The Role of Families in Adolescent Hiv Prevention a Review

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Peer-reviewed

Enquiry Commodity

Cash transfers for HIV prevention: A systematic review

• Marie C. D. Stoner,
• Kelly Kilburn,
• Peter Godfrey-Faussett,
• Peter Ghys,
• Audrey E. Pettifor

ten

• Published: November 29, 2021
• https://doi.org/x.1371/journal.pmed.1003866

Figures

Abstract

Background

Given the success of greenbacks programs in improving health outcomes and addressing upstream drivers of HIV hazard such as poverty and instruction, at that place has been an increasing interest in their potential to improve HIV prevention and care outcomes. Recent reviews take documented the impacts of structural interventions on HIV prevention, but evidence well-nigh the effects of cash transfer programs on HIV prevention has non been systematically reviewed for several years.

Methods and findings

We did a systematic review of published and unpublished literature to update and summarize the testify around cash programs for HIV prevention from January 2000 to Dec 17, 2020. We included studies with either a cash transfer intervention, savings program, or program to reduce schoolhouse costs. Included studies measured the programme'due south bear upon on HIV infection, other sexually transmitted infections (STIs), or sexual behaviors. Nosotros screened one,565 studies and examined 78 in full-text review to identify a total of 45 peer-reviewed publications and reports from 27 unlike interventions or populations. We did not do a meta-assay given the range of outcomes and types of cash transfer interventions assessed. Most studies were conducted in sub-Saharan Africa (N = 23; South Africa, Tanzania, Republic of malaŵi, Kingdom of lesotho, Kenya, Uganda, Zimbabwe, Zambia, and eSwatini) followed past Mexico (N = 2), the Us (N = ane), and Mongolia (N = 1)). Of the 27 studies, twenty (72%) were randomized trials, 5 (twenty%) were observational studies, i (4%) was a case–control study, and 1 (iv%) was quasi-experimental. Most studies did not place a strong association between the plan and sexual behaviors, except sexual debut (10/18 finding an association; 56%). Eight of the 27 studies included HIV biomarkers, but only three found a large reduction in HIV incidence or prevalence, and the rest found no statistically meaning clan. Of the studies that identified a statistically significant clan with other STIs (N = 4/viii), 2 involved incentives for staying free of the STI, and the other 2 were cash transfer programs for adolescent girls that had conditionalities related to secondary schooling. Study limitations include the modest number of studies in key populations and examining interventions to reduce school costs and matched saving programs.

Conclusions

The evidence base for large-scale impacts of greenbacks transfers reducing HIV risk is express; nonetheless, government social protection greenbacks transfer programs and programs that incentivize schoolhouse attendance amid adolescent girls and immature women evidence the greatest promise for HIV prevention.

Author summary

Why was this study done?

• Cash transfers have become a widely used policy strategy to achieve social protection and development goals in a number of different domains.
• Contempo reviews have documented the impacts of greenbacks transfer interventions on HIV prevention outcomes, but many studies have been done recently and accept non yet been captured in these reviews.

What did the researchers do and find?

• To update the current evidence related to cash transfers for HIV prevention, we did a systematic review of quantitative studies of greenbacks transfer interventions, interventions to reduce school costs, and matched savings programs extending from January 2000 to Dec 2020.
• Impacts on HIV infection were mixed. Only 3 of the 8 studies that included HIV biomarkers found a reduction in HIV incidence or prevalence.
• Four of viii studies that included other sexually transmitted infections (STIs) found a statistically pregnant clan, and all iv of these studies included conditionalities based on testing STI negative or secondary schooling.
• A total of ten/18 (56%) interventions identified a statistically meaning reduction on delaying sexual debut, in almost cases only for girls and not for boys.

What do these findings mean?

• Overall, nosotros find that nearly evidence to engagement is limited in demonstrating that cash transfers tin reduce HIV infection or have wide reaching impacts on risky sexual behaviors.
• Social protection cash transfer programs provided to poor or vulnerable households and cash transfers conditional on school attendance were more likely to lead to delays in sexual practice amid adolescents more often than not and reductions in risky sex among adolescent girls, at least while the programs were ongoing.
• Farther inquiry is needed to sympathize the touch on of cash transfer among key populations and when combined with other HIV prevention interventions.

