisanopportunemomenttoexaminethekeyachievements,barriers,andongoingchallengesofDREAMS,especiallyinlightofthenewchallengesoftheCovid-19pandemic.TheadventoftheBiden-Harrisadministration,whichhaselevatedanewframeworkforglobalhealthandgenderissues,providesanunprecedentedopeningtoadvanceastrategicvisionaroundsecuringahealthyfutureforthisgrowingpopulationofwomenandgirls.SuchavisionshouldincludecurbingtheHIVpandemicwhilealsostrengtheningtheCovid-19responseandadvancingthedevelopment,prosperity,andstabilityoftheparticipatingcountries—allcentraltoU.S.nationalinterests.Agirl-andyoungwomen-centered

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fiveyearsofDREAMSandwhatliesahead/fleischman

Agirl-andyoungwomen-centeredapproachwouldbeapowerfulandeffectivestrategytocomprehensivelyaddressHIVprevention;wehavelearnedagreatdealfromDREAMS,whichhassetinplaceaframeworkandasetofinterventionsthathaveprovedthevalueofthismultisectoralapproach.TheU.S.governmentnowneedstotakethistothenextstage.

approachwouldbeapowerfulandeffectivestrategytocomprehensivelyaddressHIVprevention;wehavelearnedagreatdealfromDREAMS,whichhassetinplaceaframeworkandasetofinterventionsthathaveprovedthevalueofthismultisectoralapproach.TheU.S.governmentnowneedstotakethistothenextstage.

ThisreportexamineswhatlessonshavebeenlearnedinthefirstfiveyearsofDREAMSandwhatthenextfive-yearapproachmightbe,includingredressingthedisruptionsandcostlydamageimposedbyCovid-19.Overthepastyear,weconductedinterviewswithover80keyinformantsinDREAMScountries,intheUnitedStates,andinEurope,includingadolescentgirlsandyoungwomenthemselves,implementingpartners,experts,nationalgovernmentofficials,representativesofmultilateralorganizations,andU.S.governmentrepresentatives,aswellaswithotheranalysts,funders,andobserversofAGYWandHIVprograms.WeanalyzehowDREAMShasevolvedandwhatitsimpactshavebeen,includingwhatfactorscontributedtosuccessorconstitutedbarriers.TounderstandtheglobalapproachestoAGYW,includinghowDREAMShelpedsparkcomplementaryefforts,thereportalsolooksatthegirlsandyoungwomenfocusoftheGlobalFundtoFightAIDS,Tuberculosis,andMalaria,aswellastheUnitedNationsProgramonHIV/AIDS(UNAIDS)andselectednationalresponses.Finally,wediscussimplicationsforU.S.policy,focusedonwhatisneededgoingforwardifDREAMSistofurtherdrivedownHIVinfectionsandincreasethehealthandagencyofgirlsandyoung

womenmorebroadly,withrecommendationsforthenewBiden-HarrisadministrationandCongress.Tereisnoquestionthatawindowhasopened,duetotheglobalCovid-19pandemicandtheadventoftheBidenadministration,toaskhowwecanachievebetterresultsfromintegrated,coordinatedapproaches.

DREAMShasbeensuccessfulinreachingmillionsofgirlsandyoungwomenin15countrieswithamultisectoralpackageofservices,andthosecontributionstoHIVpreventionwillcontinuetogrowintheyearstocome.DREAMShascatalyzedaglobalfocusonAGYWandHIV,includingbyUNAIDSandtheGlobalFundandbysomenationalgovernments.AlthoughdirectlyattributingtheDREAMSimpactiscomplicated,DREAMShascontributedtoadeclineinHIVincidenceamongAGYWinalltheDREAMSdistricts.

