Cash Transfers, Young Women’s Economic Well-Being, and HIV Risk: Evidence from HPTN 068

Abstract

Despite the large interest in economic interventions to reduce HIV risk, little research has been done to show whether there are economic gains of these interventions for younger women and what intermediary role economic resources play in changing participants’ sexual behavior. This paper contributes to this gap by examining the impacts of a conditional cash transfer (CCT) for young women in South Africa on young women’s economic resources and the extent to which they play a role in young women’s health and behavior. We used data from HIV Prevention Trials Network 068 study, which provided transfers to young women (in addition to their parents) conditional on the young woman attending at least 80% of school days in the previous month. We found that the CCT increased young women’s economic wellbeing in terms of having savings, spending money, being unindebted, and food secure. We also investigated heterogeneous effects of the program by household economic status at baseline because the program was not specifically poverty targeted and found that the results were driven by young women from the poorest families. From these results, we examined heterogeneity by baseline poverty for other outcomes related to HIV risk including sexual behavior and psychosocial well-being. We found psychosocial well-being benefits in young women from the poorest families and that economic wellbeing gains explained much these impacts.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

Notes

  1. 1.

    The CES-D was not included in the baseline survey so we show baseline descriptive data for the 10-item Children’s Depression Index (cite) in Table 1.

  2. 2.

    3.4% of control group also reported the CCT as their main source of money. This data could be due to misreporting, but as there were reports of young women in the treatment group sharing their money with friends and siblings, this may reflect those allocations.

  3. 3.

    Less than half of women report being sexual active during the trial, however, of the women that report having a partner, the majority report that they received money at some point from their partner.

  4. 4.

    Results look the same for the resource index with no paid work.

References

  1. 1.

    Levine R, Lloyd B, Greene ME, Grown C. Girls count: a global investment & action agenda. https://www.icrw.org/wp-content/uploads/2016/10/Girls-Count-A-global-Investment-and-Action-Agenda.pdf (2009).

  2. 2.

    Jones N, Harper C, Watson C, Espey J, Wadugodapitiya D, Page E et al. Stemming girls’ chronic poverty: catalysing development change by building just social institutions (SSRN scholarly paper no. ID 1719613). Rochester: Social Science Research Network. https://papers.ssrn.com/abstract=1719613 (2010).

  3. 3.

    UNICEF. The state of the World’s children 2011: adolescence—an age of opportunity. New York: UNICEF; 2011.

    Google Scholar 

  4. 4.

    Wojcicki JM. Socioeconomic status as a risk factor for HIV infection in women in east, central and southern Africa: a systematic review. J Biosoc Sci. 2005;37(1):1–36. https://doi.org/10.1017/S0021932004006534.

    Article  PubMed  Google Scholar 

  5. 5.

    Kim J, Pronyk P, Barnett T, Watts C. Exploring the role of economic empowerment in HIV prevention. AIDS. 2008;22:S57. https://doi.org/10.1097/01.aids.0000341777.78876.40.

    Article  PubMed  Google Scholar 

  6. 6.

    Gillespie S, Kadiyala S, Greener R. Is poverty or wealth driving HIV transmission? AIDS. 2007;21:S5. https://doi.org/10.1097/01.aids.0000300531.74730.72.

    Article  PubMed  Google Scholar 

  7. 7.

    Harrison A, Colvin CJ, Kuo C, Swartz A, Lurie M. Sustained high HIV incidence in young women in Southern Africa: social, behavioral, and structural factors and emerging intervention approaches. Curr HIV/AIDS Rep. 2015;12(2):207–15. https://doi.org/10.1007/s11904-015-0261-0.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Shisana O, Rehle T, Simbayi LC, Zuma K, Jooste S, Zungu N, Labadarios D, Onoya D, et al. South African national HIV prevalence, incidence and behaviour survey, 2012. Cape Town: HSRC Press; 2014.

    Google Scholar 

  9. 9.

    UNAIDS. 2016-prevention-gap-report_en.pdf. http://www.unaids.org/sites/default/files/media_asset/2016-prevention-gap-report_en.pdf (n.d.).

  10. 10.

    Luke N. Age and economic asymmetries in the sexual relationships of adolescent girls in sub-Saharan Africa. Stud Fam Plan. 2003;34(2):67–86.

    Article  Google Scholar 

  11. 11.

    Karim QA, Sibeko S, Baxter C. Preventing HIV infection in women: a global health imperative. Clin Infect Dis. 2010;50(Supplement_3):S122–9. https://doi.org/10.1086/651483.

    Article  Google Scholar 

  12. 12.

    MacPhail C, Campbell C. “I think condoms are good but, aai, I hate those things”: condom use among adolescents and young people in a Southern African township. Soc Sci Med (1982). 2001;52(11):1613–27.