Citation: Stoner MCD, Kilburn K, Godfrey-Faussett P, Ghys P, Pettifor AE (2021) Cash transfers for HIV prevention: A systematic review. PLoS Med 18(11): e1003866. https://doi.org/10.1371/journal.pmed.1003866

Academic Editor: Cheryl Baxter, Academy of Kwazulu-Natal, Due south AFRICA

Received: January 31, 2020; Accepted: November 11, 2021; Published: November 29, 2021

Copyright: © 2021 Stoner et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in whatever medium, provided the original author and source are credited.

Data Availability: All relevant data are inside the manuscript and its Supporting Information files.

Funding: This work was funded by a UNAIDS consulting award (AP). The funders had a function in study design, decision to publish, and grooming of the manuscript.

Competing interests: The authors accept declared that no competing interests be.

Abbreviations: AOR, adjusted odds ratio; CCT, conditional cash transfer; CI, confidence interval; HSV-2, herpes simplex virus type 2; IRR, incidence rate ratio; MSM, men who have sex with men; OR, odds ratio; OVC, orphans and vulnerable children; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Assay; RR, adventure ratio; SE, standard mistake; STD, sexually transmitted affliction; STI, sexually transmitted infection; UCT, unconditional cash transfer

Introduction

Globally, cash transfers have become one of the near popular policy strategies to achieve social protection and development goals in a number of different domains. Programs that provide noncontributory greenbacks payments now reach over i billion people beyond more than than 130 countries [1]. Evidence from these programs consistently points to their positive impacts on budgetary poverty, educational activity, health and nutrition, productivity and employment, and empowerment [one]. Alongside big, national programs, there are a range of other initiatives and interventions that have utilized cash payments to achieve specific outcomes, many of them either education or wellness based. Given the success of greenbacks programs in improving health outcomes and addressing upstream drivers of HIV hazard such as poverty and pedagogy, there has been an increasing involvement in their potential to improve HIV prevention and care outcomes.

Background on cash transfer interventions

In this review, we focus on several models of cash transfers that have been used to prevent HIV including greenbacks transfer programs (government programs and stand up-alone/research studies), interventions to reduce school costs (scholarship, school uniform, or school fee), and matched savings programs. Cash transfer programs mainly fall into 2 categories: (1) greenbacks payments to poor families with the aim of poverty alleviation and social protection; and (2) cash payments as incentives for behavior change [2]. The first group of programs is based on the theory that cash payments can exist used to amend underlying structural factors related to HIV hazard. National regime run cash transfer programs fall into the first category because they are designed to transfer cash to poor households with the goal of helping families run across their basic needs such as nutrient consumption, housing, and healthcare. The 2nd type of cash transfer scheme is based on the theory that cash can be used as an incentive to promote beliefs change. These programs use cash transfers as incentives for individuals to appoint in protective behaviors or remaining HIV or STI negative [2,3].

Cash transfer programs can have unconditional or conditional designs. Unconditional cash transfers (UCTs) provide cash aid to individuals or households without whatever obligations and therefore seek to encourage behaviors through a change in income resulting in changes in the demand for services. Provisional cash transfers (CCTs), on the other hand, explicitly condition the receipt of cash payments on certain behaviors that are deemed beneficial such every bit schoolhouse attendance or healthcare utilization and rail compliance. Incentive-based interventions are designed to reduce run a risk past providing firsthand benefits for avoiding high-risk behaviors [2,iii]. For example, individuals at risk of HIV must balance immediate benefits of risky sexual practice with the long-term costs of possible HIV infection. Cash incentives are designed to provide a "nudge" to avoid immediate gratification of certain behaviors past providing an incentive to not appoint in those high-chance behaviors [3,4].

Current evidence on cash transfers for HIV prevention

Recent reviews have documented the impacts of cash transfer interventions on HIV prevention for young women [5] and household economical strengthening for HIV outcomes [6]. Prove from previous reviews suggest that some of the strongest impacts of greenbacks transfers are on health and schooling outcomes for the poor. The largest systematic review of cash transfer programs to date finds that across countries, greenbacks transfers increase the consumption of diverse foods, improve the use of health services, and increase school attendance [i]. Additionally, evidence indicates that greenbacks transfers can reduce anxiety and stress, improve self-esteem and hope for the future, and reduce early marriage and pregnancy in adolescents [7]. A recent review of conditional incentive interventions found that in the curt term, these interventions can increase HIV testing rates, increase voluntary male person circumcision, and meliorate other HIV prevention and handling outcomes in certain settings, simply results are non maintained after the study ends [8].