YetDREAMSrepresentsanexpensivemodelthatwouldbedifficultforcountriestoreplicateandsustainandhassparkedcriticismforoperatinginparalleltonationalandlocalmechanisms.Althoughthefocusongirlsandyoungwomenissupportedrhetoricallybymostgovernments,inreality,fewhavemobilizeddomesticresourcesorhigh-levelnationalcommitmentfortargetednationalprograms,andmanyhavefeltsidelinedbyPEPFAR’sapproach.ThissituationisonlyexacerbatedbytheCovid-19crisis,whichfurtherstrainsnationalanddonorbudgetswhileincreasingthesocialandeconomicfactorsthatputAGYWatriskofHIVinthefirstplace.

WhileDREAMShasshowntheimportanceofamultisectoralresponse,italsohighlightsthechallenges

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fiveyearsofDREAMSandwhatliesahead/fleischman

inherentinthisapproachandraisesdifficultquestionsaboutthealignmentofinvestmentsbetweenPEPFARandotherU.S.agencies,howtobettermonitortheimpactoftheservices,andhowtoaddressthecycleoftransmissionandthemalesexualpartners.AsCatherineConnoroftheElizabethGlaserPediatricAIDSFoundation,aPEPFARimplementer,putit:“Therewasalackofservicesforthispopulation,andweneededaholisticapproachtocrackitopen...thevaluebecameeasytounderstand,you’dbehard-pressednottoseeit—health,empowerment,literacy.Butjumpingfromvaluetoimpactisharder;westillhavenorealunderstandingofwhythingsworkedinsomeareas.”4

DesmondTutuHIVCenterattheUniversityofCapeTown,“Thehugesttragedywouldbeifwelosethosefiveyears.Howdowequicklyextractthemainlessonsandputitintoanaffordablepackage?Whowilldoit,howwilltheydoitwiththesamequalityandfidelity,andhowdowescaleup?Theonlywaywe’llfeelimpactistoreachthewholeregion.”5

Thereisnoquestion

thatawindowhas

opened,duetotheglobal

Covid-19pandemicand

theadventoftheBiden

administration,toask

howwecanachieve

betterresultsfrom

integrated,coordinated

approaches.

Despiteitschallengesandcritics,DREAMShasproven

tobeapromisingmodelthatisuniquelysuitedtoan

adaptedandreimaginedU.S.strategythatmovestoward

moreintegratedapproachesandawayfromsiloed,

verticalprograms.Bysupportinggirlsandyoungwomen

tobethehealthyandempoweredfutureleadersintheir

communitiesandcountriesandadvancingbroader

healthanddevelopmentoutcomesforthispopulation,

DREAMScouldbeapivotalcomponentofanewU.S.

strategy.Seriousquestionsdoremainaboutwhether

DREAMScangobeyondproofofconceptandbecome

thekindofscalable,sustainable,andtransformative

programthatcountriescanadoptandown.According

toDr.Linda-GailBekker,aleadingHIVexpertatthe

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fiveyearsofDREAMSandwhatliesahead/fleischman

KeyRecommendationsfortheU.S.GovernmentonDREAMS

PEPFARshoulddeveloparoadmapforthenextphaseofDREAMSbyidentifyingthemostimpactfulandcost-effectivecombinationsofinterventionsforAGYWandincorporatingthatintobudgetplanningoverthenextfiveyears.ThismeansstrengtheningdataanalysisaroundthepackageofDREAMSinterventionstodevelopaminimumpackagethatcanbeadaptedfordifferentcontextsandagegroupsandinvestingincost-effectivenessanalysesofthemulticomponentprograms.Tobettermonitorprogress,adaptprogramdesign,andincentivizeinnovation,DREAMSshouldexpandwhatitmeasurestocapturetheimpactonotherkeyoutcomesforgirlsandyoungwomenbeyondHIV—suchasunintendedpregnancy,GBV,andsecondaryschoolcompletion.ThegoalshouldbetodevelopamodelforAGYWservicesthatcanbereplicatedandownedbycountries—governments,civilsociety,andgirlsandyoungwomen—sothatprogramscanbescaledupandsustained,buildingoffthelessonslearnedfromDREAMSandtailoredtolocalneeds.

