Resourcing resilience: social protection for HIV prevention amongst children and adolescents in Eastern and Southern Africa

Abstract

Adolescents are the only age group with growing AIDS-related morbidity and mortality in Eastern and Southern Africa, making HIV prevention research among this population an urgent priority. Structural deprivations are key drivers of adolescent HIV infection in this region. Biomedical interventions must be combined with behavioural and social interventions to alleviate the socio-structural determinants of HIV infection. There is growing evidence that social protection has the potential to reduce the risk of HIV infection among children and adolescents. This research combined expert consultations with a rigorous review of academic and policy literature on the effectiveness of social protection for HIV prevention among children and adolescents, including prevention for those already HIV-positive. The study had three goals: (i) assess the evidence on the effectiveness of social protection for HIV prevention, (ii) consider key challenges to implementing social protection programmes that promote HIV prevention, and (iii) identify critical research gaps in social protection and HIV prevention, in Eastern and Southern Africa. Causal pathways of inequality, poverty, gender and HIV risk require flexible and responsive social protection mechanisms. Results confirmed that HIV-inclusive child-and adolescent-sensitive social protection has the potential to interrupt risk pathways to HIV infection and foster resilience. In particular, empirical evidence (literature and expert feedback) detailed the effectiveness of combination social protection particularly cash/in-kind components combined with “care” and “capability” among children and adolescents. Social protection programmes should be dynamic and flexible, and consider age, gender, HIV-related stigma, and context, including cultural norms, which offer opportunities to improve programmatic coverage, reach and uptake. Effective HIV prevention also requires integrated social protection policies, developed through strong national government ownership and leadership. Future research should explore which combinations of social protection work for sub-groups of children and adolescents, particularly those living with HIV.

Full text

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Resourcing resilience: social protection for HIV prevention amongst children and
adolescents in Eastern and Southern Africa
Elona Toska1 2 Lesley Gittings1 3 Rebecca Hodes1 Lucie D. Cluver3 4 Kaymarlin Govender5
KE Chademana6 Vincent Evans Gutiérrez3
1 AIDS and Society Research Unit, Centre for Social Science Research, University of Cape
Town, 4.26 Leslie Social Sciences Building,12 University Avenue, Rondebosch, Cape Town,
7701, Western Cape, South Africa
2 Centre for Evidence-Based Intervention, Department of Social Policy & Intervention,
University of Oxford Barnett House, 32 Wellington Square, Oxford, OX1 2ER, UK.
3 School of Public Health and Family Medicine, Division of Social and Behavioural
Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
4 Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote
Schuur Hospital, Observatory, Cape Town 7925, South Africa.
5 Health Economics and HIV and AIDS Research Division, University of KwaZulu Natal,
Westville Campus, Private Bag X54001, Durban, 4000, South Africa.
6 School of Public Health, University of the Western Cape, Private Bag X17 Bellville, Cape
Town, South Africa.
Corresponding author: Elona Toska Elona.toska@spi.ox.ac.uk
Acknowledgements: Research presented here was conducted within the Mzantsi Wakho
study, a collaboration of the Universities of Cape Town and Oxford. We thank participants,
particularly adolescents, families, healthcare workers, social service providers, and expert
stakeholders consulted for this study. Chris Colvin, Rajen Govender, Nompumelelo Zungu,
Caroline Kuo, Nicoli Nattrass, Izidora Skracic, Julia Rosenfeld, Paediatric AIDS Treatment
for Africa, and the UNICEF-ESARO/Transfer Project provided intellectual guidance and
support for this work.
Authorship: ET, LG, KG, LC and RH conceptualized the study together with the REPPSI and
RIATT-ESA team (Noreen Huni and Naume Kupe). LG, KEC and VG led the policy review.
LG conducted the expert consultations. ET, KEC and VG conducted the literature review.
LC, KG, and RH contributed content and writing support. All authors have read and
approved this manuscript.
Funding Statement: This work was supported by the Regional Inter-Agency Task Team on
Children and AIDS in Eastern and Southern Africa (RIATT-ESA), Nuffield Foundation under
Grant CPF/41513, the International AIDS Society through the CIPHER grant (155-Hod),
DFID’s Evidence for HIV Prevention in Southern Africa (EHPSA) programme, Janssen’s
Educational Grant programme, the Clarendon-Green Templeton College Scholarship, and
the Philip Leverhulme Trust (PLP-2014-095). Additional support for Lucie Cluver was
provided by the European Research Council (ERC) under the European Union's Seventh

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Framework Programme (FP7/2007-2013)/ ERC grant agreement n°313421. Additional
support for Rebecca Hodes was provided by South Africa’s National Research Foundation
and the University of Cape Town’s Humanities Faculty. Additional support for Lesley
Gittings was provided by the South African Social Science and HIV Programme (SASH),
funded by NIH Grant R24HD077976 and the South African National Research Foundation.

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Resourcing resilience: social protection for HIV prevention amongst children and
adolescents in Eastern and Southern Africa
Abstract
Adolescents are the only age group with growing AIDS-related morbidity and mortality in
Eastern and Southern Africa, making HIV prevention research among this population an
urgent priority. Structural deprivations are key drivers of adolescent HIV infection in this
region. Biomedical interventions must be combined with behavioural and social
interventions to alleviate the socio-structural determinants of HIV infection. There is
growing evidence that social protection has the potential to reduce the risk of HIV
infection among children and adolescents. This research combined expert consultations
with a rigorous review of academic and policy literature on the effectiveness of social
protection for HIV prevention among children and adolescents, including prevention for
those already HIV-positive. The study had three goals: (i) assess the evidence on the
effectiveness of social protection for HIV prevention, (ii) consider key challenges to
implementing social protection programmes that promote HIV prevention, and (iii)
identify critical research gaps in social protection and HIV prevention, in Eastern and
Southern Africa. Causal pathways of inequality, poverty, gender and HIV risk require
flexible and responsive social protection mechanisms. Results confirmed that HIV-
inclusive child- and adolescent-sensitive social protection has the potential to interrupt
risk pathways to HIV infection and foster resilience. In particular, empirical evidence
(literature and expert feedback) detailed the effectiveness of combination social
protection particularly cash/in-kind components combined with ‘care’ and ‘capability’
among children and adolescents. Social protection programmes should be dynamic and
flexible, and take into account age, gender, HIV-related stigma, and context, including
cultural norms, which offer opportunities to improve programmatic coverage, reach, and
uptake. Effective HIV prevention also requires integrated social protection policies,
developed through strong national government ownership and leadership. Future
research should explore which combinations of social protection work for sub-groups of
children and adolescents, particularly those living with HIV.
Keywords: HIV/AIDS, adolescents, children, HIV prevention, social protection, care and
support

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Introduction
AIDS-related illness is the leading cause of death amongst adolescents in Eastern and
Southern Africa: since 2000, the number of AIDS-related adolescent deaths in the region
has tripled (WHO, 2015a). HIV infection poses a serious risk to children and adolescents
in the region, with 160,000 new infections annually in this age group (UNICEF-ESARO,
2015). Eastern and Southern Africa (ESA) is also home to 80% of the world’s 3.9-4.5 million
HIV-positive children and adolescents (Kasedde & Olson, 2012). Investing in social
protection in ESA has taken on a new urgency as HIV and AIDS interact with drivers of
poverty to disrupt livelihood systems and family and community safety nets (Adato &
Bassett, 2009). Children, in particular, are a key constituency for whom it is imperative to
scale up and deepen social protection to mitigate the effects of extreme deprivation and
vulnerability (E. Miller & Samson, 2012). The expanding evidence base on children and
HIV/AIDS has contributed to the progress of the global agenda for improving the health
outcomes of children affected by HIV/AIDS.
A growing literature investigates the potential that types of social protection have to
promote protective behaviours and reduce risk behaviours of children and adolescents
affected by HIV (Cluver, Orkin, Yakubovich, & Sherr, 2016; E. Miller & Samson, 2012;
UNICEF-ESARO, 2015). This literature points to the importance of improving our
understanding of how various modes and forms of social protection support HIV
prevention for children and adolescents. This paper aimed to (i) assess the evidence on
the effectiveness of social protection for HIV prevention, (ii) consider key challenges to
implementing social protection programmes that promote HIV prevention, and (iii)
identify critical research gaps in social protection and HIV prevention, in Eastern and
Southern Africa. It is guided by a framework that conceptualises that social protection (1)
interrupts risk pathways that result in poor health outcomes, and (2) contributes to
resilience-enhancing processes in children affected by, and infected with HIV and AIDS in
ESA (Figure 1).