The aim of this review was to update the current evidence related to greenbacks transfers for HIV prevention. Here, we use reviews, published, and unpublished literature to summarize the evidence around cash transfers and payments for HIV prevention behaviors. We reviewed quantitative studies of cash transfer interventions, interventions to reduce school costs, and matched savings programs examining HIV infection and sexual behavior outcomes in any population.

Methods

This systematic review was conducted utilizing the standard protocol for Preferred Reporting Items for Systematic Reviews and Meta-Assay (PRISMA; PRISMA checklist is bachelor in S1 PRISMA Checklist) [9]. We included quantitative studies of greenbacks transfer interventions, interventions to reduce school costs, and matched savings programs extending from January 2000 to December 2020. Searches were done on July 25, 2019, and Dec 17, 2020. Nosotros categorized cash transfer interventions every bit either government social protection programs, individual incentive-based greenbacks transfer programs, or individual structural greenbacks transfer programs to alleviate poverty. Nosotros reviewed peer-reviewed literature, gray literature (e.k., reports, working newspaper, etc.), and ongoing studies where information were available.

We first employed a systematic literature review to find all published studies that met our review criteria and were in English. We did some other search on October 26, 2021 to update our systematic review to also include articles not in English from the same period of Jan 2000 to December 2020. Studies that met inclusion criteria were those that (1) analyzed either cash transfer programs, savings plan, or programs to reduce school costs; and (two) reported impacts on HIV and HIV prevention–related sexual beliefs outcomes. The outcomes of interest were HIV infection (incidence and prevalence), other sexually transmitted infections (STIs) (all infections; incident or prevalent), condom utilise, sexual debut, number of partners, transactional sex, older partners, and other behavioral outcomes related to these sexual behaviors such equally combined behavioral take a chance scores. Our search criteria included cash transfer, cash incentive, financial incentive, greenbacks reward, monetary reward, contingency direction, savings, scholarship, school uniform, school fee, or uniform costs and HIV, sexually transmitted disease (STD), STI, condom apply, sexual debut, number of partners, sexual partners, transactional sex, older partner, or sexual behavior (see S1 Text for total search terms for each database). We searched the databases PsycINFO, EconLit, PubMed, and Web of Science. We did not do a meta-analysis because the group of studies assessed was not sufficiently homogenous; the studies take both a large variety of outcomes and various types of greenbacks transfer interventions assessed. The study protocol was prepared on February 4, 2019 for UNAIDS but was not registered in any publicly accessible database (S2 Text).

Abstracts were imported from each database and combined into Covidence online software. Two reviewers (MCDS and KK) screened the abstracts independently and and so examined the full text of articles that met the criteria or were flagged past the software as discrepancies between reviewers. Discrepancies were reviewed once more by the two reviewers to come up to a joint determination. Inclusion was based on agreement between the 2 reviewers. We identified additional studies in the gray literature by contacting experts in the field and from other systematic reviews or commentaries on the topic. One of the reviewers (MCDS) extracted information from all included studies including the report population, timeline, location, type of intervention, research design, conditionalities, and effect sizes with conviction intervals (CIs) or standard errors (SEs) and significance for each of the relevant outcomes reported (S1 Table). We did not restrict studies by type of estimate that was reported (due east.g., odds ratio (OR)). We assessed study quality past examining the strength of the inquiry design and sample size.