TheU.S.governmentshouldlaunchawhole-of-governmentapproachtoAGYW.TheStateDepartmentshouldestablishaninteragencysteeringcommitteetostrategicallyaligninvestmentsaroundAGYWandimprovecoordinationwithnationalgovernments,multilateralorganizations,andprivatesectorpartnerstoadvanceamultisectoralresponse.AlthoughU.S.governmentprogramsinHIVandotherhealthanddevelopmentareasareorganizedinsilosandfunded

separately,impactcanbemaximizedbyaligningandcoordinatinginvestmentsforgirlsandyoungwomen.Thiscallsforimprovedcountry-levelcoordinationandalignmentofresourcesfromU.S.governmentagenciesaroundHIV,Covid-19,familyplanningandreproductivehealth,primaryhealthcare,educationforgirls,GBVpreventionandresponse,andeconomicempowerment.ImprovedcoordinationisalsonecessarybetweentheUnitedStatesandotherbilateralandmultilateraldonors,especiallytheGlobalFund.Thisapproachshouldfocusonassistingnationalgovernments,withcivilsocietyengagement,toleadanintegrated,multisectoralapproachtoAGYWprogramming.Tosupportthegovernmentsandincentivizeinvestments,innovativefinancingthroughimpactinvestingandotherpublic-privatepartnershipsshouldbepursued.

TheBidenadministrationshouldworkwithCongresstoprioritizefundingforAGYWintheCovid-19response.TheCovid-19pandemichasrevealedandexacerbatedinequitiesfacedbygirlsandyoungwomenthroughincreasedGBV,unintendedpregnancies,lackofaccesstosexualandreproductivehealth(SRH)services,andlossofschoolingandeconomicopportunities.AscountriesandcommunitiesstruggletoaddressCovid-19,theU.S.shouldprioritizetheneedforacomprehensiveresponsethatbuildsonandadaptstheexistingDREAMSplatformsaspartoftheCovid-19response.ThisalignswiththenewNationalStrategyfortheCovid-19ResponseandPandemicPreparedness,whichidentifiestheneedto

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mitigatethesecondaryimpactsofCovid-19onhealthanddevelopmentforwomenandgirls.TheAmericanRescuePlan,approvedbyCongress,shouldmakegirlsandyoungwomenapriority,includingthroughthefundsprovidedtoPEPFAR,andCongressshouldensurethattheadministrationreportsonitsprogressinaddressingtheirneeds.

PEPFAR,theU.S.AgencyforInternationalDevelopment(USAID),andotherU.S.agenciesshouldpromotetheengagementofAGYWinDREAMS,ensuringthattheyareinvolvedindeterminingthedesign,implementation,andmonitoringofprograms.Toooften,girlsandyoungwomenareexcludedfromdecisionmakinginDREAMS,fromcommunityorganizations,andfromthedeliberationsofgovernmentministries—includingtheMinistryofHealth—reflectingdiscriminatorygendernorms.Goingforward,DREAMSshouldaddressthisgapbyworkingwithgirlsandyoungwomentoestablishAGYWadvisorygroupstoprovideanongoingmechanismforinputtoimplementers,communities,facilities,andgovernments.

PEPFARshoulddecentralizeservicesforAGYW.DREAMShasshownthevalueofbringingclinicalservicesoutoffacilitiesandclosertothecommunityandprovidingdifferentiatedservicedelivery.IthasalsoshownthatmultisectoralinterventionsforAGYWcanbeprovidedthroughsafespacesanddrop-incenters,includingsocial,structural,andeconomicprogramming.DREAMSshouldexpandsuchperson-centereddesignapproachesthatdecentralizeservicesandmakethemmoreaccessibletoandconvenientforgirlsandyoungwomen,includingforSRHandpre-exposureprophylaxis(PrEP)andyouth-friendlyserviceswithnonjudgmentalproviders.Thisalsoinvolvesincreasinggirls’andyoungwomen’sownpowerovertheirhealthcarethroughimprovingaccesstoself-carestrategies,suchasself-testingforHIVandself-injectionforcontraception.

