Cash transfers—magic bullet or fundamental ingredient?
Authors: Lucie Cluver, Lorraine Sherr
Journal: The Lancet Global Health (2016)

How many more trials will be needed to endorse the use of small regular cash amounts to improve the health of the very poor?1Robertson L Mushati P Eaton JW et al.Effects of unconditional and conditional cash transfers on child health and development in Zimbabwe: a cluster-randomised trial.Lancet. 2013; 381: 1283-1292Summary Full Text Full Text PDF PubMed Scopus (145) Google Scholar, 2Taaffe J Cheikh N Wilson D The use of cash transfers for HIV prevention—are we there yet?.Afr J AIDS Res. 2016; 15: 17-25Crossref PubMed Scopus (16) Google Scholar In their study in The Lancet Global Health, Audrey Pettifor and colleagues3Pettifor A MacPhail C Hughes JP et al.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.Lancet Glob Health. 2016; (published online Nov 1.)http://dx.doi.org/10.1016/S2214-109X(16)30253-4PubMed Google Scholar show that cash transfers reduce key HIV risk behaviours in adolescent girls (sexual activity in the past 12 months, unprotected sex in the past 3 months, and intimate partner violence as an additional outcome). But the unexpected findings from this study might have even greater implications for social protection and HIV prevention. This trial had robust statistical analyses and a carefully-devised hypothesis—ie, conditioning cash transfers on education would improve school attendance and consequently reduce HIV risk. But, as the authors of this study found, conditionality might make cash transfers both less feasible and less effective. Because the cash was conditioned on school attendance, the trial had to exclude adolescent girls who had left school, and those who were pregnant. Thus, some of the girls who were most vulnerable to HIV infection could not be included in the study. Participants who stopped attending school lost their cash transfer. The combination of being out of school and having no money might have made girls more vulnerable to exploitative sexual relationships. The infrastructure and cost of policing the conditions reduces reach to individuals at highest risk. The clear lessons from this study are that conditionality does not substantially advance the cause, and that cash transfers have some important effects in HIV risk reduction. The challenge now is to understand the mechanisms and to explore pathways to widen the scope of the effects. This trial provides clues for the way forward in HIV prevention. Girls who received cash transfers had reductions in some, but not all, HIV risks. However, continued school attendance did reduce HIV acquisition in both study groups. In this study, HIV infection was lower than anticipated and school attendance higher. These results might seem confusing. But in a presentation at the 21st International AIDS Conference (AIDS 2016), Pettifor and colleagues reported an important finding. Irrespective of trial intervention, 97% of the girls included in the study attended school compared with 86% of other girls in the area.4Rosenberg M, Pettifor A, Twine R, et al. Evidence for selection effect and Hawthorne effect in behavioral HIV prevention trial among young women in rural South Africa. 21st International AIDS Conference; Durban, South Africa; July 18–22, 2016. WEPDC0205.Google Scholar This suggests that inclusion in the trial participant made a difference. What distinguished these girls from their peers? This was a rigorous study, led by highly ethical researchers with data collection over several years. All participants knew that their school attendance was being monitored. They were asked about their sexual relationships. All attended study-enrolled schools in which girls' education was a focus. All were regularly tested for HIV, with pre-test and post-test counselling: a standard of care that is unusual in the region. Other findings on adolescent risk-taking show that adult monitoring and attention can reinforce positive behaviours and reduce risk.5van der Stouwe T Asscher JJ Stams GJ Dekovic M van der Laan PH The effectiveness of Multisystemic Therapy (MST): a meta-analysis.Clin Psychol Rev. 2014; 34: 468-481Crossref PubMed Scopus (143) Google Scholar The overall increased school attendance and reduced HIV incidence in this trial might have been due to this provision of care: the supervision, testing, and support that characterised a robust study and an ethical research team. Quasiexperimental evidence has shown that combinations of cash and adult monitoring of adolescents are associated with greater HIV risk reductions than cash alone.6Cluver L Orkin FM Boyes ME Sherr L Cash plus care: social protection cumulatively mitigates HIV-risk behaviour among adolescents in South Africa.AIDS. 2014; 28: S389-S397Crossref PubMed Scopus (81) Google Scholar, 7Toska E Cluver LD Boyes ME Isaacsohn M Hodes R Sherr L School, supervision and adolescent-sensitive clinic care: combination social protection and reduced unprotected sex among HIV-positive adolescents in South Africa.AIDS Behav. 2016; (published online Sept 8.)https://doi.org/10.1007/s10461-016-1539-yCrossref PubMed Scopus (20) Google Scholar In this large-scale trial, we see a parallel result. Cash helped with some HIV risks, whereas care helped with other risks. Girls who received both cash and the (unintentional) care, showed an array of prevention benefits. The evidence of enhancing the effect of cash transfers by combining them with wider care seems to be growing.8Cluver LD Orkin FM Yakubovich AR Sherr L Combination social protection for reducing HIV-risk behavior among adolescents in South Africa.J Acquir Immune Defic Syndr. 2016; 72: 96-104Crossref PubMed Scopus (51) Google Scholar Pettifor and colleagues' study comes at a time of change. Governments in countries with high prevalence of HIV are starting to realise that universal cash transfers, as well as universal school provision, are fundamental HIV prevention approaches and good policy.9Remme M Vassall A Lutz B Luna J Watts C Financing structural interventions: going beyond HIV-only value for money assessments.AIDS. 2014; 28: 425-434Crossref PubMed Scopus (39) Google Scholar As such, the study provides timely and important lessons for the scale-up of social protection. As the authors say, context is essential, and we now need evidence from other countries in the region. Cash alone is an essential component, but not a magic bullet. To navigate this risky developmental stage, adolescents also need our attention, supervision, and care. LC reports grants from United Nations International Children's Emergency Fund (UNICEF), US Agency for International Development's President's Emergency Plan for AIDS Relief (USAID/PEPFAR), European Research Council, Leverhulme Foundation, Economic and Social Research Council, Department for International Development (UK), and The Nuffield Foundation outside the submitted work. LS reports grants from USAID/PEPFAR, Norad-Sida, World Bank, National Institute for Health Research, UNICEF, HelpAge, and Children and Violence Evaluation Challenge Fund outside the submitted work. The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trialCash 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. Full-Text PDF Open Access