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Social Protection – Definitions, Conceptual and Policy Framework
Social protection is a highly contested term in the social sciences, with debates about it
grounded in complex socio-historical and ideological positions (Devereux & Sabates-
Wheeler, 2007). Recently, social protection has been used in the social development
literature, and is appearing with increasing frequency in recent policy documents and
bilateral commitments (DFID et al., 2009; PEPFAR, 2015; The World Bank, 2012; UNAIDS,
2014c). Despite the recent currency of the term, social protection is not a new concept.
In the post-World War II period, social protection provisions became common in Western
Europe alongside the idea that the role of the state is to provide for and protect its citizens
(Scott, 2012). In response to demonstrated effectiveness, including improved long-term
child outcomes, social protection is the foundation of welfare state models in Western
Europe (European Commission, 2012; Frazer, 2013), North and South America (Haushofer
& Fehr, 2014).
The multifaceted nature of the concept of social protection has resulted in numerous
working definitions (Figure 2), all of which share several components: (1) an aim to
address key structural vulnerabilities; (2) a focus on reaching the most vulnerable
populations through targeted criteria or means testing; (3) delivery by multiple actors
including the state, civil society, communities, and private entities alone or in
partnerships; (4) a combination of formal (e.g. cash transfers, national feeding scheme),
traditional, and informal (e.g. community support and leadership) modalities of delivery;
and (5) categorisation of social protection provisions into several key functions. These
functions can be summed up into four dimensions of social protection: protective
measures which provide relief from deprivation, preventative measures which seek to
avert deprivation, promotive measures which aim to enhance real incomes and
capabilities, and transformative measures which seek to address concerns of social equity
and exclusion (Devereux & Sabates-Wheeler, 2004; Guhan, 1994). The four dimensions of
social protection correspond to the main social protection categories which form the
conceptual backbone of our research: cash or in-kind interventions (protective), care

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programmes (preventative), capability-focused initiatives (promotive), and policies and
legal environments (transformative) (The African Child Policy Forum (ACPF), 2014). These
social protection categories operate at numerous, intersecting levels (UNICEF-ESARO,
2015).
While social protection can be viewed as a set of risk-mitigation measures, its relationship
to resilience – another multifaceted construct (Shaw, McLean, Taylor, Swartout, &
Querna, 2016) – requires further elucidation. A significant portion of research and policies
on HIV and children in sub-Saharan Africa focuses on children’s victimization and
vulnerability, while being neglectful of children’s agency, and their acquired life skills
(Boyden, 1997; Fassin, 2008; Skovdal & Daniel, 2012). Recent conceptualisations of child
agency encourage a move away from narrow definitions of vulnerability and resilience to
consider multiple material, social and relational factors that affect the psychosocial well-
being of children living at the intersection of poverty and HIV/AIDS (Govender, Reardon,
Quinlan, & George, 2014; Skovdal & Daniel, 2012). In particular, an emerging literature
calls for increased attention to understanding the potential resilience-enhancing
experiences of HIV-affected children and youth living in resource-poor settings
(Betancourt, Meyers-Ohki, Charrow, & Hansen, 2013; Skovdal & Daniel, 2012).
However, discussions of child and adolescent resilience are often limited, placing the
burden for overcoming adversity solely on the individual (Shaw et al., 2016). This
tendency has prompted the call for a multi-level approach to ‘identifying and learning
from children’s interaction with their social environment as a pathway to resilience’
(Skovdal and Daniel, 2012). This paper’s conceptual framework is an adaptation of the
United Nations Children's Emergency Fund’s (UNICEF) conceptual framework for social
cash transfers (Figure 1). It combines Bronfenbrenner’s ecological model of human
development with the levels across which children access both relational and material
support suggested by Skovdal and Daniel (Skovdal & Daniel, 2012). Bronfenbrenner’s
ecological model of human development conceptualises determinants at multiple levels:

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micro-system (individual and family-level), meso-system (community-level), exo-system
(socio-political, economic and structural factors), and macro-system (interactions among
the other levels) (Bronfenbrenner, 1979; Lerner, 2005). The social protection conceptual
framework applied in this study illustrates how social protection provisions may interrupt
single or multiple risk pathways and support resilience in different levels of a child’s socio-
ecological development: (1) the household; (2) the community, including schools; and (3)
the political economy and government services (Skovdal & Daniel, 2012).
Recent changes in the international policy environment recognize the pressing need for
innovative and targeted responses to support the health of HIV-positive people and
prevent new infections. The Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast
Track Strategy includes targets for increased testing, treatment and adherence by 2030
(UNAIDS, 2014b). The World Health Organization (WHO) recently released guidelines
recommending that antiretroviral therapy (ART) be initiated to everyone living with HIV,
regardless of CD4 cell count (WHO, 2015b). The Sustainable Development Goals include
setting up national social protection systems with a high coverage rate of the most
vulnerable populations by 2030
i
, with HIV as a cross-cutting theme (UNAIDS, 2014a).
Social protection commitments are also being included in regional policies such as the
Southern African Development Community’s “Minimum package of services for orphans
and other vulnerable children and youth”.
ii
These goals and strategies which are shaping
the post-2015 health and development agenda recognise that the targets for reducing
HIV-related mortality and morbidity can only be met by identifying mechanisms that link
structural deprivations with more proximal health outcomes. Short-term responses to
mitigating the negative impacts of the HIV epidemic and chronic poverty on children’s
and adolescents’ lives are not effective. Social protection is increasingly receiving
recognition as an important part of a comprehensive response HIV/AIDS response
because of its potential to address structural deprivations. At this critical junction, it is
crucial to undertake a review of the evidence on child-and adolescent-sensitive social
protection for HIV prevention in Eastern and Southern Africa.

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Methods
Two research methodologies were combined to summarise and assess the existing
evidence on child- and adolescent-sensitive social protection for HIV-prevention in
Eastern and Southern Africa: (1) A rigorous review of academic, policy and grey literature
on social protection, children and adolescents in Eastern and Southern Africa; and (2)
Consultations with 25 experts from a variety of national, regional and international
institutions and research bodies.
The rigorous literature review consisted of two components: (i) a systematic review of
intervention studies, and (ii) a desk review and mapping of policies from Southern and
Eastern Africa. Systematic Review: Peer-reviewed articles in OVIDSp and EBSCOhost were
systematically searched using key terms for social protection, children and adolescents,
and HIV/ AIDS (Table 1). Social protection was conceptualized broadly to include as many
of the possible interventions and components that may fall under this umbrella term. We
conceptualised the outcome – HIV prevention – as either prevention of acquiring HIV for
HIV-negative people or preventing the onwards transmission of HIV – prevention for
positives, an extension of recent reviews of the evidence of social cash transfers (UNICEF-
ESARO, 2015). We scanned 905 titles and abstracts for review, 15 of which were reviewed
full-text. 11 were included in this manuscript. Hand searches resulted in an additional 13
publications. Only publications on the efficacy or effectiveness of social protection
interventions were included in the final full-text reviews. Evidence from national, regional
or local programmes, and proof-of-concept/ intervention studies were included, as long
as primary data (qualitative of quantitative) was used to assess the effectiveness of one
or multiple social protection provisions.
Policy mapping and grey literature review: This systematic review was complemented by
a parallel review of policies and formal documents of international organisations: UNICEF,
UNAIDS, WHO, the World Bank; regional organisations: African Union, Southern African
Development Community, East African Community); and national ministries and

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institutions for key countries in Eastern and Southern Africa. Based on HIV prevalence
rates and numbers of children/ adolescents living with HIV, we conducted in-depth
searches for policies and programmes in three East African countries: Rwanda, Uganda,
and Kenya, as well as three Southern African countries: Malawi, South Africa, and
Zimbabwe. Additional unpublished documents on social protection interventions and
policies were identified through expert consultations.
Consultations with policy-makers and programmers: With the support of the Eastern and
Southern Africa Regional Inter-Agency Task Team on Children Affected by AIDS’s (RIATT-
ESA) Social Protection working group, we identified experts on social protection at
international, regional and national levels. We interviewed twenty-five of these
stakeholders about their national and regional experiences in designing implementing
and evaluating social protection interventions. Interviews were transcribed and manually
coded. From this coding, themes were identified, reviewed and defined. Findings from
the literature review and expert consultations were largely complimentary, and are
presented together throughout the results and discussion section.
Results
Social Protection Programmes: Cash, Care, and Capabilities
Our literature review identified 22 peer-reviewed and grey-literature publications
highlighting evidence to date on 20 social protection programmes and initiatives (Table
2). The body of knowledge on social protection for HIV prevention consists of two types
of evidence: (1) effectiveness trials or intervention studies and (2) analysis of national-
level programmes. In total, our findings located 18 pilot or effectiveness/ intervention
trials (eight randomized controlled trials (RCT), five quantitative surveys, two pre-post
pilot studies, and three qualitative), and 3 national-level programmes (one RCT, two
quantitative analysis) for which there is evidence for outcomes linked to HIV prevention
among children and adolescents in Eastern and Southern Africa. The located studies
evaluate all the categories of social protection: four programmes evaluated cash-only