    Article  CAS  Google Scholar 

  13. 13.

    Kaufman CE, Stavrou SE. ‘Bus fare please’: the economics of sex and gifts among young people in urban South Africa. Cult Health Sex. 2004;6(5):377–91. https://doi.org/10.1080/13691050410001680492.

    Article  Google Scholar 

  14. 14.

    Jennings L, Mathai M, Linnemayr S, Trujillo A, Mak’anyengo M, Montgomery BEE, Kerrigan DL. Economic context and HIV vulnerability in adolescents and young adults living in urban slums in kenya: a qualitative analysis based on scarcity theory. AIDS Behav. 2017;21(9):2784–98. https://doi.org/10.1007/s10461-017-1676-y.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Leclerc-Madlala S. Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability. AIDS. 2008;22:S17. https://doi.org/10.1097/01.aids.0000341774.86500.53.

    Article  PubMed  Google Scholar 

  16. 16.

    Harrison A, Cleland J, Frohlich J. Young people’s sexual partnerships in KwaZulu-Natal, South Africa: patterns, contextual influences, and HIV risk. Stud Fam Plann. 2008;39(4):295–308. https://doi.org/10.1111/j.1728-4465.2008.00176.x.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Luke N. Confronting the “sugar daddy” stereotype: age and economic asymmetries and risky sexual behavior in Urban Kenya. Int Fam Plan Perspect. 2005;31(1):6–14.

    Article  PubMed  Google Scholar 

  18. 18.

    Biello KB, Sipsma HL, Ickovics JR, Kershaw T. Economic dependence and unprotected sex: the role of sexual assertiveness among young urban mothers. J Urban Health. 2010;87(3):416–25. https://doi.org/10.1007/s11524-010-9449-1.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Dunkle RKJ, Brown HC, Gray GE, McIntryre JA, Harlow SD. Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection. Soc Sci Med. 2004;59(8):1581–92. https://doi.org/10.1016/j.socscimed.2004.02.003.

    Article  PubMed  Google Scholar 

  20. 20.

    Jewkes R, Dunkle K, Nduna M, Shai NJ. Transactional sex and HIV incidence in a cohort of young women in the stepping stones trial. J AIDS Clin Res. 2012. https://doi.org/10.4172/2155-61131000158.

    Article  Google Scholar 

  21. 21.

    Krishnan S, Dunbar MS, Minnis AM, Medlin CA, Gerdts CE, Padian NS. Poverty, gender inequities, and women’s risk of human immunodeficiency virus/AIDS. Ann N Y Acad Sci. 2008;1136:101–10. https://doi.org/10.1196/annals.1425.013.

    Article  Google Scholar 

  22. 22.

    Ashburn K, Warner A. Can economic empowerment reduce vulnerability of girls and young women to HIV? https://www.icrw.org/publications/can-economic-empowerment-reduce-vulnerability-of-girls-and-young-women-to-hiv/ (2010).

  23. 23.

    Heise L, Lutz B, Ranganathan M, Watts C. Cash transfers for HIV prevention: considering their potential. J Int AIDS Soc. 2013;16:18615. https://doi.org/10.7448/ias.16.1.18615.

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Pettifor A, MacPhail C, Nguyen N, Rosenberg M. Can money prevent the spread of HIV? A review of cash payments for HIV prevention. AIDS Behav. 2012;16(7):1729–38. https://doi.org/10.1007/s10461-012-0240-z.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Reed E, West BS, Salazar M, Monroy RV. Economic empowerment to improve sexual and reproductive health among women and girls. In: Global perspectives on women’s sexual and reproductive health across the lifecourse. Cham: Springer; 2018. p. 297–315. https://doi.org/10.1007/978-3-319-60417-6_17.

  26. 26.

    Tenkorang EY, Maticka-Tyndale E, Rajulton F. A multi-level analysis of risk perception, poverty and sexual risk-taking among young people in Cape Town, South Africa. Health Place. 2011;17(2):525–35.

    Article  PubMed  Google Scholar 

  27. 27.

    Thornton R. or 2010)? Sexual networks and social capital: multiple and concurrent sexual partnerships as a rational response to unstable social networks. Afr J AIDS Res. 2009;8(4):413–21. https://doi.org/10.2989/AJAR.2009.8.4.5.1042.

    Article  PubMed  Google Scholar 

  28. 28.

    Loevinsohn M, Gillespie SR. HIV/AIDS, food security and rural livelihoods: understanding and responding. Washington, DC: IFPRI. https://core.ac.uk/download/pdf/6289494.pdf (2003).

  29. 29.

    Nyanzi B, Nyanzi S, Wolff B, Whitworth J. Money, men and markets: economic and sexual empowerment of market women in southwestern Uganda. Cult Health Sex. 2005;7(1):13–26. https://doi.org/10.1080/13691050410001731099.

