The Use of Cash Transfers for HIV Prevention - Are We There Yet?

Poverty and social inequality are significant drivers of the HIV epidemic and are risk factors for acquiring HIV. As such, many individuals worldwide are at risk for new HIV infection, especially young women in East and Southern Africa. By addressing these drivers, social protection programmes may mitigate the impact of poverty and social inequality on HIV risk. 

There is reason to believe that social protection can be used successfully for HIV prevention; social protection programmes, including cash transfers, have led to positive health outcomes and behaviour in other contexts, and they have been used successfully to promote education and increased income and employment opportunities. 

Furthermore, cash transfers have influenced sexual behaviour of young women and girls, thereby decreasing sexual risk factors for HIV infection. When HIV outcomes have been measured, several randomised controlled trials have shown that indirectly, cash transfers have led to reduced HIV prevalence and incidence. 

In these studies, school attendance and safer sexual health were directly incentivised through the cash transfer, yet there was a positive effect on HIV outcomes. In this review, we discuss the growth of social protection programmes, their benefits and impact on health, education and economic potential, and how these outcomes may affect HIV risk. 

We also review the studies that have shown that cash transfers can lead to reduced HIV infection, including study limitations and what questions still remain with regard to using cash transfers for HIV prevention.

Purchase full article at:   http://goo.gl/bk1xKh

By:  Taaffe J1, Cheikh N1, Wilson D1.

• 1 The World Bank Group , Washington , DC , USA. 
• Afr J AIDS Res. 2016 Mar;15(1):17-25. doi: 10.2989/16085906.2015.1135296.

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Sexual Behavior among Young Carers in the Context of a Kenyan Empowerment Program Combining Cash-Transfer, Psychosocial Support, and Entrepreneurship

This study examined associations between sexual initiation, unprotected sex, and having multiple sex partners in the past year with participation in a three-year empowerment program targeting orphan and vulnerable children (OVC). 

The Kenya-based program combines community-conditioned cash transfer, psychosocial empowerment, health education, and microenterprise development. Program participants (n = 1,060) were interviewed in a cross-sectional design. Analyses used gender-stratified hierarchical logit models to assess program participation and other potential predictors. 

Significant predictors of increased female sexual activity included less program exposure, higher age, younger age at most recent parental death, fewer years of schooling, higher food consumption, higher psychological resilience, and lower general self-efficacy. Significant predictors of increased male sexual activity included more program exposure, higher age, better food consumption, not having a living father, and literacy. 

Findings support a nuanced view of current cash transfer programs, where female sexual activity may be reduced through improved financial status but male sexual activity may increase. Targeting of OVC sexual risk behaviors would likely benefit from being tailored according to associations found in this study. 

Data suggest involving fathers in sexual education, targeting women who lost a parent at a younger age, and providing social support for female OVC may decrease risk of human immunodeficiency virus (HIV) transmission.

Purchase full article at:   http://goo.gl/6o5kAl

By:  Goodman ML1,2,3, Selwyn BJ2, Morgan RO2, Lloyd LE2, Mwongera M4, Gitari S4, Keiser PH3.

• 1 Sodzo International.
• 2 Division of Management, Policy and Community Health, School of Public Health , University of Texas , Houston.
• 3 Center for Global Health Education , University of Texas Medical Branch , Galveston.
• 4 Community Health Department , Maua Methodist Hospital , Meru County , Kenya.
• J Sex Res. 2016 Mar-Apr;53(3):331-45. doi: 10.1080/00224499.2015.1035429. Epub 2015 Sep 30. 

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Combination Social Protection for Reducing HIV-Risk Behavior amongst Adolescents in South Africa

BACKGROUND:

Social protection (i.e. cash transfers, free schools, parental support) has potential for adolescent HIV-prevention. We aimed to identify which social protection interventions are most effective and whether combined social protection has greater effects in South Africa.