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social protection, seven care-only interventions, while eleven reviewed combinations of
social protection: four cash-plus-care,
iii
three care-plus-capability, two cash-plus-
capability, and one of three categories of social protection: cash-plus-care-plus-capability.
Seven studies of care-only interventions included HIV-positive children and adolescents:
two pre-post pilot studies (Bhana et al., 2014; Snyder et al., 2014), two mixed methods
studies (Lightfoot, Kasirye, Comulada, & Rotheram-Borus, 2007; Webster Mavhu et al.,
2013), and three qualitative studies (Parker et al., 2013; Senyonyi, Underwood, Suarez,
Musisi, & Grande, 2012; Willis et al., 2015).
Our findings complement the detailed analysis of social cash transfers prepared by The
Transfer Project (UNICEF-ESARO, 2015) and a recent mapping of social protection
programmes by the United Nations Development Programme (Cirillo & Tebaldi, 2016).
This article focuses on evidence-based social protection programmes and policies that
help HIV-negative children and adolescents to stay healthy, but also those preventing HIV-
positive children and adolescents from transmitting HIV. While there is limited evidence
on how social protection directly impacts HIV prevalence and incidence (E. Miller &
Samson, 2012), a growing body of research shows that social protection can reduce sexual
practices such as early sexual debut, unprotected sex, early pregnancy, dependence on
men for economic security, transactional sex, school dropout, food insecurity, early
marriage and economic migration (Lutz & Small, 2014; UNAIDS, 2014c; UNICEF-ESARO,
2015). Studies suggest a few – potentially overlapping – mechanisms through which social
protection may causal pathways to HIV infection: (1) poverty reduction and economic
development (Gillespie, Kadiyala, & Greener, 2007; Mishra et al., 2007; Nattrass &
Gonsalves, 2009), (2) the role of schools (A. E. Pettifor et al., 2008; UNAIDS, 2014c;
UNICEF-ESARO, 2015), (3) improved food security (Cluver, Toska, et al., 2016; Emenyonu,
Muyindike, Habyarimana, Pops-Eleches, & Thirumurthy, 2010), and (4) improved
psychosocial outcomes (Govender et al., 2014). A detailed analysis of the mechanisms of
social protection is beyond the scope of this article, however, one substantive
contribution of this article is that it summarises the burgeoning evidence base on social

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protection as a critical enabler for HIV prevention outcomes (Baird, Garfein, McIntosh, &
Ozler, 2012; Lutz & Small, 2014; UNAIDS, 2014c).
Social Cash Transfers
Amongst evaluations of cash transfers for HIV prevention located in this study, only one
found a reduction in HIV prevalence (Baird et al., 2012), with others finding no difference
in HIV infection rates (Duflo, Dupas, & Kremer, 2011; Hallfors et al., 2015; Karim, 2015; A.
E. Pettifor, Macphail, & Kahn, 2009). The lack of evidence for reduced HIV incidence could
be due to studies being statistically under-powered, very low HIV incidence rates in
younger adolescents, or because the impact of reduced HIV-risk behaviours only affect
HIV incidence later in adolescence (Duflo et al., 2011; Hallfors et al., 2015; Karim, 2015;
A. E. Pettifor et al., 2009). One study found reductions in HSV-2 incidence (Karim, 2015),
which is a strong marker for HIV incidence (Freeman et al., 2006).
Cash transfers as a form of social protection have received significant attention, resulting
in a copious literature about their efficacy (Cluver et al., 2013; Handa, Halpern, Pettifor,
& Thirumurthy, 2014; A. E. Pettifor et al., 2009), so will not be discussed in detail in this
article. Among trials and evaluations of the effect of social cash transfers on HIV-risk
behaviours, ten studies found reductions in sexual risk-taking, three improved
educational outcomes, one documented reduced food insecurity, and three improved
mental health, stigma and psychosocial support. As these high-risk sexual behaviours
have been linked with increased HIV incidence, the evidence on social protection for HIV
prevention among HIV-negative children and adolescents is encouraging. These findings
confirms that there is a critical mass of evidence to show the impact of social cash
transfers on the impacts of HIV and AIDS, although the quality and strength of this
evidence varies.
Care Social Protection Provisions
Research and programming to-date has documented several additional mechanisms of

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social protection beyond cash transfers. ‘Care’ programmes – particularly those focusing
on strengthening families and supporting caregivers – have had significant results on
outcomes proximal to reduced HIV infection (Chandan & Richter, 2008; Cluver, Orkin,
Boyes, & Sherr, 2014; Sherr et al., 2014; Visser, Zungu, & Ndala-Magoro, 2015) suggesting
that care and psychosocial support should be an integral component of HIV prevention
efforts. Our study located several ‘care-only’ or ‘care-plus’ social protection programmes
which reduced HIV risk taking: family-based interventions in South Africa (Bhana et al.,
2014; Visser et al., 2015), one-on-one counselling for adolescents and youth (Lightfoot et
al., 2007), and peer-driven or group-based interventions (W Mavhu et al., 2010; Parker et
al., 2013; Senyonyi et al., 2012; Snyder et al., 2014; Willis et al., 2015). Given that most of
the above studies were small-scale pilots, evidence from larger scale interventions is
needed, including studies that include HIV incidence as an outcome. That non-cash social
protection mechanisms require greater recognition for their potential for HIV-prevention
among children and adolescents (Chandan & Richter, 2008) was also a strong finding from
expert consultations:
‘The acknowledgement of care and support needs to be more explicit. We talk about
interventions that many wouldn’t see as social protection, that are social protection…
(the term ‘social protection’) it is so closely associated with cash… I think we need to
reclaim … care and support.’
(Expert consultation, International not-for-profit organization employee)
‘As budgets have gotten more constrained and when the strategic investment
framework was produced, everything needed to be evidence based. Care and support
dropped down into development synergies from key interventions… We haven’t heard
enough about psychosocial support... We have heard plenty on cash… we are still
missing the glue that holds it all together which is the carers and care giving
structures... I fear that with cash, you can put it into the household, but you don’t
necessarily support the caregiver… this is what is needed alongside cash. These
caregiving mechanisms are critical to ensure that care and support is delivered
successfully.’
(Expert Consultation, International not-for-profit organization employee)
‘(A social protection programme) might provide cash, but if families aren’t cognizant
of other needs that children have, the cash may not have as much of an impact.
Children must feel loved, cared for, belonging.’
(Expert Consultation, Regional not-for-profit organization employee)

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These findings suggest that the potential of ‘care’ social protection mechanisms extend
beyond ameliorating the impact of ‘cash’ interventions. ‘Care’ social protection may
have positive impact in three separate, inter-related ways. First, ‘care’ directly benefits
the intended beneficiaries as stand-alone interventions or in combination with
‘cash/in-kind’ provisions. Secondly, ‘care’ interventions act as flexible mechanisms that
can buffer and respond to the complex and shifting needs of HIV-vulnerable children
and adolescents. Thirdly, through their flexibility and responsiveness, ‘care’ social
protection may act as glue for the sustained uptake and retention of other forms of
social protection. Practical examples of such interventions include systems that
address the needs of vulnerable children and adolescents through referrals and
psychosocial support and programmes that support caregivers, which also act as
gateways to other forms of social protection. This finding dovetails with a growing
body of qualitative literature that supports the design and delivery of psychosocial
support and ‘care’ interventions (Campbell et al., 2012; Govender et al., 2014;
Winskell, Miller, Allen, & Obong’o, 2016). The current momentum around the delivery
of ‘cash’ and ‘cash-plus’ combinations of social protection provisions offers
opportunities for documenting the potential of ‘care’ interventions:
‘… there is such momentum for cash… we must (use this momentum) to
encourage the delivery of care and address the policies, norms and processes
that are stigmatizing, that are excluding… We are beating the drum for cash
transfers to be more effective and functional.’
(Expert consultation, International not-for-profit organization employee)
Capability Social Protection Provisions
An emerging category with several promising completed trials and a few underway is that
of ‘capability’ social protection provisions, which focus on long-term transfer of skills and
knowledge that addresses structural inequalities faced by children and adolescents.
‘Capability’ social protection refer to any intervention delivered under the promotive
function of social protection (Devereux & Sabates-Wheeler, 2004). Three recent trials that

