Can Money Prevent the Spread of HIV? A Review of Cash Payments for HIV Prevention

Cash payments to improve health outcomes have been used for many years; however, their use for HIV prevention is new and the impact not yet well understood. We provide a brief background on the rationale behind using cash to improve health outcomes, review current studies completed or underway using cash for prevention of sexual transmission of HIV, and outline some key considerations on the use of cash payments to prevent HIV infections. We searched the literature for studies that implemented cash transfer programs and measured HIV or HIV-related outcomes. We identified 16 studies meeting our criteria; 10 are completed. The majority of studies have been conducted with adolescents in developing countries and payments are focused on addressing structural risk factors such as poverty. Most have seen reductions in sexual behavior and one large trial has documented a difference in HIV prevalence between young women getting cash transfers and those not. Cash transfer programs focused on changing risky sexual behaviors to reduce HIV risk suggest promise. The context in which programs are situated, the purpose of the cash transfer, and the population will all affect the impact of such programs; ongoing RCTs with HIV incidence endpoints will shed more light on the efficacy of cash payments as strategy for HIV prevention.     

HPTN 068: A Randomized Control Trial of a Conditional Cash Transfer to Reduce HIV Infection in Young Women in South Africa—Study Design and Baseline Results

Young women in South Africa are at high risk for HIV infection. Cash transfers offer promise to reduce HIV risk. We present the design and baseline results from HPTN 068, a phase III, individually randomized trial to assess the effect of a conditional cash transfer on HIV acquisition among South African young women. A total of 2533 young women were randomized to receive a monthly cash transfer conditional on school attendance or to a control group. A number of individual-, partner-, household- and school-level factors were associated with HIV and HSV-2 infection. After adjusting for age, all levels were associated with an increased odds of HIV infection with partner-level factors conveying the strongest association (aOR 3.05 95 % CI 1.84–5.06). Interventions like cash transfers that address structural factors such as schooling and poverty have the potential to reduce HIV risk in young women in South Africa.     

The use of cash transfers for HIV prevention — are we there yet?

Poverty and social inequality are significant drivers of the HIV epidemic and are risk factors for acquiring HIV. As such, many individuals worldwide are at risk for new HIV infection, especially young women in East and Southern Africa. By addressing these drivers, social protection programmes may mitigate the impact of poverty and social inequality on HIV risk. There is reason to believe that social protection can be used successfully for HIV prevention; social protection programmes, including cash transfers, have led to positive health outcomes and behaviour in other contexts, and they have been used successfully to promote education and increased income and employment opportunities. Furthermore, cash transfers have influenced sexual behaviour of young women and girls, thereby decreasing sexual risk factors for HIV infection. When HIV outcomes have been measured, several randomised controlled trials have shown that indirectly, cash transfers have led to reduced HIV prevalence and incidence. In these studies, school attendance and safer sexual health were directly incentivised through the cash transfer, yet there was a positive effect on HIV outcomes. In this review, we discuss the growth of social protection programmes, their benefits and impact on health, education and economic potential, and how these outcomes may affect HIV risk. We also review the studies that have shown that cash transfers can lead to reduced HIV infection, including study limitations and what questions still remain with regard to using cash transfers for HIV prevention.     

"There's evidence that this really works and anything that works is good": views on the introduction of medical male circumcision for HIV prevention in South Africa

Three clinical trials have demonstrated the partial efficacy (40-60%) of surgically conducted medical male circumcision (MMC) in preventing HIV transmission to circumcised men. This research formed part of a larger study exploring the importance of integration of sexual and reproductive health with HIV services. The objective was to elicit key informant views on the introduction of MMC for HIV prevention in South Africa. Twenty-one key informants representing the South African Health Department, local and international NGOs and universities, were asked, via semi-structured interviews about their views on introducing MMC as an HIV prevention strategy in South Africa. Interviews were transcribed and all discussions on MMC were coded for analysis using NVivo 8. The majority of the key informants were knowledgeable about MMC for HIV prevention and felt that making MMC available in South Africa was a good idea, with some recommending immediate introduction. Others felt that MMC should be introduced with caution. Various factors were recommended for consideration, including culture, the impact of circumcision on women, possible increase in sexual risk behaviour from behavioural disinhibition and that MMC may become another vertical health service programme. Most felt that MMC should be undertaken in neonates, however, acknowledged concerns about cultural responses to this. Recommendations on the implementation of MMC ranged from integrating services at primary health care level, to provision by private medical practitioners. In conclusion, MMC is viewed as a key HIV prevention strategy. However, there are numerous factors which could hinder introduction and uptake in South Africa and in the region. It is important to explore and understand these factors and for these to be aligned in the national MMC policy.     

