EVIDENCE-BASED SOCIAL PROTECTION INTERVENTIONS FOR HIV PREVENTION GLOBAL PERSPECTIVES ON ECONOMIC STRENGTHENING & ADOLESCENT HEALTH & EDUCATION IN SUB-SAHARAN AFRICA MAY 12, 2016 COLUMBIA UNIVERSITY JASON WOLFE, USAID OFFICE OF HIV/AIDS 1
$385 million partnership PEPFAR, Gates Foundation, Girl Effect, Johnson & Johnson, Viiv Healthcare, & Gilead Sciences Reduce new HIV infections by 40% among adolescent girls and young women aged 15-24 10 high-burden countries in Africa Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia & Zimbabwe 2
DREAMS CONCEPT social asset building Segmented high-risk subpopulations in high-burden areas using best available data Social ecological model Layered package of highly effective evidence-based and age-appropriate interventions Rapid scale up to achieve saturated coverage treatment & circumcision reduce risk of SEX PARTNERS empower GIRLS & YOUNG WOMEN and reduce risk school-based interventions mobilize COMMUNITIES for change strengthen FAMILIES parenting/ caregiver programs 3
SOCIAL PROTECTION IN DREAMS Address structural drivers of HIV risk behavior, especially education Targeting both families and individuals as direct beneficiaries Illustrative interventions: Education support Cash transfers Economic strengthening Required more intensive review and interpretation of evidence 4
EVIDENCE REVIEW Outcomes of interest: Biological A. High quality evidence B. Moderate quality evidence C. Low quality evidence Behavioral Violence 1. Consistently showed effectiveness Scoring criteria: Mavedzenge et al 2014 Evidence of effectiveness Quality of evidence 2. Largely but not consistently showed effectiveness 3. Mixed beneficial and ineffective or harmful results 4. Consistent ineffective or harmful results 5
SUMMARY OF LITERATURE REVIEWED (1/4) * p 0.10 ** p 0.05 *** p 0.01 p-values not reported Study/Location Population/Setting Design Sample Intervention(s) Outcome(s) Effect(s) Baird et al 2012 Malawi Bandiera et al 2012 Uganda Björkman-Nyqvist et al 2013 Lesotho H. Cho et al 2011 Kenya Y. Cho et al 2013 Malawi Females aged 13-22 School Females (avg age 16) aged 18-30 aged 12-14 School aged 15-24 (avg 21) crct 1,289 in 176 clusters crct reported statistics from ITT analysis 4,888 in 150 communities UCT CCT schooling Vocational training + life skills RCT 3,426 CCT STI status (lottery) crct 105 in 79 households School support + UCT (1) HIV prevalence (2) HSV-2 prevalence (1) HIV knowledge (2) Childbearing (3) Condom use (4) Unwilling sex (1) HIV incidence (females + males) (2) HIV incidence (females only) (3) HIV incidence (high-value transfer) (1) School dropout (2) Sexual debut RCT 1,900 Vocational training (1) Condom use (f) (2) Childbearing (f) (1) aor 0.36 CI 0.14-0.91** (2) aor 0.24 CI 0.09-0.65** (1) β 0.465*** (2) rel 25.7%** (3) rel 24.5%** (4) rel -83.4%*** (1) OR 0.75 CI 0.58-0.97 (2) OR 0.67 CI 0.52-0.86 (3) OR 0.69 CI 0.50-0.98 (1) abs -8%** (2) abs -14%* (1) abs 1.8% SE 5.9% (2) abs -7.0% SE 4.2%* 6
