Reinforcing Support for Adolescent Girls and Young Women as PEPFAR Priorities Evolve

Women and girls in Africa are at escalated risk of violence, exploitation, poverty, and HIV infection, due to the Trump administration’s abrupt shuttering of more than 80 percent of the United States Agency for International Development and 70 percent of the agency’s HIV programs, along with deep cuts to the President’s Emergency Plan for AIDS Relief (PEPFAR). The dismantling of U.S. foreign assistance and global health programming perpetuates the reality that HIV has a female face in Africa, reversing recent progress: In 2023, women and girls accounted for 62 percent of all new infections, representing 3,100 new infections every week, down from 5,500 in 2018. These gains are now under distinct threat, with severe health security and economic consequences for the high-burden countries and the United States.

Countries with high HIV prevalence rates must now make tough choices about how to keep vulnerable young women healthy, safe, and economically productive, goals that donors, the private sector, and civil society organizations could help them achieve. Despite constrained domestic and global resources, national systems should be reinforced to provide sustainable, affordable, and accountable services. Otherwise, HIV acquisition among girls and young women, who are more than three times as likely to acquire HIV as their male peers, will be the leading edge of a resurgent epidemic that knows no borders.

The path forward will depend on national governments and their partners strategizing around four central challenges, which will require innovative financing and service delivery, prioritization, and leveraging U.S. and other bilateral and multilateral donors, and private sector capacities: (1) how to promote precision and efficiencies in public and private sector service delivery to address HIV risk for young women; (2) how to facilitate access for adolescent girls and young women to the most effective biomedical prevention products; (3) how prevention services focusing on social, economic, and health factors can be integrated into national platforms; and (4) where the use of advanced modeling and new diagnostic capabilities can help monitor impact and track progress. As Professor Quarraisha Abdool-Karim, a leading HIV researcher in South Africa, explained to me in a recent interview: “We can’t do everything everywhere all at once; we have to choose our battles and prioritize based on data and feasibility and logistics and coverage rates, and build from there.”

Lessons learned from over a decade of U.S. investments in HIV prevention for women and girls could inform the urgent process ahead of re-imagining prevention programs, particularly if national governments undertake the difficult task of mobilizing public and private resources to address the glaring gaps created by the U.S. withdrawal. U.S. resources and capacity still have a critical role to play in this transition and in scaling up new prevention options.

Impact of U.S. Investments in HIV Prevention for Adolescent Girls and Young Women

The focus on HIV prevention for young women gained momentum ten years ago, when PEPFAR announced an initiative called DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe). Through a combination of structural, behavioral, and biomedical prevention interventions, DREAMS was designed to reduce HIV incidence in adolescent girls and young women in 10 (later 15) countries. Importantly, DREAMS is a public-private partnership, including the Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, ViiV Healthcare, and Gilead Sciences. PEPFAR ultimately invested $2.7 billion in the initiative.

The DREAMS multisectoral approach targeted geographic areas of high HIV incidence and addressed the complex drivers of HIV risk for the most vulnerable girls and young women, beyond what any single intervention could accomplish on its own. In FY 2024, DREAMS reached 2.3 million adolescent girls and young women with comprehensive HIV prevention, including expanded access to pre-exposure prophylaxis (PrEP), support for keeping girls in school, violence prevention, and economic skills training. DREAMS also helped to increase young women’s access to HIV testing and prevention by helping to make family planning and reproductive health information available in a more youth-friendly, non-stigmatizing way.

The DREAMS model demonstrated the value of providing such services in places and in ways that at-risk adolescent girls and young women felt supported, including youth-friendly health services, safe spaces in communities, economic skills training, and mobile outreach. Such interventions helped reduce young women’s risks of HIV infection related to unintended pregnancy, dropping out of school, transactional sex, and gender-based violence.

These U.S. investments yielded results; available data indicate that districts where DREAMS operated were associated with greater declines in new diagnoses and in other prevention indicators than non-DREAMS districts. The Joint United Nations Programme on HIV and AIDS (UNAIDS) reported that between 2020 and 2023, new infections in adolescent girls and young women fell by 63 percent.

Importantly, DREAMS helped catalyze other efforts around HIV prevention for young women, notably the UNAIDS Education Plus Initiative to reduce HIV by promoting secondary schooling for adolescent girls, and the Global Fund to Fight AIDS, TB, and Malaria, which made HIV prevention for adolescent girls and young women a priority area. The South African government was notable for launching the She Conquers campaign focused on adolescent girls and young women and HIV, followed by Zikhala Kanjani, with a broader focus on HIV prevention for young people. These initiatives supported the implementation of evidence-based programming that extended the reach of HIV prevention for young women at high risk, notably around broadening approaches to keep girls in school, prevention of gender-based violence, and access to PrEP.

