Cash transfers plus care halve HIV risk behaviours in South African adolescents

Dr Lucie Cluver of the University of Oxford. Image via
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Combining unconditional 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.


risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

observational study

A study design in which patients receive routine clinical care and researchers record the outcome. Observational studies can provide useful information but are considered less reliable than experimental studies such as randomised controlled trials. Some examples of observational studies are cohort studies and case-control studies.

longitudinal study

A study in which information is collected on people over several weeks, months or years. People may be followed forward in time (a prospective study), or information may be collected on past events (a retrospective study).

prospective study

A type of longitudinal study in which people join the study and information is then collected on them for several weeks, months or years. 



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 their vulnerability.

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 support provision).

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 inequalities.

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%.

Socio-demographic predictors 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 social support.

Prospective multivariate 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 for boys.

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, respectively.

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.


Cluver L et al. Combination social protection halves HIV-risk behaviour incidence amongst female and male South African adolescents. 20th International AIDS Conference, Melbourne, abstract MOAC0104, July 2014.

View the abstract on the conference website.

Cluver L et al. Cash plus care: social protection cumulatively mitigates HIV-risk behaviour among adolescents in South Africa. AIDS 28 (suppl 3): S389-97, 2014. (Full text article available here).