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involved ‘capability’ social protection in the form of life skills training combined with cash
transfers had promising results in reducing HIV-risk behaviour (Duflo et al., 2011; Dunbar
et al., 2014; Karim, 2015). Though the content of ‘capability’ varied by intervention from
teacher training to life skills support for adolescents, these findings suggest that
extending social protection interventions to include promotive elements, such as
capability development, is crucial for building long-term resilience amongst children and
adolescents. This finding was supported by the expert consultations, in which ‘capability’
interventions were an important theme:
‘Building self-esteem and life skills is important. It makes sure that we are
empowering the child and adolescent to be able to live in this world. They must
be empowered to effectively communicate, negotiate and effectively seek
services. […] (Social protection) models should look at experiential learning that
empowers children to access services.’
(Expert Consultation, Regional not-for-profit organization worker)
Combination Social Protection
Growing evidence demonstrates that combinations of social protection, particularly
‘cash-plus-care’ have greater potential for HIV prevention among children and
adolescents than cash interventions alone (Bandiera, Buehren, Burgess, Goldstein, &
Gulesci, 2013; Cho et al., 2011; Cluver, Orkin, et al., 2016; Duflo et al., 2011; Karim,
2015). Social protection interventions consisting of multiple components have
additive, and potentially multiplicative effects on HIV prevention (Cluver, Orkin, et al.,
2016) and are necessary to meet the complex psychosocial needs of HIV-positive
children and adolescents, as well as those vulnerable to infection (Amzel et al., 2013;
Cluver, Toska, et al., 2016). The shift towards combinations from single forms of social
protection has emerged from two complementary movements: increased evidence on
the effectiveness of combined social protection interventions, and an adapted
conceptualization of the compounded pathways to risk and vulnerability for HIV
infection.
Social protection provisions may work better in combination by addressing the multiple
vulnerabilities and contextual barriers faced by those most at risk of HIV infection. For

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example, adolescent girls receiving a combination of an unconditional cash transfer, social
support and life skills training in Zimbabwe reported higher income, reduced food
insecurity, and less transactional sex or unwanted pregnancies (Dunbar et al., 2014).
Recent findings from a longitudinal survey in South Africa also suggest that certain
combinations of social protection provision are linked to reduced HIV risk incidence
amongst adolescent girls (Cluver, Orkin, et al., 2016).
‘The importance of deliberate, politically-backed and sustainable combinations of
child-sensitive social protection mechanisms cannot be overstated.’
(Expert Consultation, Regional not-for-profit organization worker)
However, the evidence is not conclusive on which specific social protection provisions are
best for HIV prevention and suggests that different combinations work for adolescent girls
and boys under different circumstances (Cluver, Orkin, et al., 2016; Handa et al., 2014).
Combinations, including ‘cash-plus-capability’, or multiple types of care combined also
hold great potential and merit further exploration.
‘Various interventions are necessary… think about the alignment between…
psychosocial support, family care, and the interventions that go with those…
comprehensive care and support … cash is a core, plus various care interventions
if (we want to) have a bigger impact on the broader goals that we are working
for…. it must be applied and provided with psychosocial support and care of a
range of elements.’
(Expert Consultation, International not-for-profit organization worker)
Social Protection Policy Implementation
The most effective social protection policies cannot be implemented in the absence of an
enabling environment, including the programmatic and fiscal support of states (Devereux
& Sabates-Wheeler, 2004). Transformative social protection (that is, enabling legal and
normative environments) is essential for the delivery of other social protection
mechanisms, as well as to address issues, such as stigma, that drive exclusion and create
barriers to uptake. An enabling legal environment is needed to ensure that the Fast Track
goals, which focus on increasing reach of existing services, are attainable by 2030.
International and regional directives on social protection, as well as those on HIV

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prevention and treatment provide a rhetorical framework for the delivery of child-
sensitive social protection for HIV prevention:
‘Transformative social protection is intended to address the drivers of exclusion…’
(Expert Consultation, International not-for-profit organization worker and
academic)
‘Transformative social protection… and social policy reform is talked about less
(than other forms of social protection) but has the opportunity to address the root
causes of vulnerability and exclusion… it is necessary to have policies and laws that
extend to social norms which exclude people… some of these prevent people from
accessing the cash and accessing a whole range of services… the opportunity is to
use social protection to actually ensure that marginalized groups are included
requires transformative social protection. Structural environments must be
conducive for other forms of social protection to work.’
(Expert consultation)
These relatively new directives pose a great opportunity and also raise questions
regarding the interpretation and implementation of such lofty and ambitious initiatives.
What form such initiatives should take, and how they should be targeted, funded and
delivered are all highly contested (e.g. Mkandawire, 2005; UNRISD, 2010; World Bank,
2012).
Numerous African states have an established history of social protection, including cash
transfers and in-kind interventions such as school feeding programmes and emergency
food aid (Seekings, 2007). There has been a progressive expansion in the use of
unconditional cash transfers on the continent since the 1990s, which have become a
critical instrument of many social development and poverty reduction strategies (UNICEF-
ESARO, 2015). Approximately 17 million cash transfers are provided in South Africa and
transfer programmes are being scaled up in other Eastern and Southern African countries
(Adato & Bassett, 2009; GroundUp, 2015).
Our in-depth analysis of six countries in Eastern and Southern Africa demonstrates a high
level of variation between domestic policy environments and provisions for various social
protection mechanisms. Such variety speaks to the unique social protection needs,

Page 17 of 48
resources and policy and legislative frameworks, as well as perhaps uptake and political
buy-in. Most of the documents that included specific social protection components (cash,
care, capabilities, or combinations) were strategies focusing on specific vulnerable sub-
groups such as orphans and vulnerable children (OVC), as seen in Kenya and Lesotho. Few
policy documents acknowledge the direct role that social protection may play in HIV
prevention by supporting safe sexual health behaviours for older children/ adolescents.
There are several lessons that can be gleaned from national-level policy implementation
in Eastern and Southern Africa. First, to reach those most structurally-vulnerable, good
targeting strategies or means-tested provisions (such as for the child support grant in
South Africa) are needed. Second, knowledge of the unique vulnerabilities of children and
adolescents are key to the success of health and social support interventions. National
policies that targeted HIV-affected households have negative impacts, whereas those that
combine long-term vulnerabilities such as orphanhood with poverty have had greater
impact (Handa & Stewart, 2008; Schuring, 2011). Third, good targeting does not result in
good reach. A better understanding of inclusion and exclusion errors of current targeting
strategies is needed (E. Miller & Samson, 2012). Finally, social protection policy processes
that evolve out of (or are adapted to) domestic political agendas and respond to local
conceptualizations and prioritizations of need are more likely to succeed—in terms of
their coverage, fiscal sustainability, political institutionalization, and impacts—than those
that are based on imported from elsewhere.
Discussion
A series of issues regarding the roll-out and sustainability of social protection mechanisms
emerged from the triangulation of expertise consultations with a review of policy and
literature on social protection. This section highlights issues of targeting, flexibility and
conditionality, and considers the feasibility and barriers to social protection policies and
interventions for HIV prevention for children and adolescents in Eastern and Southern
Africa.

Page 18 of 48
Targeting and Flexibility
One of the ways that social protection mechanisms reach the most vulnerable is through
targeted inclusion and exclusion criteria to ensure that scarce resources are used
efficiently (Slater, Farrington, Samson, & Akter, 2009). In order to ensure that targeting is
effective and to minimize harmful unintended consequences, targeting criteria and
methods should be transparent and clearly communicated (UNICEF, 2015). Finding HIV-
inclusive eligibility criteria that do not stigmatise beneficiaries is challenging, though some
examples include gap-generation households and child-headed households (Schuring,
2011). Targeting that focuses on the poorest families with children has the greatest
impact on orphans and vulnerable children (Handa & Stewart, 2008). Though not focused
on children or adolescents, qualitative evidence from Malawi demonstrates that targeted
Social Cash Transfers reached HIV-positive people who were able to use the income to
improve adherence to ART (Miller & Tsoka, 2012), which is key to reducing HIV
infectiousness (Rodger et al., 2014).
However, targeting may result in high inclusion and exclusion bias due to various
contextual factors such as stigma and discrimination, lack of knowledge/ agency in
accessing grants, limited ability to administer resource-heavy conditional programmes,
and poor communication about inclusion/exclusion criteria (including criteria rationale).
Additionally, targeting strategies may be expensive. Additional research is needed on
effective targeting practices that respond to localised knowledge of the HIV epidemic and
the specific vulnerabilities of children and adolescents. HIV-related stigma and
discrimination as a result of targeting can overshadow needs of other vulnerable children.
A central finding of this research was that social protection mechanisms must be flexible
to respond to the fluid and dynamic realities and needs of children and adolescents.
Common shocks to children and adolescents that may render them further vulnerable
include changes to living environments through political and natural events, moving,