Going forward, it will be vitally important to build on these multilateral and national initiatives to address some of the drivers of HIV risk for young women and to ensure continued HIV prevention services for this population. This will require going beyond rhetorical and policy commitments to mobilizing targeted funding, with monitoring of implementation and evaluation of impact. Building on the reach of these platforms could also be valuable for other public health education and access issues, including for noncommunicable diseases, vaccines, and pandemic response.

Scaling Up New Biomedical Prevention Products to Increase Access and Choice

DREAMS was an important platform to connect young women with new, potentially game-changing biomedical prevention technologies. The PrEP options include: a daily oral PrEP pill, the monthly dapivirine ring, and the two-month injectable cabotegravir. About 70 percent of all PrEP initiations were in districts where DREAMS was implemented. Expanding access to information and choice on PrEP for at-risk young women continues to present challenges, related to community attitudes and stigma about HIV risk, and the complexities around service delivery, demand creation, and adherence. This underscores the importance of providing PrEP through service delivery channels and with peer educators who meet the needs and confidentiality concerns of young women.

This area received a dramatic boost in 2024 with the results of the clinical trial for lenacapavir (len), a twice-yearly PrEP injection that showed 100 percent efficacy among young women in South Africa and Uganda.In December 2024, PEPFAR joined with other funders to increase access to len for adolescent girls and young women, pending approval by the U.S. Food and Drug Administration, which was just announced on June 18. Although the United States is no longer supporting comprehensive PrEP programs, PEPFAR could continue to play an important role in expanding access to PrEP, even though it currently only permits PrEP for pregnant and breastfeeding women through prevention of mother-to-child transmission programs.

In a recent conversation with Professor Linda-Gail Bekker from the University of Cape Town, who led the PURPOSE 1 lenacapavir trial, she told me about the stark choice ahead: “If we have len, we are more capable of reaching the 2030 goals on HIV, and to put the tiger back in the cage. Without PEPFAR and without len, we’ll go backward, and the tiger will be well and truly out of the cage. . . . We’re going to see more infections in key populations and adolescent girls and young women.”

Improving Data Analytics and Integration with National Systems to Enhance Impact and Sustainability

Despite its impact, DREAMS faced key challenges, especially around evaluating the synergistic impact of the programming and building models that could be transitioned to the host countries.

DREAMS was developed from a solid evidence base around HIV prevention, but attributing specific impact requires a more complex triangulation of multiple data sets. The Gates Foundation supported the London School of Hygiene & Tropical Medicine and research partners to conduct independent impact evaluations of DREAMS from 2016 to 2022. This generated evidence of DREAMS benefits, including greater HIV testing and social support and, in some places, adoption of safer sexual behaviors. PEPFAR did not pursue longer-term evaluations due to the prohibitive cost. Future prevention programming should ensure that ongoing evaluation components are included to inform programming.

In addition, DREAMS represented an expensive model that was implemented largely parallel to government systems, despite past PEPFAR planning efforts to better integrate the programming into country systems. Because the programming was not designed to reinforce national platforms or data systems and was dependent on outside support, it undermined goals around moving countries toward greater self-reliance. Nduku Kilonzo, former executive director of Kenya’s National AIDS Control Council, reflected on the problems inherent in such parallel architecture, and explained to me: “The resources aren’t there now, and because the program was not anchored on existing national health or social welfare infrastructure, those young girls now are not part of any system . . . one day it was there, then it was gone forever.”

Looking ahead, the way DREAMS was implemented provides lessons on the vulnerabilities created by such parallel programming and the importance of supporting national systems to be more sustainable, resilient, and accountable. This includes strengthening the education, health, and social welfare systems to mitigate HIV risk more effectively for adolescent girls and young women.

How to Reinforce Support for HIV Prevention for Adolescent Girls and Young Women

The sudden end of DREAMS creates a moment of reckoning for all stakeholders associated with this urgent agenda. How to best protect adolescent girls and young women from HIV in the future will depend on national governments increasing domestic resources and integrating support for this population into national systems, leveraging the private sector for innovative financing, biomedical prevention advances, and some service delivery, and cooperating with civil society through women’s and youth groups and faith-based organizations. It will also depend on the remaining bilateral, multilateral, and philanthropic donors’ continuing financial support for multisectoral approaches that address the drivers of young women’s HIV risk.

This opens opportunities for the United States to carve out a new role that responds to Secretary of State Marco Rubio’s assertion that foreign assistance has to make the United States stronger, safer and more prosperous, which could mean supporting access to new HIV prevention technologies that assist millions of young women to be healthy and economically empowered. Such a prospect would provide strong returns on U.S. investments, while helping to end HIV as a public health threat and benefitting U.S. health security.

As one 18-year-old DREAMS beneficiary in Zambia shared with me: “I’m afraid that there’s going to be a steep rise in cases of HIV and AIDS, because now, adolescent girls and young women have no access to mentors to guide them, especially those going through violence and abuse . . . this is a backward draw on development.” By listening to and prioritizing these young women, new public and private sector models can build on the lessons of DREAMS to improve outcomes for the future, rather than reversing decades of progress.

Janet Fleischman is a senior associate with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.