Cash Care: Transforming HIV outcomes for adolescents in Africa through social protection

Background
 

Social scientists from the Department of Social Policy and Intervention worked with a wide range of stakeholders in South and East Africa to assess how government support programmes improved social and health outcomes for young people affected by HIV and AIDS.

They conducted cohort studies of vulnerable adolescents, as well as youth consultations, and found that combining government cash grants, with aspects of social support and clinical care, generated disproportionately positive results:

• Adolescents in high-poverty areas – Across three provinces in South Africa, combining cash transfers with social welfare and caregiving support, led to HIV infection risk behaviours reducing by 50-70% among young girls. A pertinent result, when within 1·8 million new HIV infections on the subcontinent in 2011, cases were up to three-times higher among girls than boys
   
• Young people living with HIV/AIDS - Among young people living with HIV and AIDS, combining cash with clinic and ‘caring’ support reduced non-adherence with taking critical antiretroviral drugs down from 54% to 18%. Retention in HIV care increased from 3% to 70%, and rates of unprotected sex fell from 49% to 8%.

As a result, similar ‘cash and care’-led approaches have been included in adolescent policy and service delivery by agencies across the world – including the U.S Agency for International Development (USAID) President’s Emergency Plan for AIDS Relief (PEPFAR), UNICEF, UNAIDS and national governments including South Africa, Kenya, Malawi, Mozambique, Zambia and Zimbabwe.

Research was deemed to support delivery of the UN Sustainable Development Goals, and so impactful, that researchers were invited to write the South African National Adolescent and Youth Health Policy 2017-2022.
 

Young Carers’ Study (2009-2012)
 

First, social scientists investigated the impact of being a 'young carer' on children's well-being within families affected by AIDS. The team interviewed and followed up with 6,004 children and adolescents in areas with high HIV rates, and 2,500 of their caregivers between 2009-2012 – which made this the world’s largest study on children in AIDS-affected families.

Researchers analysed household receipt of state-provided child-focused cash transfers alongside instances of risky sexual behaviours among children aged 12-18, including unprotected sex, age-disparate sex, transactional sex, multiple partners, and sex while drunk or after taking drugs.

The research showed that regular, small poverty alleviation-focused cash transfers to families (the South African Child Support Grant) substantially reduced the risk of adolescent girls engaging in transactional and age-disparate sex: the region’s primary vector of HIV infection. In short, cash transfers meant that girls living in poverty did not need to have a ‘sugar daddy’ to bring food onto their family tables.

On the flipside, cash transfers alone did not reduce girls' risk behaviours related to unprotected sex, multiple partners, or sex after drinking alcohol or taking drugs. For boys, cash transfers alone were only associated with reduced incidence of multiple partners during the past year.

This highlighted the need to make cash transfers part of a combination approach to prevention, which targets structural, behavioural, and biomedical drivers of infection. There is also an urgent need for effective and scalable HIV-prevention interventions in sub-Saharan Africa for adolescents – including boys specifically.

So, the research team investigated whether combining cash transfers with good parenting (‘Cash+Care’) would increase HIV prevention across a wider range of sexual risk behaviours and across genders. They used statistical modelling to identify the most effective ways to interrupt pathways between structural deprivations, such as poverty and HIV – yielding impressive results.

HIV affected teenagers - The Mzantsi Wakho (‘Our South Africa’) Study 2014-2019
 

With the University of Cape Town, researchers then carried out a second study focused on a major risk for poor health - adolescent non-adherence to lifesaving antiretroviral medication, which increases mortality, morbidity, viral resistance and onwards HIV-transmission.

Researchers interviewed over 1,000 adolescents living with HIV, and 500 of their peers, to prevent stigma. They found that non-adherence – assumed by many to be due to adolescent misbehaviour – was actually strongly associated with social factors, such as violence and victimisation in the home, clinic and school.

For adolescents living with HIV, clinical factors were an important addition to social protection provisions, so researchers adapted their work and created a ‘Cash + Clinic + Care’ model. They found that young people who could access support groups, secure food supplies, and good parental supervision were likely to have improved adherence to antiretroviral medication requirements. In addition, access to free schooling, adolescent-sensitive clinic care, and good parental supervision were associated with safe sexual practices. 

For example, it was the combination of food provision, HIV support group access and good parenting that reduced past-week antiretroviral non-adherence from 54% to 18%. Access to free schooling, non-shouting clinical staff and good parenting reduced unprotected sex from 49% to 8%. 

Access to clinics with sufficient medications, combined with cash for transport to clinic and care aspects – such as being accompanied to clinic by a family member increased retention in HIV care from 3% to 70%.

Research showed that combining interventions had considerable additive effects, especially in reducing sexual risk-taking among adolescent girls living with HIV. It comes at a time when around 2.1 million adolescents live with HIV - 1.4 million of whom are in Eastern and Southern Africa. The findings regarding Cash+Care led to significant political and social engagement across the world.
 

Impact by Numbers

• Lead researcher Lucie Cluver was 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. Recent modelling showed significant declines in new HIV diagnoses of 25-40% amongst adolescent girls in the districts implementing DREAMS – including Cash + Care programmes - within ten African countries [E8b, E9 & E10].
   
• In total, 1.8 million adolescent girls living in 10 African countries (Eswatini, Kenya, Lesotho, Malawi, Mozambique, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe) have accessed Cash+Care programmes – delivered by a range of NGOs including Catholic Relief Services, Pact, Save the Children and World Education-Bantwana. This work has been cited in four reports to the U.S. Congress (2017, 2018, 2019, 2020). 
   
• A further 200,000 children and adolescents accessed Cash+Care services through UNICEF Eastern and Southern Africa Office, and partners in four countries. 
   
• Aidspan, the independent observer of the Global Fund, reported that from 2016 to 2018, the South African government with support from the Global Fund to end HIV/AIDS, TB and Malaria, delivered Cash+Care services to 30,000 young women.
   
• The research has won four prizes for impact, including the 2017 ESRC Outstanding International Impact Prize, the Philip Leverhulme Prize 2015, the 2018 UNICEF Women Leaders in the HIV response for Children recognition and the 2019 European Union Council Conference Social Sciences and Humanities Impact Award. Professor Cluver was included in UKRI’s 2019 ‘15 Women in Research and Innovation’.
   
• 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. This is currently being rolled out in Ethiopia, Botswana and South Sudan.