SUMMARY OF LITERATURE REVIEWED (2/4) Study/Location Population/Setting Design Sample Intervention(s) Outcome(s) Effect(s) Cluver et al 2013 Females aged 12-18 South Africa DSD, SASSA, and UNICEF 2012 South Africa Duflo et al 2006 Kenya Dunbar et al 2010 Zimbabwe Dunbar et al (in press) cited in Gibbs et al 2012 Zimbabwe aged 15-17 in grade 6 (avg age 14) School Females aged 16-19 Females (avg age 18) Case- Control PSM Cross-sectional PSM crct Pre/posttest with no comparison reported statistics and p-values are indicative only 247 UCT (1) Transactional sex (2) Age-disparate sex (3) Unprotected sex (4) Multiple partners (5) Sex under the influence of alcohol/drugs 1,726 UCT (1) Never had sex (f) (2) Sexual partners (f) (3) Pregnancy (f) (4) Alcohol use (f) (5) Drug use (f) 70,000 in 328 schools 49 Microcredit + life skills RCT 315 UCT + life skills + vocational training (1) OR 0.49 CI 0.26-0.93** (2) OR 0.29 CI 0.13-0.67*** (3)(4)(5) No effect School support Childbearing (f) abs -1.5%* rel -10%* (1) HIV knowledge (2) Relationship power (3) Current sexual activity (4) Condom use (1) Food security (2) Equitable gender norms (3) Physical and sexual violence * p 0.10 ** p 0.05 *** p 0.01 p-values not reported (1) abs 15.7% SE 7.2%, t-ratio 2.18 (2)(3)(4)(5) No significant average effect but doseresponse analysis shows consistently positive relationships, especially for females (1) Increase (abs 22%***) (2) Slight increase (3) No effect (4) No effect Potential increase in HIV risk exposure reported (1) Decrease (2) Increase (3) Decrease by 58% 7
SUMMARY OF LITERATURE REVIEWED (3/4) Study/Location Population/Setting Design Sample Intervention(s) Outcome(s) Effect(s) Erulkar and Chong 2005 Kenya Females Pre/posttest with matched comparison 222 Microfinance + discussion groups + mentoring Ability to insist on condom use abs 4.9%*** Gupta et al 2013 Côte d Ivoire Hallfors et al 2011 Zimbabwe Handa et al 2014 Kenya Females aged 18+ (avg 37) Females aged 10-16 School aged 15-25 RCT 934 VSLA + discussion groups (control = VSLA-only) crct 329 in 25 schools crct posttest only for sexual behaviors 1,443 in 28 clusters (553 females) (1) Economic abuse (2) Justification for wife-beating (3) Physical IPV (4) Sexual IPV (5) Ability to refuse sex School support School dropout aor 8.48 CI 3.6-19.8*** UCT (1) Vaginal intercourse (f) (2) Condom at last sex (f) (3) Transactional sex (f) (4) Multiple partners (f) (5) Unprotected sex in last 3 months (f) * p 0.10 ** p 0.05 *** p 0.01 p-values not reported (1) OR 0.39 CI 0.25-0.60*** (2) β -0.97 CI -1.66 - -0.28*** (3) OR 0.45 (high-adherent groups) CI 0.21-0.94** (4) OR 0.54 (high-adherent groups) CI 0.27-1.10 (5) β 0.10 CI -0.19-0.39 (1) OR 0.58 CI 0.38-0.87*** (2) OR 1.33 CI 0.70-2.51 (3) OR 0.98 CI 0.44-2.19 (4) OR 0.20 CI 0.04-0.94** (5) OR 0.65 CI 0.22-1.93 8
SUMMARY OF LITERATURE REVIEWED (4/4) Study/Location Population/Setting Design Sample Intervention(s) Outcome(s) Effect(s) Jewkes et al 2014 South Africa Kohler and Thornton 2012 Malawi Pronyk et al 2006 South Africa Rotheram-Borus et al 2012 Uganda Ssewamala et al 2010 Uganda Thornton 2008 Malawi Walque et al 2012 Tanzania aged 18-34 and out of school aged 16-75 Females (avg age 41) aged 13-23 in grades 6-7 (avg age 13.7) School aged 15+ aged 18-30 Pre/posttest: interrupted time series (2 baseline + 2 follow-up no control/ comparison) 232 Stepping Stones + economic empowerment (skills training; no cash/ material transfer) RCT 1,307 CCT maintain HIV status crct 860 Microcredit + discussion groups RCT 100 