2. CAPRISA is the UNAIDS Collaborating Centre for HIV Research and Policy Do Cash Transfers Work for HIV Prevention in young women/adolescents? Hilton Humphries Vulindlela Clinical Research Site Director Centre for the AIDS Programme of Research in South Africa (CAPRISA) On behalf of Prof Q Abdool Karim, Dr A Pettifor and study team

3. Background Conditional & Unconditional Cash Incentives have been effective for a range of behaviours Promising data that incentives may reduce risky sexual behaviours and impact HIV transmission: –Baird et al (2012, Lancet): incentivized school attendance reduced HIV and HSV-2 prevalence in Malawi –Duflo et al (2006, WDR): incentivized through assistance with school costs, reduced pregnancy rates & increased age at sexual debut in Kenya –Björkman-Nyqvist et al (2015, World bank)– community lotteries reduced HIV incidence in Lesotho (those aged 18-32) Ongoing high HSV-2 and HIV rates in adolescent girls in Africa, with few prevention options

4. Approaches to Cash transfers Promising interventions to tackle structural risk? 2 main approaches: –Cash for poverty alleviation to try reduce HIV risk – linked to social protection approaches –Cash as an incentive for behavior change (i.e., money to test for HIV, to take your ART, male circumcision) – commonalities with CM >16 studies that have been completed or are underway examining the use of cash/incentives to reduce HIV risk in adults and young women –>14 RCT’s in Africa with aim of reducing risk of sexual transmission of HIV –1 RCT in the US, and 1 observational study in Mexico Will both approaches work the same in different populations? What is the implication for scale up? Pettifor A, et al. AIDS Behav. 2012 Oct;16(7):1729-38.

5. Young Women at Risk 1 out of 3 new HIV infections are in youth in SSA (15-24yr) 2 out of 3 new HIV infections are in sub-Saharan Africa

6. HIV in pregnant women in rural South Africa (2001-2013) Age Group (Years) HIV Prevalence (N=4818) ≤1611.5% 17-1821.3% 19-2030.4% 21-2239.4% 23-2449.5% >2551.9% Source: Abdool Karim Q, 2014 Age Group (years) Prevalence of HIV infection % (95% Confidence Interval) Male (n=1252) Female (n= 1423)  15 1.0 16-171.1 18-191.5 ≥ 20*1.8 2.6 6.1 13.6 24.7 HIV & HSV-2 prevalence in young women by age Prevalence of HSV-2 (Herpes simplex virus type-2)  15 0.7 16-172.0 18-196.6 ≥ 20*3.5 9.3 30.2 43.3

7. Cash transfer and HIV infection—effect sizes Slide courtesy of Dr A Pettifor Hallfors et al, 2011, RCT with 10-16 yo Effect: Adj OR: 8.48 (95 CI) school drop-out Adj OR: 2.92 (95%CI) getting married MDICP, Malawi. Kohler (2011), 16-75 yo No effect on HIV incidence 5.2% point increase in condom use in men 9% point increase risk sexual behaviours in men, 6.7% point decrease in women RCT to provide schools with uniforms, Kenya Duflo 2006, avg age 14 15% decrease in drop-out in girls and boys 10% decrease in child-bearing 12% decrease in getting married in girls, 40% in boys

8. CAPRISA 007 Cluster RCT to assess the impact of conditional cash incentives on the incidence of HSV-2 and HIV infection in rural high school students in South Africa 14 schools matched as 7 pairs: by school enrolment size, geographical proximity & school pass rates Grade 9 & 10 students (n = 3,217 students) Parental consent with student assent HIV and HSV-2 testing done serologically:  Baseline; 12 months (91% retained) & 24 months (85% retained)  Baseline HSV-2 prevalence:Intervention: 9.0% Control: 7.3%  Baseline HIV prevalence: Intervention: 4.7% Control: 3.7% Analysis performed at the cluster level using paired t-tests (Inter-cluster correlation = 0.01)

9. CAPRISA 007 All 14 rural schools participated in a local Life skills (incl. HIV education) Program - My Life! My Future! One school in each of 7 pairs randomly assigned to receive, in addition, cash incentives for 4 conditions being met: –80% quarterly participation in My Life! My Future! (4/year) –Attaining passing score in 6-monthly academic tests (2/yr) –An annual HIV test (1/yr) –Submit report on their community project at end (once off). Maximum incentive possible is R1,750 ($1=R10), equivalent to half the local child care grant

10. Effectiveness of conditional cash incentives in preventing HSV-2 and HIV HSV-2 Incidence rate ratio*: 0.70 (CI: 0.57 to 0.86); p = 0.007 30% lower HSV-2 incidence with cash incentives Intervention Group Control Group # HSV-2 infections136183 Person-years (# students) 2091 (1329)2132 (1384) HSV-2 incidence/100 py 6.28.7 HIV incidence / 100 py 1.81.5 Too few HIV infections (n=75) to assess impact on HIV * Note: Analysis based on matched-pairs of schools & not individual students

11. HSV-2 incidence by incentive levels CCI boys had 40% lower HSV-2 incidence (p = 0.042) CCI girls had 24% lower HSV-2 incidence (p = 0.035) Too few HIV endpoints for HIV sub-group analyses. HIV incidence lower than expected - need a sample size 3-5 times larger for adequate power to assess 30% impact on HIV prevention Students who got > $95 had 71% lower HSV-2 Incidence (p = 0.034)

