Poverty, cash transfers, and risk behaviours
Authors: Stefano M Bertozzi, Juan-Pablo Gutiérrez
Journal: The Lancet Global Health (2013)

The paper by Lucie Cluver and colleagues in this month's issue of The Lancet Global Health1Cluver L Boyes M Orkin M Pantelic M Molwena T Sherr L Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study.Lancet Glob Health. 2013; 1: e362-e370Summary Full Text Full Text PDF Scopus (150) Google Scholar is an important piece of evidence in a sparsely populated field: rigorous evaluation of the impact of interventions that seek to modify the underlying structural determinants of HIV transmission. Almost since the beginning of the epidemic we have been hypothesising about the structural determinants of HIV transmission. Countless pages have been written about the effect of factors such as poverty, marginalisation, human rights abuses, and the status of women on the transmission of HIV. Improving any of those domains is good, in and of itself. We should not need an HIV justification to improve the status of women. Partly because of this sentiment, there has often been an implicit resistance to rigorous evaluation of the effect of structural interventions on HIV incidence: how could anyone be against improving the status of women? A woman who cannot control the circumstances under which she has sex will obviously be at higher risk of HIV infection, therefore why should we waste time and money measuring the impact on HIV of interventions to improve the status of women?As well as this implicit resistance, the difficulty of measurement has meant that there is very little convincing evidence of the effect of structural interventions on the incidence of HIV. Even Cluver and colleagues' study does not go all the way to measuring the effect on HIV incidence: it only measures the correlation between receiving cash transfers and sexual risk behaviour. However, as evidence grows of the effect of some interventions and, more importantly, the lack of effect of other interventions, it becomes increasingly clear that we have spent decades being foolish. By not looking rigorously at impact, we have not learned which interventions to fight poverty, human rights abuses, marginalisation, etc, also have an important effect on HIV and which ones do not. We have thus missed the opportunity to prioritise the interventions that have the greatest joint benefit.Cluver and colleagues' study suggests that unconditional anti-poverty cash transfers to poor households with children are likely to reduce two important types of risk behaviour by adolescent girls: transactional sex (sex for money or other material benefits) and age-disparate sex (sex with an older partner). That finding helps to illustrate the complex relation between poverty and risk behaviour. Previous studies have suggested that socioeconomic development can be associated with increased risk behaviour (people, especially men, have the means to purchase alcohol and drugs, to travel to places where they are more anonymous, and to purchase sex). Other studies have suggested that poverty, especially relative poverty, can also be associated with increased risk, both because of the opportunity to improve one's situation by selling sex or having sex with an older or wealthier partner (especially for women) or because wealth imbalances imply power imbalances that interfere with people's ability to reduce their risk by negotiating safer sex (especially for women). The results reported by Cluver and colleagues suggest that the poverty-related effects on women can be mitigated by cash transfers.Given these countervailing forces, it is certainly plausible that some poverty-alleviation programmes could increase risk behaviour (eg, cash transfers to poor young men) while others could decrease risk behaviour (eg, cash transfers to female heads-of-household or to poor adolescent girls). The findings from Cluver and colleagues' study are consistent with those of the evaluation of the impact of the Mexican Oportunidades programme—a conditional cash-transfer programme. In Mexico, the prevalence of transactional sex and age-disparate sex is significantly lower than in South Africa, but the programme reduced the age of sexual debut, marriage, and age of first child.2Andalón M Oportunidades to reduce overweight and obesity in Mexico?.Health Econ. 2011; 20: 1-18Crossref PubMed Scopus (15) Google Scholar, 3Gutierrez JP Youth risk behaviours as barriers for human (health) capital accumulation.http://ssrn.com/abstract=1982065Google Scholar An additional effect of Oportunidades was a reduction in the probability of having a sexually transmitted infection in male (but not female) adolescents, and also a reduction in smoking and alcohol consumption.3Gutierrez JP Youth risk behaviours as barriers for human (health) capital accumulation.http://ssrn.com/abstract=1982065Google Scholar The postulated increases in numbers of partners and in alcohol or drug use were not found. One potentially important reason for that is that the cash transfers are made to the female head-of-household, conditional on school attendance by the adolescent and that those conditions counteract the negative effects of additional resources on risk behaviours. The Malawi study led by Özler did not find a differential effect on risk behaviour dependent on whether or not the transfers to adolescents were conditional on school attendance, but that study only included adolescent girls.4Baird SJ Garfein RS McIntosh CT Özler B Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial.Lancet. 