Sub-Saharan Africa has an estimated 24.7 million people who are living with the human immunodeficiency virus (HIV), accounting for nearly 71% of the global burden [3]. HIV burdens some groups more than others. Among the most affected are young women, commercial sex workers, men who have sex with men, and youth. Uganda has an estimated 6.5% HIV prevalence and is one of two countries in Africa, where HIV rates are increasing instead of decreasing. According to the Uganda Population-Based HIV Impact Assessment [4] survey 2016-2017, the prevalence of HIV among adults aged 15 to 64 in Uganda is 6.2%: 7.6% among females and 4.7% among males. This corresponds to approximately 1.2 million people aged 15 to 64 living with HIV in Uganda. HIV prevalence is higher among women living in urban areas (9.8%) than those in rural areas (6.7%). According to the ILO report [5] HIV/AIDS is both a manifestation of poverty conditions that exist, taking hold where livelihoods are unsustainable, and the result of the unmitigated impact of the epidemic on social and economic conditions. HIV/AIDS is, at the same time a cause and an outcome of poverty, and poverty is both a cause and an outcome of HIV/AIDS. The World Bank reports that about 45% of the approximately 590 million people in sub-Saharan Africa live below the national poverty lines and Uganda is one of the least urbanized countries in Africa, with over 90% of the population living in rural areas. The analysis of poverty lines confirms that the Northern region is the poorest and the rest of the regions have poverty lines above the World Bank average of US$55. Uganda’s population is predominantly dependent on agriculture and the agriculture sector employs approximately 69% of the population [6]. Due to the high unemployment rate in Uganda, most young people are opting for Vocational skills training as a short cut to income generation. Vocational skills training and other income-generating activities are said to address the structural factors associated with HIV risk, although the effectiveness of these interventions in HIV prevention has not yet been scientifically proven [7]. The study highlights the relationship between Vocational and Life Skills Training and prevention of high-risk behavior and HIV/AIDS among rural girls engaging in Transactional Sex. Rakai Health Sciences Program is implementing the PEPFAR/CDC-funded DREAMS Initiative (DREAMS = Determined, Resilient, Empowered, AIDS Free, Mentored, and Safe) in rural districts of Uganda including: Gomba, Sembabule, and Bukomansimbi. The goal of DREAMS is to reduce the incidence of new HIV cases in girls and young women 15-24 by bringing together evidence–based approaches that address the structural drivers that increase girls’ and young women’s HIV risk, including poverty, gender inequality, sexual violence and lack of education. The program enrolls AGYW in TS who are taken through a rigorous vocational and skills training for a period of six to nine months.

      The study was cross sectional covering 10 UYDEL safe spaces located in the three districts of Gomba, Bukomansimbi and Ssembabule. These safe spaces were chosen because they are hotspots for Transactional Sex and among AGYW in rural Districts in Uganda [8]. These safe spaces work with only Adolescent Young Girls and Women ages 15-24 years who are engaging in Transactional Sex in rural Districts. The safe spaces were implementing the DREAMS Project in partnership with Rakai Health Sciences Program. The study population was selected using purposive sampling technique. The study collected information about 8620 AGYW (n=8620). Of these, 6,145 AGYW received services at the formal space and 2475 at the informal safe space between the periods of 2016 to 2019. To achieve this, the researchers carried out a quantitative research and used a questionnaire to collect responses from the safe space managers/social workers regarding the AGYW. In total 10 safe space managers provided responses. Their responses were guided by data collected from AGYW as recorded in the data collection tools known as the Beneficiary Information File. Upon enrollment, each AGYW is issued a Beneficiary information file. This file captures sections like Assessment, Change talk, AUDIT instrument, Consent form, Counseling report, Behavioral change talk after 6 months, Beneficiary retention form, Home visit, and follow up form. Information captured by these files guided the social workers in responding to the questions in the questionnaire. The follow up form is used in the second phase when the AGYW graduate and leave the safe space. The AGYW are followed up by the social workers for a period of two years following graduation. The researchers did not obtain validation from the AGYW regarding obtaining responses from the safe space managers on their behalf because the manuscript was intended to record a program evaluation [9]. The questionnaire covered both open and close ended questions. This method was chosen because of time and simplicity reasons for using questionnaire. Due to the long distance, the questionnaires were sent out via email and the communication happened through phone and email. The study participants were selected based on their location in Gomba, Bukomansimbi and Ssembabule.

