Five Years of DREAMS and What Lies Ahead

How to Address the Intersecting Crises of HIV, Gender Inequality, and Health Security

On December 1, 2014—World AIDS Day—PEPFAR launched a bold initiative called DREAMS—Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe. The goal was to significantly reduce new HIV incidence among adolescent girls and young women in the highest-burden countries in sub-Saharan Africa and in Haiti, where they face a far higher risk for new HIV infection—2 to 14 times higher—than their male peers. Despite the urgency of reducing HIV in this population to reach global goals for epidemic control, Covid-19 and new global efforts around health security threaten to divert the focus on this critical population. DREAMS is now at an inflection point, facing the risk that its progress on girls and young women will be reversed, along with decades of health and development gains for women and girls.

A major new report for the CSIS Global Health Policy Center examines what lessons have been learned in the first five years of DREAMS and what the next five-year approach might be, including redressing the disruptions and costly damage imposed by Covid-19. The report analyzes how DREAMS has evolved and what its impacts have been, including what factors contributed to success or constituted barriers. It also discusses implications for U.S. policy, focused on what is needed going forward if DREAMS is to further drive down HIV infections and increase the health and agency of girls and young women more broadly, with recommendations for the new Biden-Harris administration and Congress. The report argues that DREAMS has been successful in reaching millions of girls and young women with a multisectoral package of services and has catalyzed a global focus on young women and HIV. Although directly attributing the DREAMS impact is complicated, DREAMS has contributed to a decline in HIV incidence among AGYW in all the DREAMS districts. Yet DREAMS represents an expensive model that would be difficult for countries to replicate and sustain and has sparked criticism for operating in parallel to national and local mechanisms. Despite its challenges and critics, DREAMS has proven to be a promising model that is uniquely suited to an adapted and reimagined U.S. strategy that moves toward more integrated approaches and away from siloed, vertical programs.

This work was made possible with the generous support of ViiV Healthcare. 

Janet Fleischman
Senior Associate (Non-resident), Global Health Policy Center