PEPFARshouldworkwithotherU.S.governmentagenciestoexpandintegrationofSRHandHIVandtopreparefornewbiomedicalpreventiontechnologies.GirlsandyoungwomenareoftenmoreconcernedwithgettingpregnantthangettingHIV,underscoringtheimportanceofintegrationofSRHandHIVservicesasawaytoovercomebarrierstouptake.Thiswillrequiredevelopingintegratedfundingopportunitiesandindicatorstomeasureprogress.WithPrEPbeingscaledupforgirlsandyoungwomenandnewpreventiontechnologies

onthehorizon,includinglong-acting,injectablecabotegravir(CAB-LA)andthedapivirinevaginalring,6acceleratingqualityintegrationofservicesbecomesevenmoreessentialforbothHIVandSRHoutcomesforgirlsandyoungwomen.IfthefullrangeofcontraceptivecommoditiesisnotavailableforAGYWthroughHIVclinics,PEPFARshouldfillthesegapsbyusingitsfundstoprocurecontraceptives.

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fiveyearsofDREAMSandwhatliesahead/fleischman

Background:WhyAGYWRiskFactorsRequireaMultisectoralResponse

ReducingHIVincidenceingirlsandyoungwomenisindispensabletocurbtheHIVepidemicinhighburdencountries.Thedisproportionate

impactofHIVonthispopulationisglaringlyevidentinsub-SaharanAfrica,whereanestimated5,500AGYWaged15–24yearsoldbecomeinfectedwithHIVeveryweek7—2to14timeshigherthantheirmalepeers—andconstitute67percentofnewinfectionsamongyoungpeople.8Thesealarmingdataunderscorethatgenderinequalities—andintersectingbiological,behavioral,andstructuralfactors—directlyandindirectlyfueltheheightenedriskofHIVinfection.This,inturn,hasclearimplicationsfortheglobalresponsetoHIV,sincethegoalofanAIDS-freegenerationwillbeimpossibletoachieveifgirlsandyoungwomenarenotacentralfocuswithstrategiesthataddresstheirmultifacetedvulnerabilities.Dr.RuthLaibon-Masha,CEOofKenya’sNationalAIDSControlCouncil,stateditsuccinctly:“TheepidemicinAfricawillneverbewonunlessweaddressAGYW.”9

PublichealthexpertsacknowledgethatinterruptingthecyclesofHIVtransmissioniscriticaltocontrollingtheepidemic.Researchershaveshownthataperniciouscycleoftransmissioninvolvesmenaged25–34infectingAGYWaged15–24,whothengrowupandinfecttheirlonger-termpartnersaged24–35,andthecyclecontinues.10TheimplicationsofthesefindingsforhealthsystemsintheDREAMScountriesaresobering:

whilewomenover20gototheclinicsformaternalandchildhealthservices,womenunder18andyoungmenrarelyinteractwiththehealthsystem.“Ifyouthinkyoucanintervenebyusingthecurrentapproachtohealthdelivery,itwon’twork,”notedCaprisa’sassociatescientificdirector,ProfessorQuarraishaAbdoolKarim.11

