Julie Pulerwitz ScD and Sanyukta Mathur DrPH MHS Girl uninterrupted Evidence implementation and agency 24 July 2018 No conflicts of interest to disclose Context Should address the context in which AGYW live to improve health amp development outcomes ID: 781311
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Slide1
Emerging evidence on AGYW HIV risk and prevention from the DREAMS partnership: the role of gender
Julie Pulerwitz, ScD and Sanyukta Mathur, DrPH MHS Girl uninterrupted: Evidence, implementation and agency24 July 2018
Slide2No conflicts of interest to disclose
Slide3ContextShould address the context in which AGYW live, to improve health & development outcomes
Gender-based power dynamics underpins many relationshipsPower in sexual relationships* linked with violence, condom use, HIV incidence, untreated STIs, etcHigh HIV risk and incidence rates among AGYW (esp. Southern and Eastern Africa)
*Pulerwitz, J, Gortmaker, SL, & DeJong, W. (2000) Measuring relationship power in HIV/STD Research. Sex Roles. 42(7/8); McMahon, JM, Volpe, EM,
Klostermann
, K,
Trabold
, N, &
Xue
, Y. (2015) A Systematic Review of the Psychometric Properties of the Sexual Relationship Power Scale in HIV/AIDS Research. Arch Sex
Behav
; 44(2): 267–294.
Slide4Adapted from:
Preventing HIV in Adolescent Girls and Young Women: Guidance for PEPFAR Country Teams on the DREAMS Partnership, March 2015DREAMS partnership as case study
Mobilize
Communities
for change
Reduce risk of
Male sexual partners
Empower
Adolescent Girls & Young Women (AGYW)
and reduce risk
Strengthen
Families
Slide5Generating evidence around DREAMS3 cross-cutting themes—focused on unique features; country priorities
Assessing reach and effectiveness of community-based girl-centered programming
Introducing
oral
PrEP
among adolescent girls and young women
Characterizing male partners
of adolescent girls and young women, and use of HIV services
Slide6Double orphans
Sometimes hungry
Not connected to adult in HH
Sexual debut ≤14
Limited HIV knowledge
Acknowledge inequitable gender norms
Vulnerability profiles of
out-of
school AGYW, Kisumu, Kenya
Preliminary findings from latent class analysis (15-24yrs, n=1,014)
LOWER
VULNERABILITY
71% of sample
HIGHER
VULNERABILTY
29% of sample
Slide7AGYW’s relationship power in Kenya
*p < 0.05
Pulerwitz, Mathur, and Woznica. (2018) How empowered are girls/young women in their sexual relationships?: relationship power, HIV risk, and partner violence in Kenya.
PLoS
ONE. 13(7): e0199733.doi:10.1371/journal.pone.0199733
Slide8Relationship power, sexual violence & HIV riskAGYW who experienced sexual violence were 2x as likely to report an STI symptom, and anxiety and depression
Pulerwitz, Mathur, and Woznica. (2018) How empowered are girls/young women in their sexual relationships?: relationship power, HIV risk, and partner violence in Kenya. PLoS ONE. 13(7): e0199733. doi: 10.1371/journal.pone.0199733; Mathur, Okal, Musheke, et al. Forthcoming (PLoS ONE). High rates of sexual violence by both intimate and non-intimate partners experienced by adolescent girls and young women in Kenya and Zambia: Findings around violence and other negative health outcomes.
Less sexual and physical violence
More condom use at last sex
More knowledge of partner’s HIV status
Having relationship power strongly associated
with:
Sexual violence experience in the last 12 months
From
partners
(n=597)
From
non-intimate partners
(n=1,778)
19%
21%
Slide9Conflict & miscommunication characterize relationships
Study site: Uganda (n=94 IDIs with male partners of AGYW)
Slide10PrEP power dynamics in the health care setting
Adj.
IRR
1
(95% CI)
Negative
attitudes toward AGYW sexuality
0.81
(0.66–0.99)*
Behavioral Disinhibition scale
0.89
(0.79
–
0.99)*
Pilgrim, N. et al. (2018) Provider perspectives on
PrEP
for adolescent girls and young women in Tanzania: The role of provider biases and quality of care.
PLoS ONE 13(4): e0196280. doi: 10.1371/journal.pone.0196280.
“
Some of us are very critical and judgmental. We just judge someone, “Ooh you came again? Last time you had gonorrhea, did you do it again?”
—Service
provider
,
age
32
Factors associated with providers’ willingness to prescribe
PrEP
(n=316)
1
Adjusted for provider demographics, prior
PrEP
knowledge, other facility factors (e.g., stockouts)
*p<0.05
Slide11Framework for
PrEP introduction to AGYW
Mathur, S, Pilgrim N, and Pulerwitz, J. (2016)
PrEP
introduction for adolescent girls & young women.
The Lancet HIV
3(9): e406-e408.
Slide12Implications/next steps
Gender-related dynamics accentuate HIV risk and inhibit service useUnpacking these relationships can provides useful insights for strengthening program/policyShould be more consistently measured in programs Phase 2 DREAMS Implementation Science will explore program effectsWhat worked, when, for whom, and why?
Slide13Pulerwitz, Julie and Sanyukta Mathur. 2018. “Addressing adolescent girl and young women’s risk and empowerment: Emerging lessons from the DREAMS Partnership.” Presented at 22nd International AIDS Conference (AIDS 2018), Amsterdam, The Netherlands, 24 July.
Slide14The
Population Council
conducts biomedical, social science, and public health research. We deliver solutions that lead to more effective policies, programs, and technologies that improve lives around the world.