Impact Case Study: Cash + Care: Transforming HIV outcomes for adolescents in Africa through social protection
Since 2009, ground-breaking research by the University of Oxford, has reduced HIV infection risks and improved health for 2,000,000 adolescents across Southern and Eastern Africa. Specifically, the research demonstrated that combinations of social welfare, cash transfers and caregiving support gave 50-70% reductions in HIV infection risk behaviours, such as transactional sex. This has been directly translated into policy and service delivery for adolescents by USAID-President’s Emergency Plan for AIDS Relief (PEPFAR), UNICEF, UNAIDS and national governments including South Africa, Kenya, Malawi, Mozambique, Zambia and Zimbabwe.
Co-created with the South African government, UNICEF and the U.S. Agency for International Development (USAID) through their ‘President’s Emergency Plan for AIDS Relief’ (PEPFAR) programme, Lucie Cluver and Frances Gardner alongside their partner the University of Cape Town, have led two studies with major impact on adolescent health in Africa:
The Young Carer’s Study: 2009-2013 -
in collaboration with Mark Boyes (Curtin University) Franziska Meinck (University of Edinburgh) and Mark Orkin (University of the Witswatersrand).
This is the world’s largest study of AIDS-affected children, following 6004 children and interviewing 2500 of their primary caregivers.
The research showed that by giving small amounts of regular cash the risk of adolescent girls engaging in transactional and age-disparate sex, which is a cause of HIV transmission, was substantially reduced. Furthermore the research revealed that by combining cash transfers with social or family support (‘Cash+Care’) HIV prevention increased across a wider range of sexual risk behaviours and across genders.
The Mzantsi Wakho (‘Our South Africa’) Study 2014-2019 –
in collaboration with Elona Toska (UCT) Rebecca Hodes (UCT) and Lorraine Sherr (UCL)
The study surveyed 1,000 adolescents living with HIV over four years, alongside 500 of their HIV-negative peers. It focuses on adolescent non-adherence to lifesaving antiretroviral medication and the impact of this on health.
The study found that non-adherence – thought to be due to adolescent misbehaviour – was strongly associated with social factors such as violence victimisation in the home, clinic and school. For HIV-infected adolescents, clinical factors were an important addition to social protection provisions, leading to ‘Cash + Clinic + Care’, such as combining food provision and HIV support group access with good parenting.
The utilisation of these studies by policymakers and practitioners in sub-Saharan Africa has helped mitigate the effects of AIDS on families and communities.
‘This research team have spearheaded novel research on cash transfers and in particular ‘Cash plus Care’ as a prevention measure for HIV/AIDS risk behaviour in adolescents…Since then, the concept has become an integral part of UN planning and response to the HIV epidemic…At every stage, this research has been a partnership between the academic team, myself and other colleagues within the UN, including UNICEF and the UN Development Programme…… This really is an example of collaboration to fight the HIV/AIDS epidemic.’
Senior Advisor, UNAIDS
‘Cash+Care’ services were delivered to 200,000 children and adolescents through UNICEF Eastern and Southern Africa Office country partners in four countries.
The research team worked with PEPFAR-USAID to develop HIV-enhanced and sexual violence-enhanced versions of a Cash+Care programme that increased caregiver support to adolescents and reduced household hunger in countries such as Ethiopia, Botswana and South Sudan.
The findings regarding Cash+Care led to direct engagement with PEPFAR-USAID and the World Bank, with Prof. Cluver invited in 2014 to the Advisory Board of the US government’s USD1,000,000,000 flagship HIV-prevention programme ‘DREAMS’ (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe). Cash+Care was identified as one of the required set of services for adolescents in the DREAMS guidance.
The Cash+Care findings have also been included and the research cited extensively in South Africa’s National HIV and TB Investment Case.
Cash+Care findings are cited in the 2020 World Health Organisation (WHO) Global Status Report on Violence against Children.
The South African National Department of Health and the United Nations Population Fund (UNFPA) invited the research team to write the South African National Adolescent and Youth Health Policy 2017-2022, which was co-written with government colleagues, and with the research team’s Teen Advisory Group of HIV-affected adolescents. This policy was signed by the Minister of Health in 2017.
The research has been used and cited in guidance by a range of UN agencies. For example, UNICEF recommend Cash+Care in their 2016 Call to Action.