What HIV-positive young women want from behavioral interventions: a qualitative approach

Young women living with HIV in the United States face many social and psychological challenges, including involvement in health care and secondary prevention efforts. The factors that put these young women at risk for HIV acquisition initially, such as poverty, gender roles, cultural norms, and limited perceived control over sexual relationships, continue to place them at risk for both adverse mental and physical health outcomes that impact their daily lives and secondary prevention efforts. This study utilized focus groups with young HIV-positive women in order to better understand their perceived problems and pressures and to inform a developmentally appropriate secondary prevention intervention for young HIV-positive women that could be implemented in clinical care settings. Focus groups with young HIV-positive women were convened in three U.S. cities: Baltimore, Chicago, and Tampa. A total of 17 young, HIV-positive women, age range 17–24 (mean age=21), participated in the focus groups. This article describes the psychological and social challenges these young women face as well as their suggestions regarding secondary HIV prevention intervention components.     

Women migrant workers' vulnerability to HIV infection in Hong Kong

Research on population mobility and HIV/AIDS risk among migrant populations is quite limited, and research on migrant women workers' vulnerability is further limited. Hong Kong, the Special Administrative Region of China, has currently about 200,000 women migrant workers working as domestic helps. This paper reports migrant women worker's access to AIDS-related health information and health care facilities, perceptions about vulnerability, and risk behaviour profile. Data was collected through a pre-tested questionnaire from a random sample of 2,010 women migrant workers. A majority of the migrant women workers (63.6%) have been living and working in Hong Kong for between 4-10 years. Fifty-four per cent of the respondents felt that being a female they were vulnerable to HIV infection. Overall, the knowledge regarding HIV/AIDS and its route of transmission is inadequate amongst the migrant women workers in Hong Kong. It appears that AIDS-related information education and communication needs of women migrants workers are not met by the current HIV prevention and care activities in Hong Kong. The study indicates that migrant women workers who experienced sexual violence (9%) in Hong Kong perceive themselves to be 'at risk' of HIV infection. Seventy per cent of the respondents reported that they have felt discriminated against in Hong Kong, of which 42% felt discriminated against in Hong Kong hospitals. Addressing discrimination in health care settings is an essential element of AIDS prevention. The discussion urges researchers and policy makers to pay more attention to the vulnerability of migrant women workers.     

Poverty,sexual behaviour,gender and HIV infection among young black men and women in Cape Town,South Africa

This article contributes methodologically and substantively to the debate over the importance of poverty, sexual behaviour and circumcision in relation to HIV infection, using panel data on young black men and women in Cape Town, South Africa. Methodological challenges included problems of endogeneity and blunt indicator variables, especially for the measurement of sexual behaviour. Noting these difficulties, we found that the importance of socioeconomic and sexual-behavioural factors differed between men and women. While we found a clear association between the number of years of sexual activity and HIV status among both men and women, we found that past participation in a concurrent sexual partnership increased the odds of HIV infection for men but not women. Women, but not men, who made the transition from school to tertiary education (our key indicator of socioeconomic status) were less likely to be HIV-positive than those who made the transition from school to unemployment. Both poverty and sexual behaviour matter to individuals’ HIV risk, but in gendered ways.     

