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Time discounting is thought to influence decision-making in almost every sphere of life, including personal finances, diet, exercise and sexual behavior. In this article we provide evidence on whether a national poverty alleviation program in Kenya can affect inter-temporal decisions. We administered a preferences module as part of a large-scale impact evaluation of the Kenyan Government's Cash Transfer for Orphans and Vulnerable Children. Four years into the program we find that individuals in the treatment group are only marginally more likely to wait for future money, due in part to the erosion of the value of the transfer by inflation. However among the poorest households for whom the value of transfer is still relatively large we find significant program effects on the propensity to wait. We also find strong program effects among those who have access to credit markets though the program itself does not improve access to credit.

We examined the association of orphanhood and completion of compulsory school education among young people in South Africa. In South Africa, school attendance is compulsory through grade 9, which should be completed before age 16. However, family and social factors such as orphanhood and poverty can hinder educational attainment. Participants were 10,452 16–24‐year‐olds who completed a South African national representative household survey. Overall, 23% had not completed compulsory school levels. In univariate analyses, school completion was lower among those who had experienced orphanhood during school‐age years, males, and those who reported household poverty. In multivariate analyses controlling for household poverty, females who had experienced maternal or paternal orphanhood were less likely to have completed school; orphanhood was not independently associated with males' school completion. Findings highlight the need for evidence‐informed policies to address the education and social welfare needs of orphans and vulnerable youth, particularly females, in South Africa.

AbstractIntroductionCash transfers have been promoted as a means to reduce HIV risk for adolescent girls and young women (AGYW) in sub‐Saharan Africa. One of the main mechanisms whereby they are hypothesized to reduce risk is by deterring transactional sex. In this paper, we use qualitative methods to explore participant experiences, perspectives and reported behaviours of a cash transfer plus financial education programme among out of school, 15‐ to 23‐year‐old AGYWs in rural Tanzania with a focus on partner choice and transactional sex.MethodsWe conducted 60 in‐depth interviews (IDIs) and 20 narrative timeline interviews with participants of the PEPFAR DREAMS Sauti/WORTH+ cash transfer programme between June 2017 and July 2018. Interviews were taped, transcribed and translated from Kiswahili to English. Transcripts were coded and analysed for key themes.ResultsWe found that participants in a cash transfer plus programme discussed behaviours that could reduce HIV risk through decreasing their dependence on male sex partners. There appeared to be two main mechanisms for this. One, young women discussed the cash transfer providing for basic needs (e.g. food, toiletries) which appeared to reduce their dependence on male sex partners who previously provided these goods (e.g. transactional sex). This experience was more pronounced among the poorest participants. Two, young women discussed how the financial education/business development aspect of the programme empowered them to refuse some sex partners; unmarried women discussed these experiences more than married women. Social support from family and programme mentors appeared to strengthen young women's ability to successful start businesses, produce income and thus be less dependent on partners.ConclusionsThe cash transfer programme may have reduced AGYW engagement in transactional sex that occurred to meet basic needs (one form of transactional sex). The financial education/business development and mentorship elements of the programme appeared important in building AGYW agency, self‐esteem and future orientation which may support AGYWs in refusing unwanted sex partners. Future cash plus programmes should consider adding or strengthening financial education and job skills training, mentorship and future orientation to see stronger and perhaps sustainable outcomes for HIV prevention.

BACKGROUND: Given the success of cash programs in improving health outcomes and addressing upstream drivers of HIV risk such as poverty and education, there has been an increasing interest in their potential to improve HIV prevention and care outcomes. Recent reviews have documented the impacts of structural interventions on HIV prevention, but evidence about the effects of cash transfer programs on HIV prevention has not been systematically reviewed for several years. METHODS AND FINDINGS: We did a systematic review of published and unpublished literature to update and summarize the evidence around cash programs for HIV prevention from January 2000 to December 17, 2020. We included studies with either a cash transfer intervention, savings program, or program to reduce school costs. Included studies measured the program's impact on HIV infection, other sexually transmitted infections (STIs), or sexual behaviors. We screened 1,565 studies and examined 78 in full-text review to identify a total of 45 peer-reviewed publications and reports from 27 different interventions or populations. We did not do a meta-analysis 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, Malawi, Lesotho, Kenya, Uganda, Zimbabwe, Zambia, and eSwatini) followed by Mexico (N = 2), the United States (N = 1), and Mongolia (N = 1)). Of the 27 studies, 20 (72%) were randomized trials, 5 (20%) were observational studies, 1 (4%) was a case-control study, and 1 (4%) was quasi-experimental. Most studies did not identify a strong association between the program and sexual behaviors, except sexual debut (10/18 finding an association; 56%). Eight of the 27 studies included HIV biomarkers, but only 3 found a large reduction in HIV incidence or prevalence, and the rest found no statistically significant association. Of the studies that identified a statistically significant association with other 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. Study limitations include the small 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 cash transfers reducing HIV risk is limited; however, government social protection cash transfer programs and programs that incentivize school attendance among adolescent girls and young women show the greatest promise for HIV prevention.

