Cash Incentives Fail to Prevent HIV in Impoverished Girls

Pam Harrison

July 28, 2015

VANCOUVER, British Columbia — Paying parents and guardians to make sure that girls in South Africa attend high school at least 80% of the time failed to reduce the incidence of HIV infection, results from the HPTN 068 study indicate.

"It's not what we expected at all," said Audrey Pettifor, PhD, from the University of North Carolina at Chapel Hill. There was no difference in school attendance rates for girls who received money and those who did not.

"It's really puzzling," Dr Pettifor said. "There is lot of literature showing that cash keeps girls in school, and there is also literature showing that school is protective against HIV acquisition."

HPTN 068 was designed to evaluate the effect of conditional cash transfers on the incidence of HIV in young women 13 to 20 years of age.

Results from the study, conducted in northeastern South Africa, a poor rural area with an extremely high prevalence of HIV, were presented here at the 8th International AIDS Society Conference.

Each month, participating families in the cash group received roughly $300 rand (about US$24) if the student attended school at least 80% of the time. The girls were followed until the end of the twelfth grade. Families in the control group received no cash.

At the end of the study, there was no significant difference in the incidence of HIV infection between the cash group and the control group (hazard ratio, 1.17; 95% confidence interval [CI], 0.80 - 1.72; P = .42).

Of the 107 incident infections documented during the study, there were 59 in the cash group and 48 in the control group, for an overall HIV incidence of 1.8%.

It's not what we expected at all.

"Contrary to what we expected, there was no significant difference in school or permanent school dropout rates out by study arm," Dr Pettifor explained.

However, "attendance was high — at 95% — in both study arms, and the permanent school dropout rate was low — at 3% — again in both study arms," she acknowledged.

Still, as the investigators hypothesized, school enrolment and attendance were protective against HIV acquisition, irrespective of study group.

In fact, girls who dropped out of school were three times more likely to become infected with HIV than those who stayed in school during the study period, as were the girls who did not attend school at least 80% of the time.

The young women in the cash group were significantly less likely to have had a sex partner in the previous 12 months, to report unprotected sex in the previous 3 months, and to have experienced partner violence during the trial than those in the control group.

However, there was no difference in the age at which the girls became sexually active, the rate of having older partners, or the number of episodes of transactional sex between the two study groups, Dr Pettifor reported.

"Our primary thought was if we keep girls in school, we will decrease the risk of infection," she explained. But there was also a suggestion that cash would help prevent transactional sex, dependence on male partners, and risky behavior; "that was another mechanism by which we thought this cash transfer might work."

"Further analyses will allow us to establish factors that might explain the high-school attendance we observed in the study and the mechanisms through which schooling was protective against HIV," she pointed out.

This study took place in a setting characterized by high levels of poverty and, in this context, cash transfers can significantly help alleviate poverty. In fact, payment has played a key role in social protection in many settings, including South Africa.

Dr Pettifor speculated that cash transfers to keep girls in school might have a greater impact in settings where secondary school enrolment is low for young women.

In the meantime, HPTN 068 is ongoing, and the investigators are developing interventions to reduce HIV risk as young women transition out of high school and into a highly vulnerable period for HIV infection.


There is economic evidence to suggest that cash transfers to change behavior are both effective and cost-effective, said session comoderator David Wilson, MD, from the World Bank in Washington, DC.

"I don't think it should be done indiscriminately," he told Medscape Medical News, "but I think there are certainly occasions where it's worth looking at as an option."

In South Africa, for example, there are pockets where the incidence of HIV is very high, particularly among girls and young women.

"We continue to look at additional interventions that could help protect these girls, and one of them may be to combine the positive evidence on pre-exposure prophylaxis with incentives to take it," Dr Wilson suggested.

"Among people who are very impoverished, relatively small amounts of cash can present life-changing alternatives," he pointed out.

The HPTN 068 study was funded by the National Institute for Allergy and Infectious Diseases. Dr Pettifor has disclosed no relevant financial relationships.

8th International AIDS Society (IAS) Conference: Abstract TUAC0106LB. Presented July 21, 2015


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