Microenterprise Development Interventions for Sexual Risk Reduction: A Systematic Review

Comprehensive interventions that address both individual and structural determinants associated with HIV/STI risk are gaining increasing attention over the past decade. Microenterprise development offers an appealing model for HIV prevention by addressing poverty and gender equality. This study systematically reviewed the effects of microenterprise development interventions on HIV/STI incidence and sexual risk behaviors. Microenterprise development was defined as developing small business capacity among individuals to alleviate poverty. Seven eligible research studies representing five interventions were identified and included in this review. All of the studies targeted women, and three focused on sex workers. None measured biomarker outcomes. All three sex worker studies showed significant reduction in sexual risk behaviors when compared to the control group. Non-sex worker studies showed limited changes in sexual risk behavior. This review indicates the potential utility of microenterprise development in HIV risk reduction programs. More research is needed to determine how microenterprise development can be effectively incorporated in comprehensive HIV control strategies.     

The Impact of a National Poverty Reduction Program on the Characteristics of Sex Partners Among Kenyan Adolescents

Cash transfer programs have the potential to prevent the spread of HIV, particularly among adolescents. One mechanism through which these programs may work is by influencing the characteristics of the people adolescents choose as sex partners. We examined the four-year impact of a Kenyan cash transfer program on partner age, partner enrollment in school, and transactional sex-based relationships among 684 adolescents. We found no significant impact of the program on partner characteristics overall, though estimates varied widely by gender, age, schooling, and economic status. Results highlight the importance of context in exploring the potential HIV preventive effects of cash transfers.     

Food insecurity,HIV/AIDS pandemic and sexual behaviour of female commercial sex workers in Lagos metropolis,Nigeria

This study examined the role of hunger and food insecurity in the sexual behaviour of female commercial sex workers in Lagos metropolis, Nigeria within the context of HIV/AIDS. In addition, the study investigated the prevalence of sexually transmitted infections (STIs) and induced abortion among the respondents. Cross-sectional survey and in-depth interview research methods were adopted to generate both quantitative and qualitative data from the respondents. Findings of the study showed that 35.0% of the respondents joined the sex industry because of poverty and lack of other means of getting daily food. While all the respondents had knowledge about the existence of HIV/AIDS, 82.0% of them identified sexual intercourse as a major route of HIV transmission. There was a significant relationship between poverty, food insecurity and consistent use of condoms by female sex workers at P<0.01. Specifically, only 24.7% of the respondents used condoms regularly in every sexual act. Consequently, 51.6% had previous cases of STIs. The most prevalent STI among the respondents was gonorrhea, with 76.4% prevalence among ever infected female sex workers. This was followed by syphilis with a prevalence of 21.1%. In addition, 59.1% of the sample had become pregnant while on the job and 93.1% of these pregnancies were aborted through induced abortion. In conclusion, hunger and malnutrition were the factors that pushed young women into prostitution in Nigeria and these same factors hindered them from practicing safe sex within the sex industry. Thus, it is recommended that the Nigerian government should develop programmes that will reduce hunger and food insecurity, in order to reduce rapid transmission of HIV infection in the country.     

Association between parent–adolescent communication about sex-related topics and HIV testing,United States. 2006–2013

Adolescents need information about sex-related topics in order to reduce risk behavior and engage in healthy sexual decision-making. Parents have the potential to be an important source of this information. Using the 2006–2010 and 2011–2013 National Survey of Family Growth, we examined associations between parent–adolescent communication before age 18 about sex-related topics and HIV testing among respondents aged 18–24 that ever had sexual intercourse (women?=?3893; men?=?3359). Analyses showed that for both men and women, discussing how to prevent HIV/AIDS and how to use a condom with a parent before age 18 were positively associated with HIV testing. Among women only, discussions about methods of birth control, where to get birth control, and STDs were positively associated with HIV testing. Developing strategies and interventions to facilitate parent–adolescent communication about sex-related topics, particularly HIV prevention and condom use, may be important to increase HIV testing among young women and men.     

The effects of sexism, psychological distress, and difficult sexual situations on U.S. women's sexual risk behaviors

Women represent almost half of the people living with HIV worldwide. Although social discrimination has been recognized as a major obstacle to HIV prevention, few empirical studies have examined the effects of sexism on women's HIV sexual risk behaviors. We analyzed data collected from an ethnically diverse sample of 754 women attending family planning clinics in the San Francisco Bay Area. A majority of respondents reported lifetime experiences of sexism (e.g., 94% reported sexual harassment). Structural equation modeling results demonstrated that experiences of sexism and reports of recent unprotected sex with a primary or a secondary sexual partner were linked through psychological distress and difficult sexual situations. Our results suggest the need to develop HIV prevention strategies for women that address two mechanisms-psychological distress and difficult sexual situations-that link social discrimination to women's sexual risk for HIV.     

