Cash, care and HIV-prevention for adolescent girls Latest evidence from southern africa

Transcription

1 Cash, care and HIV-prevention for adolescent girls Latest evidence from southern africa L Cluver, M Orkin, M Boyes, L Sherr, F Meinck, A Yakubovich, E Toska, R Hodes, with the team C Ward, L Button, S Hoeksma, A Redfern, S De Stone, N Salah, M Isaacsohn, J Lachman, M Pantelic, J Steinert, J Sandelson, R Herrero Romero, Y Shenderovich, L Parmley. STRIVE, March 2015

2 COLLABORATIVE RESEARCH FOR POLICY Childfocused research Universities: Oxford, UCT, Wits, Curtin, UKZN

3 HIV-AFFECTED ADOLESCENTS World s first community survey of HIV-positive adolescents World s largest study of children in AIDS-affected families Free child abuse prevention programmes for families in the developing world

4 NATIONAL LONGITUDINAL STUDY OF ADOLESCENTS 6,850 adolescents, 2,500 adult caregivers, 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 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 referrals Controlling for prior HIV risk

5 EFFECTS OF ABUSE, POVERTY & PARENTAL AIDS ON FEMALE ADOLESCENT RISK OF TRANSACTIONAL SEX 57% Cluver, Orkin, Boyes, Meinck, Makhasi (2011). JAIDS 1% 7% 13% Healthy family AIDS-sick parent Abused & hungry AIDS-sick parent, abused, hungry

6 STRIVE: STRUCTURAL DRIVERS OF HIV

7 PROOF OF CONCEPT: CASH INCENTIVES

8 UNCONDITIONAL CASH TRANSFERS: RANDOMISED TRIAL

9 NATIONAL PROGRAMMING IN SOUTH AFRICA: CHILD GRANT REDUCES INCIDENCE OF TRANSACTIONAL SEX AND AGE- DISPARATE SEX FOR GIRLS % Incidence of transactional sex (OR.49 CI *) years years No cash transfer Child cash transfer % Incidence of age-disparate sex (OR.29 CI **) years years Cluver, Boyes, Orkin, Pantelic, Molwena, Sherr (2013). The Lancet Global Health.

10 KENYA NATIONAL PROGRAMMING: OVC CASH TRANSFER DELAYS SEXUAL DEBUT & REDUCES PREGNANCY FOR ADOLESCENTS (ODDS RATIOS) All Females Delayed Debut Never pregnant No depressive Symptoms Hope Scale<Median School Enrollment Handa, Halpern, Pettifor, Thirmurthy (2014) PLOS One.

11 Impacts on educational outcomes and indirect effects on prevention Direct impacts reducing a range of risky behaviours - Drug abuse - Alcohol use - Youth sexual activity Samson et al (2012) UNICEF and DSD.

12 CAN CASH + CARE REDUCE HIV RISK BEHAVIOR? BEHAVIORAL HIV-RISK INCIDENCE: CASH Transactional sex Age-disparate sex CARE Sex using alcohol/drugs Multiple partners Unprotected sex

13 THE WILSON VALIDITY CHECK HIV-risk behavior Link to pregnancy Link to HIV-incidence Transactional sex OR 11.0 CI HIV+ OR 19.2 Meta-analysis Watts et al 2015 Age-disparate sex OR 5.7 CI HIV+ OR 7.8 Meta-analysis (abstract) Akileswaran 2006 [Tanser 2011 no link] Sex using alcohol/drugs OR 5.1 CI Meta-analysis Woolfe-King et al 2013 Multiple partners OR 3.8 CI HIV+ OR 14.8 Tanser 2011 yes, but not concurrency Unprotected sex OR 11.6 CI HIV+ OR 17.9 Meta-analysis Drake 2014

14 Child-focused grant Food garden Positive parenting Regular food parcels School counsellor Free school meals Teacher support

