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cash, care and HIV‐risk
for adolescents in southern africa
Cluver, Lucie; Orkin, Mark; Boyes, Mark; Sherr, Lorraine
South Africa national longitudinal study of adolescents6850 adolescents, 2500 adult caregivers, 2008‐2012
• N=6000 (age: 10‐18) • 3 provinces South Africa; 6 sites >30% HIV‐prevalence• Stratified random sampling of census areas, urban/rural• Every household with a child aged 10‐17• 1 year follow‐up in 2 provinces: 97% follow‐up
Controlling for prior HIV risk
Effects of abuse, poverty & parental AIDS on female adolescent risk of transactional sex
Cluver, Orkin, Boyes, Meinck, Makhasi (2011). JAIDS
1%
7%
13%
57%
Healthy family AIDS‐sick parent Abused & hungry AIDS‐sick parent,abused, hungry
unconditional governmentcash transfers
0
1
2
3
4
5
6
7
8
12‐14 years 15‐17 years
% Incidence of transactional sex(OR .49 CI .26‐.93*)
National cash transfers reduce 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.
12‐14 years 15‐17 years
% Incidence of age‐disparate sex (OR .29 CI .13‐.67**)
cash plus care?
Can CASH + CARE reduce HIV risk behavior?
CASH
CARE
Incidence rates:
Transactional sex
Age‐disparate sex
Sex using substances
Multiple partners
Unprotected sex
Child‐focused grant
Regular food parcels
Free school meals
School counsellor
Food garden
Positive parenting
Teacher support
% girls with incidence of 1+ HIV risk behavior: Cash plus care = halved risk
Cash alone: OR .63Cash plus care: OR .55
41%
25%
15%
0
10
20
30
40
50
60
no support cash cash plus care
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 (in press). AIDS.
% boys with incidence of 1+ HIV risk behavior:Cash plus care = halved risk
Cash alone: no significant effectCash plus care: OR .50
42%
28%
17%
0
10
20
30
40
50
60
no support cash cash plus care
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 (in press). AIDS.
how does social protection work?
Hunger
Community violence
Parental HIV/AIDS
Informal settlement
2011Structural deprivation
2012HIV‐risk behavior incidence
Poverty & family AIDS predict adolescent HIV‐risks: how?
Transactional sex
Age‐disparate sex
Sex using substances
Multiple partners
Unprotected sex
controlling for: baseline HIV‐risk, age, gender
HIV‐risk behaviorincidence
Structural deprivation
school dropout
child abuse
conduct problems
drug/alcohol use
psychological distress
controlling for: baseline HIV‐risk, age, genderAll p= .05‐.001
Psychosocial problems
Structural deprivation increases HIV‐risk by increasing psychosocial problems
ReducedHIV‐risk behaviorincidence
Structural deprivation
Reduced psycho‐social problems
controlling for: baseline HIV‐risk, age, gender
CASH
CARE
Cash and care: greatest effects for highest‐risk adolescents
New analyses – social protection and ART adherence
HIV+ adolescents: ART adherence, cash and care• Indicative percentages only, n=250• Random sampling 32 state clinics, South Africa
30
35
40
45
50
55
60
65
70
75
80
no support cash: transfer/foodgarden/food parcel
care: positiveparenting/treatment
buddy
cash plus care
Past week ART adherent (%)Cash plus care: OR 2.42
Unconditional, government cash transfers reduce adolescent HIV risks
Cash plus care gives greater effects
Effective in real‐world sub‐Saharan Africa
Cash and care mitigate risk pathways
Funders: thank you.
Noxolo Nitricia Myeketsi
My personal experience of social protection and HIVSouth Africa
Crossroads where I live
My grandmother
Outside my grandmother’s house
Now I am at the University of the Western Cape
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