Abstract Background To describe malaria knowledge, attitudes toward malaria and bed net use, levels of ownership and use of bed nets, and factors associated with ownership and use among pregnant women attending their first antenatal care (ANC) visit in Kinshasa, DRC. Methods Women attending their first ANC visit at one maternity in Kinshasa were recruited to take part in a study where they were given free insecticide treated bed nets (ITNs) and then followed up at delivery and 6 months post delivery to assess ITN use. This study describes the baseline levels of bed net ownership and use, attitudes towards net use and factors associated with net use Results Among 351 women interviewed at baseline, 115 (33%) already owned a bed net and 86 (25%) reported to have slept under the net the previous night. Cost was reported as the reason for not owning a net by 48% of the 236 women who did not own one. In multivariable analyses, women who had secondary school or higher education were 3.4 times more likely to own a net (95% CI 1.6–7.3) and 2.8 times more likely to have used a net (95% CI 1.3–6.0) compared to women with less education Conclusion Distribution of ITNs in antenatal clinics in this setting is needed and feasible. The potential for ITN use by this target population is high.

IntroductionYoung key populations, defined in this article as men who have sex with men, transgender persons, people who sell sex and people who inject drugs, are at particularly high risk for HIV. Due to the often marginalized and sometimes criminalized status of young people who identify as members of key populations, there is a need for HIV prevention packages that account for the unique and challenging circumstances they face. Pre‐exposure prophylaxis (PrEP) is likely to become an important element of combination prevention for many young key populations.ObjectiveIn this paper, we discuss important challenges to HIV prevention among young key populations, identify key components of a tailored combination prevention package for this population and examine the role of PrEP in these prevention packages.MethodsWe conducted a comprehensive review of the evidence to date on prevention strategies, challenges to prevention and combination prevention packages for young key populations. We focused specifically on the role of PrEP in these prevention packages and on young people under the age of 24, and 18 in particular.Results and discussionCombination prevention packages that include effective, acceptable and scalable behavioural, structural and biologic interventions are needed for all key populations to prevent new HIV infections. Interventions in these packages should meaningfully involve beneficiaries in the design and implementation of the intervention, and take into account the context in which the intervention is being delivered to thoughtfully address issues of stigma and discrimination. These interventions will likely be most effective if implemented in conjunction with strategies to facilitate an enabling environment, including increasing access to HIV testing and health services for PrEP and other prevention strategies, decriminalizing key populations' practices, increasing access to prevention and care, reducing stigma and discrimination, and fostering community empowerment. PrEP could offer a highly effective, time‐limited primary prevention for young key populations if it is implemented in combination with other programs to increase access to health services and encourage the reliable use of PrEP while at risk of HIV exposure.ConclusionsReductions in HIV incidence will only be achieved through the implementation of combinations of interventions that include biomedical and behavioural interventions, as well as components that address social, economic and other structural factors that influence HIV prevention and transmission.

AbstractIntroductionExperiences of violence during youth contravene young people's rights and increase the risk of depression and poor human immunodeficiency virus (HIV) care outcomes among youth living with HIV (YLWH). Intervention targets for mitigating the negative psychosocial effects of violence are needed, particularly in areas like rural South Africa where violence remains pervasive and mental healthcare is limited. This study aims to quantify the associations between physical and sexual violence and depressive symptoms in YLWH in rural South Africa and explore the modification of these associations by key measures of psychosocial well‐being.MethodsWe conducted a cross‐sectional survey among 362 YLWH ages 12 to 24 in rural South Africa to ascertain participants' history of physical and sexual violence, current depressive symptoms (Center for Epidemiological Studies‐Depression Scale) and levels of social support (Medical Outcomes Social Support Scale), resilience (Conner‐Davidson Resilience Scale) and self‐esteem (Rosenberg Self‐Esteem Scale). Log‐binomial regression was used to estimate the association between history of physical or sexual violence and clinically meaningful depressive symptoms (scores 16). Effect measure modification by high versus low resilience, social support and self‐esteem was assessed using likelihood ratio tests (α = 0.20).ResultsA total of 334 individuals with a median age of 21 (interquartile range: 16 to 23) were included in this analysis. Most participants were female (71.3%), single (81.4%) and attending school (53.0%). Ninety‐four participants (28.1%) reported a history of physical or sexual violence and 92 individuals (27.5%) had clinically meaningful depressive symptoms. Meaningful depressive symptoms were significantly higher among participants with a history of physical or sexual violence as compared to those with no history of violence (adjusted prevalence ratio: 2.01; 95% CI: 1.43, 2.83). However, this association was significantly modified by social support (p = 0.04) and self‐esteem (p = 0.02).ConclusionsIn this setting, the prevalence of meaningful depressive symptoms was significantly higher among YLWH with a history of physical or sexual violence as compared to those without a history of violence. However, higher levels of self‐esteem or social support appeared to mitigate this association. Programmes to improve self‐esteem and social support for youth have the potential to minimize depressive symptoms in YLWH who have experienced physical or sexual violence.