Results

A total of ane,642 records were imported through the database search, and eight boosted studies were added from the gray literature (Fig one). Of these studies, i,607 were screened and 1,484 records were excluded. In the full-text review, 78 studies were included, and 33 were excluded that did not meet inclusion criteria. We identified a full of 45 peer-reviewed publications and reports from 27 dissimilar interventions or populations (Table ane) [x–55]. Most studies were conducted in sub-Saharan Africa (N = 23; South Africa, Tanzania, Republic of malaŵi, Lesotho, Kenya, Uganda, Zimbabwe, Zambia, and eSwatini) followed past Mexico (N = 2), the United states of america (N = ane), and Mongolia (N = ane)). Of the 27 studies, xx (74%) were randomized trials, Northward (18%) were observational studies, 1 (4%) was a case–control study, and 1 (four%) was quasi-experimental. Nearly interventions assessed sexual behavior outcomes in adolescent populations (N = 15; 3 among girls simply), followed by orphans and vulnerable children (OVC) (Due north = five), both adolescents and adults (N = ii), adults merely (North = 1), men who sell sex (N = 1), and women who sell sex (N = i). Of the studies among adolescents, most studies (8 of fourteen) involved a government cash transfer to the household. Nosotros identified 12 ongoing studies (S2 Table).

A total of 21 studies included a cash transfer intervention (33 publications or reports) (Tabular array i). Three studies (four publications or reports) assessed a matched savings program. Three interventions (8 publications or reports) assessed interventions to reduce school costs. Of these 21 cash transfer interventions, nine studies assessed the impact of household grants from the government, four were incentive-based programs, and 8 were individual cash transfers for poverty alleviation. Government greenbacks transfer programs/grants were assessed in Kenya, Zambia, Republic of malaŵi, Tanzania, Republic of zimbabwe, and in South Africa where 4 studies assessed different programs (child support grant or foster grant (Due north = 1); child support grant alone (N = 2); and old-age alimony (North = 1)).

HIV outcomes

Eight studies examined HIV incidence of prevalence equally an event, and results were mixed (Table 2; S1 Tabular array). Three of the v greenbacks transfer studies that assessed HIV infection found a significant reduction; a cash transfer intervention provided to young women aged thirteen to 22 years, and their families, to stay in schoolhouse in Republic of malaŵi constitute a reduction in HIV prevalence (adjusted odds ratio [AOR] 0.36; 95% CI: 0.xiv, 0.91 [10]), and a lottery intervention for adults who tested STI negative in Lesotho establish a reduction in HIV incidence by ii.5 percentage points (95% CI: 0.0%, five.0%, p = 0.046) and HIV prevalence past iii.4 percentage points (95% CI: 0.0%, 5.9%; p = 0.044) [33]. An intervention for boyish girls combining incentives to enroll and attend school with a lottery provisional on being STI negative in eSwatini reduced HIV incidence amidst girls getting educational incentives (OR 0.77; 95% CI 0.60 to 0.98) and with the STI lottery lone (OR 0.83 95% CI 0.65 to 1.07,[nineteen,56]), although the lottery alone was not significant. Conversely, ii other cash transfer studies did not reduce HIV incidence: 1 study examining the outcome of a greenbacks transfer conditional on school attendance amongst adolescent girls in South Africa (AOR 1·17; 95% CI: 0·lxxx to ane·72; p = 0.42) [37] and some other examining an incentive conditional on testing HIV negative (β = 0.001, robust SE, 0.005) [29]. I report that examined a cash transfer that had various school-based conditionalities did not study the impact on HIV incidence in boys and girls in South Africa due to low HIV incidence (N = 75) [28]. Ii studies that evaluated programs to reduce school costs for adolescent orphans in Kenya and Zimbabwe also found no meaning upshot on HIV prevalence, although in that location was a nonsignificant reduction in one study (AOR 0.72; 95% CI: 0.15 to 3.42; p = 0.68 and AOR 1.15; 95% CI: 0.47 to ii.79) [21,52]. None of the governmental cash transfer intervention studies or savings program studies evaluated the impacts of the programs on HIV or other STIs.

