HIV risks and vulnerabilities reported among adolescent girls and young women accessing DREAMS services in three Zambian districts: Monze, Mazabuka, and Mongu, 2020–2022

BACKGROUND: Adolescent girls and young women (AGYW) in sub-Saharan Africa face socio-economic and gender-related factors that heighten risk of HIV infection. We examined HIV risks and vulnerabilities among AGYW enrolled in the Determined Resilient Empowered AIDS-free Mentored and Safe (DREAMS) program in Zambia. METHODS: AGYW aged 10-24 years were screened at enrollment in DREAMS using a standardized tool assessing exposure to sexual and reproductive health risks, gender-based violence, and orphanhood. We analyzed 24 months of data (October 2020-September 2022) from six centers in Southern and Western Provinces. We characterized age-disaggregated risks and used multivariable logistic regression to examine associations with engagement in HIV-related clinical services. RESULTS: Among 63,118 AGYW screened, 34.9% were aged 10-14 years, 50.7% aged 15-19 years, and 14.4% aged 20-24 years. Emotional or physical violence (78.0%) and orphanhood (22.3%) were most common among girls aged 10-14 years. Among AGYW 15-19 years, top risks included no/irregular condom use (58.1%), orphanhood (29.2%), multiple partners (23.5%), and transactional sex (20.1%). In the 20-24 years group, 83.5% reported no/irregular condom use, with 29.9% reporting multiple partners and 23.0% transactional sex. Clinical service engagement was positively associated with being out of school, sexually active, using drugs/alcohol, and reporting prior pregnancy, STIs, or multiple sexual partners. CONCLUSION: Socio-economic vulnerabilities were common among younger AGYW in Zambia, while older AGYW reported high levels of behavioral HIV risk. DREAMS reached vulnerable and at-risk AGYW in Zambia, representing an opportunity to reduce HIV acquisition through targeted prevention services.