This blog was written by Lesley Gittings, Dr Elona Toska, Dr Rebecca Hodes, Professor Lucie Cluver.
AIDS-related illness is the leading cause of death amongst adolescents in sub-Saharan Africa, home to an estimated 2 million HIV-positive adolescents (1). Since the year 2000, adolescent AIDS-related deaths have tripled, while declining in all other age groups (1). Unfortunately, adolescents are underserved by existing HIV services, have significantly worse access to antiretroviral therapy, lower rates of adherence, and poorer health outcomes than adults (2).
This evidence on poor HIV-related health outcomes among adolescents makes a strong case for efforts to better understand and respond to the needs of this crucial demographic. Last year, we spoke with social protection experts, service providers, and adolescents themselves and conducted a review on the literature on social protection for adolescents living with HIV in Eastern and Southern Africa (3).
There was a strong acknowledgement in the literature and amongst research participants that social protection can interrupt some of the known pathways for HIV transmission amongst adolescents. Many of these pathways (including social and structural issues, food insecurity and disrupted family structures) are also pathways for adolescent non-adherence to ART. Promisingly, evidence suggests that certain social protection provisions can work for a variety of adolescent HIV and sexual and reproductive health outcomes. For example, there is a strong evidence base that ‘cash’ provisions (i.e. grants, social cash transfers and other in-kind provisions such as food) can support HIV prevention initiatives, and a growing literature demonstrating that these same social protection mechanisms may also improve adolescent adherence to ART.
Another clear message that emerged from this study was that the component of social protection which is traditionally classified as ‘care’ (including for example, social services, good parental supervision or support groups) deserves more attention by health and development partners. While acknowledging the potential of ‘cash’ social protection, research participants emphasized the importance of a broader conceptualization of social protection that includes explicit acknolwedgement of the role of care and support (4). Such ‘care’ social protection, because it is delivered by people, is more flexible in its response to issues that young people face, and facilitates linkages to other services. Many of the promising interventions included in the review consisted of provisions which fit the definition of ‘care’ social protection, even if they weren’t explicitly identified as social protection in their presentation. Examples of promising ‘care’ interventions include community and home-based care, psychosocial support for children/adolescents and their caregivers, adolescent and youth friendly clinic services, peer interventions and disclosure support (for examples, see 5–13).
‘Care’ social protection may support improved HIV outcomes as stand-alone initiatives, or in combination with other forms of social protection. When combined with ‘cash’ social protection, it may act as a kind of ‘glue’ to improve the efficacy of cash interventions (14). The evidence clearly shows that social protection combinations including ‘cash’ combined with certain kinds of ‘care’, work better than the provision of cash alone towards improving HIV-related health outcomes (15).
We also found promising social protection initiatives, which we have deemed ‘capability’ provisions, which focus on a long-term transfer of skills and knowledge. Despite varying in content from life skills support to teacher training, these interventions, alone and in combination, may be crucial in supporting the long-term resilience of adolescents. These provisions can support young people as they move into adulthood by enabling them to develop the skills necessary to cope financially as adults (14).
Despite this exciting emerging evidence, it is important to remember the contexts in which these provisions are being implemented. The geographic, legislative, fiscal and cultural landscapes of different locations mean that there is no one-size-fits-all model. Similarly, the age, life circumstances and developmental stage of an adolescent will directly affect their social protection needs. For example, the needs of a 13 year-old orphan may be very different from a 17 year-old adolescent mother living with her parents. Given the dynamic and fluid nature of young people’s realities, especially in contexts of extreme deprivation, social protection mechanisms need to be flexible in order to respond to their changing needs.
It is perhaps unsurprising that when young people are provided with multiple, overlapping and complementary forms of support, they will have improved health outcomes. However, developing a strong evidence base on the types and forms of social protection that work for adolescents living with HIV is a crucial endeavour, so that policy and programmatic initiatives can respond to their specific needs. The benefits of combinations of certain types of ‘cash’ and ‘care’ social protection for HIV-related health outcomes are clear. There is also promising prelimiary evidence for ART adherence specifically. This information makes a strong case for further policy, research and programming on adolescent sensitive social protection for adolescents and children living with, or at high risk of, contracting HIV.
Further research is also required in order to understand which types of social protection interventions, alone, and in combination, work best for adolescents who are understood to be part of groups who experience additional forms of marginalization and stigma, and who face additional challenges in accessing and adhering to healthcare. This includes adolescents who are disabled, identify as queer, or are TB co-infected. Another new and important frontier of social protection for adolescent HIV-related outcomes is combining social protection with biomedical and behavioural interventions, as is being done in the DREAMS PEPFAR initiative (16). Future research should also consider the risk of onward transmission for adolescents who are on ART, and the gendered vulnerabilities and pathways for contracting and transmitting HIV and taking up HIV prevention and treatment services. Further analyses on the allocative efficiencies of different social protection provisions are also needed to determine which are the highest-impact and most cost effective for different contexts and adolescent populations.
