Interdisciplinary study in South Africa examines whether paying girls to attend school reduces their risk of acquiring HIV

Of all the countries in the world, South Africa has the most people living with HIV. Even more than China or India with much larger population sizes. Among the nearly 50 million people living in South Africa, the current HIV prevalence is about 12%.

The adolescent and young adult years are a particularly risky time for acquiring HIV, especially for young South African women. Among 15-16 year olds, about 4% are infected with HIV. By the time South African women reach their early 20s, over one quarter are already infected.

A pivotal structural context during adolescence is schooling– some youth stay in school and some do not. Research has shown that girls who continue to attend high school – grades 8 through 12 – are less likely to acquire HIV. So, to reduce HIV in youth, can a strategy be implemented that encourages girls to stay in school?

A study to explore this question is already in progress in Agincourt, South Africa. Carolina Population Center Faculty Fellow Audrey Pettifor is Principal Investigator of the study.

Pettifor said, “In our earlier studies, we saw over and over again that girls who were no longer attending school were four times more likely to be infected with HIV compared to girls who stayed in school. So, we designed this study to create incentives for girls to stay in school.”

For a country that has an unemployment rate of 40% and a wide disparity between the uber-wealthy and the poor, the incentive that is being tested is cash. Girls who stay in school receive monthly cash payments for both their family and themselves.

Officially, the name of the project is HPTN 068. It is also being called Swa Koteka which means “it is possible” in Shangaan. Swa Koteka evokes the concept that there is hope for the future through education and that interventions, such as conditional cash transfers, may reduce the incidence of HIV infection in young South African women.

The Swa Koteka project is situated in Agincourt, a rural area in the northeastern part of South Africa, near Kruger National Park. The project will include approximately 2,900 young women aged 13-20 in grades 8-11 and their parents. The study also includes an intervention aimed at changing negative gender norms among men living in the villages the young women live in. Working with a local non-governmental organization called Sonke Gender Justice, the community element of the project aims to work with men aged 18-35 years (the age of most young women’s partners) to change negative gender norms and HIV risk behaviors through community mobilization [Audio clip: Pettifor talks about the South African context.]

Because the risk factors for acquiring HIV are so complex, it is important to address them at multiple levels. The Swa Koteka project is designed to address both structural factors such as education and poverty that operate at the household level but also community level factors such as negative gender norms. “By addressing both levels of risk, we might be more effective than addressing one or the other,” Pettifor explains.

In December 2010, Pettifor and her team trained 85 interviewers about the study’s protocol and interview instruments. In February 2011, the baseline survey began with rolling enrollment of eligible girls and their families. Each month that a girl attends 80% of school days, the family and the young woman will receive a cash transfer payment. The community-based intervention is slated to begin in August 2011.

Pettifor is a Faculty Fellow of the Carolina Population Center and Assistant Professor in the Department of Epidemiology at University of North Carolina at Chapel Hill’s Gillings School of Global Public Health.

She has conducted HIV prevention research in South Africa since 1996, with a particular focus on behavioral and social factors. And since joining UNC in 2005, she has expanded her research to other sub-Saharan countries such as Democratic Republic of Congo, Madagascar, and Malawi.

Pettifor’s current research draws upon a nationally representative household survey that she conducted in South Africa in 2003 among young people ages 15-24 years. Analysis of this survey led to a broad understanding of the many determinants of HIV infection in young women, importantly the role of structural factors like education and the role of male partners.

The strategy of using cash transfers as incentive to stay in school to reduce risk of getting HIV was adapted from the social protection and development fields. Though cash transfers have been used successfully in Latin America and Asia, they are a new intervention to sub-Saharan Africa, especially conditional cash transfers.

“Cash transfers are completely new to the field of HIV prevention,” Pettifor explains. “Nobody thought about cash transfers in the arena of HIV prevention. And now there are a burgeoning number of programs in the HIV field that are thinking about how to use cash incentives or transfers to achieve prevention goals.”

One of the strengths of the study is the interdisciplinary team of experts. Pettifor collaborates with CPC Faculty Fellows Sudhanshu Handa (Public Policy), Chirayath Suchindran (Biostatistics), and Harsha Thirumurthy (Economics). Another collaborator at UNC is Suzanne Maman (Health Behavior and Health Education). Pettifor is also supported strongly in this project by the Division of Infectious Diseases in the School of Medicine, the Clinical Trials Unit at UNC, lead by Dr. Joe Eron who along with the UNC CTU has played a pivotal role in the implementation of this randomized controlled trial. The study is being funded by the National Institutes of Health and is part of the NIH HIV Prevention Trials Network (HPTN 068). The study is thus supported by a strong network of partners based at FHI, Johns Hopkins University and the University of Washington.

Pettifor has extensive experience working with the study’s South African partners: Kathleen Khan of the Agincourt Health and Population Unit and Catherine MacPhail of the Reproductive Health and HIV Research Unit. Both units are part of the University of the Witwatersrand in Johannesburg.

With this team, Pettifor is able to gather valuable information from various sources of data including survey data on study participants, social and contextual factors, biomedical and clinical information; data about development policy and behavioral economics; statistical methodologies; as well as a qualitative data component that will include longitudinal case studies looking at effects of transfers within the home.

The study will run for 3 years, with the aim to have final results released in 2014.