Adolescents, social protection and HIV in South Africa


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A presentation given at the Sixth RENEWAL Regional Workshop: A decade of work on HIV, food and nutrition security. By Rhian Twine

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  • Poverty and its associated consequences erode the opportunities for youth to attend school, creating a vicious cycle of destitution by undermining the household’s capacity to accumulate the human capital necessary to break the cycle of poverty.
  • Adolescents, social protection and HIV in South Africa

    1. 1. Effects of (conditional) cash transfer and community mobilization for prevention of HIV in young South African women (Swa Koteka study) Rhian Twine: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) Principal Investigators: Audrey Pettifor: UNC; Catherine MacPhail: RHRU; Kathleen Kahn: Wits SPH Project Manager: Mandie Selin UNC
    2. 2. 15 Males Females 16 17 18 19 20 21 22 23 24 HIV Prevalence by Age and Gender among South African youth age 15-24 years Pettifor A, et al. AIDS 2005, 19: 1525-1534.
    3. 3. Prevention Packages are needed <ul><li>Young South African women do not report engaging in excessive “high risk” sexual activity </li></ul><ul><li>Young women are put at risk through multiple risk factors </li></ul><ul><ul><li>Poverty </li></ul></ul><ul><ul><li>Social norms </li></ul></ul><ul><ul><li>Education </li></ul></ul><ul><li>Interventions addressing structural risk factors are lacking </li></ul><ul><li>Swa Koteka (We have goals) aims to address these key risk factors </li></ul>
    4. 4. School attendance reduces vulnerability <ul><li>Young women NOT attending school 4 times more likely to be HIV infected compared to those who DO attend school (Pettifor et al, 2008) (no protective factor shown for young men) </li></ul><ul><li>More education in young women: </li></ul><ul><ul><li>Delay coital debut </li></ul></ul><ul><ul><li>Use condoms more often </li></ul></ul><ul><ul><li>Delay marriage and childbearing </li></ul></ul><ul><ul><li>Hargreaves et al (2008) showed protective association between higher education and HIV infection (not many longitudinal studies) </li></ul></ul>
    5. 5. Barriers to Education <ul><ul><li>- Cost - 65% of young people who were not in school indicated that they did not have enough money to continue their education. </li></ul></ul><ul><ul><li>- 30% of girls who were not in school indicated that they left school due to pregnancy </li></ul></ul><ul><ul><ul><ul><ul><li>- Family commitments the reason for not attending school by 9% of non-school attending females, as opposed to <1% of non-attending males </li></ul></ul></ul></ul></ul>Samson et al, 2004
    6. 6. Lets keep them in school
    7. 7. Conditional cash transfers to keep young women in school <ul><li>In South Africa </li></ul><ul><li>Children in households receiving social welfare grants more likely to attend school </li></ul><ul><li>Effects are greater for young women than young men (Samson 2004) </li></ul>
    8. 8. Conditional Cash Transfers increase school attendance <ul><li>In Mexico </li></ul><ul><li>The Progresa/Oportunidades program, which provides conditional cash transfers to poor families to send their children to school, has found that the program increases school enrollment, particularly for girls (Schultz T. IFPRI 2000) </li></ul><ul><li>Evaluations also find positive impacts on girls school enrollment and/or attendance at primary and/or secondary levels in Nicaragua, Ecuador, Colombia, Brazil, Jamaica, Bangladesh, Cambodia, Turkey, and Pakistan (Adato and Bassett 2008) </li></ul>06/16/11
    9. 9. Male partners are also key <ul><li>Reducing economic barriers to education may reduce young women’s risk of HIV BUT </li></ul><ul><li>High risk social environments </li></ul><ul><li>Men control conditions of sexual relationships </li></ul><ul><li>Community mobilisation for HIV prevention </li></ul><ul><li>has demonstrated promise in changing social norms and improving sexual behaviors </li></ul><ul><li>Can create supportive environments that reduce women’s HIV risk </li></ul>
    10. 11. Purpose of Swa Koteka <ul><li>Determine whether cash transfers, conditional on school attendance, given to young women and their households reduces the young women’s risk of HIV infection </li></ul>Goal Reduce structural barriers to school thus increasing school attendance thereby reducing HIV risk
    11. 12. Key questions <ul><li>Do young women who receive cash transfers conditional on school attendance have a relatively lower incidence of HIV infection? </li></ul><ul><li>Do young people receiving mobilization intervention focused on young men demonstrate positive changes in gender norms? </li></ul><ul><li>  </li></ul>