Page 19 of 48
losing caregivers and grief, as well as other situational factors (Amzel et al., 2013; Chandan
& Richter, 2008; Richter et al., 2009; Vale & Thabeng, 2015). In recognizing the unique,
rapidly changing and often volatile situations and needs of adolescents, it is important to
ensure that social protection mechanisms are flexible and dynamic enough to provide the
appropriate support that is fundamental for HIV-prevention among this vulnerable group.
As significant administrative and bureaucratic infrastructure has to be created to disburse
and manage social cash transfer programmes, they provide a crucial entry point to reach
those most vulnerable with multiple social protection provisions, including ‘cash-plus’
combinations. Combinations of social protection that include ‘care’ components can offer
the flexibility necessary to addressing the realities in which HIV-vulnerable children and
adolescents live.
Flexibility of social protection mechanisms is key to their effectiveness in adapting to
young people’s needs as they transition from childhood to adolescence. This theme was
born out from expert consultations:
‘Social protection should be very dynamic to adapt to the evolving needs that
children may have… the stagnant nature of some social protection mechanisms
mean that they can’t adapt to the needs of young people as they go through
adolescence… There is a current failure to adapt to children and their evolving
needs.’
(Expert consultation, academic)
Unfortunately, social protection provisions that address issues of sexual and reproductive
health often perceive young people as children: sexually naïve until they become
pregnant or contract HIV through sexual relationships.
Conceptually treating childhood and adulthood as two mutually exclusive life stages is
limiting and ‘hugely misses the point of adolescence… Social protection that perceives
young people as children until evidence to the contrary, for example when they become
pregnant, is not dynamic enough to be effective in terms of prevention… Social protection
needs evolve and vary for individuals as they grow up: there is a vacuum between
paediatric and adult care… treating people as children and then adults is inadequate and
doesn’t reflect their needs and experiences.’
(Expert consultation, academic)

Page 20 of 48
A common theme from expert consultations was that age is an important (and sometimes
overlooked) consideration in the conceptualization, design and provision of child and
adolescent sensitive, HIV-inclusive social protection. Though the needs of children (0-15
years old) and adolescents (10-19 years old) vary by socio-economic and family factors,
age plays an important role in their vulnerabilities, and also their ability to access and
benefit from various social protection mechanisms. Younger children are likely to access
social protection mechanisms for HIV prevention through caregivers and households, for
example, in the case of cash transfers to mothers. Older children and adolescents, on the
other hand, should be targeted and receive social protection provisions directly (UNICEF-
ESARO, 2015). Programmes that focus on caregivers have greater effect and reach for
younger children however, older adolescents may find that programmes focusing on the
home/ caregivers do not match their expectations (Busza, Besana, Mapunda, & Oliveras,
2014).
Conditionality
Some social cash transfer programmes are conditional, whereas others, including many
in Africa are unconditional
iv
. There are essentially two types of conditional programmes,
those that are conditional on avoiding undesirable sexual health outcomes, such as HIV-
infection, sexually transmitted infections or adolescent pregnancy and others that aim to
encourage protective health behaviours such as retention-in-care and immunizations.
The former category is based on the premise that risk is driven by rational behaviour
choices (de Walque et al., 2012), and has raised serious ethical considerations (Cluver,
Hodes, Sherr, et al., 2015). The latter category is less concerning, although efforts must
be made to ensure that the most vulnerable families do not ‘slip through the net’ because
they are unable to meet the requirements. The Zomba trial in Malawi is the only evidence
to date that both conditional and unconditional cash transfers among adolescents worked
in reducing HIV prevalence (Baird et al., 2012). However, there was no significant
difference in HIV prevalence amongst the groups receiving the unconditional and
conditional cash transfers. Neither of the two recent trials of conditional cash transfers

Page 21 of 48
showed results on reducing HIV incidence (Karim, 2015; A. E. Pettifor et al., 2009).
National-level conditional cash transfers such as the Malawi and Zambian cash transfer
schemes – conditional upon children enrolment in school and vaccinations – have had
more encouraging results (Schuring, 2011). Given the costs of administering a conditional
social protection scheme, particularly at a national level, further research is needed to
discern whether it is the cash transfer in itself or the conditionality that makes the
difference. Experts consulted expressed a strong preference for unconditional cash
transfers, for a variety of reasons including perceptions of effectiveness, stigma and
discrimination:
‘There is a body of evidence that suggests that unconditional cash transfers tackle
vulnerability in important ways while also building human capital in ways that
improve capacity and that address vulnerabilities in early childhood, adolescence
and into early adulthood. This is important to supporting the health and well-being
of vulnerable young people.’
(Expert Consultation, academic and international not-for-profit organization
worker)
Stigma must also be an important consideration in the delivery of conditional cash
transfers. ‘Stigma and discrimination can exclude households and adolescents from
getting a whiff of the cash… and a whole range of services.’ (Expert Consultation,
International not-for-profit organization worker). Simply accessing services can be
stigmatizing, which is one of the core arguments for the delivery of HIV-inclusive, rather
than HIV-specific social protection. Additionally, social protection targets should include
those who most need services, and that these in turn will include those both at risk, and
living with HIV: ‘Conditional transfers can be discriminatory. We want to see systems that
are built on a universal approach….’ (Expert consultation, international not-for-profit
organization worker). This approach therefore appreciates that, at times, one needs to
deliver specific services to children who are HIV-positive and in need of medical services
and psychosocial support.

Page 22 of 48
Feasibility and barriers to ensuring effective implementation and uptake of social
protection for HIV prevention
The World Bank State of Safety Nets 2015 report, which looked at social assistance in 120
developing countries, indicates that well-designed social assistance programmes are cost-
effective, costing between 1.5 and 1.9% of gross domestic product (The World Bank,
2015). In Sub-Saharan Africa, social assistance currently covers just one-tenth of the
poorest 20% (The World Bank, 2015). Estimates of the reach of non-cash social protection
initiatives are not available. The expansion of social protection provisions is possible for
most African countries (Garcia & Moore, 2012). Such initiatives are not only an
investment for the health and wellbeing of children and adolescents, but also a long-term
cost-saving mechanism by nature of avoidance of negative future outcomes and the
realization of long-term savings (Remme, Vassall, Lutz, Luna, & Watts, 2014; Sherr et al.,
2014). Budgetary commitments for social protection can be made more manageable by
co-financing from multiple government departments, as demonstrated by the STRIVE
consortium (Kim, Lutz, Dhaliwal, & O’Malley, 2011; Remme et al., 2014). Further cost
analysis of existing successful social protection initiatives is needed to support
governments in deciding where to invest their social protection funding (E. Miller &
Samson, 2012).
Complex challenges such as HIV prevention among children and adolescents require
combinations of well-integrated interventions. Silo-based approaches to policy making
and implementation can fail to capitalise on the additive effects of combinations of social
protection interventions. Just as combinations are required at a programmatic level, from
a policy and an evaluation perspective, integrated approaches are needed. Co-financing
and the delivery of integrated interventions was a common theme in expert
consultations:
‘HIV money is limited, so as soon as you peg something as an HIV intervention, you
slot it into the HIV funding slot and then other health budgets don’t want to pay,
education doesn’t want to pay, social protection doesn’t want to pay for it. The
reality is international funds are shrinking and there are budget crises in many

Page 23 of 48
sectors that need to be better funded. Co-financing says that there is a trap that if
programmes are implemented in silos… we have many valuable, cost effective and
impactful interventions that cannot demonstrated single-sector value to warrant
complex cost. In a silo-based world, we are underfunded. Co-financing is a
framework for making decisions based on comprehensive approaches, integrated
evaluations, developing mechanisms for budgeting that responds to them.’
(Expert Consultation, Academic and international not-for-profit organization
worker)
‘We need to intersect livelihoods and health and education and parental care…
what is important is how you get different interventions to work together… it is
important to have complementarity among interventions. The focus must be on
synergy and interventions working together.’
(Expert Consultation, Academic and international not-for-profit organization
worker)
‘If we are going to reach all of those that have not been tested, if we are to get to
90% of treatment, if we want to end AIDS by 2030, we all have to collaborate. Not
one sector by itself is going to achieve this. We all have to pull together.’
(Expert Consultation, International not-for-profit organization worker in Mudekunye,
2015)
Despite the promising potential and sustainability of social protection, barriers exist to
ensuring that social protection initiatives are enshrined in policy. These include the social
and political attitudes within governments, based on perceptions of who is deserving of
support, with young people often being deemed undeserving (Seekings, 2007). Political
ownership and domestic funding are fundamental to the sustained success of national
social protection initiatives (Adato & Bassett, 2009). The key message here is the
importance of long-term government-led social protection initiatives and on the
feasibility of such programmes.
‘The success of [social protection] programmes is incumbent on whether
governments are willing to take responsibilities of ownership… owned or co-
financed (interventions) by governments are more sustainable.’
(Expert Consultation, International not-for-profit organization worker)
Even when there are strong policies in place, there can be wide discrepancies between
social protection and health policy provisions and their successful implementation.