2012; 379: 1320-1329Summary Full Text Full Text PDF PubMed Scopus (414) Google Scholar, 5Baird S McIntosh C Özler B Cash or condition? Evidence from a cash transfer experiment.Q J Econ. 2011; 126: 1709-1753Crossref Scopus (321) Google Scholar The opposite could easily have been the case had it focused on adolescent boys.Poverty alleviation is not the only area where the relation with HIV incidence is difficult to predict and therefore where it makes sense to measure the impact. We mentioned above the postulated relation in Mexico between increased school participation and reduction in risk behaviour. The relation is thought to be mediated partly by adolescents being occupied more in school, partly by improved education being associated with better understanding of the consequences of unsafe behaviours and of how to practise safer behaviours, and also by the adolescents having improved expectations for the future and therefore greater reasons to safeguard future health. Extreme poverty could also increase risk behaviours because the perceived short-term benefits are large compared with the costs they may bear in a distant, uncertain future.6Pennings JME Garcia P The poverty challenge: how individual decision-making behavior influences poverty.Econ Lett. 2005; 88: 115-119Crossref Scopus (11) Google Scholar, 7Cardenas JC Carpenter J Behavioural development economics: lessons from field labs in the developing world.J Dev Stud. 2008; 44: 311-338Crossref Scopus (301) Google ScholarThe clear value of Cluver and colleagues' study should spur additional efforts to measure the effect of structural interventions and to use such results to guide social policy.We declare that we have no conflicts of interest. The paper by Lucie Cluver and colleagues in this month's issue of The Lancet Global Health1Cluver L Boyes M Orkin M Pantelic M Molwena T Sherr L Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study.Lancet Glob Health. 2013; 1: e362-e370Summary Full Text Full Text PDF Scopus (150) Google Scholar is an important piece of evidence in a sparsely populated field: rigorous evaluation of the impact of interventions that seek to modify the underlying structural determinants of HIV transmission. Almost since the beginning of the epidemic we have been hypothesising about the structural determinants of HIV transmission. Countless pages have been written about the effect of factors such as poverty, marginalisation, human rights abuses, and the status of women on the transmission of HIV. Improving any of those domains is good, in and of itself. We should not need an HIV justification to improve the status of women. Partly because of this sentiment, there has often been an implicit resistance to rigorous evaluation of the effect of structural interventions on HIV incidence: how could anyone be against improving the status of women? A woman who cannot control the circumstances under which she has sex will obviously be at higher risk of HIV infection, therefore why should we waste time and money measuring the impact on HIV of interventions to improve the status of women? As well as this implicit resistance, the difficulty of measurement has meant that there is very little convincing evidence of the effect of structural interventions on the incidence of HIV. Even Cluver and colleagues' study does not go all the way to measuring the effect on HIV incidence: it only measures the correlation between receiving cash transfers and sexual risk behaviour. However, as evidence grows of the effect of some interventions and, more importantly, the lack of effect of other interventions, it becomes increasingly clear that we have spent decades being foolish. By not looking rigorously at impact, we have not learned which interventions to fight poverty, human rights abuses, marginalisation, etc, also have an important effect on HIV and which ones do not. We have thus missed the opportunity to prioritise the interventions that have the greatest joint benefit. Cluver and colleagues' study suggests that unconditional anti-poverty cash transfers to poor households with children are likely to reduce two important types of risk behaviour by adolescent girls: transactional sex (sex for money or other material benefits) and age-disparate sex (sex with an older partner). That finding helps to