Still,DREAMShasbeencriticizedinthehostcountriesandbymanyobserversfornotfocusingalsoonadolescentboysandyoungmen.PEPFARcontendsthatitsfocusisjustifiedbytheongoinghealthdisparitiesbetweengirls/youngwomenandboys/youngmen,notingthatboys/youngmenhaveahighlyeffectiveHIVpreventioninterventionthathasbeenimplementedforyearstothetuneofbillionsofdollarsbeforeDREAMS—voluntarymedicalmalecircumcision(VMMC).Ata2017CSISevent,AmbassadorBirxtookthiscriticismhead-on:“Westartedouryoungmen’sprogramin2009,withvoluntarymedicalmalecircumcisionandreallyaggressivepreventionmessaging,andatthattime,nooneaskeduswhatweweredoingforyoungwomen.ButassoonaswelaunchedDREAMS,everybodycameandsaid‘whatareyoudoingforyoungmen?’Sothatstillshowsushowweareabitprejudicedstillinourthinkingandinourprogramming.”12

WhiletheoverallrateofnewHIVinfectionsinsomeofthehardest-hitcountrieshasdeclinedinrecentyears,aparalleltrendinvolvestheburgeoningyouth

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fiveyearsofDREAMSandwhatliesahead/fleischman

GirlsinKenya’sKisumuCountyaresensitizedonHIVandviolenceprevention,aspartofDREAMS.

Photocredit:FlorenceOgola/CatholicReliefServices

population,linkedtotheimprovementsinunder-fivechildsurvival.Thesedemographictrendsareespeciallynotableinsub-SaharanAfricaandareoftenreferredtoas“theyouthwave”or“theyouthbulge.”ThismeansthatthetotalnumberofAGYWisrising,andbecausetheycontinuetoexperienceunacceptablyhighHIVrates,thisisleadingtoanunsustainableHIVtreatmentburdenontheircountries—forexample,inSouthAfrica,whichhasoneoftheworld’slargestHIVepidemics,approximately45percentofthepopulationisunder25yearsold.Giventheserealities,

arecentbookonHIVpreventionamongyoungpeople

insouthernandeasternAfricaconcluded:“SpeedingupthereductionofnewHIVinfectionsandsecuringandprotectingthesexualandreproductivehealthofyoungpeoplebecomesevenmoreofanimperativetoavoidtheseloomingfuturechallenges.”13

AcentralchallengeinHIVpreventionisthatthereisnosingleinterventionthatworksonitsown,andpreventionprogramshavetobetailoredtothecomplexitiesofpeople’slives.Toitscredit,PEPFARrecognizedtheneedforamultifacetedapproachtoaddresstherisksthatgirlsandyoungwomenfaceandtokeepthemHIV-free.Dr.JenniferKatesoftheKaiserFamilyFoundationsummarizedwhyDREAMSissuchauniquepreventionprogram:“DREAMSprovidedproofofconceptthatyoucanapproachasinglehealthissuefromamultisectorallensandthattheU.S.governmentcanfigureouthowtodoit.Ithasn’tbeeneasy,butknittingtogetherapproaches,programs,andpartnerstoaddressthecomplexlivesofAGYWisacriticalbutrarelypursuedstrategy.”14

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TheLaunchofDREAMS

PEPFARrecognizedgender-relatedfactorsintheearlyyearsoftheprogramundertheGeorgeW.Bushadministration,whichwasreflected

intheauthorizinglegislationpassedbyCongressin2003,theUnitedStatesLeadershipAgainstHIV/AIDS,TB,andMalariaActof2003.Thelegislationrequiredtheadministrationtoestablishacomprehensive,integrated,five-yearstrategyandtoincludespecificobjectives,multisectoralapproaches,andstrategiestoprovidetreatmentandpromoteprevention,includingafocusontheneedsofwomen.15UndertheObamaadministration,thefocusonwomenandgirlsincreased,boththroughPEPFARandthroughassociatedinitiativesandprogramsatUSAIDandtheStateDepartment.PEPFARadoptedfivecross-cuttinggenderareasandin2010launchedathree-countryGBVinitiative.16PEPFARalsosupportedthefirstVACS—ViolenceagainstChildrenSurvey—inTanzaniain2011andmanyotherVACSsincethen.17Allofthisworkwascritical,butnosingleinitiativefocusedspecificallyonthealarminglyhighratesofHIVinfectionamongAGYW.

