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.

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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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Conditional Cash Transfers & Uptake Of & Retention in Prevention of Mother-To-Child HIV Transmission Care

BACKGROUND:

Novel strategies are needed to increase retention in and uptake of prevention of mother-to-child HIV transmission (PMTCT) services in sub-Saharan Africa. We aimed to determine whether small, increasing cash payments, which were conditional on attendance at scheduled clinic visits and receipt of proposed services can increase the proportions of HIV-infected pregnant women who accept available PMTCT services and remain in care.

METHODS:

In this randomised controlled trial, we recruited newly diagnosed HIV-infected women, who were 32 or less weeks pregnant, from 89 antenatal care clinics in Kinshasa, Democratic Republic of Congo, and randomly assigned (1:1) them to either the intervention group or the control group using computer-based randomisation with varying block sizes of four, six, and eight. The intervention group received compensation on the condition that they attended scheduled clinic visits and accepted offered PMTCT services (US$5, plus US$1 increment at every subsequent visit), whereas the control group received usual care. Outcomes assessed included retention in care at 6 weeks' post partum and uptake of PMTCT services, measured by attendance of all scheduled clinic visits and acceptance of proposed services up to 6 weeks' post partum. Analyses were by intention to treat. This trial is registered with ClinicalTrials.org, number NCT01838005.

FINDINGS:

Between April 18, 2013, and Aug 30, 2014, 612 potential participants were identified, 545 were screened, and 433 were enrolled and randomly assigned; 217 to the control group and 216 to the intervention group. At 6 weeks' post partum, 174 participants in the intervention group (81%) and 157 in the control group (72%) were retained in care (risk ratio [RR] 1·11; 95% CI 1·00-1·24). 146 participants in the intervention group (68%) and 116 in the control group (54%) attended all clinic visits and accepted proposed services (RR 1·26; 95% CI 1·08-1·48). Results were similar after adjustment for marital status, age, and education.

INTERPRETATION:

Among women with newly diagnosed HIV, small, incremental cash incentives resulted in increased retention along the PMTCT cascade and uptake of available services. The cost-effectiveness of these incentives and their effect on HIV-free survival warrant further investigation.

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By:  Yotebieng M1, Thirumurthy H2, Moracco KE3, Kawende B4, Chalachala JL4, Wenzi LK4, Ravelomanana NL5, Edmonds A5, Thompson D5, Okitolonda EW4,Behets F6.

• 1The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, USA; The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA. Electronic address: yotebieng.2@osu.edu.
• 2The University of North Carolina at Chapel Hill, Department of Health Policy and Management, Chapel Hill, NC, USA.
• 3The University of North Carolina at Chapel Hill, Department of Health Behavior, Chapel Hill, NC, USA.
• 4The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo.
• 5The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA.
• 6The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA; The University of North Carolina at Chapel Hill, Department of Social Medicine, Chapel Hill, NC, USA. 
• Lancet HIV. 2016 Feb;3(2):e85-93. doi: 10.1016/S2352-3018(15)00247-7.

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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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Effectiveness of Conditional Cash Transfers to Increase Retention in Care & Adherence to PMTCT Services: A Randomized Controlled Trial

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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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