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Conditional Cash Transfers

School-based sexuality programmes fail to demonstrate an influence on STI and pregnancy outcomes

7 Dec, 16 | by Leslie Goode, Blogmaster

The 2016 UNAIDS Report – Get on the Fast Track: a Life-Cycle Approach to STI Prevention/STI/blogs – underlines the particular vulnerability to infection of women at a relatively early phase of the life-cycle, especially in limited resource settings such as sub-Saharan Africa as a result of structural factors .  These can seem intractable, but the authors of the report propose a number of practical measures for this group that include sexuality education in schools, social transfers and PrEP.  So the recent publication of a Cochrane Review of studies assessing the effectiveness of two of these interventions – sexuality education in schools and social transfers in the form of material incentives for girls to remain in school – is very timely – especially as five of the eight studies included in the analysis are based in the limited resource settings of sub-Saharan Africa that are the focus of the UNAIDS report.

A number of both European and non-European countries have incorporated some form of sexuality education into their school syllabuses, and there have been attempts to investigate their effectiveness in a number of places, including the UK (Stephenson & Johnson/STIs; Stephenson & Oakley; Henderson & Hart).  Unfortunately many of these trials rely on self-reported data, a tendency that has been shown to be problematic in this area (Langhaug & Cowan/STIs; Plummer & Hayes/STIs). The importance of the recent Cochrane Review is that it focuses largely on biological outcomes: namely, rates of STIs and pregnancy at follow-up.  The studies of sexuality education that are based on these outcomes have been undertaken in sub-Saharan Africa: Ross & Hayes (R&H,Tanzania); Cowan & Pascoe (C&P, Zimbabwe); Duflo & Kremer (D&K, Kenya). The same applies to studies of social transfers based on biological outcomes (Baird & Oezler (B&O) and Duflo & Kremer (D&K)).  (The non-African studies in the analysis use pregnancy prevalence as their preferred outcome (Cabezon & Garcia (C&G, Chile); Stephenson & Oakley (S&O, England); Henderson & Hart) (H&H, Scotland)).)

So what biological evidence do we find of the effectiveness of school-based education interventions? Practically none, say the reviewers.  No difference was reported between intervention and control groups for HIV or for other STIs – except in the case of R&H for syphilis prevalence at the end of follow up (RR 0.81: CI 0.47-1.39).  Even the statistically significant aggregate outcome for long-term pregnancy prevalence (0.55: CI 0.34-0.91) (C&G, S&O, H&H, D&K) seems largely accounted for by the results of C&G, which were at particularly high risk of bias.  When the latter were excluded, differences in pregnancy prevalence dropped to 0.93.

When it came to the other element of this survey, social transfers (B&O and K&K), only B&O reported a significant effect for HIV prevalence and HSV-2 prevalence.  This evidence was considered weak because, in the former case, it concerned data for school ‘drop-outs’ which, say the reviewers, the B&O study was not powered to detect, and, in the latter, because there was no measurement of prevalence at baseline.  As for pregnancy outcomes, both studies reported a reduction in short-term prevalence (0.76).

The trials of educational interventions may simply have been underpowered to detect small, but clinically important effects (especially with HIV).  On the other hand, the authors of the review also point to a growing consensus among experts that the determinants of sexual health outcomes and sexual risk-taking are wider structural factors such as poverty and cultural gender norms that lie beyond the capacity of school-based education programmes to influence.  The evidence for the effectiveness of incentives to stay at school, though as yet very inadequate, seems more encouraging.  This is evidently a field that requires further research.

Living dangerously in the Dominican Republic and Mexico City: can cash transfer payments be used to counteract the “risk premium”?

17 Dec, 14 | by Leslie Goode, Blogmaster

The Caribbean has the highest levels of HIV outside sub-Saharan Africa – and the Dominican Republic (DR), which together with Haiti accounts for 70% of all people living with HIV in the Caribbean region, is a hotspot.  While there has been a 73% reduction in the rate of new infections in the DR between 2001 and 2011, prevalence of HIV remains high among key populations of MSM (6%) and female sex-workers (3%).  A recent qualitative study has sought to investigate the relations between the drug trade, sex tourism, and risk taking which may hold the secret of the obstinately high-levels of HIV in these key populations (Guillamo-Ramos & Robles).  In-depth interviews, along with drug screening, were conducted with 30 local drug users in Sosua, known for its tourist sex industry.

Three major themes emerge.  First, drugs are freely available as a result of diversion from the major drug routes running from N to S America through the DR.  Second, they have become integral to the local tourist industry – specifically as a vital component of sex work.  Third, the engagement of locals, along with tourists, in commercial sex fuelled by drug use gives rise to the kind high-risk behaviours that sustain the spread of HIV in the local population.

What, from the public health angle, seems particularly challenging in this situation is that the element of risk-taking isn’t merely an incidental effect of the sexual activity; it is precisely the element that makes that activity attractive, and – from the locals’ point of view – lucrative.  Participants associate sex work and drug use with improved livelihood, and describe how risk behaviours are part of the economic negotiating process.

This is the same general kind of problem described in the reported base-line study of a pilot trial of an intervention among male sex workers in Mexico City (STI/Galarraga & Sosa-Rubi).  These male sex-workers are at particular risk of infection because they receive market-based inducements from clients to engage in condomless sex.  It is not simply that MSW are neglecting to take precautions; the average price for a sex transaction is 35% higher for condomless sex – and, given MSW may be unemployed (16%), or dependent for their income on sex work (37%), the economic pressures to engage in unsafe practices are considerable.

The Punto Seguro pilot trial, based at the Clinica Condesa, an HIV centre in Mexico City, is considering as a potential solution the idea of a conditional cash transfer (CCT) whereby MSW are rewarded for keeping themselves free of curable STIs over a six-month period.  Within Mexico CCT has been employed, since the 1990s to provide incentives for poor people to keep their children in school, and to attend preventative check-ups, though not apparently in the sphere of HIV.  In the US, however, it has been used to prevent persistent STIs and pregnancy amongst the Latino population (STI/Minnis & Padian), in Pakistan to encourage infected men to disclose to their wives, and have them tested (STI/Khan & Khan).

The paper sets out the procedures and the baseline data for investigating the effectiveness of a form of this kind of intervention.  The 267 participants have been randomized to four groups: control; medium conditional incentive ($50); high conditional incentive ($75); unconditional incentive ($50). Previous formative work established the incentive levels necessary for behaviour change ($156 per year).  It is also hoped that CCT interventions may benefit participants by helping to link them into care – since of the participants in the trial who knew they were infected with HIV, only 40% were on treated, and of these, only 61% had achieved viral suppression.

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