    Article  PubMed  Google Scholar 

  30. 30.

    Mumah JN, Jackson-Smith D. Why are the benefits of increased resources not impacting the risk of HIV infection for high SES women in Cameroon? PLoS ONE. 2014;9(6):e100507. https://doi.org/10.1371/journal.pone.0100507.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Jennings L, Pettifor A, Hamilton E, Ritchwood TD, Gómez-Olivé FX, MacPhail C, et al. Economic resources and HIV preventive behaviors among school-enrolled young women in rural South Africa (HPTN 068). AIDS Behav. 2017;21(3):665–77. https://doi.org/10.1007/s10461-016-1435-5.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet. 2006;368(9551):1973–83. https://doi.org/10.1016/S0140-6736(06)69744-4.

    Article  PubMed  Google Scholar 

  33. 33.

    Ssewamala FM, Han C-K, Neilands TB, Ismayilova L, Sperber E. Effect of economic assets on sexual risk-taking intentions among orphaned adolescents in Uganda. Am J Public Health. 2010;100(3):483–8. https://doi.org/10.2105/AJPH.2008.158840.

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Ssewamala FM, Ismayilova L, McKay M, Sperber E, Bannon W, Alicea S. Gender and the effects of an economic empowerment program on attitudes toward sexual risk-taking among AIDS-orphaned adolescent youth in Uganda. J Adolesc Health. 2010;46(4):372–8. https://doi.org/10.1016/j.jadohealth.2009.08.010.

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Taaffe J, Cheikh N, Wilson D. The use of cash transfers for HIV prevention—are we there yet? Afr J AIDS Res. 2016;15(1):17–25. https://doi.org/10.2989/16085906.2015.1135296.

    Article  PubMed  Google Scholar 

  36. 36.

    Dunbar MS, Dufour M-SK, Lambdin B, Mudekunye-Mahaka I, Nhamo D, Padian NS. The SHAZ! project: results from a pilot randomized trial of a structural intervention to prevent HIV among adolescent women in Zimbabwe. PLoS ONE. 2014;9(11):e113621. https://doi.org/10.1371/journal.pone.0113621.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Baird S, Chirwa E, McIntosh C, Özler B. The short-term impacts of a schooling conditional cash transfer program on the sexual behavior of young women. Health Econ. 2010;19(S1):55–68.

    Article  PubMed  Google Scholar 

  38. 38.

    Baird SJ, Garfein RS, McIntosh CT, Özler B. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet. 2012;379(9823):1320–9.

    Article  PubMed  Google Scholar 

  39. 39.

    Pettifor A, MacPhail C, Hughes JP, Selin A, Wang J, Gómez-Olivé FX, et al. The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial. Lancet Glob Health. 2016;4(12):e978–88.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    MacPhail C, Khoza N, Selin A, Julien A, Twine R, Wagner RG, et al. Cash transfers for HIV prevention: what do young women spend it on? Mixed methods findings from HPTN 068. BMC Public Health. 2017;18:10. https://doi.org/10.1186/s12889-017-4513-3.

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Kahn K, Collinson MA, Gómez-Olivé FX, Mokoena O, Twine R, Mee P, et al. Profile: agincourt health and socio-demographic surveillance system. Int J Epidemiol. 2012;41(4):988–1001. https://doi.org/10.1093/ije/dys115.

    Article  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Gómez-Olivé FX, Angotti N, Houle B, Klipstein-Grobusch K, Kabudula C, Menken J, et al. Prevalence of HIV among those 15 and older in rural South Africa. AIDS Care. 2013;25(9):1122–8. https://doi.org/10.1080/09540121.2012.750710.

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Baird S, de Hoop J, Özler B. Income shocks and adolescent mental health. J Hum Resour. 2013;48(2):370–403. https://doi.org/10.3368/jhr.48.2.370.

    Article  Google Scholar 

  44. 44.

    Ssewamala FM, Neilands TB, Waldfogel J, Ismayilova L. The impact of a comprehensive microfinance intervention on depression levels of AIDS-orphaned children in Uganda. J Adolesc Health. 2012;50(4):346–52. https://doi.org/10.1016/j.jadohealth.2011.08.008.

    Article  PubMed  Google Scholar 

  45. 45.

    Ssewamala FM, Han CK, Neilands TB. Asset ownership and health and mental health functioning among AIDS-orphaned adolescents: findings from a randomized clinical trial in rural Uganda. Soc Sci Med. 2009;69(2):191–8.

    Article  PubMed  PubMed Central  Google Scholar 

  46. 46.

    Pulerwitz J, Gortmaker SL, DeJong W. Measuring sexual relationship power in HIV/STD research. Sex Roles. 2000;42(7–8):637–60. https://doi.org/10.1023/A:1007051506972.