Page 24 of 48
Supply-side barriers to ensuring adequate implementation and coverage of social
protection policies include inadequate awareness among implementers, inadequate
skills, government coordination, human and health resources, insufficient motivation of
social and health service providers and inconsistent service provision among street-level
bureaucrats as to who receives social protection services. An additional barrier is the
unsubstantiated yet widespread impression that social protection provisions fuel/
incentivize sexual irresponsibility, risk-taking and recklessness:
‘[I]n these days teenagers at the age of 16 and 18 are getting pregnant just to
get the grant… All they care about is having fun and nothing else… Some of
them get pregnant on purpose of getting the grant money from government…
But now they use the money that was meant to feed their babies to have fun…
go to braai places and buy alcohol… They say, “success is all about making
profit”, so by having babies they are making a profit’.
(Anonymous interviewee in Hodes, Toska, & Gittings, 2016).
Such claims are not borne out of accounts of girls and adolescent women receiving cash
transfers in South Africa (Rosenberg et al., 2015), but are present in the accounts of a
range of adult authorities, including caregivers, healthcare workers and social service
providers, as well as boys.
There are a variety of factors that will affect the successful uptake, reach and coverage of
social protection mechanisms. These may include inadequate awareness on the part of
potential beneficiaries and inadequate support for beneficiaries to sustainably access
available social protection provisions. For example, the impact of social transfers that aim
to improve health outcomes depend not only on the availability of the transfers but also
the accessibility, cost and quality of health services as well as social norms that establish
attitudes about healthcare (UNICEF, 2012).
A comprehensive analysis of potential risks and benefits of social protection mechanisms
is necessary before designing and implementing successful social protection
programmes. The importance of context cannot be overstated. The settings where social
protection is provided and received mediate behaviours, experiences and outcomes

Page 25 of 48
(Seekings, 2007). Social protection forms must respond to local needs and be adapted in
accordance with the specificities of context (Adato & Bassett, 2009) and account for
different dimensions of agency and subjectivity. The categories, forms and combinations
of social protection that best support children and adolescents at high-risk of HIV-
infection will vary contextually. Such programmes must resonate with local
understandings of health and illness and intersect with political norms, social practices
and symbolic beliefs in ways that enhance, rather than obstruct, their efficacy, and their
social and epidemiological benefits (de Haan, 2014). Researchers and implementers must
grapple with the situation-dependent and context-specific natures of behaviour and
identity and how these are negotiated, produced, and constructed in a dynamic
interaction between individual and locality (Campbell, Kalipeni, Craddock, Oppong, &
Ghosh, 1997; Devereux, 2015).
‘It is important to consider regions (Eastern and Southern Africa) and countries
separately… In every country there are different components of social protection
provision and different stages of development. In-country contexts are also
important… For example, in Kenya, despite cash transfers and policies being in
place, in some areas infections haven’t stabilized… it is also important to include,
urban and rural considerations.’
(Expert Consultation, International not-for-profit organization worker)
‘Topography of access (to social protection services) is wildly different. Needs are
also different as are the expenses you may incur, even within a country, can be
totally different between places… situations are fluid and dynamic geographically
as well as in the life course of an adolescent. There are also risks when social
protection is withdrawn… there isn’t national coherence or consistency – funding
schemes come and go and non-governmental organisations (NGOs) are constantly
changing and folding.’
(Expert consultation, Academic)
Ongoing need for evidence and future directions
While there is consensus amongst beneficiaries, practitioners and decision-makers that
social protection can play a key role to attenuate the structural deprivations that lead to
HIV infection and AIDS-related morbidities (Cluver, Orkin, et al., 2016; E. Miller & Samson,

Page 26 of 48
2012; A. Pettifor et al., 2015), it is unclear which social protection initiatives are best for
which key child and adolescent populations and priority groups, including lesbian, gay,
bisexual, intersex and transgender children and adolescents, and children and
adolescents with disabilities. Furthermore, research that directly assesses the effect of
social protection on HIV and HSV-2 incidence is needed, although using biomarkers in
adolescent samples requires very large study sample sizes, which massively increases cost
of research. Nonetheless, the potential pathways through which social protection
provisions reduce HIV infections are increasingly being mapped out through qualitative
and quantitative studies. The next generation of research and programming must answer
the questions of what works best, for whom, under which circumstances and most cost
effectively.
‘Research is needed to identify the most cost-effective combinations that generate
impact… we often live in a world where evaluation technologies drive policy
solutions, rather than the most important policy interventions driving demand for
evidence building approaches.’
(Expert Consultation, Academic and international not-for-profit organization
worker)
Prevention for Positives
HIV-focused programmes, including awareness initiatives, are often univocal. Their
principal message is to ‘Prevent HIV’, but this does not encompass the realities of those
who are already HIV-positive, including over 5 million children and adolescents under 19
years old. While we need to stop HIV-negative people from getting infected, we can make
great progress by supporting HIV-positive people to stop onwards transmission. Findings
in this paper support the delivery of social protection interventions to help young people
(children, adolescents and youth) live healthier lives and access preventive care (E. Miller
& Samson, 2012; UNICEF-ESARO, 2015), particularly with regards to sexual well-being and
HIV prevention (Cluver et al., 2014; Cluver, Orkin, et al., 2016). However, there is limited
evidence about the effect of social cash transfers on ART adherence among children and
adolescents (Cluver, Toska, et al., 2016) and on interventions that reduce HIV risk taking.
Furthermore, there is a dearth of research on what social protection combinations may

Page 27 of 48
be best suited to address the compounded vulnerabilities of HIV-positive children and
adolescents. Preliminary findings from a community-traced study in South Africa, indicate
that access to in-kind cash benefits and care such as parenting supervision and supported
disclosure may have positive effects on adherence to ART (Cluver, Hodes, Toska, et al.,
2015; Cluver, Toska, et al., 2016) and safe sex (Toska, Cluver, Hodes, & Kidia, 2015). In
light of potential linkages between poor adherence and sexual risk-taking among HIV-
positive adolescents (Marhefka, Elkington, Dolezal, & Mellins, 2010), it is crucial to
identify policy and programmatic interventions that can address the vulnerabilities of HIV-
positive children as they become adolescents. In doing so they may improve health
behaviours among HIV-positive adolescents, shoring up their resilience and thus also
helping to prevent onwards transmission of HIV.
Combinations of interventions
One of the most important contributions that social protection provisions may make is
through novel interventions that straddle biomedical and social spheres (Cluver, Hodes,
Sherr, et al., 2015). One next step in HIV prevention research and programming is actively
combining social protection and biomedical programmes (Coates, Richter, & Caceres,
2008). The DREAMS initiative is one such example which includes ‘combination
prevention’ of social protection (e.g. cash transfers and parenting programmes) and
biomedical and behavioural interventions (i.e. HIV testing, condom provision and PrEP)
(PEPFAR, 2015 in Cluver 2015)(PEPFAR, 2014). Questions regarding the scalability and
durability of these interventions remain unanswered (Delany-Moretlwe et al., 2015),
presenting a powerful potential for further research in this field.
Gender
Growing evidence indicates that HIV-infection risk is linked to economic-disparate (where
one partner has significantly greater financial means than the other) and
intergenerational sex, as well as to unequal gender norms that limit women’s power to
negotiate safer sex or to protect themselves from violence (Harrison, Colvin, Kuo, Swartz,

Page 28 of 48
& Lurie, 2015; Shisana et al., 2014; Toska, Cluver, Boyes, Pantelic, & Kuo, 2015). As a result
of these intersecting structural factors, adolescent girls account for over 62% of new
infections in Eastern and Southern Africa (UNICEF-ESARO, 2015). Mixed-methods
investigations provide increased recognition of the associations between gender
inequality, transactionality, poverty and HIV-risk behaviours. Girls and young women
tolerate condom refusal and sexual concurrency to maintain relationships with male
sexual partners who supported them materially (Toska, Cluver, Hodes, et al., 2015).
However, critics note that dominant discourses around gender inequalities and the ability
of women and girls to protect themselves can be reductionist, and there is a need for
more nuanced understandings of the relationships between HIV prevention and gender
inequalities, including how they articulate with poverty and other factors (Govender,
2011; Jewkes & Morrell, 2012; Shefer, Kruger, & Schepers, 2015).
In light of the increased vulnerability of adolescent girls and young women to HIV
infection, the gendering of regional social protection policies and interventions in
commendable. However, a more nuanced analysis of the relationships between
inequality, poverty and gender in HIV risk is required (Jewkes, Levin, & Penn-Kekana,
2003). Further research on social protection amongst adolescents, gender and HIV risk
could also interrogate masculinities, given that norms of masculinity (Colvin, Robins, &
Leavens, 2010; Jewkes et al., 2007; Sonke Gender Justice & MenEngage Africa, 2015) and
institutional supply-side barriers (Dovel, Yeatman, Watkins, & Poulin, 2015) make men
less likely to access prevention, testing, treatment and support services and more likely
to be lost to follow-up or die on ART (Johnson et al., 2013).
There is a growing body of literature that indicates that efforts with men and boys for
gender transformation have the potential to impact gender norms and practices that are
harmful to men, women, girls and boys (Dworkin, Fleming, & Colvin, 2015; Dworkin,
Hatcher, Colvin, & Peacock, 2013; Gittings, 2016). Research about masculinities as well as
femininities, adolescence and HIV risk is an under-explored area that has the potential to