illustrate the complex relation between poverty and risk behaviour. Previous studies have suggested that socioeconomic development can be associated with increased risk behaviour (people, especially men, have the means to purchase alcohol and drugs, to travel to places where they are more anonymous, and to purchase sex). Other studies have suggested that poverty, especially relative poverty, can also be associated with increased risk, both because of the opportunity to improve one's situation by selling sex or having sex with an older or wealthier partner (especially for women) or because wealth imbalances imply power imbalances that interfere with people's ability to reduce their risk by negotiating safer sex (especially for women). The results reported by Cluver and colleagues suggest that the poverty-related effects on women can be mitigated by cash transfers. Given these countervailing forces, it is certainly plausible that some poverty-alleviation programmes could increase risk behaviour (eg, cash transfers to poor young men) while others could decrease risk behaviour (eg, cash transfers to female heads-of-household or to poor adolescent girls). The findings from Cluver and colleagues' study are consistent with those of the evaluation of the impact of the Mexican Oportunidades programme—a conditional cash-transfer programme. In Mexico, the prevalence of transactional sex and age-disparate sex is significantly lower than in South Africa, but the programme reduced the age of sexual debut, marriage, and age of first child.2Andalón M Oportunidades to reduce overweight and obesity in Mexico?.Health Econ. 2011; 20: 1-18Crossref PubMed Scopus (15) Google Scholar, 3Gutierrez JP Youth risk behaviours as barriers for human (health) capital accumulation.http://ssrn.com/abstract=1982065Google Scholar An additional effect of Oportunidades was a reduction in the probability of having a sexually transmitted infection in male (but not female) adolescents, and also a reduction in smoking and alcohol consumption.3Gutierrez JP Youth risk behaviours as barriers for human (health) capital accumulation.http://ssrn.com/abstract=1982065Google Scholar The postulated increases in numbers of partners and in alcohol or drug use were not found. One potentially important reason for that is that the cash transfers are made to the female head-of-household, conditional on school attendance by the adolescent and that those conditions counteract the negative effects of additional resources on risk behaviours. The Malawi study led by Özler did not find a differential effect on risk behaviour dependent on whether or not the transfers to adolescents were conditional on school attendance, but that study only included adolescent girls.4Baird SJ Garfein RS McIntosh CT Özler B Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial.Lancet. 2012; 379: 1320-1329Summary Full Text Full Text PDF PubMed Scopus (414) Google Scholar, 5Baird S McIntosh C Özler B Cash or condition? Evidence from a cash transfer experiment.Q J Econ. 2011; 126: 1709-1753Crossref Scopus (321) Google Scholar The opposite could easily have been the case had it focused on adolescent boys. Poverty alleviation is not the only area where the relation with HIV incidence is difficult to predict and therefore where it makes sense to measure the impact. We mentioned above the postulated relation in Mexico between increased school participation and reduction in risk behaviour. The relation is thought to be mediated partly by adolescents being occupied more in school, partly by improved education being associated with better understanding of the consequences of unsafe behaviours and of how to practise safer behaviours, and also by the adolescents having improved expectations for the future and therefore greater reasons to safeguard future health. Extreme poverty could also increase risk behaviours because the perceived short-term benefits are large compared with the costs they may bear in a distant, uncertain future.6Pennings JME Garcia P The poverty challenge: how individual decision-making behavior influences poverty.Econ Lett. 2005; 88: 115-119Crossref Scopus (11) Google Scholar, 7Cardenas JC Carpenter J Behavioural development economics: lessons from field labs in the developing world.J Dev Stud. 2008; 44: 311-338Crossref Scopus (301) Google Scholar The clear value of Cluver and colleagues' study should spur additional efforts to measure the effect of structural interventions and to use such results to guide social policy. We declare that we have no conflicts of interest. Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control studyNational, child-focused cash transfers to alleviate poverty for households in sub-Saharan Africa can substantially reduce unsafe partner selection by adolescent girls. Child-focused cash transfers are of potential importance for effective combination strategies for prevention of HIV. Full-Text PDF Open Access