Sexually transmitted infections outcomes

Eight studies examined other STIs. Five studies examined canker simplex virus type 2 (HSV-2) infection, only but 2 of these 5 studies plant a statistically meaning reduction. One written report plant a reduction in HSV-2 incidence with a cash transfer intervention provisional on diverse schooling-related outcomes in both boyish girls and boys combined (incidence rate ratio (IRR): 0.70, 95% CI: 0.57 to 0.86, p = 0.007; [28]), while the other cash transfer trial conditional on school attendance amidst girls in Malawi reduced prevalence of HSV-2 but non of syphilis (HSV-2 OR 0.24, 95% CI: 0.09 to 0.65; syphilis AOR 0.91; 95% CI: 0·12 to 6·viii [10]). In addition, 3 incentive-based studies examined blended measures of STIs. All 3 studies were greenbacks transfer programs conditional on negative STI status. One of these, an incentive-based intervention provisional on testing negative for four curable STIs in adults in Tanzania, identified a reduction in incidence of a composite measure out that included Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium (risk ratio (RR): 0.73, 95% CI: 0.47 to 0.99; [57]). However, the same study did not find a reduction in a different composite measure out that included prevalence of HIV, HSV-ii, or syphilis (RR 1.03, 95% CI: 0.74 to one.32; [57]). Nyquist and coauthors also found that a lottery incentive for adults in Lesotho that was provisional on testing negative for syphilis and trichomoniasis led to a reduction in prevalence of both syphilis and trichomoniasis past 3.ii percentage points (95% CI: 1.4%, v.0%; p < 0.001) [33].

Sexual beliefs outcomes

A total of nineteen studies examined unprotected sex as an outcome, 15 examined partner number, 8 examined transactional sexual practice, and 8 examined partner historic period. Amid the studies that examined the impact of cash transfers on sexual behavior outcomes, most found a statistically insignificant clan including on unprotected sex (N = 14/19), partner number (N = 11/15), transactional sexual activity (Due north = vi/viii), and having an older partner (Due north = four/viii). Among studies that reported differences disaggregated by biological sex, several studies found larger reductions amidst women or girls compared to men or boys.

Interventions that did have an overall statistically significant reduction in unprotected sex, partner number, transactional sex, and having an older partner varied widely in the type of intervention and population studied (S1 Table). The 3 interventions that found statistically significant reductions in unprotected sexual practice were all cash transfer programs but amidst diverse populations including a cash transfer provisional on school attendance in adolescent girls (RR 0.81, 95% CI: 0.67 to 1.0; [37]); an incentive-based intervention provisional on testing STI negative amongst men who sell sexual activity (high incentive β = 0.113, SE = 0.060, p = <0.10; [16]) and an incentive-based lottery for testing STI negative amid adults in Lesotho (β = 10.85; SE = 5.89, p < 0.10) [33]. The South African greenbacks transfer intervention conditional on schooling reduced the take chances of having whatsoever sex partner in the last 12 months (RR 0.ninety, 95% CI: 0.83 to 0.99), just did not significantly reduce having more 1 sex partner in the terminal 12 months (RR 0.86 (95% CI: 0.67 to 1.1) [37]. One study identified a statistically significant reduction in transactional sex activity examining the clan with a household government grant plan amidst adolescents in South Africa (AOR 0.49, 0.25 to 0.96, p = 0.03; [53]). Additionally, a savings programme for women (aged eighteen or older) involved in street-based sex piece of work led to a statistically significant reduction in the number of unprotected vaginal sex acts for pay (IRR 0.78, 95% CI: 0.67 to 0.71); however, it is important to notation that this is a dissimilar indicator than transactional sex in the other studies [40]. Of the three studies that establish an impact on having an older partner, 2 were among adolescents in households receiving government greenbacks transfers in Malawi (−3.ix percent points, p < 0.05) and Zambia (−3.3 percentage points, p < 0.01) [41,46]. The third program was a greenbacks transfer conditional on school attendance for female adolescents in Republic of malaŵi (AOR 0.21, 95% CI: 0.07 to 0·60; [ten]) [37].

In dissimilarity to other sexual behaviors, most studies examining sexual debut plant a statistically significant reduction in ever having sex or a delay in age of first sex (North = ten/eighteen), although some of them identified a reduction for only girls or women simply non boys or men (N = vi/18). Of the 10 interventions that saw a statistically significant reduction fifty-fifty if the reduction was only in females, i was a cash transfer conditional on completion of life skills activities among both boyish males and females in the US [thirty], 5 were national authorities cash transfer programs [23,26,45,47,49], 1 was a study CCT to OVC-headed households in Kenya [18],and ii were programs to reduce school fees adolescents in Kenya [15] and OVC in Zimbabwe [21] (see estimates in S1 Table). The bulk of national government cash transfer programs decreased the proportion with early on sexual debut [23,45,49], although ii only had a reduction in girls but not boys [26,47].

