Effective combination prevention:

Cash, care and HIV-risk for adolescents in South Africa.

L Cluver, M Orkin, M Boyes, L SherrIAS, July 2014

Child-focused research

Universities: Oxford, UCT, Wits, Curtin,

UKZN

Collaborative research: science to assist policy

National longitudinal study of adolescents6850 adolescents, 2500 adult caregivers, 2008-2012

Longitudinal national survey• Main study: N=6000 (age: 10-18) • 3 provinces South Africa; 6 sites >30% prevalence• Stratified random sampling of census EAs• Every household with a child aged 10-17• Urban/rural, 1 year follow-up in 2 provinces • n=3401, 97% follow-up

Measures• Standardised scales, national surveys

Ethics• Approved by Universities of Cape Town, • Oxford, KwaZulu-Natal,• 6 Provincial Health & Education Departments• Social & health service referralsControlling for prior HIV risk

Effects of abuse, poverty & parental AIDS on female adolescent risk of transactional sex

Cluver, Orkin, Boyes, Meinck, Makhasi (2011). JAIDS

Healthy family AIDS-sick parent Abused & hungry AIDS-sick parent, abused, hungry

1%

7%

13%

57%

Proof of concept: cash incentives

Unconditional cash transfers

12-14 years 15-17 years0

1

2

3

4

5

6

7

8 % Incidence of transactional

sex (OR .49 CI .26-.93*)

South Africa: Child grant reduces incidence & prevalence of transactional sex and age-disparate sex for girls

No cash transfer

Child cash transfer

Cluver, Boyes, Orkin, Pantelic, Molwena, Sherr (2013). The Lancet Global Health.

12-14 years 15-17 years

% Incidence of age-disparate sex (OR .29 CI .13-.67**)

Cash plus care?

Can CASH + CARE reduce HIV risk behavior?

CASH

CARE

Incidence rates:

Transactional sex

Age-disparate sex

Sex using substances

Multiple partners

Unprotected sex

Teen pregnancy

Child-focused grant

Regular food parcels

Free school meals

Free school transport

School counsellor

Food garden

Home-based carer

Positive parenting

Free school uniform

Teacher supportSoup kitchen

Child-focused grant

Free school meals

Food garden

Positive parenting

Teacher support

n=3515, longitudinal

% girls with incidence of 1+ HIV risk behavior: Cash plus care = halved risk

Cash alone: OR .63Cash plus care: OR .55

no support cash cash plus care0

10

20

30

40

50

60

41%

25%

15% Controlling for: family HIV/AIDS, informal/formal housing, age of child, poverty levels, number of moves of home, baseline HIV risk behaviour

Cluver, Orkin, Boyes, Sherr (2014). AIDS.

% boys with incidence of 1+ HIV risk behavior:Cash plus care = halved risk

Cash alone: no significant effectCash plus care: OR .50

no support cash cash plus care0

10

20

30

40

50

60

42%

28%

17% Controlling for: family HIV/AIDS, informal/formal housing, age of child, poverty levels, number of moves of home, baseline HIV risk behaviour

Cluver, Orkin, Boyes, Sherr (2014). AIDS.

Structural drivers and mechanisms

Hunger

Community violence

Parental HIV/AIDS

Informal settlement

2011Structural deprivation

2012HIV-risk behavior

incidence

Poverty & family AIDS predict adolescent HIV-risks: how?

Transactional sex

Age-disparate sex

Sex using substances

Multiple partners

Unprotected sex

Pregnancy

controlling for: baseline HIV-risk, age, gender

all p<.001

HIV-risk behaviorincidence

Structural deprivation

school dropout

child abuse

conduct problems

drug/alcohol use

psychological distress

p<.0

01p<

.001

p<.0

01

p<.001

p<.001

p<.001p<.001

p<.002

p<.05

p<.001

controlling for: baseline HIV-risk, age, gender

Psychosocial problemsp<.004

ReducedHIV-risk behaviorincidence

Structural deprivation

Reduced psycho-social

problems

controlling for: baseline HIV-risk, age, gender

CASH

CARE

Cash and care: greatest effects for highest-risk adolescents

P<.001P<.001P<.001

P<.001

P<.001

P<.001 P<.001

P<.001

P<.001

0

5

10

15

20% adolescents with multiple

past-year sexual partners

Cumulative HIV-prevention impact

Unconditional, government cash transfers reduce adolescent HIV risks

Cash plus care gives greater effects

Effective in real-world sub-Saharan Africa

Cash and care mitigate structural risk

Cumulative impacts of 2+ interventions

Funders: thank you.