METHODS:

In this prospective longitudinal study, we interviewed 3516 adolescents aged 10-18 between 2009 and 2012. We sampled all homes with a resident adolescent in randomly-selected census areas in four urban and rural sites in two South African provinces. We measured household receipt of fourteen social protection interventions and incidence of HIV-risk behaviors. Using gender-disaggregated multivariate logistic regression and marginal-effects analyses, we assessed respective contributions of interventions and potential combination effects.

RESULTS:

Child-focused grants, free schooling, school feeding, teacher support, and parental monitoring were independently associated with reduced HIV-risk behavior incidence (OR 0.10-0.69). Strong effects of combination social protection were shown, with cumulative reductions in HIV-risk behaviors. For example, girls' predicted past-year incidence of economically-driven sex dropped from 11% with no interventions, to 2% amongst those with a child grant, free school and good parental monitoring. Similarly, girls' incidence of unprotected/casual sex or multiple-partners dropped from 15% with no interventions to 10% with either parental monitoring or school feeding, and to 7% with both interventions.

CONCLUSION:

In real-world, high-epidemic conditions, 'combination social protection' shows strong HIV-prevention effects for adolescents and may maximize prevention efforts.This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially.

Full PDF article at:  http://goo.gl/ojMVoi  Abstract:  http://goo.gl/fXkGhX

By:  Cluver LD1, Orkin MF, Yakubovich AR, Sherr L.

• 1Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK 2Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa 3DST-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa 4University College London, London, UK. 

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Behavioral Interventions for Cambodian Female Entertainment & Sex Workers Who Use Amphetamine-Type Stimulants

Conditional cash transfer (CCT) and cognitive-behavioral treatments are evidence-based approaches to reduce stimulant use and sexual risk taking. We describe the adaptation and implementation of sequential behavioral interventions for Cambodian female entertainment and sex workers (FESW) who use amphetamine-type stimulants (ATS): (1) a 12-week CCT intervention; and (2) a 4-week cognitive-behavioral aftercare (AC) group. 

An ongoing cluster randomized stepped wedge trial in 10 Cambodian provinces is enrolling FESW with confirmed recent ATS use to examine the effectiveness of CCT + AC. In the first six provinces, 138 of the 183 eligible FESW (75 %) enrolled in CCT and completed a median of 25 (interquartile range 9-32) of the 36 urine screening visits. 

Of the 84 participants who were eligible for AC, 79 completed at least one session (94 %) and 57 completed three or more sessions (68 %). Culturally tailored behavioral interventions to reduce ATS use and optimize HIV prevention are feasible in resource-limited settings.

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By:  Carrico AW1,2, Nil E3, Sophal C4, Stein E5, Sokunny M3, Yuthea N6, Evans JL4, Ngak S3, Maher L7, Page K8.

• 1University of California, San Francisco School of Nursing (https://nursing.ucsf.edu/), 2 Koret Way, N511 M, San Francisco, CA, 94143, USA. adam.carrico@ucsf.edu.
• 2University of California, San Francisco Center for AIDS Prevention Studies, San Francisco, CA, USA. adam.carrico@ucsf.edu.
• 3Family Health International 360 (FHI 360), Phnom Penh, Cambodia.
• 4Department of Mental Health and Substance Abuse, Ministry of Health, Phnom Penh, Cambodia.
• 5University of California, San Francisco Global Health Sciences, San Francisco, CA, USA.
• 6National Authority for Combatting Drugs, Phnom Penh, Cambodia.
• 7Kirby Institute for Infection and Immunity, UNSW Australia, Sydney, Australia.
• 8University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
• J Behav Med. 2016 Jan 18.