Page 29 of 48
provide valuable insights. Further research is needed to elucidate the complex gendered
vulnerabilities and pathways for contracting and transmitting HIV and the uptake of HIV
prevention and treatment services.
Conclusion
Our findings suggest that flexible and responsive social protection mechanisms may be
an important component in the response to the complex causal pathways resulting in HIV
infection. Evidence on social protection programmes and policies highlights the potential
for combinations of social protection interventions, particularly ‘cash’ combined with
‘care’ and ‘capability’ to interrupt risk pathways and build resilience. Social protection can
play a role in HIV prevention among adolescents through alleviating economic and
structural drivers of HIV risk, including economic and gender inequalities and social
exclusion, which are at the root of HIV susceptibility and vulnerability, and underlie HIV-
risk behaviours. As critical evaluations have shown, if social protection is to be effective
for children and adolescents, it must be both HIV-inclusive and responsive to their unique
needs (Delany-Moretlwe et al., 2015; A. Pettifor et al., 2015).
Recent global strategies – such as UNAIDS’ Fast Track targets – and policy directives –
such as the Sustainable Development Goals – provide an exciting opportunity for
considering comprehensive forms of social protection and strengthening health and
community systems for scaling up national responses. Given the urgency to implement
effective programmes, a better understanding of which combinations of social protection
packages have the most impact for HIV prevention and poverty mitigation among children
in different HIV/AIDS contexts. As a large cohort of HIV-affected children in Sub-Saharan
Africa reaches adolescence, social protection that improves the resilience to affect good
health outcomes of young people is needed, particularly combination social protection,
which include ‘capabilities’ components in addition to ‘cash’ and ‘care’ provisions.
Ensuring the reach and uptake of such social protection programmes for the most
vulnerable will be integral to ensuring that no child or adolescent is left behind.

Page 30 of 48
Equally important, is the need to ensure that social protection policies and programmes
are driven by local processes and embedded in national agendas. This requires supporting
governments to take full responsibility for pilot projects, and to scale them up to
sustainable national programs, when evidence on programmatic and cost-effectiveness
is available. International donors and development partners need to support regional
agendas on implementation of evidence-based programmes and build local capacity to
improve access and delivery to social protection provisions.

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Figure 1. Child-sensitive HIV-inclusive Social Protection Conceptual Framework

Page 32 of 48
All public and private measures to provide income or consumption transfers to the
poor, protect the vulnerable and enhance the social status of the marginalized, as well
as to prevent, reduce and eliminate economic and social vulnerabilities to poverty and
deprivation (Devereux & Sabates-Wheeler, 2004).
UNICEF: A set of public and private policies and programmes aimed at preventing,
reducing and eliminating economic and social vulnerabilities to poverty and
deprivation (UNICEF, 2012).
DFID: Social protection can be broadly defined as public actions – carried out by the
state or privately – that: a) enable people to deal more effectively with risk and their
vulnerability to crises and changes in circumstances (such as unemployment or old
age); and b) help tackle extreme and chronic poverty.
Overseas Development Institute (ODI): Social protection refers to the public actions
taken in response to levels of vulnerability, risk and deprivation which are deemed
socially unacceptable within a given polity or society (Norton, Conway, & Foster, 2001).
World Bank: Social protection is a collection of measures to improve or protect human
capital, ranging from labor market interventions, publicly mandated unemployment or
old-age insurance to targeted income support. Social protection interventions assist
individuals, households, and communities to better manage the income risks that
leave people vulnerable (Yemtsov, 2013).
International Labour Organisation (ILO): The provision of benefits to households and
individuals through public or collective arrangements to protect against low or
declining living standards –(van Ginneken, 1999).
Child-sensitive social protection considers different dimensions of children’s
well-being and addresses “the inherent social disadvantages, risks and
vulnerabilities children may be born into, as well as those acquired later in
childhood” (UNICEF, 2014) while aim to maximize opportunities and
developmental outcomes for children (DFID et al., 2009).
HIV-inclusive social protection is sensitive to HIV, reaching people who are either
at risk of HIV infection or vulnerable to HIV consequences (Miller & Samson,
2012). HIV-inclusive social protection advocates a comprehensive approach to
addressing the socio-structural drivers of HIV, while avoiding identifying or
stigmatizing people on the basis of their HIV-status.
Figure 2. Social Protection Definitions

Page 33 of 48
Table 1. Search terms and strings used in OvidSP
String
Category
Concept
Search terms
1
Population
Adolescents
and children
(((HIV or AIDS or ((human or acquired) adj1
(immunodeficiency or immune-deficiency or
immuno-deficiency))) adj2 (child* or adolescen* or
teen* or you*)) or ALHIV or PHIV or BHIV).ab,ti,kw.
HIV-positive
2
Programmes
Social
Protection
(Social Protection OR Safety net OR Welfare OR
Social assistance OR social security OR Social
benefit).ti,ab,kw.
3
Cash
(School feeding OR Cash Transfer OR Grant OR
Voucher OR Food OR Money Transfer OR Fund*
Transfer OR Payment OR Reimbursement OR Airtime
OR Uniform OR School fee OR Financial instrument
OR Microfinance OR Employment OR Work OR
Bursary OR Cash OR Money).ti,ab,kw.
4
Care
(Social support OR parent* OR caregiver OR
psychosocial support OR teach* support OR Health
work* OR Counsellor OR Counselor OR Care Work*
OR Home visits* OR Treatment support OR
Adherence support OR Treatment buddies OR
Treatment buddy OR Peer support* OR Peer
educator OR After-school OR Support groups OR
Learner support OR Student OR Care).ti,ab,kw.
5
Social
protection
strings
2 OR 3 OR 4
6
Final: SP &
Adolescents
1 AND 5

Page 34 of 48
Table 2. Summary of Evidence on Social Protection for HIV Prevention
Citation/
Publication
Status
Social Protection
Intervention
Type
Country
Age Group
Methodology
& Sample size
Outcomes
Results
Ssewamala
2013, 2014
2013 -
On-
going
Cash – youth-focused
grants
Capability – economic
empowerment approach
Pilot/
intervention
study
Uganda
10-16
years old
RCT,
n=736(est.)
HIV treatment
adherence
Psychosocial
functioning
Sexual risk-
taking
On-going trial
Pettifor
2015
2013-
2015
Cash –CCT on School
attendance (HTPN 068)
Pilot/
intervention
study
South
Africa
13-20
RCT, n=2,523,
women
HIV Prevalence,
School
attendance
No difference in new
HIV infections,
reduced risk
behaviours
Baird 2012
2008-
2009
Cash – CCT and UCT
(Zomba trial)
Pilot/
Intervention Trial
Malawi
13-22
RCT, n=2,915
HIV infection
(incidence)
Both CCT and UCT to
girls reduce likelihood
of HIV infection by
about half.
Bandiera
2013
2008-
2010
Care – life skills
Capability – vocational
training
Pilot/
Intervention Trial
Uganda
14-20
RCT, n=4,800
Risky
behaviours
(unprotected
sex), knowledge
about HIV and
pregnancy
prevention,
unwilling sex
Self-reported routine
condom usage
increases by 50%,
26% drop in fertility
rates over two years,
and from baseline
21%, near elimination
of unwilling sex.
Hallfors
2011, 2014
2007-
2010
Cash – school fees,
uniforms, and school
supplies
Care – school-based
“helper”
Pilot/
Intervention
Study7
Zimbabwe
10-16 at
baseline
RCT, n=329
(baseline)
287 (5-year
follow up)
Female
adolescent
orphans only
Sexual debut,
ever married,
school dropout,
years of
schooling,
meals per day,
HIV HSV-2
biomarkers
no difference in HIV,
HSV-2 biomarkers.
Intervention group
reduced sexual
debut, marriage, or
pregnancy, less likely
to drop out of school
and almost one

