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Cash + Care: Transforming HIV outcomes for adolescents in Africa through social protection.

1. Summary of the impact

Since 2009, ground-breaking research by the University of Oxford has reduced HIV infection risks and improved health for 2,000,000 adolescents across Southern and Eastern Africa. Specifically, the research demonstrated that combinations of social welfare, cash transfers and caregiving support gave 50-70% reductions in HIV infection risk behaviours, such as transactional sex. This has been directly translated into policy and service delivery for adolescents by USAID-President’s Emergency Plan for AIDS Relief (PEPFAR), UNICEF, UNAIDS and national governments including South Africa, Kenya, Malawi, Mozambique, Zambia and Zimbabwe.

2. Underpinning research

Co-created with the South African government, UNICEF and the U.S. Agency for International Development (USAID) through their ‘President’s Emergency Plan for AIDS Relief’ (PEPFAR) programme, researchers within the department of Social Policy and Intervention at the University of Oxford, and their partner University of Cape Town, have led two studies with major impact on adolescent health in Africa. All studies and policy engagement have been co-developed with Adolescent Advisory Groups in South Africa, Kenya, Uganda and Sierra Leone.

The Young Carers Study: 2009-2013 (Cluver, Gardner, Meinck, and Dawes from University of Cape Town).

This Oxford-led study was conceptualised with the South African Minister of Social Development, Dr Zola Skweyiya, and co-created with UNICEF and PEPFAR-USAID. It followed 6,004 children and adolescents and 2,500 of their caregivers, between 2009-2012, using stratified random sampling and interviews in urban and rural sites within three South African provinces.

The research showed that regular, small poverty alleviation-focused cash transfers to families (the South African Child Support Grant) substantially reduced the risk of adolescent girls engaging in transactional and age-disparate sex: the region’s primary vector of HIV infection [R1]. Incidence rates of transactional sex were reduced by 50%, and age-disparate sex by 70%. Subsequent investigations showed that combining cash transfers with social or family support (‘Cash+Care’) increased HIV prevention across a wider range of sexual risk behaviours and across genders [R2]. Statistical modelling identified the key mechanisms of impact for these interventions, in terms of their role in interrupting pathways between structural deprivations, such as poverty and HIV, and family psychosocial problems, such as abuse and mental health distress, and later psychosocial problems and adolescent risk behaviours (Fig.1). Furthermore, combination Cash+Care provisions were found to have greater impacts than single provisions; for example, girls' annual incidence of unprotected, casual or intoxicated sex or multiple partners dropped from 15% with no interventions to 7% among those who received both school feeding (government-provided free lunch) schemes and good parental monitoring [R3].

Fig.1

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The Mzantsi Wakho (‘Our South Africa’) Study 2014-2019 (Cluver, Toska University of Cape Town).

This study, also Oxford-led, was conceptualised with the South African Deputy Director-General and Minister of Health, Dr Yogan Pillay and Minister Aaron Motsoeledi, and co-created with UNICEF Eastern and Southern Africa. It was a cohort survey of 1,000 adolescents living with HIV over four years, alongside 500 of their HIV-negative neighbours, with linked participatory work of adolescent input into policy.

The study focuses on a major risk for poor health: adolescent non-adherence to lifesaving antiretroviral medication, which results in mortality, morbidity, viral resistance and onwards HIV-transmission. It found that non-adherence – thought to be due to adolescent misbehaviour – was strongly associated with social factors, such as violence victimisation in the home, clinic and school . For HIV-infected adolescents, clinical factors were an important addition to social protection provisions, leading to ‘Cash + Clinic + Care’. For example, the combination of food provision, HIV support group access and good parenting reduced past-week antiretroviral non-adherence from 54% to 18%, and free schooling, non-shouting clinical staff and good parenting reduced unprotected sex from 49% to 8% [R4].

The research team worked with the South African Minister of Health, Dr Aaron Motsoaledi, to identify what could be done in the health sector, and found that retention in HIV care was increased from 3% to 70% through a combination of health service provisions (such as clinics with enough medication), cash (for transport to clinic), and care (such as being accompanied to clinic by a family member) [R5]. Later analyses have examined effects of Cash+Care social protection on a wider set of Sustainable Development Goal (SDG) outcomes [R6], finding cumulative impacts of safe schooling, good parenting and cash transfers across seven SDG targets within the goals of health (SDG 3), violence prevention (SDG 16), education (SDG 4) and gender equality (SDG 5) .