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Social Protection: Potential for Improving HIV Outcomes among Adolescents

Introduction

Advances in biomedical technologies provide potential for adolescent HIV prevention and HIV-positive survival. The UNAIDS 90–90–90 treatment targets provide a new roadmap for ending the HIV epidemic, principally through antiretroviral treatment, HIV testing and viral suppression among people with HIV. However, while imperative, HIV treatment and testing will not be sufficient to address the epidemic among adolescents in Southern and Eastern Africa. In particular, use of condoms and adherence to antiretroviral therapy (ART) remain haphazard, with evidence that social and structural deprivation is negatively impacting adolescents’ capacity to protect themselves and others. This paper examines the evidence for and potential of interventions addressing these structural deprivations.

Discussion

New evidence is emerging around social protection interventions, including cash transfers, parenting support and educational support (“cash, care and classroom”). These interventions have the potential to reduce the social and economic drivers of HIV risk, improve utilization of prevention technologies and improve adherence to ART for adolescent populations in the hyper-endemic settings of Southern and Eastern Africa. Studies show that the integration of social and economic interventions has high acceptability and reach and that it holds powerful potential for improved HIV, health and development outcomes.

Conclusions

Social protection is a largely untapped means of reducing HIV-risk behaviours and increasing uptake of and adherence to biomedical prevention and treatment technologies. There is now sufficient evidence to include social protection programming as a key strategy not only to mitigate the negative impacts of the HIV epidemic among families, but also to contribute to HIV prevention among adolescents and potentially to remove social and economic barriers to accessing treatment. We urge a further research and programming agenda: to actively combine programmes that increase availability of biomedical solutions with social protection policies that can boost their utilization.

Below:  Impacts of cash and care provision on HIV-risk behaviour among adolescents in South Africa (marginal effects models, controlling for covariates) 

Full article at:    http://goo.gl/6TM8hV

By:   Lucie D Cluver,§,1,2 Rebecca J Hodes,3,4 Lorraine Sherr,5 F Mark Orkin,6 Franziska Meinck,1 Patricia Lim Ah Ken,7Natalia E Winder-Rossi,8 Jason Wolfe,9 and Marissa Vicari10

¹Centre for Evidence-Based Intervention, Department of Social Policy & Intervention, University of Oxford, Oxford, UK

²Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa

³AIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town, Cape Town, South Africa

⁴Department of Historical Studies, University of Cape Town, Cape Town, South Africa

⁵Health Psychology Unit, Department of Infection & Population Health, University College London, London, UK

⁶School of Clinical Medicine and DST-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa

⁷HIV and AIDS Section, UNICEF, New York, USA

⁸UNICEF Regional Office for Eastern and Southern Africa, Nairobi, Kenya

⁹Office of HIV/AIDS, Bureau for Global Health, US Agency for International Development, Washington, DC, USA

¹⁰Collaborative Initiative for Paediatric HIV Education and Research (CIPHER), International AIDS Society, Geneva, Switzerland

^§Corresponding author: Lucie D Cluver, Centre for Evidence-Based Interventions, Department of Social Policy and Intervention, University of Oxford, Barnett House, 32 Wellington Square, Oxford OX1 2ER, UK. Tel: +44(0)1865 270325. (Email: ku.ca.xo.ips@revulC.eicuL)

 

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Child-Focused State Cash Transfers & Adolescent Risk of HIV Infection in South Africa: A Propensity-Score-Matched Case-Control Study

Effective and scalable HIV prevention for adolescents in sub-Saharan Africa is needed. Cash transfers can reduce HIV incidence through reducing risk behaviours. However, questions remain about their effectiveness within national poverty-alleviation programmes, and their effects on different behaviours in boys and girls.

In this case-control study, we interviewed South African adolescents (aged 10-18 years) between 2009 and 2012. We randomly selected census areas in two urban and two rural districts in two provinces in South Africa, including all homes with a resident adolescent. We assessed household receipt of state-provided child-focused cash transfers, incidence in the past year and prevalence of transactional sex, age-disparate sex, unprotected sex, multiple partners, and sex while drunk or after taking drugs. We used logistic regression after propensity score matching to assess the effect of cash transfers on these risky sexual behaviours.