An examination of knowledge, attitudes and practices related to HIV/AIDS prevention in Zimbabwean university students: comparing intervention program participants and non-participants.

OBJECTIVES: This study represents a comprehensive assessment of differences between participants in an HIV/AIDS prevention program (SHAPE: Sustainability, Hope, Action, Prevention, Education) and non-participants in knowledge, attitudes and practices with a focus on cultural, sociological and economic variables. METHODS: We developed an eight-page questionnaire that was administered to 933 randomly selected students at the University of Zimbabwe. Survey items addressed sexual decision-making, condom use, limiting sexual partners, cultural power dynamics and access to HIV testing. RESULTS: Results show participants are statistically more likely to report being sexually abstinent, and understand the prevention benefits of condom use. SHAPE members had fewer sexual partners in the previous year than non-SHAPE members (1.4 vs. 2.2). SHAPE members were significantly more likely (67%) than non-SHAPE respondents (48%) to indicate that they knew their HIV sero-status and to state that they knew their status because they had been tested (85% vs. 71%). DISCUSSION: Though we found differences between the groups suggesting that program participation increases awareness concerning gender equity, there continue to be many intractable cultural attitudes in this age group. Findings suggest that the attitudes and practices of young men and women are changing, but that progress in some areas does not assure progress in all areas.     

Sexual risk reduction needs of adolescents living with HIV in a clinical care setting

As anti-retroviral therapy becomes increasingly available, young people living with HIV need tailored support to adopt healthy sexual behaviors. There has been a gap in the availability of culturally appropriate techniques for secondary prevention and sexual risk reduction in this target group. This formative study assessed sexual and reproductive health needs and problems, as well as determinants of sexual risk-taking among young people living with HIV aged 11-21 years attending the Paediatric Infectious Disease Clinic in Kampala, Uganda. Theoretical guidance was provided by the Information-Motivation-Behavioral Skills Model. Socio-demographic and selected psychosexual data were assessed using a brief anonymous questionnaire. A total of 75 young people living with HIV participated in eight focus group discussions. In addition, one focus group was conducted with adult key informants (service providers). About a quarter of the young participants reported prior or current sexual experience. The study revealed knowledge gaps relating to reproductive health, HIV transmission, and contraceptive methods. Motivations for protection included hope for the future, good counseling, and fear of the consequences of sexual activity such as unwanted pregnancies. Barriers to adopting preventive behaviors included peer pressure, poverty, HIV-related stigma, ignorance of their partners, alcohol use, and a desire to have children for the older ones. Young sero-positive people in this setting lacked specific behavioral skills, such as disclosure of HIV status to their sexual partners, this being closely linked to fear of rejection and stigma. HIV-positive youths need support in developing the appropriate behavioral skills to adopt healthy sexual behaviors. Interventions in this field need to be developmentally appropriate and tailored to young people's specific needs. Structural interventions should at the same time address and reduce HIV-related stigma and socio-economic needs of young people living with HIV.     

HIV-testing behavior among young migrant men who have sex with men (MSM) in Beijing, China

Previous studies suggested a rapid increase of HIV prevalence among men who have sex with men (MSM) in China in recent years, from 0.4% in 2004 to 5.8% in 2006. However, some MSM had never been tested for HIV. In order to expand the accessibility to HIV testing, understanding HIV-testing behavior and barriers among MSM is important. Using data collected from 307 young migrant MSM (aged 18-29 years) in 2009 in Beijing, we aimed to identify psychological and structural barriers to HIV testing. MSM were recruited through peer outreach, informal social networks, Internet outreach, and venue-based outreach. Participants completed a confidential self-administered questionnaire. Results show that about 72% of MSM ever had an HIV test. Logistic regression analysis indicated that the HIV-testing behavior was associated with sexual risk behaviors (e.g., multiple sexual partners and inconsistent condom use for anal sex) and history of sexually transmitted diseases. Eighty four MSM (28%) who never had an HIV test reported that the psychological barriers mainly were perceived low risk of HIV infection and fears of being stigmatized. The structural barriers reported inconvenience of doing test and lack of confidentiality. Future HIV prevention programs should be strengthened among MSM to increase their awareness of HIV risk. Efforts are needed to increase access to quality and confidential HIV testing among MSM and reduce stigma against MSM.     