15 % ADOLESCENTS INCIDENCE OF 1+ HIV RISK BEHAVIOR: CASH PLUS CARE = HALVED RISK % Cash alone: OR.63 Cash plus care: OR.55 42% Cash alone: no effect Cash plus care: OR % 30 25% 20 15% 17% 10 0 no support cash cash plus care Cluver, Orkin, Boyes, Sherr (2014). AIDS. no support cash cash plus care Controlling for: family HIV/AIDS, informal/formal housing, age of child, poverty levels, number of moves of home, baseline HIV risk behaviour

16 PREDICTORS OF ADOLESCENT HIV-RISKS 2011 Structural deprivation Hunger Community violence Parental HIV/AIDS Informal settlement all p< HIV-risk behavior incidence Transactional sex Age-disparate sex Sex using substances Multiple partners Unprotected sex Pregnancy Cluver, Orkin, Meinck, Boyes, Sherr controlling for: baseline HIV-risk, age, gender

17 school dropout child abuse conduct problems psychological distress drug/alcohol use Structural deprivation Psychosocial problems p<.004 HIV-risk behavior incidence controlling for: baseline HIV-risk, age, gender

18 GIRLS: STARVING SEX INCIDENCE (longitudinal, 60% of HIV-risk behavior explained) CARE (pos parenting, monitoring, teacher support CASH (child grant, pension, food garden) High vulnerability (AIDS-affected, informal housing, domestic violence in home etc) Psychosocial risks (depression, suicidality, abuse) Starving Sex (transactional, age-disparate) Cluver, Orkin, Meinck, Boyes, Sherr CLASSROOM (free school & books, school feeding) controlling for: age, baseline HIV-risk

19 GIRLS: CARELESS SEX INCIDENCE (longitudinal, 44% of HIV-risk behavior explained) CARE (pos parenting, monitoring, teacher support CASH (child grant, pension, food garden) Psychosocial risks (depression, suicidality, abuse) High vulnerability (AIDS-affected, informal housing, violent areas etc) Stupid Sex (unprotected, multiple partners, alcohol/drugs) Cluver, Orkin, Meinck, Boyes, Sherr CLASSROOM (free school & books, school feeding) controlling for: age, baseline HIV-risk

20 WHAT DO POLICY-MAKERS WANT TO KNOW? Which types of social protection work best? Can a social protection that doesn t work alone become effective when combined with another? (integrated effects) Does adding two or more social protection interventions work better than one? (cumulative effects) How much will it cost and where will we find the money?

21 SPECIFIC COMBINATIONS FOR HIV-PREVENTION with odds ratios, in multivariate logistic regression Males Careless sex Females CommodityCareless sex sex Commodity sex Cash Child Grants 0.48 Classroom Care School feeding 0.61 Free school & books Monitoring Teacher support Cluver, Orkin, Yakubovich

22 COMBINATIONS: ADDITIVE EFFECTS % probability 30 MALES: % PROBABILITY INCIDENCE OF CARELESS SEX (modelled marginal effects using multivariate logistic regression coefficients) No interventions Free school Good monitoring Teacher support Free school + monitoring Free school + teacher support Monitoring + teacher support All interventions Cluver, Orkin, Yakubovich

23 COMBINATIONS: ADDITIVE EFFECTS % probability FEMALES: % PROBABILITY OF INCIDENCE OF CARELESS SEX HIV-RISKS 25 (modeled marginal effects using multivariate logistic regression coefficients) No intervention Good monitoring School feeding Both interventions Cluver, Orkin, Yakubovich

24 COMBINATIONS: ADDITIVE EFFECTS % probability FEMALES: % PROBABILITY OF INCIDENCE OF ECONOMIC SEX HIV- RISKS (modeled marginal effects using multivariate logistic regression coefficients) No intervention Child grant Free school Both interventions Cluver, Orkin, Yakubovich

25 COMBINATIONS: ADDITIVE EFFECTS % probability 9 8 FEMALES: % PROBABILITY OF INCIDENCE OF PREGNANCY (modeled marginal effects using multivariate logistic regression coefficients) No interventions Monitoring Free school School feeding Monitoring + free school Monitoring + school feeding Free school + school feeding All interventions Cluver, Orkin, Yakubovich