      Data was organized and managed using Statistical Package for the Social Sciences (SPSS) in conjunction with excel, which supported calculations and graphing. Descriptive statistics were used to summarize data and make meaning of it. Sample data was compared to previous research. The sample data obtained regarding the small number of AGYW in TS at the UYDEL safe spaces in Gomba, Bukomansimbi and Ssembabule were used to predict outcomes for the bigger population of AGYW in TS residing in Rural Districts in Uganda.

      This among AGYW in rural districts and the role played by Vocational and Life Skills Training in the prevention of high-risk behavior and HIV/AIDS among these AGYW. All the statistics included herein are summarized in the Tables 1-6 at the end of the document.

      Of the 8620 AGYW, 77.9% tested for HIV and of these 1% tested positive for HIV as indicated in Table 1 and 2680 AGYW said YES to consuming alcohol. 32% of the AGYW had children. 90% of these AGYW started having sexual intercourse and engaging in Transactional Sex at the age of 15 and 4% had terminated pregnancy. On average, the AGYW who engaged in TS had 3 sexual partners and these fell in the category of boda-boda men, chapat sellers, friends, community elders, boyfriends, sugar daddies, strangers, builders, farmers, mechanics, truck driver, businessmen, bar owners, bar bosses, herdsmen, builders, peers, parents, community members, married men, truck loaders, electricity & road construction workers. Transactional Sex was reported to take place at home and bars, motel, brothels, discotheques, karaoke concerts, market places.

Risky behavior among adolescent girls and young women

      AGYW in a bid for survival are predisposed to a number of risky behaviors including; substance use, engagement in transactional sex and unprotected sexual intercourse. Alcohol was identified as one of the abused substances by AGYW in this study. Alcohol is a psychoactive substance with toxic and dependence-producing properties and is usually consumed as a beverage. According to the WHO’s discussion paper on the Global Strategy to Reduce the harmful use of alcohol, it is stated that the harmful use of alcohol causes 3 million deaths per year, is responsible for 5.1% of the global burden of disease expressed in DALYs and continues to be one of the leading risk factors for poor health globally. Alcohol use has in the past been related to causing Gender Based Violence (GBV), HIV related cases and other forms of deviant behavior in society [10]. Figure 1 shows the total number of young people who were drinking alcohol in the three districts of Bukomansimbi, Gomba and Ssembabule with Ssembabule registering the highest numbers of alcohol drinking and Gomba the least number. This statistic gives a picture of the young people who maybe predisposed to GBV, engagement in unprotected sexual intercourse and increased HIV risk as a result of alcohol use.

Life skills training (LST) and sexual reproductive health services

      UYDEL engages AGYW and their parents/caretakers in life skills training with the aim of equipping the young girls with decision-making skills, refusal skills, negotiation skills including social and interpersonalskillsthat enable them to cope with the challenges of everyday life. The LST trainings help build self-confidence, encourage critical thinking, foster independence and help young people to communicate more effectively. The LST package given to the AGYW is comprised of; Stepping stones and Sinovuyo packages. The stepping stone is an LST series that is designed to promote sexual health, improve psychological wellbeing and prevent HIV\AIDS. It is one of the DREAMS Evidence based interventions, it is a 14weeks curriculum and it addresses questions of gender, sexuality, HIV\AIDS, gender violence, communication and relationship skills. It helps in identifying key risk behaviors that make people vulnerable to HIV\AIDS and helps promote sexual health, improve psychological wellbeing and prevent HIV\AIDS among AGYW. Sinovuyo, on the other hand, is aimed at enhancing positive parenting skills among AGYW and their caretakers and also reduce cases of Gender Based Violence. 31 percent of the caretakers attended Life skills Training with their children, the AGYW. 41% of the AGYW were engaged in Sinovuyo sessions and 61.5% in stepping stones. As a result, there was a reduction in engagement in TS by 70%, improved ability of AGYW to care for their children and 62% of AGYW were enrolled onto family planning services and were able to plan for their families. These statistic were measured within the two years of follow up after the AGYW had graduated and exited the program.

