Washington D.C., USA, 22-27 July 2012 Social protection in HIV prevention, treatment and care “We...

Washington D.C., USA, 22-27 July 2012www.aids2012.org

Social protection in HIV prevention, treatment and care

“We can’t live without it”

Linda RichterHuman Sciences Research Council, South Africa

AIDS 2012 Symposium

Social protection: Promoting a more effective response

23 July 2012


Outline

• What is social protection? • Accumulating evidence for social protection

in HIV prevention, treatment, care and support

• Advocacy for social protection• HIV programmes in the context of national

social welfare and social security• Conclusions


What is social protection?Policies and programs designed to reduce poverty

and vulnerability (both social and economic)– Labour market interventions (training,

employment, public works)

– Social insurance (contributory unemployment, disability, old age, health insurance)

– Social transfers (money, goods) to the most vulnerable people

– Protective legislation (non-discrimination, equity)


Many applications to HIVExamples:

• Protecting PLWA– Employment, housing, health insurance

• Protecting vulnerable groups (key populations, migrants

– Access to health care, non-discrimination

• But emphasis in this presentation on social transfers


Social transfers

Social security or social assistance

• Money or goods given directly

– Money eg non-contributory allowances (family, fuel, old age pension, disability, child)

– Food stamps, vouchers

• Free services eg health, education, social services

• Subsidies, exemptions eg housing, food, transport

• Crisis interventions eg shelter, food


History• Tumult in Europe late 18th and early 19th C –

universal vulnerability and protection

• Transformation of Latin American social assistance programmes to address poverty and promote economic growth – new era of evaluation

• Increased interest in social protection in Africa and other LMICs to complement economic growth

• Urgency associated with the impact of HIV and AIDS and poverty-associated vulnerability on prevention, treatment, care and support


Accumulating evidence

• HIV prevention – school fees, cash transfers, savings schemes

• HIV treatment – payments, reimbursements for food, transport

• HIV and AIDS care and support – cash transfers, food, school fees, health insurance

• In Africa, mainly unconditional cash transfers


Evidence – HIV prevention 1Adolescent prevention

– 14 studies in Africa, 6 completed – moving field

– All positive results: attitudes, school retention, reported sexual risk behaviour, HIV prevalence

– Rationale: increase autonomy, future expectations/hope of young women living in poverty to decrease STIs and

HIV

– Eg RESPECT, Tanzania; Zomba, Malawi

• Cluster randomised trial, 1289 individuals

• Average $10/mth, conditional on staying in school• 12mth outcome - declines in early marriage, teenage pregnancy,

and self-reported sexual activity• 18mth outcome – HIV prevalence in intervention group more

than half that in controls


Evidence – HIV prevention 2Prevention of vertical transmission to children

– Distance/cost of travel most frequently identified as barrier to access, retention in HIV treatments programmes (19 studies in 2008)

– Payments/incentives have been shown to increase:

• Safe delivery in Nepal – universal; cash to deliver in health centre; 30-50% of mean transport cost; low awareness; uptake 16-58%

• Safe delivery in India – significant drop in perinatal & neonatal mortality

• Uptake of HIV testing – payment of $1 doubled rate from 34% among controls in Malawi

– Couldn’t find specific PMTCT uptake and retention transfer interventionS


Evidence – HIV treatment 1• Long history and evidence - incentives for

treatment adherence• TB programmes – living expenses, food/transport• Systematic reviews - CCTs & health

– Positive for health seeking, immunization, anthropometric status

• Estimates based on data from several countries put the direct patient cost of HIV treatment at anywhere up to 100% of annual income (China, Cote d’Ivoire, Indonesia, South Africa, Tanzania and Thailand)


Evidence – HIV treatment 2

User fees main barrier to ART adherence. Free health care associated with better virological results, increased survival (Souteyrand et al 2008)

– Uganda 2010 – travel allowance ($5-8pm) increased ARTadherence (increased adherence can save up to

$85pm)

– India 2012 – food as incentive for clinic attendance HIV+ children. Increased adherence and health


Evidence – Care & support 1• HIV-affected families get poorer because of loss of

income/livelihood and cost of healthcare– Coping strategies: cut consumption, reduce expenditure on

education, health care particularly damaging for children

• Large body of evidence from Conditional Cash Transfer (CCT) programmes in Latin America on social and economic benefits – Especially nutrition, health and education of children