Long-term impacts and combination impacts

Iii studies examined the longer-term affect of cash interventions once the programs finish, and findings suggest that impacts are non sustained once the cash stops. The interventions that were evaluated include the Malawi Zomba greenbacks transfer for adolescent girls [43], the incentive-based intervention amid men who sell sex in Mexico [16], and an intervention to reduce schoolhouse costs for girls in Kenya [15]. Yet, recent prove suggests that cash transfers may be more effective in combination with other interventions and may also lead to longer-term impacts [54,56,58]. For example, in Kenya, subsidies alone did not accept a lasting affect on HSV-2 in girls or boys 7 years following the implementation of an education subsidy program, simply the plan did reduce HSV-2 in girls when subsidies were combined with the government's HIV curriculum [15]. Lastly, an observational study in South Africa constitute that receipt of a authorities grant in combination with teacher or parental support was associated with a larger reduction in HIV hazard behavior than with receipt of greenbacks alone [54].

Ongoing studies

Nosotros identified 12 ongoing studies: 10 of these studies are being conducted in adolescent populations, 9 of which focus on adolescent girls and young women (S2 Table) [59–69]. All 8 of the interventions include adolescents are in sub-Saharan Africa (Ghana, South Africa (N = 4), Zimbabwe, Republic of kenya (N = two), Malawi, Uganda, and Tanzania). The 2 other studies are with women who sell sexual activity in Republic of kazakhstan [64] and Uganda [66]. All studies are combination prevention studies combining greenbacks assist with other interventions.

Discussion

In this review of cash transfer programs for HIV prevention, we found that overall, there is express prove for the impact of cash transfers for reducing new HIV infections. The strongest show that emerged was for HIV prevention behavior change, specifically delaying sexual debut for young people; x/18 (56%) interventions had a statistically significant reduction on delaying sexual debut, in a number of cases simply for girls and non for boys. For the bulk of other HIV risk behaviors examined including partner number, older partners, and transactional sex, the prove is not every bit strong—virtually a third of the studies found a reduction in risky behaviors.

It is noteworthy that government social protection programs, which target the most poor and vulnerable households, have shown some of the strongest impacts on HIV chance reduction, particularly among adolescents. The bulk of program evaluations looking at HIV prevention have been among adolescents and immature people. As government social protection cash transfers intend to reduce poverty and smoothen consumption, the evidence of their impact on adolescent beliefs supports the hypothesis that addressing upstream drivers of HIV risk such as poverty can reduce risky beliefs, especially for the most vulnerable. In improver, there is a strong evidence base that cash transfers (both conditional and unconditional programs) can improve school enrollment and attendance and that schooling is protective for HIV infection. Greenbacks transfer programs, therefore, may reduce gamble the most by keeping adolescents in school, particularly girls. In fact, almost of the positive impacts on adolescents' risky sexual behavior are among girls; associations amid boys were frequently nada or in the opposite direction. This is in line with the literature on the impact of cash transfers to improve schoolhouse enrollment and attendance where effects are stronger for girls than boys [five]. The one trial to appointment showing an touch of cash transfers on HIV incidence was an explicit incentive paid to adolescent girls for enrolling in and attending school in eSwatini where secondary school enrollment for girls is mostly depression (33%) [56].

One of the other major mechanisms through which greenbacks transfers are thought to reduce HIV risk for girls and young women are by reducing girl'southward financial dependence on male person partners and thus reducing the need for sexual partnerships that include transactional sex activity [lxx]. However, of the 8 studies that examined transactional sex, only 2/8 (25%) institute a statistically significant reduction—one was amid immature women in Due south Africa living in homes receiving the child support grant [53] and the second was in Republic of kenya amid OVC receiving support for schooling costs [52]. Additionally, there is emerging bear witness that context may be important in determining the impact of cash transfers on reducing take chances behavior. In settings where transactional sex is driven primarily by basic needs (east.yard., obtaining food), small cash transfers may have an affect on reducing run a risk for poor immature women [71]. In settings where the primary motivator for engagement in transactional sexual practice is related to obtaining material goods to increase social status and self-esteem, it is less likely that small-scale cash payments volition accept much of an impact. At that place is evidence that engagement in transactional sex is associated with low self-esteem, and thus programs that combine cash with other program elements to increase hope for the future and cocky-esteem may have more hope than cash alone [72].

