to orphans and vulnerable children in Kenya
are associated with later onset of sexual activity and fewer sexual partners,
but no increase in condom use among those already sexually active, according to
long-term follow-up from Kenya’s
national cash transfer programme presented last week at the Nineteenth
International AIDS Conference in Washington
What are cash transfers?
While there has
been a small dip globally in new HIV infections, rates are still soaring among
adolescents and women in sub-Saharan Africa.
This is due in large part to their marginalized social position, and to
poverty, gender inequality, and violence against women.
In order to
address socio-economic concerns fueling the epidemic globally amongst women and
girls in sub-Saharan, governments and researchers have considered the effect
that cash transfers may have on behaviour change, and therefore risk of HIV
generally come in two forms:
cash transfers, in which cash is given in reward for positive behavior or
general economic development and empowerment programmes aimed at reducing
poverty, but with the either intended or unintended side-effect of
reducing HIV risk.
The evidence of
the HIV preventative effect of cash transfers is promising. Speaking at a session
entitled "Is Money Alone Enough: The
'Value' of Cash Transfers" during the conference, Charlotte Watts of the London School of Hygiene and Tropical
Medicine presented findings on several studies that have been conducted in the
past several years.
As an example of potential efficacy, Watts
noted that the Zomba Cash Transfer Programme - which took place in
Zomba, Malawi, and gave money to girls
attending schools and their families, as well as payment of school fees - showed
64% lower HIV prevalence in the intervention arm when compared to the control
arm. Importantly, these results did not differ significantly if money was given
on a conditional or unconditional basis.
Malawi-based study has shown that even small economic incentives can double the
number of people returning to collect HIV results. A study conducted in
Tanzania showed that a conditional cash transfer given to participants who
remained free of STIs resulted in a 25% lower prevalence when considering the
intervention versus the control arm, with the impact greater among poorer
households in rural areas.
presented by Lorraine Sherr of the
University College London and Morten Skovdal of the University of
Bergen showed that community buy-in to programmes was important, in order to
de-stigmatise the link between cash transfer and HIV; to allow for broader
discussions of social and behavioral change; and to ensure that programmes were
tailored to local needs.
that sustaining results outside of these programmes is difficult, however,
especially for populations considered most at risk, such as youth and women. The
Tanzanian STI study showed that behaviour changes were only sustained among men,
and not among women; the South African micro-finance study showed that there
was no long-term impact on HIV incidence on adolescents in the community.
Results do vary.
A study in rural Malawi
considering economic rewards for remaining HIV negative over a year period
showed no effect on HIV status. Watts said
that while cash transfers had a clear impact on uptake of services, the
long-term impact on HIV risk was less clear.
Michelle Reme of
the London School of Hygiene and Tropical Medicine said that structural
interventions should be considered not only for their value in reducing
HIV-risk behavior, but also other health and development objectives. Pointing
again to the Zomba study, Reme noted that beyond the 64% reduction in HIV risk,
the study resulted in a 35% reduction in school drop-out rate; 40% reduction in
early marriages; 76% reduction in genital herpes risk; 58% reduction in
depression risk; and 30% reduction in teen pregnancies. While the cost per HIV
infection averted ranged from $5,000 to $12,500 - much higher than the cost per
HIV infection averted by other interventions, such as VCT, PMTCT, and male
circumcision - these costs do not take into account the programme's positive
impact on other aspects of participants' lives, and society as a whole.
HIV risk stems from myriad factors, and not poverty alone, Watts pointed to a
programme in South Africa which considered the coupling effect of micro-finance
loans enhanced with community mobilisation and participatory training in
gender, violence and HIV. The results were promising, with younger women
especially more likely to improve HIV testing and safe sex behaviors, with 64%
testing for HIV, and a 25% increasing safe sexual practice. Additionally,
participants experienced 55% less violence in the past year; researchers noted
that this was due to a multi-pronged approach, with micro-finance alone not
enough to reduce violence or empower women.