economic support in the form of government cash transfers, school feeding and
food gardens, and psychosocial support (positive parenting and teacher social
support) reduced incidence of HIV risk behaviour by around half for both female and
male adolescents in South Africa, Dr Lucie Cluver of the University of Oxford
told participants at the 20th International AIDS Conference (AIDS 2014) in
Melbourne on Monday.
Social protection in the form
of cash transfers and other measures to reduce HIV risk and vulnerability
caused by poverty is being explored in a variety of settings, especially among
adolescents in southern and eastern Africa. There is strong evidence that
poverty increases HIV risk through a variety of mechanisms, and that HIV in the family increases adolescent vulnerability to HIV through a variety of pathways.
A longitudinal national study
of 6000 South African adolescents conducted by Dr Cluver and colleagues between
2008 and 2012 found that the greater the economic and social disadvantages
reported by adolescent girls, the greater the increase in female adolescent
risk for transactional sex. The percentage of female adolescents having
transactional sex who 1) had a healthy family, 2) had an AIDS-sick parent, 3) was abused
and hungry, and 4) was abused, hungry and had an AIDS-sick parent was 1%,
7%, 13% and 57% respectively.
Benefits of social protection
(for example, cash transfers, food, transport allowances, school uniforms) for
families and children include better negotiation skills, improved condom use, a
reduction in the number of sexual partners, and increased uptake of testing – as well
as improved school enrolment and attendance, so expanding access to the “social
vaccine” of education against HIV infection.
Young people in southern Africa are at high risk of HIV infection, especially adolescent girls. Recent research in South Africa found that by the age of 18 and 19, 13.6% of adolescent girls in a rural district were already HIV positive. Additional interventions to reduce HIV incidence and HIV risk behaviours among adolescent girls are needed urgently.
Citing a study undertaken in
South Africa in 2013, Dr Cluver commented that an unconditional cash transfer
in the form of a child grant reduced the incidence and prevalence of
transactional sex as well as age-disparate sex for girls by a half and a third,
respectively, (odds ratio [OR]:0.49, 95% CI:0.26-0.93 and OR: 0.29, 95% CI: 0.13-0.67)
compared to no grant.
Adolescence is recognised as
a time of significant physical, biological and psychological changes, of rapid
cognitive and social development, as well as a time of increased risk for HIV. The
many social and economic pressures adolescents experience further contribute to
While there is increasing
evidence of the positive effects of conditional or unconditional cash transfers
mitigating the impact of HIV and in reducing HIV-related risk, little is known
of the effects of non-cash economic support or of combinations of ‘cash and care’ (economic and psychosocial
Factors contributing to HIV
vulnerability include poverty and gender inequality, as well as lack of education.
Evidence suggests that poverty on its own is not a driver of HIV risk, but
interacts with a number of other factors including social and economic
In this prospective
observational sub-study of a longitudinal national survey undertaken between
2009 and 2012 of adolescents and adult caregivers, Lucy Cluver and her colleagues
interviewed 3515 adolescents aged 10 to 18 twice; once at baseline with less than
a 2.5% refusal and at one-year follow-up with a 97% retention rate. Females
comprised just over half the participants (57%).
All homes with a resident
adolescent within randomly selected census areas in two urban and two rural areas in two provinces in South Africa were sampled. HIV prevalence in all
sites was over 30%.
of very high-risk behaviour that were measured included: unprotected sex,
transactional sex, age-disparate sex, multiple partners, sex while using
substances and teen pregnancy.
Environmental factors (structural
deprivation) measured included parental HIV and AIDS, community violence, informal
settlement and poverty.
Forms of economic support
included: unconditional government cash transfers, free school meals and food
gardens, while psychosocial support included positive parenting and teacher
logistic regression showed that cash alone predicted reduced HIV-risk behaviour
incidence for adolescent girls, OR: 0.63, 95% CI: 0.44-0.91, p = 0.02, but not
When compared to no support and
controlling for confounders, combined receipt of cash plus care was associated
with an approximate halving in HIV-risk behaviour for both girls and boys, OR:
0.55, 95% CI: 0.35-0.85, p = 0.007 and OR: 0.50, 95% CI: 0.31-0.82, p = 0.005,
However, female adolescents
experiencing parental AIDS-related mortality or morbidity had increased overall
HIV risk behaviour as did male adolescents in informal dwellings.
Cash plus care had the
greatest impact on higher-risk adolescents, mitigating structural risks and the
consequent psycho-social problems including dropping out of school, child
abuse, conduct problems, psychological distress and drug or alcohol use.
Integrating cash with care
had a significant impact with follow-up HIV-risk behaviour reduced from 41 to
15% for girls and from 42 to 17% for boys.
The cumulative impact of
combined social protection measures was illustrated by the decrease in the percentage
of adolescents with multiple sexual partners in the past year according to the
level of support – no support (20%), cash transfer (10%), cash plus teacher
support (7.5%), cash plus good parenting (4%), and cash plus teacher support
plus good parenting (2%), respectively.
Increasing adolescent access
to ‘cash plus care’ may be an effective and important real-world HIV prevention
strategy in sub-Saharan Africa.
However, the observational
study found wide variations in the level of coverage of different social
protection measures. Whereas more than half of adolescents received a
child-focused cash transfer or school feeding, only 3.7% had received support
from a school counsellor and around 8% from a teacher. Furthermore, only one
quarter had received 'positive parenting', a measure of positive affirmation and
support from a primary caregiver.
The full study report is available in a supplement to the journal AIDS, on Children born into families affected by HIV, published to coincide
with the conference.