Title : Using the safe space model to increase uptake of HIV pre-exposure prophylaxis among adolescent girls and young women in the DREAMS program, Malawi (2021-2024)

Background: The United States Government, through the President's Emergency Plan for AIDS Relief (PEPFAR), implemented the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) programme in 15 countries, including Malawi, from 2016 to 2024. DREAMS aimed to reduce HIV incidence among vulnerable adolescent girls and young women (AGYW) aged 10-24 years at higher risk of HIV acquisition. The programme used a safe space model to provide private, youth-friendly and supportive environments where AGYW could access information, build social networks and discuss health needs without fear of judgement. Safe spaces included classrooms, church halls and community centres. HIV biomedical prevention services, including pre-exposure prophylaxis (PrEP), were also provided within these spaces to improve access and reduce travel barriers.

Methods: We conducted a retrospective analysis of DREAMS programme data for AGYW aged 15-24 years enrolled in Malawi in 2021 and 2024. Data included 93,427 AGYW in 2021 and 128,822 in 2024, representing periods before and after implementation of community safe-space PrEP service delivery. A Wilcoxon Signed-Rank Test was used to compare PrEP uptake following introduction of the safe-space delivery model.

Results: PrEP uptake increased by 96% in 2024 when PrEP services were delivered through community safe spaces compared with 2021, when AGYW were referred to health facilities. The increase in PrEP uptake was statistically significant (p = 0.03125). Over the same period, HIV incidence among AGYW decreased from 0.23 in 2021 to 0.15 in 2024.

Conclusions: The DREAMS safe space model contributes to increased uptake of HIV biomedical prevention services, including PrEP, among AGYW at higher risk of HIV acquisition. By bringing services closer to young women, the model helps address barriers related to distance, transport costs and time. Maintaining accessible, youth-friendly community delivery approaches remains important for expanding PrEP access and supporting efforts to reduce new HIV infections among AGYW in Malawi.

Virginia Thonyiwa, MPH, is a Public Health Specialist and Senior Technical Advisor with the U.S. Embassy/PEPFAR Malawi. She has more than 18 years of experience in HIV prevention, adolescent and youth health, maternal and child health, implementation science, health systems strengthening, and health diplomacy. She holds an MPH in Applied Epidemiology from Amref International University and a BSc in Public Health. She has led and coordinated major HIV programmes, supported national policy and strategy development, and contributed to more than 15 peer-reviewed publications and scientific products.