• 12 African countries have ongoing rigorous impactevaluations– Burkino Faso, Ethiopia, Ghana, Kenya, Lesotho, Malawai,

Mozambique, Niger, SA, Tanzania, Uganda, Zambia, Zimbabwe


Evidence – Care & support 2• Data available from Kenya, Malawi, Mozambique, SA

• Kenya (±$20pm, 17 500 households, expanding)– Increased expenditure on health and food– Decreased expenditure on tobacco and alcohol– Increased enrolment children in secondary school– Decreased probability of dropping out

• Malawi (±$11pm, 3 000 households)– Increased investment livestock, agriculture– Decreased labour on other’s land– Decrease in removing children from school

• South Africa (±$35pm, 11m children)– Improved height-for-age– Increased school grades – especially girls– Higher maths scores


Advocacy – social protection• 2008 Mexico IAS plenary on children affected by AIDS• 2009 Joint Learning Initiative on Children and AIDS

(JLICA) – SP to support children in families affected by HIV and AIDS

• 2010 UNAIDS-led Expanded Business Case: Enhancing Social Protection

• 2010 UN Working Group on Social Protection, Care and Support

• 2012 UNAIDS-led HIV and Social Protection Guidance Note

• Also strong advocacy by UNICEF and ILO


UNAIDS Guidance

Social protection can help to:

• Address some of the multiple determinants of the epidemic – income and gender inequalities, social exclusion – PREVENTION

• Relieve demand-side barriers to services – TREATMENT

• Mitigate the significant social and economic impacts of HIV – CARE AND SUPPORT


Conclusions• Impacts of protective legislation – more must be done• Strong and growing evidence for beneficial effects of

social transfers on HIV prevention, treatment, care and support

• Potential increased by expanding treatment, prevention (eg B+), care and support

• Caveats– Understanding variations in outcomes– Ensure inclusion of most vulnerable groups – importance

of constituency engagement and outreach mechanisms– Impact of time-limited HIV projects on roll-out and

effectiveness of emerging national social assistance programmes


Variations in results• Not all good news – eg.

– Kohler & Thornton (2011) – Rural Malawi – Financial incentives to men and women to maintain their HIV

status for one year– Amounts 0 to ±3-4mths wage– No effect on HIV status, reported sexual behaviour – 1 week after programmme ended, male recipients reported

9% more likely and female 7% less likely to engage in risky sex

• Other variations – eg by amount paid (RESPECT, Tanzania)


Social protection in Africa• In 22 of 42 SSA countries, half of all people live on

<$1.25/day

• 39 countries in Africa are discussing (11) or have emerging, expanding or established social assistance programmes (28)

• Even extremely poor countries eg Lesotho – old-age pension govt-funded 2.4% of GDP


Cash transfer programmes• Identified 123 cash transfer programmes between 2000-mid

2009 – not in-kind, food, voucher (Garcia & Moore, 2012)• Apart from purely experimental trials, at least 2 main types:

– Cash transfers within a social protection system, eg.• Constitutional, legal entitlements eg South Africa• Emerging or expanding towards social security eg Kenya

– Time- and area-bound cash transfers, including crisis, HIV-targeted or HIV-sensitive cash transfers – some of which are:

• Ad hoc, donor-driven• Patchy, fragmented• Little local ownership• Not linked to other programs or country structures• Danger of political manipulation• Potentially a threat to evolution of national systems


HIV and national programmes• 2004 African Union support development Social Policy

Frameworks• 2006 Livingstone Declaration – countries committing to social

protection• 2007 Yaounde Declaration – countries making budget allocation• Have HIV impacts eg SA CSG – reduction in partners,

pregnancy, alcohol & drug use; being evaluated• Some countries hesitant, faltering eg empowered citizenry• Need champions eg AIDS community without donor agendas

and local political manipulation• HIV interventions need to contribute to and align with national

efforts


Stop worrying that HIV and AIDS $ are being used for poverty alleviation

Rather, champion national social protection commitments and programmes and ensure that they benefit everyone affected by HIV and AIDS

Washington D.C., USA, 22-27 July 2012 Social protection in HIV prevention, treatment and care “We...

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