1. Cash, care, prevention and adherence for adolescents: Latest evidence from southern africa L Cluver, M Orkin, M Boyes, L Sherr, F Meinck Arusha, December 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. N=700 adolescents, 3-year tracking All 32 ART clinics (>5 adolescents) Buffalo City/Amathole Districts, Eastern Cape Enrolled and lost-to-follow-up Viral load, CD4, pharmacy refills, self-reported adherence Clinic assessments for facility-level effects + 2-year qualitative ethnography Predicting adolescent ART adherence & SRH use

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

7. AIDS- orphan HIV Risk Behaviour Abuse AIDS- sick parent Psych. distress Stigma Poverty.08.13.22.10.15.32.43.72.15.24.12 mean χ 2 (679) Bollen- Stine mean χ 2 /df RMSEASRMRCFITLI 640.06p=.0011.57.032.044.939.930 Pathways to HIV-risk Cluver, Orkin, Boyes, Sherr, Nikelo, Makhasi (2013). Soc. Sci & Medicine. Analyses funded by RIATT. Education risks.18.14

8. Unconditional cash transfers

9. 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.

10. Kenya: Summary Impacts of OVC cash transfer on adolescents (Odds Ratios) Handa, Halpern, Pettifor, Thirmurthy (2014) PLOS One.

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 School counsellor Food garden Positive parenting Teacher support

14. % 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. Cash alone: no effect Cash plus care: OR.50

15. HIV+ adolescents: ART adherence, cash and care Indicative percentages only, n=250 Random sampling 32 state clinics, South Africa

16. Structural drivers and mechanisms

17. 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 Cluver, Orkin, Boyes, Sherr (2014). AIDS.

18. 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 Cluver, Orkin, Boyes, Sherr (2014). AIDS.

19. High vulnerability Starving Sex Psychosocial risks Girls: ‘starving sex’ incidence (longitudinal, 60% of HIV-risk behavior explained) CARE CASH CLASSROOM controlling for: age, baseline HIV-risk

20. What kinds of cash and care work best? (preliminary analyses)

21. Combinations for HIV-prevention Males Females CarelessEconomicCarelessEconomic Pregnancy Cash Child Grants Medical care Class- room School feeding Free school & books Care Monitoring Teacher support

24. Operationalising care (preliminary analyses)

25. Aims: Reduce child abuse, improve parenting and supervision Local NGO staff, no materials needed Free: Creative Commons WHO and UNICEF: scale-up to other countries Thula Sana (pregnancy – 6 months) Book sharing (toddlers) Sinovuyo Kids (ages 2-9) Sinovuyo Teen (ages 10-17) Group work, collaborative problem-solving Home practice, role-playing Evidence-based core principles Building a Rondavel of Support Parenting for Lifelong Health: Sinovuyo SA

28. Controlling for: age, formal/informal housing, poverty, urban/rural, household employment, child migration, caregiver gender, non-biological caregiver & outcome risk at baseline. Cash alone, care alone & cash+care entered simultaneously.

29. 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

30. Funders: thank you.

31. ‘I would like to advice the government to issue grants to those countries that are suffering socially and see the difference. And see how the impact it could create in the life many of youngsters. How it can better their decision and destiny.Take it from me I am the living difference.’ Noxolo, 19 yrs.