Constructions of sexuality and HIV risk among young people in Venda,South Africa: implications for HIV prevention

The study explored constructions of sexuality among young people of Venda in Limpopo, South Africa, and cultural practices that can be used to develop context-specific HIV prevention programmes. HIV prevention can be promoted by including some cultural practices in prevention programmes and changing some aspects of culture that may contribute negatively to health. Six focus group discussions were held with school-going young people (Grades 10 to 12) in urban and rural areas to explore their constructions of sexuality and HIV risk. Four focus group discussions were held with community leaders in the same areas to explore their constructions of young people’s sexuality and cultural practices relevant to HIV prevention. Through discourse analysis, the following dominant discourses that influence young people’s sexual risk behaviour were identified: rite of passage, the male sexual drive discourse (sex is natural and unavoidable); discourse of hegemonic masculinity (sex to prove masculinity); sex as a commodity; non-adherence to cultural practices; and HIV is normalised (AIDS is like flu). Some alternative constructions and shifts in gender norms were noticed, especially among female participants. The constructions of young people were not culture-specific but similar to those identified in other South African cultures. Community leaders identified a few cultural practices that could be considered in HIV prevention, for example, reinstating the rite of passage to provide age-appropriate sex and HIV education (behavioural intervention), and promoting traditional male circumcision (biological intervention). Cultural practices that contribute negatively to health should be challenged such as current constructions of gender roles (masculinity and femininity) and the practice that parents do not talk to young people about sex (both structural interventions).     

Stakeholder acceptability of adolescent participation in clinical trials for biomedical HIV prevention products: considerations from Tanzania and India

Researchers and advocates have increasingly called for adolescent participation in clinical trials for new HIV prevention products, particularly adolescent girls in areas most affected by the epidemic. However, recent trials have highlighted the challenges for young women and adolescents to be able to effectively use new products that require daily dosing. This analysis provides a highly relevant context for this challenging environment by examining community members acceptability of adolescent girls’ participation in clinical trials for new HIV prevention products. We conducted 41 in-depth interviews in Dar es Salaam, Tanzania and Pune, India with 22 key informants (KIs). Cultural perspectives on adolescent sexuality varied between countries, with KIs in Tanzania more readily acknowledging adolescent girls’ sexual activity than KIs in India. KIs in both countries felt strongly adolescents must be well-informed about research concepts prior to participation, and emphasis should be given to preventative misconception. Despite concern in both countries that the trials might be seen as encouraging sexual behavior, KIs in Tanzania overwhelmingly supported adolescent inclusion, whereas KIs in India were more cautious. Involving adolescent girls in clinical trials for new HIV prevention products is potentially acceptable, although meaningful community engagement will be necessary.     

ARVs and cash too: caring and supporting people living with HIV/AIDS with the Malawi Social Cash Transfer

Objectives The Malawian Social Cash Transfer Scheme (SCT) is a social protection programme for ultra poor and labour‐constrained households, including people living with HIV/AIDS (PLWHA). We aimed to gain insight into respondents’ circumstances prior to becoming transfer beneficiaries and to examine how PLWHA used transfers to support themselves and their families. Methods We conducted 24 semi‐structured qualitative interviews with PLWHA who were also SCT beneficiaries and living in villages where the scheme was operational in 2008. Results Respondents were destitute and lacked food and basic necessities prior to the transfer. As cash recipients, the majority of respondents reported positive impacts on health, food security and economic well‐being as well as an improved ability to care for their families. Conclusion Important unanswered programmatic questions persist, such as ‘What is the appropriate transfer level?’ And ‘Should recipients graduate from the scheme?’ Moreover, the scheme’s long‐term sustainability is still unclear. Nevertheless, this analysis presents evidence describing how PLWHA used cash transfers to improve their situation and mitigate the impact of HIV/AIDS on families.