The child support grant and adolescent risk of HIV infection in South Africa
Authors: Tanya Doherty, Wanga Zembe, Yanga Zembe, Natalie Leon, David Sanders
Journal: The Lancet Global Health (2014)

The report by Lucie Cluver and colleagues (December, 2013)1Cluver 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 a welcome effort to document the effects of the child support grant in South Africa and shows the complexities of assessment of cash transfers in programmatic settings. The Article raises several questions which would benefit from further consideration.With regard to study design, the study is described both as a case-control study and as a prospective observational study. It is not clear that the same adolescents were interviewed at baseline and follow-up. It seems in table 11Cluver 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 as if different adolescents were interviewed, since among both sexes, from families not in receipt of the grant, there were fewer maternal and paternal orphans at follow-up and a more than 10 percentage point difference in the prevalence of both sexes living in informal housing (fewer at follow-up). This shift is fairly large over a 1 year period, which could point to other improvements in social status of these households that could affect sexual risk behaviour.The investigators conclude that this study provides evidence of feasibility and scalability of child-focused cash transfers as an HIV prevention method. We would like to add some caution to this message. Although socioeconomic status is among the social determinants of health, it cannot realistically be expected that a small cash transfer to mothers should result, by itself, in changes in adolescent sexual risk behaviour. There has been much discourse regarding the adequacy of the child support grant to meet even basic needs of children.2Zembe W Good but not good enough: the limitations of a social assistance program for children in South Africa—the case of the Child Support Grant. DPhil Thesis. Department of Social Policy and Intervention. Oxford University, Oxford2013Google Scholar At US$35, the child support grant is not likely to be used for high-value social items (eg, clothing, hair products, mobile phones), which are known to underlie poor girls' motivations for engaging in transactional sex.3Zembe YZ Townsend L Thorson A Ekstrom AM “Money talks, bullshit walks” interrogating notions of consumption and survival sex among young women engaging in transactional sex in post-apartheid South Africa: a qualitative enquiry.Global Health. 2013; 9: 28Crossref PubMed Scopus (65) Google Scholar The child support grant presents immense opportunities as a policy instrument for alleviation of child poverty in South Africa, but we argue that to reach its full potential the value of the grant needs to be higher. In its current form it is not a magic bullet for HIV prevention and there is a danger in oversimplifying the complex mix of challenges of living in poverty and of solutions that might be needed to improve the health and wellbeing of vulnerable families.We declare that we have no competing interests. The report by Lucie Cluver and colleagues (December, 2013)1Cluver 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 a welcome effort to document the effects of the child support grant in South Africa and shows the complexities of assessment of cash transfers in programmatic settings. The Article raises several questions which would benefit from further consideration. With regard to study design, the study is described both as a case-control study and as a prospective observational study. It is not clear that the same adolescents were interviewed at baseline and follow-up. It seems in table 11Cluver 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 as if different adolescents were interviewed, since among both sexes, from families not in receipt of the grant, there were fewer maternal and paternal orphans at follow-up and a more than 10 percentage point difference in the prevalence of both sexes living in informal housing (fewer at follow-up). This shift is fairly large over a 1 year period, which could point to other improvements in social status of these households that could affect sexual risk behaviour. The investigators conclude that this study provides evidence of feasibility and scalability of child-focused cash transfers as an HIV prevention method. We would like to add some caution to this message. Although socioeconomic status is among the social determinants of health, it cannot realistically be expected that a small cash transfer to mothers should result, by itself, in changes in adolescent sexual risk behaviour. There has been much discourse regarding the adequacy of the child support grant to meet even basic needs of children.2Zembe W Good but not good enough: the limitations of a social assistance program for children in South Africa—the case of the Child Support Grant. DPhil Thesis. Department of Social Policy and Intervention. Oxford University, Oxford2013Google Scholar At US$35, the child support grant is not likely to be used for high-value social items (eg, clothing, hair products, mobile phones), which are known to underlie poor girls' motivations for engaging in transactional sex.3Zembe YZ Townsend L Thorson A Ekstrom AM “Money talks, bullshit walks” interrogating notions of consumption and survival sex among young women engaging in transactional sex in post-apartheid South Africa: a qualitative enquiry.Global Health. 2013; 9: 28Crossref PubMed Scopus (65) Google Scholar The child support grant presents immense opportunities as a policy instrument for alleviation of child poverty in South Africa, but we argue that to reach its full potential the value of the grant needs to be higher. In its current form it is not a magic bullet for HIV prevention and there is a danger in oversimplifying the complex mix of challenges of living in poverty and of solutions that might be needed to improve the health and wellbeing of vulnerable families. We declare that we have no competing interests. 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 AccessThe child support grant and adolescent risk of HIV infection in South Africa – Authors' replyWe welcome the comments of Tanya Doherty and colleagues, in particular the excellent point that consideration should be given to raising cash transfer values to further alleviate poverty. Whether raising the value of cash transfers would increase the effects on adolescent HIV-risk behaviour is an empirical question, and deserves testing. Indeed, in a World Bank study in Tanzania,1 changes in sexual behaviour were noted with higher rates of cash transfer but not with lower rates. We also agree that cash transfers are not a so-called magic bullet, and accordingly suggested that they “might be most effective as part of a combination of prevention methods”. Full-Text PDF Open Access