The association of exposure to DREAMS on sexually acquiring or transmitting HIV amongst adolescent girls and young women living in rural South Africa: a cohort study

Background: We investigate how the risk of sexually acquiring or transmitting HIV in adolescent girls and young women (AGYW) changed following the real-world implementation of DREAMS (Determined, Resilient, Empowered, AIDS free, Mentored and Safe) combination HIV prevention. Methods: We recruited a randomly selected population-based cohort of AGYW aged 13 to 22 years (at baseline) living in rural KwaZulu-Natal whom we interviewed annually (2017 to 2019). We measured exposure to DREAMS as self-reported receipt of an invitation to participate and/or participation in DREAMS activities. HIV status was ascertained through blood tests on Dried Blood Spot. We used multivariable regression to assess the association between exposure to DREAMS and risk of acquiring HIV (incident HIV) or having transmissible HIV (being HIV positive with a detectable HIV viral load of >50 copies per millilitre) on the last available DBS. We adjusted for socio-demographic, sexual relationship and migration. Results: A total of 2184 (86.4%) of those eligible agreed to participate and 2016 (92.3%) participants provided data for at least one follow-up time-point. 1030 (54%) were exposed to DREAMS; HIV incidence was 2.2/100 person-years (95% Confidence Interval [CI]: 1.66 to 2.86). There was no evidence that HIV incidence was lower in those exposed to DREAMS: adjusted rate ratio (aRR) 0.83 (95% CI: 0.46 to 1.52). HIV viral load was detectable for 169 (8.9%) respondents one to two years following enrolment; there was no evidence this was lower in those exposed to DREAMS with an adjusted risk difference, compared to those not exposed to DREAMS, of 0.99% [95% CI: -1.52 to 3.82]. Participants who lived in peri-urban/urban setting were more likely to have incident HIV and transmissible HIV. Detectable HIV viral load was also associated with older age and ever having sex. Findings did not differ substantively by respondent age group. Conclusions: DREAMS exposure was not associated with reductions in risk of sexually acquiring or transmitting HIV among a representative cohort of AGYW in rural South Africa.