26 ADOLESCENT ART-ADHERENCE AND HIV-PREVENTION Eastern Cape South Africa, 39 state health facilities N=700 (+200) HIV+ adolescents Every teen who ever started on ART Community tracing: including lost-to-follow-up Standardized interviews; Biomarkers (VL/CD4) PAST-WEEK NON-ADHERENCE TO ART: 36% (SELF-REPORT) ADHERENT NON-ADHERENCT Symptom validation: significantly associated* Shingles (p<.03) Bodily sores (p<.01) Mouth ulcers (p<.01) Diarrhea (p<.001) TB symptoms (p<.03) *MV logistic regression Cluver, Orkin, Sherr, Meinck

27 PREDICTORS OF NON-ADHERENCE (SEPARATE LOGISTIC REGRESSION CONTROLLING FOR SOCIODEMOGRAPHICS, THEN MODELLED PERCENTAGE PROBABILITIES) Medication side-effects OR (95% CI) 2.1 ( ) Hunger 2.2 ( ) Abuse 2.1 ( ) Domestic violence 2.1 ( ) Depression 1.7 ( ) Attention deficit 1.6 ( ) Behavioral problems 1.5 ( ) Cluver, Orkin, Sherr, Meinck no risk factors % adolescents non-adherent hunger hunger + side-effects 44 hunger, sideeffects, attention deficit27

28 CUMULATIVE ADHERENCE-PROMOTING INPUTS (SEPARATE LOGISTIC REGRESSION CONTROLLING FOR SOCIODEMOGRAPHICS, THEN MODELLED PERCENTAGE PROBABILITIES) Free school meals OR (95% CI).65 ( ) % adolescents non-adherent: Parental monitoring.63 ( ) High social support.63 ( ) Cluver, Orkin, Sherr, Meinck No intervention School feeding Social Support School Feeding and social support 28

29 FREE, NGO-LED, EVIDENCE-BASED PARENTING PROGRAMS Sinovuyo Teen/Parenting for Lifelong Health Aims: Reduce child abuse, improve parenting and monitoring Local NGO staff, no materials Free: Creative Commons WHO and UNICEF: scale-up to other countries 2012 Qualitative 2013 Pre-post test N= Pre-post test N= Cluster RCT N=1000, 1 year follow-up

30 Physical abuse p<.001 Emotional Abuse p<.001/ Pre Post Pre Post Caregiver Teen Positive Parenting p<.001/<.01 Poor monitoring p<.002/<.04) Pre Post Caregiver Teen

31 STRIVE: REMME, WATTS et al: CROSS-SECTORAL CBA Net intervention costs US$ 74,284 Implementation costs US$ 110,250 HIV treatment savings US$ 35,966 Net intervention benefits US$ 478,373 HIV infections and DALYs averted US$ 83,600 Long-term benefits to education and health (excl. HIV) US$ 384,773 Benefit-cost ratio (overall) 6.4 HIV only 1.3 Health and education only 3.5 Net Benefit US$ 404,088 Financing decision: Worth funding

32 REMME, WATTS et al: CO-FINANCING AND AFFORDABILITY IN MALAWI (Sub-) Sector National scale (million US$) National sector budget (million US$) 2011/12 HIV Health Donor disbursements (million US$) 2010/11 Average size of donor projects (million US$) 2010/ Education Total 3.2 (national programme) 1,980 (national budget) 1,022 (overall) 2.3 (overall) Relative contributions for a national-scale scheme appear quite affordable (1.2% HIV, 0.9% health, 0.6% education national budgets) (Source: GoM Budget Statement 2011/12, MoF Aid Atlas 2010/11) (Remme et al, AIDS, 2014)

33 Funders: thank you.

34 EVIDENCE SUMMARY Unconditional cash reduces adolescent HIV risks Cash + care + classroom = greater effects Cash + care + classroom buffer structural risk Cumulative impacts of 2+ interventions Effective in real-world sub-saharan Africa

35 I would like to advice the government to issue grants and support. And see how the impact it could create in the life of many youngsters. How it can better their decision and destiny. Take it from me I am the living difference. Noxolo, 19 yrs. UNAIDS PCB.