3. References to the research

R1. Cluver, L., Boyes, M., Orkin, M., Pantelic, M., Molwena, T., & Sherr, L. (2013). Child-focused state cash transfers and adolescent HIV-infection risks: A prospective multi-site study in South Africa. The Lancet: Global Health, 1(6), e362-e370. http://doi.org/10.1016/S2214-109X(13)70115-3 [output type D]

R2. Cluver, L., Orkin, M., Boyes, M., & Sherr, L. (2014). Cash plus care: Social protection cumulatively mitigates HIV-risk behaviour among adolescents in South Africa. AIDS, 28, S389-S397. PMID:24991912. http://doi.org/10.1097/QAD.0000000000000340 [output type D]

R3. Cluver, L., Orkin, M., Yakubovich, A., & Sherr, L. (2016). Combination social protection for reducing HIV-risk behaviour amongst adolescents in South Africa. JAIDS, 72(1), 96-104.

http://doi.org/10.1097/QAI.0000000000000938 [output type D]

R4. Toska, E., Cluver, L., Boyes, M., Isaacsohn, M., Hodes, R., & Sherr, L. (2017). School, supervision and adolescent-sensitive clinic care: Combination social protection and reduced unprotected sex among HIV-positive adolescents in South Africa’. Journal of AIDS and Behavior, 21(9), 2746-2759. https://doi.org/10.1007/s10461-016-1539-y [output type D]

R5. Cluver, L., Pantelic, M., Toska, E., Orkin, M., Casale, M., Bungane, N., & Sherr, L. (2018). STACKing the odds for adolescent survival: Health service factors associated with retention in care and adherence amongst adolescents living with HIV in South Africa. Journal of the International AIDS Society, 21, e25176. PMID:30240121.. http://doi.org/10.1002/jia2.25176 [output type D]

R6. Cluver, L., Orkin, M., Campeau, L., Toska, E., Sherr, L., Webb, D., & Carlqvist, A. (2019). Improving lives by accelerating progress towards the Sustainable Development Goals for adolescents living with HIV: A prospective analysis. The Lancet Child and Adolescent Health. 3: 245-54. https://doi.org/10.1016/S2352-4642(19)30033-1 [output type D]

This research has led to the recent award of a GBP18,500,000 by the UKRI Global Challenges Research Fund for an ‘Accelerating Achievement for Africa’s Adolescents Hub’ to identify combination services that can best improve multiple SDGs for adolescents across Africa. (February 2019 – May 2024, PI: Cluver)

4. Details of the impact

‘This research team have spearheaded novel research on cash transfers and in particular ‘Cash plus Care’ as a prevention measure for HIV/AIDS risk behaviour in adolescents…Since then, the concept has become an integral part of UN planning and response to the HIV epidemic…At every stage, this research has been a partnership between the academic team, myself and other colleagues within the UN, including UNICEF and the UN Development Programme. They have been successful in building long lasting partnerships with practitioners, policy makers and governmental departments that are having major societal impacts. This really is an example of collaboration to fight the HIV/AIDS epidemic.’ Senior Advisor, UNAIDS [E1].

Direct impacts on global UN guidance and South African national policy

The research has been used and cited in guidance by a range of UN agencies. For example, UNICEF recommend Cash+Care in their 2016 Call to Action [E2a] and 2016 UNICEF Children and AIDS Stocktaking report [E2b]. The United Nations Development Programme (UNDP) cite the research in their discussion brief on social protection; and UNAIDS have extensively cited the studies – for example in the 2016 UNAIDS Fast Track Report [E3a], the 2018 UNAIDS Global AIDS Update ‘Miles to Go’ [E3b], the 2019 UNAIDS Global AIDS Update ‘Communities at the Center’ [E3c], and the 2020 update ‘Seizing the Moment’ [E3d], all of which provide evidence to guide the global response to HIV/AIDS. The team have worked with the World Food Programme to jointly produce evidence-based guidance with their regional offices in Africa, which are used to support country-level programming [E4]. Cash+Care findings are cited in the 2020 World Health Organisation (WHO) Global Status Report on Violence against Children [E5].

The South African National Department of Health and the United Nations Population Fund (UNFPA) invited the research team to write the South African National Adolescent and Youth Health Policy 2017-2022, which was co-written with government colleagues, and with the research team’s Teen Advisory Group of HIV-affected adolescents [E6]. This policy was signed by the Minister of Health in 2017 and has also been used to train 90 senior Department of Health officials from all nine South African provinces. This training has been conducted annually with the research team, to support youth-focused national health services delivery. The Cash+Care findings have also been included and the research cited extensively in South Africa’s National HIV and TB Investment Case [E7], with Prof Cluver and Dr Toska on the South African National AIDS Council Steering Group (2017-2020).

In 2020, UNICEF asked Cluver, with Prof Lorraine Sherr (UCL), to lead the review of the impacts and response to the social impacts of COVID on children and adolescents. This was released as a major advocacy report on World Children’s Day, November 2020, to guide UNICEF and wider policy responses to the epidemic by using COVID-adapted combinations of Cash + Care [E2c].

