With more than 1,000 new infections daily, young women and adolescent girls are the biggest risk group for HIV infection in the world, according to UNAIDS. The risk is highest in sub-Saharan Africa.
Some sobering statistics about the region:
• More than seventy percent of all new HIV infections among adolescents are girls.
• HIV/AIDS is the leading cause of death for females between fifteen and forty-nine years-old.
• A quarter of girls age fifteen to nineteen report that their first sexual experience was involuntary.
These statistics represent a “fundamental neglect” of young women by policymakers in the HIV/AIDS community, which has historically neglected young women, according to Global Fund Executive Director Mark Dybul.
To address this long-term neglect, the $385 million DREAMS partnership was launched by the President’s Emergency Plan for AIDS Relief (PEPFAR) in partnership with the Bill and Melinda Gates Foundation, Nike, Johnson & Johnson, and Girl Effect.
DREAMS stands for Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women, according to PEPFAR.
In real numbers, this empowerment is projected to reduce HIV transmission in “high-burden” areas by forty percent by 2019.
The high burden areas include Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. Those countries account for nearly half of all the new HIV infections that occurred among adolescent girls and young women globally in 2014.
PEPFAR says DREAMS will deliver outreach, education, and information exchange that “combines evidence-based approaches that go beyond the health sector, addressing the structural drivers that directly and indirectly increase girls’ HIV risk, including poverty, gender inequality, sexual violence, and a lack of education.”
At a DREAMS kick-off conference in June hosted by the U.S. State Department and sponsored by the President’s Emergency Plan for AIDS Relief (PEPFAR) and Population Services International (PSI), PEPFAR Ambassador Deborah Birx, actor and PSI Ambassador Debra Messing [A&U, November 2012], and founder of Maverick Collective, Pam Scott, unveiled some of those goals and discussed how to change minds in order to save lives.
They agreed that not only have women and girls been left behind in HIV/AIDS prevention, the efforts to reach them have been top-down and ineffective. Through DREAMS they aim to change that.
Human-centered design: meeting people where they are
At the conference Pam Scott, whose company uses “human-centered design” to approach harm reduction, describes how to meet women and girls and health professionals in Africa where they are.
“In development, the first thing we do is we go into communities and we start to understand where, how, and why problems perpetuate,” Scott said in her presentation.
“We spent quite a bit of time interviewing individuals and influencers in our audience themselves, families and groups, and we use those insights to help us understand where design can intervene in the narrative to have exponential impact.”
Scott used an example of using empathy while working with PSI to address unintended teen pregnancy in Tanzania. She shared that the people most often standing in the way of the social change they wanted to create were the doctors, nurses, and pharmacy staff that refuse to give girls the contraception that they have a legal right to. Instead of fighting them, Scott and her team visited villages around Tanzania to make friends but didn’t come bearing sexual “shoulds.”
“We did role-play and storytelling to understand their point of view and really start to unpack it,” Scott said. “One of the techniques we use is to scribble little concepts—we call these sacrificial concepts—and show them to people to see if they change the trajectory of the conversation.”
Scott recalled showing a box of oral contraceptives for adolescents to a nurse and how re-framing safer sex messages for the user can work.
“The nurse looked at the box and looked at me wide-eyed and she said, ‘Wait a minute. You mean I could give this to a girl and it wouldn’t harm her fertility?’” Scott said. “We heard this over and over and over again, and we started to realize these weren’t bad people who were against girls. These were actually people who thought they were protecting girls. They thought that contraception would harm their fertility. And what’s a girl’s greatest asset in East Africa? Her fertility.”
First steps
To unpack the goals and strategies of DREAMS, I recently spoke with Ambassador Debra Messing and Deborah Birx.
Birx said that as a global community, there have been some big successes in reducing HIV/AIDS transmission, including mother-child transmission, and encouraging young men to have safer sex, but adolescent girls have been left behind.
“What we’ve found is that one-third of young women’s first sexual experience is rape, and that [their rapists] are typically around thirty years-old and many of them are HIV-positive,” Birx said.
One might be inclined to focus education and outreach on teaching men not to rape and to get tested for HIV. That’s part of the equation, Birx said. The other part is empowering women and girls to “understand their value as females” and so that they understand what rape is and that it’s actually not okay.
That message that young women and girls need to value themselves enough to say ‘no’ may seem obvious to those in western industrial societies. In sub-Saharan Africa, though, it’s not.
DREAMS outreach and education advocates don’t aim to completely upend cultural norms in the largely patriarchal societies they’re working in. Their strategies are more subversive, using girls’ outlook about sex to take control of their bodies.
Birx added that girls who have access to secondary schools are at lower risk of HIV.
Because DREAMS is new, it’s long on goals but vague about specific solutions at this point. Birx said PSAs with culturally relevant language would be part of the overall package.
Both Birx and Messing told me that specific outreach programs will depend on a strong understanding of cultural attitudes, both spoken and unspoken, that result in disempowering girls and young women in the region.
Debra Messing, who’s spent years in listening tours, gave an example of some attitudes she discovered in her previous tours through sub-Saharan Africa.
“Teen girls in these regions understand what HIV is, but they don’t understand their depth of risk,” Messing says. “What they are sure about is that they don’t want to get pregnant.”
That attitude is important to know when crafting messages, and media, for reaching women and girls with messages to promote empowerment and safer sexual choices.
Messing is now traveling in Malawi with PSI and UNITAID. It’s a learning tour, she told me, to understand the effects of gender-based violence, exclusion from economic opportunities, lack of access to secondary school, and other factors that make girls and young women particularly vulnerable to HIV.
“After learning more about these women and girls, I will advocate for what they say they need and want.”
Larry Buhl is a journalist, radio producer, screenwriter, and novelist living in Los Angeles.