We interviewed 3515 participants (one per household) at baseline, and interviewed 3401 at follow-up. For adolescent girls (n=1926), receipt of a cash transfer was associated with reduced incidence of transactional sex, and age-disparate sex, with similar associations for prevalence (for transactional sex, OR 0·47, 95% CI 0·26-0·86; p=0·015; for age-disparate sex, OR 0·37, 95% CI 0·18-0·77; p=0·003). No significant effects were shown for other risk behaviours. For boys (n=1475), no consistent effects were shown for any of the behaviours.

National, child-focused cash transfers to alleviate poverty for households in sub-Saharan Africa can substantially reduce unsafe partner selection by adolescent girls. Child-focused cash transfers are of potential importance for effective combination strategies for prevention of HIV.

Below:  Incidence in the past year of risky sexual behaviours by adolescent girls

Table 3

Incidence of risky sexual behaviour in the past year, by household grant receipt and sex

Data are n (%).

Full article at: http://goo.gl/50wMlE

By: Cluver L1, Boyes M2, Orkin M3, Pantelic M2, Molwena T4, Sherr L5.

• 1Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa. Electronic address: lucie.cluver@spi.ox.ac.uk.
• 2Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK.
• 3School of Public and Development Management, University of the Witwatersrand, Johannesburg, South Africa.
• 4Cape Town Child Welfare, Cape Town, South Africa.
• 5Royal Free and University College Medical School, University College London, London, UK.  

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Impact of the Kenya Cash Transfer for Orphans & Vulnerable Children on Early Pregnancy & Marriage of Adolescent Girls

There is promising evidence that poverty-targeted cash transfer programs can have positive impacts on adolescent transitions to adulthood in resource poor settings, however existing research is typically from small scale programs in diverse geographic and cultural settings. 

We provide estimates of the impact of a national unconditional cash transfer program, the Kenya Cash Transfer for Orphans and Vulnerable Children, on pregnancy and early marriage among females aged 12 to 24, four years after program initiation. The evaluation was designed as a clustered randomized controlled trial and ran from 2007 to 2011, capitalizing on the existence of a control group, which was delayed entry to the program due to budget constraints. 

Findings indicate that, among 1549 females included in the study, while the program reduced the likelihood of pregnancy by five percentage points, there was no significant impact on likelihood of early marriage. Program impacts on pregnancy appear to work through increasing the enrollment of young women in school, financial stability of the household and delayed age at first sex. 

The Kenyan program is similar in design to most other major national cash transfer programs in Eastern and Southern Africa, suggesting a degree of generalizability of the results reported here. Although the objective of the program is primarily poverty alleviation, it appears to have an important impact on facilitating the successful transition of adolescent girls into adulthood.

Via: http://goo.gl/Pyv617  Purchase full article at: http://goo.gl/o8Aa18

By: Handa S1, Peterman A2, Huang C3, Halpern C4, Pettifor A5, Thirumurthy H6.

• 1Department of Public Policy, University of North Carolina, Chapel Hill, USA; UNICEF Office of Research Innocenti, Piazza SS. Annunziata 12, 50122 Florence, Italy.
• 2UNICEF Office of Research Innocenti, Piazza SS. Annunziata 12, 50122 Florence, Italy. Electronic address: apeterman@unicef.org.
• 3Department of Public Policy, University of North Carolina, Chapel Hill, USA.
• 4Department of Materal and Child Health, UNC Gillings School of Global Public Health, USA.
• 5Department of Epidemiology, UNC Gillings School of Global Public Health, USA.
• 6Department of Health Policy and Management, UNC Gillings School of Global Public Health, USA. 

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Sexual Behavior among Young Carers in the Context of a Kenyan Empowerment Program Combining Cash-Transfer, Psychosocial Support, and Entrepreneurship

This study examined associations between sexual initiation, unprotected sex, and having multiple sex partners in the past year with participation in a three-year empowerment program targeting orphan and vulnerable children (OVC). The Kenya-based program combines community-conditioned cash transfer, psychosocial empowerment, health education, and microenterprise development. 