Vocational training + life skills crct 260 in 15 schools Matched savings + school support RCT 2,812 CCT learn HIV status (1) Gender attitudes scale (2) Relationship control scale (3) Physical IPV in last 3 months (4) Sexual IPV in last 3 months (5) Condom use at last sex (6) Transaction sex in last month (1) HIV incidence (2) Condom use (f) (3) Condom use (m) (4) Risky sex (f) (5) Risky sex (m) (1) *** (f), *** (m) (2) no effect (f), *** (m) (3) no effect (f), no effect (m) (4) ** (f), no effect (m) (5) no effect (f), no effect (m) (6) no effect (f), no effect (m) (1) no effect (2) no effect (3) abs 5.2%* (4) abs -6.7%* (5) abs 9.0%** IPV in past 12 months arr 0.45 CI 0.23-0.91 (1) Number of sexual partners (2) Condom use * p 0.10 ** p 0.05 *** p 0.01 p-values not reported (1) Decrease (2) Increase Intention to engage in risky sex β -1.64 CI -2.92 - -0.35** Learning HIV test results abs 43%*** RCT 2,399 CCT STI status STI incidence arr 0.73 (high-value transfer) CI 0.47-0.99** 9
CASH TRANSFERS overview of outcomes by intervention BIOLOGICAL OUTCOMES Experimental Quasi-experimental HIV Transmission HIV incidence CCT (STI status) HIV prevalence UCT, CCT (schooling) STI Transmission HSV prevalence UCT, CCT (schooling) STI incidence CCT (STI status) BEHAVIORAL OUTCOMES Experimental Quasi-experimental Condom Use Condom use CCT (maintain HIV status) HIV Testing Learning HIV results CCT (learn HIV status) Risky Sex Age-disparate sex UCT Multiple partners UCT Risky sex CCT (maintain HIV status) Transactional sex Sexual Activity Childbearing School support Ever had sex Sexual debut UCT, school support UCT UCT 10
ECONOMIC STRENGTHENING overview of outcomes by intervention BEHAVIORAL OUTCOMES Experimental Quasi-experimental Condom Use Condom use Vocational training Microfinance Risky Sex Age-disparate sex Intentions to engage in risky sex Microfinance Multiple partners Vocational training Transactional sex Sexual Activity Childbearing Vocational training VIOLENCE OUTCOMES Experimental Quasi-experimental Intimate Partner Violence IPV in past 12 months Microfinance Physical IPV Unwilling sex Other Violence and Abuse Economic abuse Microfinance Justification for wife-beating 11
COMBINATION APPROACHES overview of outcomes by intervention BEHAVIORAL OUTCOMES Experimental Quasi-experimental Condom Use Condom use Vocational training + life skills Microfinance + discussion groups + mentoring Risky Sex Age-disparate sex Cash + care Intentions to engage in risky sex Multiple partners Transactional sex Matched savings + mentoring Vocational training + life skills Sexual Activity Childbearing Vocational training + life skills Cash + care VIOLENCE OUTCOMES Experimental Quasi-experimental Intimate Partner Violence IPV in past 12 months Microfinance + Physical IPV discussion groups Unwilling sex Other Violence and Abuse Economic abuse Microfinance + Justification for wife-beating discussion groups 12
EVIDENCE EVALUATION CASH TRANSFERS Biological Outcomes Behavioral Outcomes Violence Outcomes UCT CCT (schooling) Included in DREAMS Core Package CCT (STIs) ECONOMIC STRENGTHENING Credit-based Income-based Savings-based Combo approaches 13
Thank you! Jason Wolfe, Senior Technical Advisor USAID Office of HIV/AIDS jwolfe@usaid.gov (571) 451-4341 14