Curious to learn more? Please find the whole report at:
This blog post is published as part of the Social Protection and Health Series, sponsored by the German Development Cooperation within the EU SPS Initiative, and presents contributions from international agencies, government representatives and academic researchers.
1. WHO. Estimates for 2000–2012: Disease burden [Internet]. World Health Organization; 2015 [cited 2016 Feb 22]. Available from: http://www.who.int/healthinfo/global%7B_%7Dburden%7B_%7Ddisease/estimate...
2. Nachega JB, Stein DM, Lehman DA, Hlatshwayo D, Mothopeng R, Chaisson RE, et al. Adherence to antiretroviral therapy in HIV-infected adults in Soweto, South Africa. AIDS Res Hum Retroviruses [Internet]. 2004;20(10):1053–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15585095
3. Gittings L, Toska E, Hodes RJ, Cluver LD, Zungu N, Govender K, et al. Resourcing resilience: The case for social protection for adherence and HIV-related outcomes in children and adolescents in Eastern and Southern Africa. 2016.
4. Cluver LD, Toska E, Orkin FM, Meinck F, Hodes R, Yakubovich AR, et al. Achieving equity in HIV-treatment outcomes: Can social protection improve adolescent ART-adherence in South Africa? AIDS Care. 2016;28(Sup2):73–82.
5. Hudelson C, Cluver LD. Factors associated with adherence to antiretroviral therapy among adolescents living with HIV/AIDS in low- and middle-income countries: a systematic review. AIDS Care. 2015;27(7):805–16.
6. Visser M, Zungu N, Ndala-Magoro N. ISIBINDI, creating circles of care for orphans and vulnerable children in South Africa: post-programme outcomes. AIDS Care Psychol Socio-medical Asp AIDS/HIV [Internet]. Taylor & Francis; 2015;27(8):1014–9. Available from: http://dx.doi.org/10.1080/09540121.2015.1018861
7. Paediatric Adolescent Treatment Africa (PATA). “If you come, they will help you with a smile on your face”. Promising practices in health provider sensitisation for adolescents and young people living with HIV. Cape Town, South Africa; 2017.
8. Paediatric Adolescent Treatment Africa (PATA). ’If you trust us, help us to do it by ourselves." Promising practices in peer support for adolescents and young people living with HIV. Cape Town, South Africa; 2017.
9. Paediatric Adolescent Treatment Africa (PATA). Every adolescent clinic day I feel very excited to look out for young people to refer to the SRH unit". Promising practice in integrating HIV and SRH services for adolescents and young people living with HIV. Cape Town, South Africa; 2017.
10. Lightfoot MA, Rotheram-Borus MJ, Tevendale H. An HIV-preventive intervention for youth living with HIV. Behav Modif. 2007;31:345–63.
11. Van Winghem J, Telfer B, Reid T, Ouko J, Mutunga A, Jama Z, et al. Implementation of a comprehensive program including psycho-social and treatment literacy activities to improve adherence to HIV care and treatment for a pediatric population in Kenya. BMC Pediatr. 2008;8:52.
12. Young LS, Jackson C, Young LS. Journal of Psychology in Africa “ Bhuti ”: Meaning and Masculinities in Xhosa Brothering “ Bhuti ”: Meaning and Masculinities in Xhosa Brothering. 2014;(January 2015):37–41.
13. Busza J, Besana GVR, Mapunda P, Oliveras E. Meeting the needs of adolescents living with HIV through home based care: Lessons learned from Tanzania. Child Youth Serv Rev [Internet]. 2014;45(February):137–42. Available from: http://www.sciencedirect.com/science/article/pii/S0190740914001364
14. Toska E, Gittings L, Cluver LD, Hodes RJ, Chademana E, Gutierrez VE. Resourcing resilience: social protection for HIV prevention amongst children and adolescents in Eastern and Southern Africa. African J AIDS Res. 2016;15(2):123–40.
15. Cluver LD, Orkin FM, Boyes ME, Sherr L. Cash plus care: social protection cumulatively mitigates HIV-risk behaviour among adolescents in South Africa. AIDS [Internet]. England: Cluver,Lucie D. aCenter for Evidence-Based Social Intervention, Department of Social Policy and Intervention, University of Oxford and Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa bWits School of Governance,; 2014;28 Suppl 3:S389-97. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=...
16. Cluver LD, Hodes RJ, Sherr L, Orkin FM, Meinck F, Lim PLAK, et al. Social protection: potential for improving HIV outcomes among adolescents. J Int AIDS Soc [Internet]. 2015;18(Suppl 6):202607. Available from: http://www.jiasociety.org/index.php/jias/article/view/20260