Direct cash plus care services to reduce adolescent HIV risk

The findings regarding Cash+Care led to direct engagement with PEPFAR-USAID and the World Bank, with Cluver invited in 2014 to the Advisory Board of the US government’s USD1,000,000,000 flagship HIV-prevention programme ‘DREAMS’ (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) [E8b]. Cash+Care was identified as one of the required set of services for adolescents in the DREAMS guidance [E8a]. Cash+Care programmes have been delivered by a range of NGOs including Catholic Relief Services, Pact, Save the Children and World Education-Bantwana to 1,800,000 adolescent girls in 10 African countries (Eswatini, Kenya, Lesotho, Malawi, Mozambique, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe). This work has been cited in four reports to the U.S. Congress (2017, 2018, 2019, 2020 **[E8b]**).

The research team worked with PEPFAR-USAID to develop HIV-enhanced and sexual violence-enhanced versions of a Cash+Care programme that increased caregiver support to adolescents and reduced household hunger. This is currently being rolled out in Ethiopia, Botswana and South Sudan, and has been included in 2020 as one of only two approved caregiver-child programmes in the PEPFAR 2020 Country Operational Plan Guidance [E12, p.175]. Recent modelling showed significant declines in new HIV diagnoses of 25-40% amongst adolescent girls in the districts implementing DREAMS – including Cash + Care programmes - within ten African countries [E8b, E9 & E10].

In addition, Cash+Care services were delivered to 200,000 children and adolescents through UNICEF Eastern and Southern Africa Office country partners in four countries. Aidspan, the independent observer of the Global Fund, reported that from 2016 to 2018, the South African government with support from the Global Fund to end HIV/AIDS, TB and Malaria, delivered Cash+Care services to 30,000 young women [E11].

This research has won four prizes for impact, including the 2017 ESRC Outstanding International Impact Prize, the Philip Leverhulme Prize 2015, the 2018 UNICEF Women Leaders in the HIV response for Children recognition and the 2019 European Union Council Conference Social Sciences and Humanities Impact Award. Professor Cluver was included in UKRI’s 2019 15 ‘Women in Research and Innovation’

5. Sources to corroborate the impact

E1. Letter from the Senior Advisor Social Protection, UNAIDS, in support of ESRC Celebrating Impact Prize. Corroboration details entered into REF2021 system [Corroborator 1].

E2. UNICEF

  1. ‘Call to Action for All Children’ (2014). This launched, among other initiatives, the 90-90-90 targets aimed at rallying global efforts on HIV testing and treatment

  2. ‘For Every Child End AIDS: Seventh Stocktaking Report,2016’

  3. ‘Beyond Masks: Societal impacts of COVID-19 and accelerated solutions for children and adolescents’ (Nov. 2020)

E3. UNAIDS

  1. ‘Get on the Fast Track: The life-cycle approach to HIV’ (2016)

  2. ‘Miles to Go: Closing Gaps, Breaking Barriers, Righting Injustices’, Global AIDS Update (2018)

  3. ‘Communities at the Centre: Defending Rights, Breaking Barriers, Reaching people with HIV services’, Global AIDS Update (2019)

  4. ‘Seizing the Moment: Tackling entrenched inequalities to end epidemics, Global AIDS Update’ (2020)

E4. World Food Programme Policy Brief (Sept 2019), ‘Leaving No-One Behind’. Information about the team’s work with WFP can also be verified by Corroborator 2, Public Health and Social Protection Head, UN World Food Programme.

E5. World Health Organisation: Global Status Report on Preventing Violence Against Children (2020)

E6. South Africa National Adolescent and Youth Health Policy 2017-2022. Information about how the research has influenced this policy can also be verified by Corroborator 3, former Deputy-Director General for Heath, National Department of Health, South Africa.

E7. South African HIV and TB Investment Case (2016)

E8. PEPFAR

  1. DREAMS
  • Guidance

  • Evaluation of the DREAMS core package of interventions

  1. PEPFAR annual reports:
  • 2017, pp.73-4

  • 2018, p.96;

  • 2019, pp.48-9.

  • 2020, pp.52-3.

E9. US Department of State, ‘A look at PEPFAR’s latest HIV program results’, Speech from the 2020 AIDS Conference by the Deputy US AIDS Coordinator

E10. US Agency for International Development (USAID): DREAMS partnership to reduce HIV/AIDS in adolescent girls and young women

E11. - Aidspan article regarding USD314,500,000 in funding awarded March 2016 to TB/HIV grants for South Africa from the Global Fund

  • The Global Fund report (2017), p.31.

E12. PEPFAR 2020 Country Operational Plan – Guidance for all PEPFAR Countries (p.175)

Additional contextual information

Grant funding

Grant number Value of grant
ES/S008101/1 £18,531,197