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.