    Article  Google Scholar 

  47. 47.

    Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet. 2004;363(9419):1415–21.

    Article  PubMed  Google Scholar 

  48. 48.

    Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401. https://doi.org/10.1177/014662167700100306.

    Article  Google Scholar 

  49. 49.

    Abler L, Hill L, Maman S, DeVellis R, Twine R, Kahn K, et al. Hope matters: developing and validating a measure of future expectations among young women in a high HIV prevalence setting in rural South Africa (HPTN 068). AIDS Behav. 2017;21(7):2156–66. https://doi.org/10.1007/s10461-016-1523-6.

    Article  PubMed  PubMed Central  Google Scholar 

  50. 50.

    Bedoya, G., Bittarello, L., Davis, J., & Mittag, N. (2017). Distributional impact analysis. World Bank policy research working paper 8139.

  51. 51.

    Keele L, Tingley D, Yamamoto T. Identifying mechanisms behind policy interventions via causal mediation analysis. J Policy Anal Manag. 2015;34(4):937–63.

    Article  Google Scholar 

  52. 52.

    Inson MA, White MJ, Ginsburg C, Gómez-Olivé FX, Kahn K, Tollman S. Youth migration, livelihood prospects and demographic dividend: a comparison of the Census 2011 and Agincourt Health and Demographic Surveillance System in the rural northeast of South Africa. Afr Popul Stud. 2016;30(2 Suppl):2629–39.

    Google Scholar 

  53. 53.

    Stats SA. Poverty trends in South Africa: an examination of absolute poverty between 2006 and 2011. Pretoria: Stat South Africa; 2014.

    Google Scholar 

  54. 54.

    Dunbar MS, Maternowska C, Kang M-SJ, Laver SM, Mudekunye I, Padian NS. Findings from SHAZ!: a feasibility study of a microcredit and life-skills HIV prevention intervention to reduce risk among adolescent female orphans in Zimbabwe. J Prev Interv Commun. 2010;38(2):147–61. https://doi.org/10.1080/10852351003640849.

    Article  Google Scholar 

  55. 55.

    Baird S, McIntosh C, Özler B. Cash or condition? Evidence from a cash transfer experiment. Q J Econ. 2011;126(4):1709–53.

    Article  Google Scholar 

  56. 56.

    Bastagli F, Hagen-Zanker J, Harman L, Barca V, Sturge G, Schmidt T, Pellerano L. Cash transfers: what does the evidence say. A rigorous review of programme impact and the role of design and implementation features. London: ODI; 2016.

    Google Scholar 

Download references

Funding

Funding support for the HPTN was provided by the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute of Mental Health (NIMH), and the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH; Award Numbers UM1AI068619 [HPTN Leadership and Operations Center], UM1AI068617 [HPTN Statistical and Data Management Center], and UM1AI068613 [HPTN Laboratory Center]. The study was also funded under R01MH110186, R01MH087118, and R24 HD050924 to the Carolina Population Center. Research reported in this publication was also supported by the NIAID of the NIH [Award Number T32AI007001]. Additional funding was provided by the Division of Intramural Research, NIAID, and NIH. The Agincourt Health and Socio-Demographic Surveillance System is supported by the University of the Witwatersrand, the Medical Research Council, South Africa and the Wellcome Trust, UK (Grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; and 085477/B/08/Z).

Author information

Affiliations

Authors

Corresponding author

Correspondence to Kelly Kilburn.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Appendix

Appendix

See Figs. 3 and 4 and Tables 6 and 7.

Fig. 3
figure3

Cumulative distribution functions (CDFs) for the economic index. CDFs show the cumulative distribution of the economic index separately for treatment and control arms across baseline and follow-up visits. Panel 1 shows the distributions for full sample, while panels 2 and 3 divide the sample by baseline poverty status (panel 2, bottom half; panel 3, top half)

Fig. 4
figure4

Marginal effects for the impact of the CCT on young women’s economic participation and resources. Notes Marginal effects for the total treatment effect and by baseline poverty status (top or bottom half). Estimates provided with 95% confidence interval bars (insignificant results cross the vertical line at 0)

Table 6 Baseline comparison between young women from the poorest (bottom half) of households to the top half at baseline
Table 7 Impacts of CCT on Young women’s economic resources and moderation by baseline poverty

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kilburn, K., Hughes, J.P., MacPhail, C. et al. Cash Transfers, Young Women’s Economic Well-Being, and HIV Risk: Evidence from HPTN 068. AIDS Behav 23, 1178–1194 (2019). https://doi.org/10.1007/s10461-018-2329-5

Download citation

Keywords

  • Adolescent girls and young women
  • South Africa
  • Economic empowerment
  • Cash transfers
  • Psychosocial well-being