Combination Social Protection for Reducing HIV-Risk Behavior Among Adolescents in South Africa

Abstract

Background: Social protection (ie, cash transfers, free schools, parental support) has potential for adolescent HIV prevention. We aimed to identify which social protection interventions are most effective and whether combined social protection has greater effects in South Africa.

Methods: In this prospective longitudinal study, we interviewed 3516 adolescents aged 10-18 between 2009 and 2012. We sampled all homes with a resident adolescent in randomly selected census areas in 4 urban and rural sites in 2 South African provinces. We measured household receipt of 14 social protection interventions and incidence of HIV-risk behaviors. Using gender-disaggregated multivariate logistic regression and marginal effects analyses, we assessed respective contributions of interventions and potential combination effects.

Results: Child-focused grants, free schooling, school feeding, teacher support, and parental monitoring were independently associated with reduced HIV-risk behavior incidence (odds ratio: 0.10-0.69). Strong effects of combination social protection were shown, with cumulative reductions in HIV-risk behaviors. For example, girls' predicted past-year incidence of economically driven sex dropped from 11% with no interventions to 2% among those with a child grant, free school, and good parental monitoring. Similarly, girls' incidence of unprotected/casual sex or multiple partners dropped from 15% with no interventions to 10% with either parental monitoring or school feeding, and to 7% with both interventions.

Conclusion: In real world, high-epidemic conditions, "combination social protection," shows strong HIV prevention effects for adolescents and may maximize prevention efforts.

Figure 1. Predicted incidence of incautious sex among adolescent boys (n=1170)

All analyses controlled for the following variables at Time 1: incautious sex, age, food insecurity, informal housing, urban location, school non-enrolment, migration, number of children in the home, female primary caregiver, maternal and paternal orphanhood, and having a birth certificate. We also controlled for HIV knowledge, measured at Time 2. Error bars are 95% confidence intervals.

Figure 2. Predicted incidence of HIV-risk behaviors among adolescent girls (n=1498)

For incautious sex (A), economically-driven sex (B), and pregnancy (C). All analyses controlled for the following variables at Time 1: sexual risk behavior, age, food insecurity, informal housing, urban location, school non-enrolment, migration, number of children in the home, female primary caregiver, maternal and paternal orphanhood, and having a birth certificate. We also controlled for HIV knowledge, measured at Time 2. Analysis of pregnancy as an outcome controlled for receipt of a child support or foster child grant at Times 1 and 2. Error bars are 95% confidence intervals.