Social economic strengthening

      Social Economic Strengthening comprises a portfolio of interventions to reduce the economic vulnerability of families and empower them to provide for the essential needs of the children they care for, rather than relying on external assistance (PEPFAR working definition, 2011). The program (DREAMS Project) provided beneficiaries with Business Skills Training i.e. Financial Literacy, budgeting and Village Saving and Loans Associations (VSLA). 46% of AGYW were engaged in VSLA although 54% were not able to join the VSLA groups due to challenges such as poverty and influence from their husbands who stopped them from joining the saving groups. However, those who joined the savings groups started small businesses and a reasonable percentage who had bank accounts formed groups and applied for the Community Development Fund after graduation.

Vocational skills training

      All the AGYW enrolled on the DREAMS program were engaged in Vocational Skills Training. Of these, 11 percent were reported to have dropped out and the reasons for dropping included; forced marriage, desired marriage, AGYW moving to new districts, AGYW vacating from village, AGYW losing interest in program, AGYW not receiving start up kits and some went looking for greener pasture. 70 % of the AGYW trained in tailoring were reported to be working and 33% of AGYW trained in hair dressing were also employed. The employed AGYW are currently working in the following areas; Kyabi, Maddu, Masaka, Ssembabule, Mubende, Nabiseke, Seeta, Kasambya, Lyantonde, Mityana, Mbarara, Kasese, Bukomansimbi, Kyatuba, Kigando, Karushonshomezi. After the nine months of acquiring vocational skills training, the AGYW were able to obtain employment and improve family incomes by 63%. This economic empowerment then improved ability of AGYW to provide basic needs for their families by 44%.

      As a result of VT and engagement in the village savings and loan association, family income improved and AGYW in TS registered improvement in the quality of life, significant reduction in TS engagement and improved family relationships. A similar study conducted in Uganda ‘Vocational Training with HIV Prevention for Ugandan Youth’ in 2012 indicated that four months after beginning vocational training, the young people receiving vocational training showed reduced delinquent behaviors and greater improvements than control participants in employment, quality of life, and social support. Both conditions demonstrated such improvements at 24 months, especially sustained employment and also a significant reduction in the number of sexual partners and increased abstinence and condom use. The decrease in alcohol, marijuana use, and hard drug use was clinically significant [11].

Other psychosocial activities

      Psychosocial supports are activities that help individuals and communities to heal the psychological wounds and rebuild social structures after an emergency or a critical event. According to UNICEF, psychosocial support helps change people into active survivors rather than passive victims. Some of the activities adopted for the AGYW in this regard are indicated in Figure 2; Sports, aerobics, dance, music are psychosocial activities in which AGYW are engaged to improve their learning experience. They help in the identification and development of AGYW inner talents like creativity, public-speaking skills, leadership qualities, teamwork and confidence building. Psychosocial activities offer AGYW an opportunity of thinking unusually and getting the innovative ideas of their own.

      The graph shows AGYW engaged in psychosocial activities by number.

      These percentages were arrived at using the administrative data captured in beneficiary files at enrollment and post the program data collected following graduation/exit of AGYW from the program.

Behavioral change sessions

      Behavioral change on the other hand plays an important role in health promotion for example, having multiple partners, engaging in Transactional sex, smoking, poor diet, lack of exercise and sexual risk-taking can cause a large number of diseases. Behavioral change interventions have enormous potential to alter current patterns of disease like reducing HIV spread among AGYW. According to results from the study TS reduced by 70% hence reduction in unwanted pregnancy, improvement in relationships between AGYW and their caretakers and the rest of the community but above all promoted opting for single sex partners and condom use. This outcome was arrived at post engagement in the DREAMS project.

