Effective combination prevention: Cash, care and HIV -risk for adolescents in South Africa.

1. Effective combination prevention: Cash, care and HIV-risk for adolescents in South Africa. L Cluver, M Orkin, M Boyes, L Sherr IAS, July 2014

2. Collaborative research: science to assist policy

3. National longitudinal studyof adolescents 6850 adolescents, 2500 adult caregivers, 2008-2012 Longitudinal national survey • Main study: N=6000 (age: 10-18) • 3 provinces South Africa; 6 sites >30% prevalence • Stratified random sampling of census EAs • Every household with a child aged 10-17 • Urban/rural, 1 year follow-up in 2 provinces • n=3401, 97% follow-up • Measures • Standardised scales, national surveys • Ethics • Approved by Universities of Cape Town, • Oxford, KwaZulu-Natal, • 6 Provincial Health & Education Departments • Social & health service referrals • Controlling for prior HIV risk

5. Effects of abuse, poverty & parental AIDS on female adolescent risk of transactional sex Cluver,Orkin, Boyes, Meinck, Makhasi (2011). JAIDS

6. Proof of concept: cash incentives

9. Unconditional cash transfers

10. South Africa: Child grant reduces incidence & prevalence of transactional sex and age-disparate sex for girls No cash transfer Child cash transfer Cluver, Boyes, Orkin, Pantelic, Molwena, Sherr(2013). The Lancet Global Health.

11. Cash plus care?

12. Can CASH + CARE reduce HIV risk behavior? Incidence rates: Transactional sex Age-disparate sex Sex using substances Multiple partners Unprotected sex Teen pregnancy CASH CARE

13. Food garden Child-focused grant Free school uniform Positive parenting Home-based carer Regular food parcels School counsellor Free school meals Teacher support Soup kitchen Free school transport

14. Food garden Child-focused grant Positive parenting n=3515, longitudinal Free school meals Teacher support

15. % girls with incidence of 1+ HIV risk behavior: Cash plus care = halved risk Cash alone: OR .63 Cash plus care: OR .55 Controlling for: family HIV/AIDS, informal/formal housing, age of child, poverty levels, number of moves of home, baseline HIV risk behaviour Cluver, Orkin, Boyes, Sherr(2014). AIDS.

16. % boys with incidence of 1+ HIV risk behavior:Cash plus care = halved risk Cash alone: no significant effect Cash plus care: OR .50 Controlling for: family HIV/AIDS, informal/formal housing, age of child, poverty levels, number of moves of home, baseline HIV risk behaviour Cluver, Orkin, Boyes, Sherr(2014). AIDS.

17. Structural drivers and mechanisms

18. Poverty & family AIDS predict adolescent HIV-risks: how? 2011 Structural deprivation 2012 HIV-risk behavior incidence Hunger Transactional sex Age-disparate sex Sex using substances Multiple partners Unprotected sex Pregnancy Community violence Parental HIV/AIDS all p<.001 Informal settlement controlling for: baseline HIV-risk, age, gender

19. school dropout p<.001 p<.001 child abuse p<.001 p<.001 conduct problems p<.001 p<.002 psychological distress p<.05 p<.001 drug/alcohol use p<.001 p<.001 HIV-risk behavior incidence Structural deprivation Psychosocial problems p<.004 controlling for: baseline HIV-risk, age, gender

20. Cash and care: greatest effects for highest-risk adolescents CASH P<.001 P<.001 P<.001 P<.001 Reduced psycho-social problems P<.001 P<.001 Reduced HIV-risk behavior incidence Structural deprivation P<.001 P<.001 P<.001 CARE controlling for: baseline HIV-risk, age, gender

21. Cumulative HIV-prevention impact

22. Unconditional, government cash transfers reduce adolescent HIV risks Cash plus care gives greater effects Cash and care mitigate structural risk Cumulative impacts of 2+ interventions Effective in real-world sub-Saharan Africa

23. Funders: thank you.