Page 35 of 48
Citation/
Publication
Status
Social Protection
Intervention
Type
Country
Age Group
Methodology
& Sample size
Outcomes
Results
additional year of
schooling.
Karim 2015
2010-
2012
Care – lifeskills program
Cash – conditional
transfer (Caprisa 007)
Pilot/
intervention
study
South
Africa
15-16
RCT, n=3,217
HSV, HIV
Incentives conditional
on participation in
life skills program
reduced HSV but not
HIV.
Duflo 2011
2003-
2006
Cash – School uniforms
on condition of being
enrolled in school (CCT)
Capability – teacher
training
National
programme
impact evaluation
Kenya
11 - 16
(and some
older due
to grade
repetition)
4-arm RCT
with 7-year
follow-up,
n=19,000
Fertility, School
Attendance,
marriage rate,
HIV and HSV-2
prevalence
18% reduction in
school dropout rate
across cohort. For
girls, significant
reduction in teen
pregnancy and teen
marriage but no
reduction in risk of
STI. No reduction in
HIV and HSV-2.
Cho 2011
2008-
2009
Care – “community
visitor” to monitor
school attendance
Cash – UCT (School fees,
uniforms)
Pilot/Intervention
Trial
Kenya
12-14
Pilot RCT,
n=105
School
enrolment, age
of sexual debut,
attitudes about
early sex
Control more likely
than intervention
group to: Drop out of
school (12% vs 4%)
and begin sexual
intercourse (33% vs
19%) and report
attitude supporting
early sex.
Dunbar
2014
2006-
2008
Care – social support
Cash – UCT
Capability – life-skills
and health education,
vocational training,
micro-grants
Pilot/
intervention
study
Zimbabwe
16-19
Pilot RCT,
n=315
Food insecurity,
risky behaviour,
fertility
Intervention arm
showed reduced food
insecurity [IOR=0.83
vs. COR=0.68,
p=0.02], having own
income [IOR=2.05 vs.
COR=1.67, p=0.02]

Page 36 of 48
Citation/
Publication
Status
Social Protection
Intervention
Type
Country
Age Group
Methodology
& Sample size
Outcomes
Results
lower risk of
transactional sex
[IOR=0.64, 95% CI
(0.50, 0.83)], and
increase condom use
with partner
[IOR=1.79, 95% CI
(1.23, 2.62)] and
fewer teen
pregnancies
[HR=0.61, 95% CI
(0.37, 1.01)]
Cluver
2013
2009 -
2012
Cash – child-focused
cash transfers both UCT
and CCT comparison
National
programme
impact evaluation
South
Africa
10-18
Quantitative,
n=3,515
Risky Behaviour
Reduced incidence of
transactional sex
amongst girls (odds
ratio [OR] 0·49, 95%
CI 0·26–0·93;
p=0·028), and age-
disparate sex (OR
0·29, 95% CI 0·13–
0·67; p=0·004). No
significant effects for
boys.
Cluver
2014, 2016
2009 -
2012
Cash alone UCT – child-
focused grants, free
school
Cash + care – cash
transfers, free schools,
parental support
National
programme
impact evaluation
South
Africa
10-18
Quantitative,
n=2,515
Risky Behaviour
Girls: Economically
driven sex incidence
in last year dropped
from 11% (no
intervention) to
2%.(intervention).
Unprotected/casual
sex dropped from
15% (no intervention)
to 10% (either

Page 37 of 48
Citation/
Publication
Status
Social Protection
Intervention
Type
Country
Age Group
Methodology
& Sample size
Outcomes
Results
parental monitoring
or school feeding)
and to 7% (with both
PM and SF).
Handa
2014
2007-
2011
Cash – UCT
National
programme
impact evaluation
Kenya
15-24
Quantitative,
n=1,540
Sexual debut
Reduction in
likelihood of sexual
debut by 23% among
young people.
Kauffman
2010
2002-
On-
going
Care – sports based
programmes
Capability – life skills
National
programme
impact evaluation
Zimbabwe
Botswana
15-19
Quantitative,
n=553
Risky Behaviour,
sexual debut
No differences in
sexual debut;
Sexually active
participants had
fewer sexual
partners.
Mahvu
2013
Aug-
Sept
2009
Care - Support Group
Pilot/
intervention
study
Zimbabwe
6-18
Mixed-
methods,
n=229
Mental Health,
Risky behaviour
Support group
attendance is helpful,
young people
stressed that life
outside the confines
of the group was
more challenging
Lightfoot
2007
2003-
2004
Care – one-to-one
sessions with nurse
Pilot/
intervention
study
Uganda
16-24
Mixed-
methods,
n=100
Risky behaviour
Intervention
decrease in number
of sexual partners
(3.1 at baseline to 0.7
at follow up )
Condom use
increased from 10%
at baseline to 93% at
follow up in
intervention

Page 38 of 48
Citation/
Publication
Status
Social Protection
Intervention
Type
Country
Age Group
Methodology
& Sample size
Outcomes
Results
Visser,
Zungu,
Ndala-
Magoroa
2015
2003-
On-
going
Care – Home visits and
family support, personal
guidance and
counselling,
empowerment
programme, access to
health care and
treatment
Capability – Help with
study
programme/homework,
help with further
education and training,
bursary application, job
skills, career guidance,
life skills training
Post-programme
impact evaluation
South
Africa
<18
Mixed-
methods
N=427
OVC
participants
over 18 who
had
previously
been project
beneficiaries
(70% for over
a year)
HIV risk,
educational
attainment, self
esteem, family
support,
employment,
income
Higher self-esteem
and problem-solving
abilities.
Improved family
support.
Less reported HIV risk
behaviour (men -
binge drinking 12.3%
vs. 30.6% for control
group. Women -
fewer unwanted
pregnancies – 28.8%
vs. 37% for control
group.women)
No difference in
education levels.
Higher employment
(20.8% vs. 11.5% in
control group).
Financially somewhat
advantaged (45.5%
vs. 28.7% in control
group).
More optimistic
about future
opportunities (70.5%
vs. 56.3%).
Bhana
2015
2012-
On-
going
Care – Family-based
psychosocial
intervention
Pilot/
Intervention Trial
South
Africa
10-14
Pre-post pilot
study, n=65
Mental Health,
Knowledge
about HIV,
Stigma, sexual
risk-taking
Trial on-going.

Page 39 of 48
Citation/
Publication
Status
Social Protection
Intervention
Type
Country
Age Group
Methodology
& Sample size
Outcomes
Results
Snyder
2014
2009
Care – structured
support group -
Hlanganani
Pilot/
intervention
study
South
Africa
16-24
Pre-post RCT,
n=109
adherence to
ARVS, increase
Knowledge of
HIV and
promote better
SRH practise
amongst
adolescents
Condom use at last
sex rose from 71% to
83% at follow-up.
Linkage to care 100%
of all ART eligible
participants (n=13),
compared to 58% in
comparison (n=31).
Parker
2013
2012
Care – support groups
(SYMPA)
Pilot/
intervention
study
DRC
15-24
Qualitative,
n=13
Communication
with significant
other, risky
behaviour,
knowledge
about HIV
Reduction in sexual
risk taking and
improved ability to
negotiate safer sex.
Participants also
reported feeling
more comfortable
speaking with care-
giver about sex
Senyonyi
2013
2011
Care – Cognitive
Behavioural Therapy,
support groups
Pilot/
intervention
study
Uganda
12-18
Qualitative,
n=171
Sexual risk-
taking
Mental health
No change in
depression.
Reduction in sexual
risk taking reported.
Willis 2015
On-
going
Care – Zvandiri
programme: Theraputic
digital story telling
Pilot/
intervention
study
Zimbabwe
14-16
Qualitative,
n=12
Improved
psychosocial
well-being
Improved
communication with
caregivers reported,
acquisition of digital
media skills, feeling
of empowerment

Page 40 of 48
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i
Sustainable Development Goal #1 is to “End poverty in all its forms everywhere” and target 1.3 calls for
the implementation of “nationally appropriate social protection systems and measures for all, including
floors, and by 2030 achieve substantial coverage of the poor and the vulnerable” as a means to achieve this.
ii
Regionally, the Southern African Development Community’s ‘Minimum package of services for orphans
and other vulnerable children and youth’ recognizes the vulnerabilities of children and youth in the region.
It has defined the basic needs and minimum services for vulnerable children and youth and entrenched
policy recommendations for provision of these services in a comprehensive and holistic manner (SADC,
2011). In Eastern Africa, there has been a recent push towards the harmonization of laws and policies in
order to create common health environments. A feasibility study has been conducted about harmonizing
social health protection systems across the region and providing universal healthcare (East African
Community (EAC), 2014), and implementation conversations are currently underway. It is within these
rich policy environments that we consider the potential for, and future of, social protection for HIV
prevention among children and adolescents.
iii
The term ‘plus’ is used throughout the paper to refer to combinations of social protection categories, for
example a cash-plus-care provision is a programme combining cash/ cash-in-kind and care components, as
used by Cluver and colleagues (Cluver et al., 2014), to refer to combinations of child support grants (cash)
and positive parenting (care).
iv
The term ‘unconditional’ is used to mean that receipt of the transfer is not linked to the recipient doing
certain tasks (such as taking children for health checks, school enrolment or participating in community
works programmes).