While all studies reported on at to the lowest degree ane HIV adventure behavior, not many collected HIV biomarkers, then prove is limited to make conclusions on the direct impacts of cash transfers on HIV. 8 of the 27 studies included HIV biomarkers, merely merely 3 plant a statistically significant reduction in HIV incidence or prevalence, and the rest found no touch. The 3 studies that showed an impact included a cash transfer provisional on schooling among adolescent girls in Republic of malaŵi (reduction in HIV prevalence), an incentive-based lottery study among adults in Lesotho for testing negative for STIs (reduction in HIV incidence), and a cash transfer conditional on school enrollment and attendance in eSwatini (reduction in HIV incidence). There was slightly more evidence of the bear on of cash transfers on STI outcomes. Of the studies that found an impact on STIs (N = 4/8), 2 involved incentives for staying free of the STI, and the other 2 were cash transfer programs for adolescent girls that had conditionalities related to secondary schooling.

The evidence of the impact of cash transfers amid cardinal populations is express. Of the 27 studies included in this review, one was amid men who sell sex and who had sex activity with men in Mexico and one written report was among women who sell sex in Mongolia. Only 2 of the 12 ongoing studies is being conducted among key populations, interventions for women who sell sexual activity in Kazakhstan and Uganda. More studies are needed to evaluate the impacts of cash transfer interventions and government grants amongst primal populations who may experience discrimination or have limited admission to services and may benefit from these programs.

There are 2 additional areas where more research is needed. First, there is very limited evidence to appointment that combining social protection programs with additional back up (due east.thou., caring adult and other social support services) can take stronger impacts on reducing HIV hazard behaviors. In this area, yet, there are at to the lowest degree 3 large programs in the field (DREAMS, Global Fund, and Tanzania/UNICEF) that should produce more evidence about the touch of combination programs in reducing HIV risk. 2d, there is limited evidence nigh the touch on of cash transfer programs for either out-of-school girls or young women aged eighteen to 24 year where HIV incidence is highest. In the "Zomba trial" that included out-of-school girls, the prevalence of most risk behaviors was as well low at baseline to meet any significant difference at the end of the plan [10]; yet, some of the DREAMS programs include out-of-schoolhouse girls: The Sauti program in Tanzania and the AGI-Kenya written report, implemented by the Population Council, include out-of-school girls.

This review focuses on several dissimilar forms of interventions to provide cash payments, some explicitly for HIV prevention and some intended for poverty reduction. Overall, there are a large number of studies evaluating cash transfers and national government social protection cash transfer programs with large sample sizes and rigorous methods (and the majority are randomized controlled trials). All the same, the take chances of bias in the study outcomes was difficult to evaluate across studies because of the broad range of intervention types and targeted populations, but the strong study designs of the majority of evaluations propose that the show generated to date is robust. Given that we were unable to do a meta-assay, studies are summarized by statistical significance and should also be considered with the estimates in S1 Table. The main surface area where evidence is still lacking is for specific populations (eastward.g., people who sell sexual practice and men who have sex with men [MSM]) and for transactional sex which has not been evaluated in many studies. There is less prove on interventions to reduce school costs (N = iii) and matched saving programs (N = 3) or combination interventions that add multiple elements into a unmarried program (cash plus programs). Few interventions that have actually measured HIV incidence.

Overall, we observe that well-nigh show to date is limited in demonstrating that greenbacks transfers can reduce HIV infection or have broad reaching impacts on risky sexual behaviors. However, there are some populations and program designs that seem to be more promising for impacting HIV preventive behaviors. Social protection cash transfer programs provided to poor or vulnerable households and greenbacks transfers conditional on schoolhouse attendance (or related to incentivizing schooling omnipresence for girls) were more likely to lead to delays in sexual activity amongst adolescents generally and reductions in risky sexual activity amid boyish girls, at to the lowest degree while the programs were ongoing. To date, the strongest evidence related to cash transfer programs for HIV prevention suggests that social protection programs for poor and vulnerable families may reduce gamble behaviors of adolescents living in those homes, especially girls. Plan and policymakers interested in HIV prevention for immature women should consider programs that directly incentivize school enrollment and attendance or are conditional on attendance, which may have the largest impact on HIV risk for girls, specially in contexts where secondary schoolhouse attendance is low.

Supporting information

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