1. Effective combination prevention: Cash, care and HIV-risk for adolescents in South Africa. L Cluver, M Orkin, M Boyes, L Sherr IAS, July 2014

2. Child- focused research Universities: Oxford, UCT, Wits, Curtin, UKZN Collaborative research: science to assist policy

3. National longitudinal study of adolescents 6850 adolescents, 2500 adult caregivers, 2008-2012 Longitudinal national survey Main study: N=6000 (age: 10-18) 3 provinces South Africa; 6 sites >30% prevalence Stratified random sampling of census EAs Every household with a child aged 10-17 Urban/rural, 1 year follow-up in 2 provinces n=3401, 97% follow-up Measures Standardised scales, national surveys Ethics Approved by Universities of Cape Town, Oxford, KwaZulu-Natal, 6 Provincial Health & Education Departments Social & health service referrals Controlling for prior HIV risk

5. Effects of abuse, poverty & parental AIDS on female adolescent risk of transactional sex Cluver, Orkin, Boyes, Meinck, Makhasi (2011). JAIDS

6. Proof of concept: cash incentives

9. Unconditional cash transfers

10. South Africa: Child grant reduces incidence & prevalence of transactional sex and age-disparate sex for girls No cash transfer Child cash transfer Cluver, Boyes, Orkin, Pantelic, Molwena, Sherr (2013). The Lancet Global Health.

11. Cash plus care?

12. Can CASH + CARE reduce HIV risk behavior? CASH CARE Incidence rates: Transactional sex Age-disparate sex Sex using substances Multiple partners Unprotected sex Teen pregnancy Incidence rates: Transactional sex Age-disparate sex Sex using substances Multiple partners Unprotected sex Teen pregnancy

13. Child-focused grant Regular food parcels Free school meals Free school transport School counsellor Food garden Home-based carer Positive parenting Free school uniform Teacher support Soup kitchen

14. Child-focused grant Free school meals Food garden Positive parenting Teacher support n=3515, longitudinal

15. % girls with incidence of 1+ HIV risk behavior: Cash plus care = halved risk Cash alone: OR.63 Cash plus care: OR.55 Controlling for: family HIV/AIDS, informal/formal housing, age of child, poverty levels, number of moves of home, baseline HIV risk behaviour Cluver, Orkin, Boyes, Sherr (2014). AIDS.

16. % boys with incidence of 1+ HIV risk behavior: Cash plus care = halved risk Cash alone: no significant effect Cash plus care: OR.50 Controlling for: family HIV/AIDS, informal/formal housing, age of child, poverty levels, number of moves of home, baseline HIV risk behaviour Cluver, Orkin, Boyes, Sherr (2014). AIDS.

17. Structural drivers and mechanisms

18. Hunger Community violence Parental HIV/AIDS Informal settlement 2011 Structural deprivation 2012 HIV-risk behavior incidence Poverty & family AIDS predict adolescent HIV-risks: how? Transactional sex Age-disparate sex Sex using substances Multiple partners Unprotected sex Pregnancy Transactional sex Age-disparate sex Sex using substances Multiple partners Unprotected sex Pregnancy controlling for: baseline HIV-risk, age, gender all p<.001

19. HIV-risk behavior incidence HIV-risk behavior incidence Structural deprivation school dropout child abuse conduct problems drug/alcohol use psychological distress p<.001 p<.002 p<.05 p<.001 controlling for: baseline HIV-risk, age, gender Psychosocial problems p<.004

20. Reduced HIV-risk behavior incidence Reduced HIV-risk behavior incidence Structural deprivation Reduced psycho-social problems Reduced psycho-social problems controlling for: baseline HIV-risk, age, gender CASH CARE Cash and care: greatest effects for highest-risk adolescents P<.001

21. Cumulative HIV-prevention impact

22. Unconditional, government cash transfers reduce adolescent HIV risks Cash plus care gives greater effects Effective in real-world sub-Saharan Africa Cash and care mitigate structural risk Cumulative impacts of 2+ interventions

23. Funders: thank you.