    12. 13. Study Design <ul><li>Multi-level randomised control trial </li></ul>Mob Yes Mob No Cash Yes Cash+ Mob Mob Only Cash No Cash only No intervention
    13. 14. Cash Transfer <ul><li>Randomize 2900 HIV negative girls – 1450 to get monthly cash transfer payment conditional on 80% school attendance </li></ul><ul><ul><li>Girls 14-20 in grades 8-11 in Jan 2011 </li></ul></ul><ul><ul><li>Monthly cash transfer to female household head (R200/US$26) and girl (R100/US$13) -similar to SA child support grant </li></ul></ul><ul><ul><li>Total intervention time 3 years </li></ul></ul><ul><ul><li>Assessments at baseline, 12, 24 and 36 months </li></ul></ul>
    14. 15. Mobilization <ul><li>Randomize 24 villages – 12 get community mobilization from Sonke Gender Justice </li></ul><ul><ul><li>Target men 18-25 </li></ul></ul><ul><ul><li>Outreach activities aim to: </li></ul></ul><ul><ul><ul><li>mobilize the intervention communities </li></ul></ul></ul><ul><ul><ul><li>change gender norms and sexual behaviors that place young women and men at risk of HIV infection. </li></ul></ul></ul><ul><ul><li>Intervention activities will occur for 3 years </li></ul></ul><ul><ul><li>Baseline and post intervention survey </li></ul></ul><ul><ul><li>Qualitative data collection throughout </li></ul></ul>
    15. 16. Important end points <ul><li>Primary </li></ul><ul><li>HIV status </li></ul><ul><li>Secondary </li></ul><ul><li>HSV 2 (herpes) status </li></ul><ul><li>less unprotected sex </li></ul><ul><li>younger male partners </li></ul><ul><li>an older age of coital debut </li></ul><ul><li>a lower incidence of self-reported pregnancy and </li></ul><ul><li>greater school attendance </li></ul><ul><li>Other key measures </li></ul><ul><li>SES (World Bank LSMS), HIV knowledge, sexual history and relationships, education history, finance consumption, social networks….. </li></ul>
    16. 17. Study Schema
    17. 18. Study Site Agincourt sub-district Bushbuckridge Municipality Mpumalanga Province 24 villages Agincourt Health and socio- Demographic Surveillance Site (AHDSS) since 1992 – sample from database
    18. 19. Child enrollment in various levels of school, ages 14-20, Agincourt HDSS, 2009
    19. 20. Current status <ul><li>HIV Prevention Trial Network (HPTN) funded – HPTN 068 (NIH) </li></ul><ul><li>Ethical approval in process from Wits and UNC </li></ul><ul><li>Ethical approval and discussion with Departments of Education, Health and Social Security (National and Mpumalanga) </li></ul>
    20. 21. Current status (cont) <ul><li>Formative work being analysed/published (partly funded by RENEWAL) </li></ul><ul><ul><ul><li>School survey </li></ul></ul></ul><ul><ul><ul><li>FGDs with young women and teachers </li></ul></ul></ul><ul><ul><ul><li>Hope scale development </li></ul></ul></ul><ul><ul><ul><li>Pilot of young woman and household questionnaire using Audio- computer assisted self interview (ACASI) and Computer assisted personal interviewing (CAPI) </li></ul></ul></ul><ul><ul><ul><li>Repilot of young woman questionnaire </li></ul></ul></ul><ul><ul><ul><li>Pilot of community mobilisation questionnaire (ongoing) </li></ul></ul></ul>
    21. 22. Current status (cont) <ul><ul><ul><li>Loads of work on lab, SOPs, staffing, procurement, field work planning, training.. whew…… </li></ul></ul></ul><ul><ul><ul><li>Working with Sonke Gender Justice on community mobilisation curriculum </li></ul></ul></ul>
    22. 23. And then? <ul><li>If conditional cash transfers reduce HIV infection risk (not mitigate the effects) – can they be upscaled throughout SA? </li></ul><ul><li>SA already provides grants to over 5 million people </li></ul><ul><li>Conditionality is in policy, but not implemented </li></ul><ul><li>Will government consider conditionality </li></ul>
    23. 24. Swa Koteka Team <ul><li>Study Investigators </li></ul><ul><li>Audrey Pettifor (UNC- PI) </li></ul><ul><li>Catherine MacPhail (RHRU-Site PI) </li></ul><ul><li>Kathleen Kahn (AHPU)- Site PI </li></ul><ul><li>UNC </li></ul><ul><li>Suzanne Maman </li></ul><ul><li>Suchindran Chirayath </li></ul><ul><li>Harsha Thirumurthy </li></ul><ul><li>Sudhanshu Handa </li></ul><ul><li>Amanda Selin </li></ul><ul><li>Mary Jane Hill </li></ul><ul><li>Laurie Abler </li></ul><ul><li>AHPU </li></ul><ul><li>Rhian Twine </li></ul><ul><li>Paul Mee </li></ul><ul><li>Xavier Gomez-Oliver </li></ul><ul><li>Steve Tollman </li></ul><ul><li>Mark Collinson </li></ul><ul><li>RHRU </li></ul><ul><li>Helen Rees </li></ul><ul><li>LSHTM </li></ul><ul><li>James Hargreaves </li></ul><ul><li>UCSF </li></ul><ul><li>Sheri Lippman </li></ul><ul><li>IFPRI/RENEWAL </li></ul><ul><li>Michelle Adato (moved to a new org but still involved) </li></ul><ul><li>CORE/FHI </li></ul><ul><li>Deborah Hilgenberg </li></ul><ul><li>DAIDS </li></ul><ul><li>Sheryl Zwerski </li></ul>NIH Susannah Allison DMC/SCHARP Jim Hughes Lynda Emel Network Laboratory Susan H. Eshleman LeTanya Johnson-Lewis