Conditional cash transfers had no effect on HIV in high school attendance setting

The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial.

Pettifor A, MacPhail C, Hughes JP, Selin A, Wang J, Gomez-Olive FX, Eshleman SH, Wagner RG, Mabuza W, Khoza N, Suchindran C, Mokoena I, Twine R, Andrew P, Townley E, Laeyendecker O, Agyei Y, Tollman S, Kahn K. Lancet Glob Health. 2016 Dec;4(12):e978-e988. doi: 10.1016/S2214-109X(16)30253-4. Epub 2016 Nov 1.

Background: Cash transfers have been proposed as an intervention to reduce HIV-infection risk for young women in sub-Saharan Africa. However, scarce evidence is available about their effect on reducing HIV acquisition. We aimed to assess the effect of a conditional cash transfer on HIV incidence among young women in rural South Africa.

Methods: We did a phase 3, randomised controlled trial (HPTN 068) in the rural Bushbuckridge subdistrict in Mpumalanga province, South Africa. We included girls aged 13-20 years if they were enrolled in school grades 8-11, not married or pregnant, able to read, they and their parent or guardian both had the necessary documentation necessary to open a bank account, and were residing in the study area and intending to remain until trial completion. Young women (and their parents or guardians) were randomly assigned (1:1), by use of numbered sealed envelopes containing a randomisation assignment card which were numerically ordered with block randomisation, to receive a monthly cash transfer conditional on school attendance (≥80% of school days per month) versus no cash transfer. Participants completed an Audio Computer-Assisted Self-Interview (ACASI), before test HIV counselling, HIV and herpes simplex virus (HSV)-2 testing, and post-test counselling at baseline, then at annual follow-up visits at 12, 24, and 36 months. Parents or guardians completed a Computer-Assisted Personal Interview at baseline and each follow-up visit. A stratified proportional hazards model was used in an intention-to-treat analysis of the primary outcome, HIV incidence, to compare the intervention and control groups. This study is registered at (NCT01233531).

Findings: Between March 5, 2011, and Dec 17, 2012, we recruited 10 134 young women and enrolled 2537 and their parents or guardians to receive a cash transfer programme (n=1225) or not (control group; n=1223). At baseline, the median age of girls was 15 years (IQR 14-17) and 672 (27%) had reported to have ever had sex. 107 incident HIV infections were recorded during the study: 59 cases in 3048 person-years in the intervention group and 48 cases in 2830 person-years in the control group. HIV incidence was not significantly different between those who received a cash transfer (1.94% per person-years) and those who did not (1.70% per person-years; hazard ratio 1.17, 95% CI 0.80-1.72, p=0.42).

Interpretation: Cash transfers conditional on school attendance did not reduce HIV incidence in young women. School attendance significantly reduced risk of HIV acquisition, irrespective of study group. Keeping girls in school is important to reduce their HIV-infection risk. 

Abstract  Full-text [free] access 

Editor’s notes: Cash transfers to vulnerable household and/or individuals have been used successfully in a variety of settings as a means to reduce poverty, improve health and achieve other development-associated outcomes. Cash transfers can help address structural drivers of HIV, such as economic and gender inequalities and low levels of education, and have been proposed as a potentially important addition to HIV prevention efforts. However, the evidence of their effectiveness in the context of HIV prevention is mixed. This study is the first randomized controlled trial to examine the effect of cash transfers conditional on school attendance with HIV incidence in adolescent girls and young women in sub-Saharan Africa. The trial found no evidence that receipt of the conditional cash transfer reduced HIV or HSV-2 incidence.

Staying in education has been highlighted as a key factor for reducing the risk of HIV infection in girls and young women. In this setting, school attendance based on attendance registers was high in both trial arms (95%). This is much higher than in South Africa overall, and higher than in Mpumalanga Province (the study area). Eligibility for the trial was restricted to girls and young women who were currently enrolled in school, so the trial participants may have been more motivated to attend school than those who were not eligible. Interestingly, 75% of individuals who were screened for the trial were found to be ineligible, although the reasons for their exclusion are not given, and it is difficult to know how generalizable the results are. South Africa has a strong social protection system for poor families, and 80% of the study participants were from households that were receiving child support grants. The benefits of additional cash transfers in areas with high coverage of social protection may be minimal. Cash transfers to girls and young women for HIV prevention are likely to have a greater effect in settings with low school attendance and more limited social protection coverage.

Consistent with other studies, the trial found that staying in school was associated with a reduced risk of HIV, irrespective of trial arm. The cash transfer was also associated with a strongly reduced risk of intimate partner violence, and a small effect on reducing some sexual risk behaviours. Cash transfers may work both directly and indirectly, through a variety of different pathways that are likely to vary between settings and between populations. The high-recorded school attendance in both trial arms will have limited the ability to examine education as a pathway through which the cash transfer may have influenced HIV risk. A better understanding of these pathways and how they are affected by the setting may help inform the conditions under which cash transfers may be an effective component of an HIV prevention programme.

South Africa
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