Program participants (n = 1,060) were interviewed in a cross-sectional design. Analyses used gender-stratified hierarchical logit models to assess program participation and other potential predictors. 

• Significant predictors of increased female sexual activity included 
• less program exposure, 
• higher age, 
• younger age at most recent parental death, 
• fewer years of schooling, 
• higher food consumption, 
• higher psychological resilience, 
• and lower general self-efficacy. 
• Significant predictors of increased male sexual activity included 
• more program exposure, 
• higher age, 
• better food consumption, 
• having a living father, 
• and literacy. 

Findings support a nuanced view of current cash transfer programs, where female sexual activity may be reduced through improved financial status but male sexual activity may increase. Targeting of OVC sexual risk behaviors would likely benefit from being tailored according to associations found in this study. 

Data suggest involving fathers in sexual education, targeting women who lost a parent at a younger age, and providing social support for female OVC may decrease risk of human immunodeficiency virus (HIV) transmission.

Via: http://goo.gl/680j1q  Purchase full article at: http://goo.gl/Sjuxg6

By: Goodman ML1,2,3, Selwyn BJ2, Morgan RO2, Lloyd LE2, Mwongera M4, Gitari S4, Keiser PH3.

• 1a Sodzo International.
• 2b Division of Management, Policy and Community Health, School of Public Health , University of Texas , Houston.
• 3c Center for Global Health Education , University of Texas Medical Branch , Galveston.
• 4d Community Health Department , Maua Methodist Hospital , Meru County , Kenya 

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Designing and Implementing a Socioeconomic Intervention to Enhance TB Control: Operational Evidence from the CRESIPT Project in Peru

Below:  Conceptual framework of the conditional cash transfer scheme within the CRESIPT project

Below:  Flow diagram of CRESIPT project activities during planning, implementation and refinement of the social protection intervention

Below:  Cash transfer received by participants in seven different potential scenarios during intervention implementation. Note: Typically in Peru, treatment of TB in people with non-MDR TB has a duration of 6 months, in people with HIV-TB co-infection treatment lasts 9 months, and in people with MDR TB treatment lasts 24 months. Key: ✓ = condition optimally achieved and double incentive cash transfer provided; X = condition not achieved thus no incentive cash transfer given/paid

Below:  a Proportion of patients optimally achieving (double incentive), adequately achieving (simple incentive) and not yet achieving project conditions. b Total amount provided to patients by conditional cash transfers in total and for each condition achieved

Over 7 months, 135 randomly-selected patients and their 647 household contacts were recruited from 32 impoverished shantytown communities. Of 1299 potential cash transfers, 964 (74 %) were achieved, 259 (19 %) were not achieved, and 76 (7 %) were yet to be achieved. Of those achieved, 885/964 (92 %) were achieved optimally and 79/964 (8 %) sub-optimally.

Key project successes were identified during 135 formative activities and included: strong multi-sectorial collaboration; generation of new evidence for TB-specific cash transfer; and the project being perceived as patient-centred and empowering.

Challenges included: participant confidence being eroded through cash transfer delays, hidden account-charges and stigma; access to the initial bank-provider being limited; and conditions requiring participation of all TB-affected household members (e.g. community meetings) being hard to achieve.

Refinements were made to improve project acceptability and future impact: the initial bank-provider was changed; conditional and unconditional cash transfers were combined; cash transfer sums were increased to a locally-appropriate, evidence-based amount; and cash transfer size varied according to patient household size to maximally reduce mitigation of TB-related costs and be more responsive to household needs.

Conclusions

A novel TB-specific socioeconomic intervention including conditional cash transfers has been designed, implemented, refined and is ready for impact assessment, including by the CRESIPT project. The lessons learnt during this research will inform policy-makers and decision-makers for future implementation of related interventions.

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Effectiveness of Conditional Cash Transfers to Increase Retention in Care and Adherence to PMTCT Services

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