Inamajorshift,PEPFARlaunchedDREAMSinDecember2014tosignificantlyreducenewHIVinfectionsinAGYW.Atthetime,thisinitiativeseemedtobearadicaldeparturefromaveryverticalprogramtoabroad,multisectoralapproachthatwouldbefarmoredifficulttodemonstrateclearandquickconcreteresults.This

signatureinitiativeraninparalleltootherPEPFAReffortstonarrowthesetoffocalcountriesbydisinvestingfromareaswithlessHIVandwasseenassomethingthatcouldgarnerbipartisansupportinCongress.

SpeakingataCSISeventonDREAMSinApril2015,AmbassadorBirxdeliveredastarkmessageaboutthedisproportionateburdenofdisease,citingstudiesshowing7,000newinfectionsperdayinthispopulation,including50percentprevalenceofHIVamongyoungwomeninruralSouthAfricabyage24.“ThisshouldbemobilizingalloftheresourcesandthesamefocusthatweputonEbola...Thisisacrisis.

..Anemergencyrequiresrisk-taking.”18Shefurtherexplainedthatthedemographicshiftsandrisingyouthpopulationinsub-SaharanAfrica—the“youthbulge”—meantthatbetween30and60percentmoregirlswereatriskthanatthebeginningoftheepidemicandthattheworlddidnothavetheresourcestopayforthecostoftreatingthislevelofrisinginfections.“TheveryprogressthatwemadeonHIV/AIDSoverthelast20yearsisatriskrightnowbecauseofourlackofengagementwithyoungwomen.”

With$210millionandhighlyambitiousgoalsforaninitialtwoyears,theDREAMSpartnershipaimedtoaddressHIVrisksforAGYWinhigh-burden“hotspots”in10countriesineasternandsouthernAfricabyidentifyingwheretheseyoungwomenarebeing

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fiveyearsofDREAMSandwhatliesahead/fleischman

Year1

Year2

Year3

Year4

Year5

Year6

(COP17)

(COP18)

(COP19)

(COP20)

OriginalDREAMSCountries

Kenya

$19,742,670

$19,742,670

$29,242,670

$29,242,670

$29,242,670

$40,047,491

Lesotho

$7,017,660

$7,017,660

$10,017,660

$10,017,660

$10,017,660

$14,000,000

Malawi

$7,017,790

$7,017,790

$7,017,740

$8,517,740

$8,517,740

$20,000,000

Mozambique

$10,195,770

$10,195,770

$10,195,770

$10,195,770

$10,195,770

$35,000,000

SouthAfrica

$33,323,381

$33,323,381

$33,323,381

$33,323,381

$33,323,381

$90,000,000

Eswatini(Swaziland)

$5,009,695

$5,009,695

$5,009,695

$5,009,695

$5,009,695

$14,219,584

Tanzania

$8,163,178

$8,163,178

$18,163,178

$18,163,178

$18,163,178

$25,000,000

Uganda

$15,717,403

$15,717,403

$15,717,403

$15,717,403

$15,717,403

$23,000,000

Zambia

$8,124,208

$8,124,208

$13,124,208

$13,124,208

$13,124,208

$30,156,723

Zimbabwe

$10,310,785

$10,310,785

$15,310,785

$15,310,785

$15,310,785

$40,277,472

DREAMSInnovationChallenge

$80,000,000

Botswana

$4,792,016

$4,792,016

$4,792,016

$19,000,000

CoteD’Ivoire

$10,000,000

$10,000,000

$10,000,000

$16,000,000

Haiti

$2,000,000

$2,000,000

$2,000,000

$3,500,00

Namibia

$10,000,000

$10,000,000

$10,000,000

$20,000,000

Rwanda

$5,000,000

$5,000,000

$5,000,000

$10,122,200

SouthSudan

$1,000,000

Total

$124,622,540

$204,622,540

$188,914,506

$