12. Important considerations from CAPRISA 007 Context for cash incentives important: –This study is in poor rural high school students in S. Africa –Few (< 1/3) conditions met, hence median cash incentive = $60 –Cash incentives for school performance made little impact –Impact: ↑ uptake of HIV tests and lifeskills program attendance –Incentive dose-response should be interpreted with caution Could not establish impact of cash incentives on HIV –lack of statistical power due to lower than expected HIV incidence (?background trend, ?community interventions ?study-related interventions)

13. HPTN 068 Randomized Controlled Trial Intervention: Cash transfer conditional on school attendance to young woman and parent/guardian Population:~ 2,500 South African young women in grades 8-11, ages 13- 20 yrs (Agincourt, South Africa) Primary endpoint: HIV incidence in young women Monthly payment conditioned on 80% school attendance: R100 girl/ R200 guardian Slide courtesy of Dr A Pettifor and HPTN 068 team

14. HPTN 068: Findings There was no difference in HIV incidence between those that received the cash transfer and those that did not. –Hazard Ratio (HR) 1.17 (95% CI 0.80-1.72, p=0.42). Young women receiving the CCT reported fewer sex partners, less unprotected sex and experienced less IPV. School attendance similar in both arms –Attendance 95% in intervention/95.3% in control (95% CI-1.44-0.56), p=0.39 –School drop-out 2.7% intervention/2.9% in control (RR=0.90, 95% CI 0.67-1.24), p=0.53 Schooling was protective, & staying in school and greater attendance significantly reduced HIV risk for young women. –Risk of HIV infection comparing school drop out to non drop out, HR 3.21 (95% CI 1.81, 5.71), p<.0001 –Risk of HIV infection comparing <80% attendance to ≥80% school attendance, HR 3.05 (95% CI 1.81,5.13), p<0.0001 HIV incidence was 1.8% and risk behaviours were relatively low. Slide courtesy of Dr A Pettifor and HPTN 068 team

15. HPTN 068: Behavioural Findings EndpointControlInterventionRRCIp-value Had any sex partner in past 12 months 35.2%32.2%0.900.83 - 0.990.023 Any unprotected sex (past 3 mo) 10.2%8.1%0.810.67 – 1.00.05 IPV at any visit36.5%29.6%0.810.74 - 0.88<0.0001 Coital debut17.6%/yr15.3%/yr0.920.78 - 1.080.30 Partner age diff >5yr19.1%16.0%0.900.72 - 1.120.34 Transactional sex10.5%9.7%0.950.78 - 1.150.57 Any pregnancy during the study 13.6%13.0%0.940.76 – 1.170.58 Slide courtesy of Dr A Pettifor and HPTN 068 team

16. Cash Plus Care: Lessons from SA Social Protection Approach Prospective observational study in SA 3515, 10-18yo interviewed 2009-2010 and 2011 and 2012 Cluver, Orkin, Boyes, Sherr (2014). AIDS. % of risk behaviour at follow up Odds Ratio (95% CI) GirlsNo support41.2 Cash24.50.63 Cash plus care15.40.55 BoysNo support42 Cash28No effect Cash plus care170.50 Protection increased with care Halved incidence of HIV risk behaviour Young men need both for protective effect Halved incidence of HIV risk behaviour Predictors of adolescent risk behaviour included being older, moved house 2+ times, being AIDS affected (for girls), and informal dwelling (for boys) Controlling for: family HIV/AIDS, informal/formal housing, age of child, poverty levels, number of moves of home, baseline HIV risk behaviour

17. Important Findings To date, only 1 study has had a reduction in HIV incidence (Lesotho) but in an older cohort Reduction in HSV-2 is positive outcome, and long term impact of this reduction for HIV infection needs further research Evidence of delaying sexual debut, early marriage, condom use, IPV are promising for interrupting transmission routes or reducing risk in particularly risky periods of adolescents Clear that the transmission dynamics and routes of infection are multi-level and how CT can interrupt these dynamics needs more research Little sustained impact of CT on risk behavior once incentive removed How does cash fit into combination prevention?

18. Conclusions Questions remain –Think hard about the purpose of the cash- what are we trying to achieve with the cash? –Context, context, context –Targeting- who gets money/incentives? Who will benefit most? Gender differences? –How long do you give the cash for? And How to package cash with care? With CCT or CTs the goal is important –Needs to be HIV specific to change HIV specific behaviours Establish relevance of goal in context –eg school completion rates may be important in some settings where it is low but if it is already >90% it will have little impact Localised responses are going to be critical rather than a cookie cutter approach In vs out of school youth especially important for young women – those in school may be lower risk already Structural interventions in the real world - Challenging!

19. Acknowledgements  KwaZulu-Natal Department of Education Provincial and District and Circuit Offices Pietermaritzburg and Vulindlela  School Governing Boards, students and staff at the schools  MiET Africa  CAPRISA 007 study team: Quarraisha Abdool Karim, Kerry Leask, Ayesha Kharsany, Hilton Humphries, Fanele Ntombela, Natasha Samsunder, Cheryl Baxter, Janet Frohlich, Lynn van der Elst & Salim S. Abdool Karim  This material is based upon work supported by the Embassy of the Kingdom of Netherlands (EKN) under activity number 20336 through a subcontract with MiET Africa.  Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and therefore the EKN does not accept any liability in regard thereto.  HPTN 068 Team and Dr A Pettifor