Objectives: It is not known whether cumulative ‘cash plus care’ interventions can
reduce adolescent HIV-infection risks in sub-Saharan Africa. This study investigated
whether parental AIDS and other environmental adversities increase adolescent HIVrisk
behaviour and whether social protection provision of ‘cash’ or integrated ‘cash plus
care’ reduces HIV-risk behaviour.
Design: A prospective observational study with random sampling (<2.5% baseline
refusal, 1-year follow-up, 96.8% retention).
Methods: Three thousand five hundred and fifteen 10–18 year-olds (56.7% girls) were
interviewed in South Africa between 2009–2010 and 2011–2012. All homes with a
resident adolescent were sampled, within randomly selected census areas in two urban
and two rural districts in two provinces. Measures included potential environmental
risks (e.g. parental HIV/AIDS, poverty), social protection: receipt of cash/food support
(e.g. child grants, school feeding), care (e.g. positive parenting) and HIV-risk behaviours
(e.g. unprotected sex). Analyses used logistic regression.
Results: Cash alone was associated with reduced HIV risk for girls [odds ratio (OR)
0.63; 95% confidence interval (95% CI) 0.44–0.91, P ¼ 0.02] but not for boys.
Integrated cash plus care was associated with halved HIV-risk behaviour incidence
for both sexes (girls OR 0.55; 95% CI 0.35–0.85, P ¼ 0.007; boys OR 0.50; 95% CI
0.31–0.82, P ¼ 0.005), compared with no support and controlling for confounders.
Follow-up HIV-risk behaviour was reduced from 41 to 15% for girls and from 42 to 17%
for boys. Girls in AIDS-affected families and informal-dwelling boys had higher HIV-risk
behaviour, but were less likely to access integrated social protection.
Conclusion: Integrated cash plus care reduces male and female adolescent HIV-risk
behaviours. Increasing adolescent access to social protection may be an effective HIV
prevention strategy in Sub-Saharan Africa.