Cash, care, preventionand adherencefor adolescents:

Latest evidence from southern africa

L Cluver, M Orkin, M Boyes, L Sherr, F MeinckArusha, December 2014

Child-focused research

Universities: Oxford, UCT, Wits, Curtin,

UKZN

Collaborative research: science to assist policy

National longitudinal study of adolescents6850 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 referralsControlling for prior HIV risk

• N=700 adolescents, 3-year tracking

• All 32 ART clinics (>5 adolescents) Buffalo City/Amathole Districts, Eastern Cape

• Enrolled and lost-to-follow-up• Viral load, CD4, pharmacy refills,

self-reported adherence• Clinic assessments for facility-level

effects• + 2-year qualitative ethnography

Predicting adolescent ART adherence & SRH use

Effects of abuse, poverty & parental AIDS on female adolescent risk of transactional sex

Cluver, Orkin, Boyes, Meinck, Makhasi (2011). JAIDS

Healthy family AIDS-sick parent Abused & hungry AIDS-sick parent, abused, hungry

1%

7%

13%

57%

AIDS-orphan

HIV Risk Behaviour

Abuse

AIDS-sick

parent

Psych. distress

Stigma

Poverty

.08

.13

.22

.10.15

.15

.32

.43

.72

.15

.24

.12

mean χ2(679)

Bollen-Stine

mean χ2/df

RMSEA SRMR CFI TLI

640.06 p=.001 1.57 .032 .044 .939 .930

Pathways to HIV-risk

Cluver, Orkin, Boyes, Sherr, Nikelo, Makhasi (2013). Soc. Sci & Medicine. Analyses funded by RIATT.

Education risks

.18

.14

Unconditional cash transfers

12-14 years 15-17 years0

1

2

3

4

5

6

7

8 % Incidence of transactional

sex (OR .49 CI .26-.93*)

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.

12-14 years 15-17 years

% Incidence of age-disparate sex (OR .29 CI .13-.67**)

Kenya: Summary Impacts of OVC cash transfer on adolescents (Odds Ratios)

1

1.2

1.4

1.6

1.8

2

2.2

2.4AllFemales

Handa, Halpern, Pettifor, Thirmurthy (2014) PLOS One.

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

Teen pregnancy

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

no sup-port

cash cash plus care

0

10

20

30

40

50

60

41%

25%

15%

Controlling for: family HIV/AIDS, informal/formal housing, age of child, poverty levels, number of moves of home, baseline HIV risk behaviourCluver, Orkin, Boyes, Sherr (2014). AIDS.

no sup-port

cash cash plus care

42%

28%

17%

Cash alone: no effectCash plus care: OR .50

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 Past week ART adherent (%)Cash plus care: OR 2.42

Past

-wee

k se

lf-r

epor

ted

adhe

renc

e (%

)

Structural drivers and mechanisms

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

Pregnancy

controlling for: baseline HIV-risk, age, gender

all p<.001

Cluver, Orkin, Boyes, Sherr (2014). AIDS.

HIV-risk behaviorincidence

Structural deprivation

school dropout

child abuse

conduct problems

drug/alcohol use

psychological distress

p<.0

01p<

.001

p<.0

01

p<.001

p<.001

p<.001p<.001

p<.002

p<.05

p<.001

controlling for: baseline HIV-risk, age, gender

Psychosocial problemsp<.004

Cluver, Orkin, Boyes, Sherr (2014). AIDS.

High vulnerability Starving Sex

Psychosocial risks

Girls: ‘starving sex’ incidence (longitudinal, 60% of HIV-risk behavior explained)

CARE CASH

CLASSROOM controlling for: age,baseline HIV-risk

What kinds of cash and care work best?

(preliminary analyses)

Combinations for HIV-prevention

    Males Females    

    Careless Economic Careless Economic   Pregnancy

CashChild Grants          

Medical care          

Class-room

School feeding            

Free school & books            

CareMonitoring            

Teacher support            

Boys: % Probability of ‘Stupid’ Sex(unprotected sex, sex using substances, mul-tiple partners, casual sex)

No intervention Good monitoring Teacher support Both interventions0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

MALES: % Probability of incidence of ’careless sex' HIV-risk behaviors (unprotected sex, sex whilst on drugs/

drunk, multiple partners, casual sex)

No intervention Child grant Free school Both interventions0.0

2.0

4.0

6.0

8.0

10.0

12.0

FEMALES: % Probability of incidence of 'Economic Sex' HIV-risks (transactional or age-disparate sex)

Operationalising care

(preliminary analyses)

• Aims: Reduce child abuse, improve parenting and supervision• Local NGO staff, no materials needed• Free: Creative Commons• WHO and UNICEF: scale-up to other countries

• Thula Sana (pregnancy – 6 months)• Book sharing (toddlers)• Sinovuyo Kids (ages 2-9)• Sinovuyo Teen (ages 10-17)

• Group work, • collaborative problem-solving • Home practice, role-playing • Evidence-based core principles Building a Rondavel of Support

Parenting for Lifelong Health: Sinovuyo SA

Pre Post0

0.5

1

1.5

2

2.5Physical abuse p<.001

Pre Post0

0.51

1.52

2.53

3.5Emotional Abuse p<.001/.002

CaregiverTeen

Pre Post0

0.2

0.4

0.6

0.8

1

1.2Neglect p<.001/<.004

Pre Post0

0.05

0.1

0.15

0.2

Sexual Abuse not signif-icant

Pre Post5

10

15

20

25

30

Caregiver depression p<.001

Caregiver depressionCaregiver parenting stress

pre post01234567

Teen depression and Suicidality p<.001

Teen de-pressionSuicidal teen

Pre Post0

0.51

1.52

2.53

Caregiver negative coping i.e. alcohol use

pre post0

2

4

6

8

10

Adolescent Aggressive behav-ior p<.002/<.02)

CaregiverTeen

Controlling for: age, formal/informal housing, poverty, urban/rural, household employment, child migration, caregiver gender, non-biological caregiver & outcome risk at baseline. Cash alone, care alone & cash+care entered simultaneously.

multiple partners transactional sex unprotected sex pregnancy school dropout

0.57

0.25

0.47

0.15

0.31

0.17

0.49

0.32

0.06

Girls: odds reduction in risk incidence cash only

cash +care

multiple partners unprotected sex school dropout criminal behavior

0.310.35

0.11

0.28

0.2

Boys: odds reduction in risk incidence

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 structural risk

Cumulative impacts of 2+ interventions

Funders: thank you.

‘I would like to advice the government to issue grants to

those countries that are suffering socially and see the difference. And see how the

impact it could create in the life many of youngsters. How it can

better their decision and destiny.Take it from me I am the

living difference.’

Noxolo, 19 yrs.