      According to feedback received from implementing social workers regarding the DREAMS program design and its impact in the prevention of engagement in risky behavior by AGYW, Livelihood skills training is key in addressing structural factors associated with HIV risk among AGYW in rural areas. They commended the good intervention because it occupies the AGYW and keeps them busy, empowers them with employable and negotiation skills, sensitizes them on condom use, enhances psychological wellbeing and reduces engagement in Transactional Sex and number of sexual partners. They also appreciated the start-up capital given to the beneficiaries as it promoted selfreliance and sustainability of the project outcomes.

      The sample size and geographical limitation significantly affects generalization from the study. However, given the high unemployment rate in Uganda coupled with generational poverty and ignorance, our observations recommend the use of a combination of life skills training, vocational skills training and HIV prevention skills in HIV prevention programs. This combination addresses the socio-economic and psychological challenges faced by AGYW and their care takers. The DREAMS program has a unique aspect of being a prevention focused program as it empowers and equips the AGYW with life skills to be able to cope positively in risky environments. Unlike most programs it has a ripple down effect in the sense that behavior change and DREAMS values in AGYW are passed onto the caregivers of the AGYW and other people in the community hence enhancing a safe and stronger environment for HIV prevention. The program also has an intensive follow up program which extends up to two years following exit of the program for each AGYW. This promotes continuity of the DREAMS program values and avails professional support to AGYW in case of challenges following graduation from the program. The social workers in this program support AGYW when they are faced with relapse, failure to secure employment, family misunderstandings among others. This is because we believe everyone needs someone to hold their hand through the process of making significant life changing decisions. The social workers provide mentorship, guidance and support to the AGYW and facilitate this process of change which ensures sustainability of outcomes and impact. From the findings, we noted that AGYW who received VT as well as Behavioral Change Communications, Life Skills Training and SRHR services showed sustained employment, significant reduction in the number of sexual partners, increased condom use among AGYW and ability to sup ort their families. The AGYW also showed significant improvement in standards of living, saving culture and the ability to care for their children, and good interpersonal relationships with their family members. Larger trials of HIV interventions addressing structural factors associated with HIV are required especially regarding the economic, social, and environmental factors as this study only covers rural Districts of Kampala.

      Adolescent Girls and Young Women (AGYW): Young girls between ages 15 to 24 years [12]

      DREAMS: DREAMS = Determined, Resilient, Empowered, AIDS Free, Mentored, and Safe is an initiative by CDC, PEPFAR and Rakai Health Sciences Program in 5 districts including: Mityana, Mubende, Gomba, Sembabule, and Bukomansimbi. The goal of DREAMS is to reduce the incidence of new HIV cases in girls and young women 15-24 by bringing together evidence– based approaches that address the structural drivers that increase girls’ and young women’s HIV risk, including poverty, gender inequality, sexual violence and lack of education.

      Sexual Reproductive Health: Good sexual and reproductive health is a state of complete physical, mental and social wellbeing in all matters relating to the reproductive system. It implies that people are able to have a satisfying and safe sex life, the capability to reproduce, and the freedom to decide if, when, and how often to do so [5].

      Safe space: refers to places created for individuals who feel marginalized to come together to communicate regarding their experiences with marginalization, most commonly located on university campuses in the western world, but also at workplaces [13].

      Transactional sex: Transactional sex is not sex work but refers to non-marital, non-commercial sexual relationships motivated by an implicit assumption that sex will be exchanged for material support or other benefits. Most women and men involved in transactional sex relationships consider themselves as partners or lovers rather than sellers or buyers [14].

      Vocational Skills Training: Vocational education is education that prepares people to work as a technician or in various jobs such as a tradesman or an artisan. Vocational education is sometimes referred to as career and technical education.

      Uganda Youth Development Link (UYDEL): UYDEL is an NGO that works with youth aged 10 – 24 years who are vulnerable to exploitation and at risk to HIV/AIDs infection