AbstractIntroductionAs a user‐controlled HIV prevention method, oral pre‐exposure prophylaxis (PrEP) holds particular promise for adolescent girls and young women (AGYW). HIV prevention cascades, critical frameworks for the design and evaluation of PrEP programmes, outline the priorities of identifying individuals at greatest HIV risk and motivating them to initiate PrEP through perceived HIV risk. To inform future iterations of these cascades and PrEP delivery for AGYW, the objective of this study was to understand the level of interest in PrEP among AGYW at highest HIV risk, and the potential role of perceived risk in motivating PrEP interest.MethodsUsing data from a cohort study of HIV‐negative AGYW in Lilongwe, Malawi (February 2016 to August 2017), we assessed the relationship between epidemiologic HIV risk (risk index developed in a previous analysis) and PrEP interest, and the extent to which perceived risk explains the relationship between HIV risk and PrEP interest. We further aimed to operationalize the pre‐initiation steps of the HIV prevention cascade in the study population.ResultsIn total, 825 AGYW were included in analyses, of which 43% met the criterion for high epidemiologic HIV risk. While epidemiologic risk scores were positively associated with PrEP interest, high numbers of AGYW both above and below the high‐risk cutoff were very interested in PrEP (68% vs. 63%). Perceived risk partially explained the relationship between HIV risk and PrEP interest; greater epidemiologic HIV risk was associated with high perceived risk, which was in turn associated with PrEP interest. Many more high‐risk AGYW were interested in PrEP (68%) than expressed a high level of perceived HIV risk (26%).ConclusionsThese results highlight key relationships between epidemiologic HIV risk, risk perception and interest in PrEP. While risk perception did partially explain the relationship between epidemiologic risk and PrEP interest, there may be other important motivational mechanisms that are not captured in many HIV prevention cascades. The high number of participants with risk scores below the high‐risk cutoff who both expressed high perceived risk and interest in PrEP suggests that demand for PrEP among AGYW may not be well aligned with epidemiologic risk.

AbstractIntroductionTo maximize impact and minimize costs, antiretroviral pre‐exposure prophylaxis (PrEP) interventions should be offered to those at highest risk for HIV infection. The risk score derived from the VOICE trial is one tool currently being utilized to determine eligibility in adolescent PrEP trials in sub‐Saharan Africa. This study is aimed at evaluating the utility of the risk score in predicting HIV incidence among a cohort of adolescent girls in rural South Africa.MethodsWe utilized data from HIV Prevention Trials Network (HPTN) 068, a phase III randomized controlled trial conducted in rural Mpumalanga province, South Africa. School‐attending young women aged 13 to 20 years were enrolled into the trial from 2011 to 2012 and followed for up to three years. A risk score based on individual‐level risk factors measured at enrolment was calculated for HPTN 068 participants who completed a one‐year follow‐up visit and were HIV seronegative at enrolment. Possible scores ranged from 0 to 10. A proportional hazards model was then used to determine if risk score at enrolment was predictive of incident HIV infection at follow‐up and an area under the curve analysis was used to examine the predictive ability of the score.Results and DiscussionThe risk score had limited variability in the HPTN 068 sample. Scores ≥5 identified 85% of incident infections from 94% of the sample, compared to the VOICE sample in which scores ≥5 identified 91% of incident infections from only 64% of participants. The risk score did not predict HIV incidence after one year of follow‐up (hazard ratio = 1.029; 95% confidence interval (CI): 0.704, 1.503, p = .884) and showed poor predictive ability (area under the curve = 0.55; 95% CI: 0.44, 0.65). Certain individual risk factors that comprise the risk score may be context specific or not relevant for adolescent populations. Additional factors should be considered when assessing risk for the purposes of determining PrEP eligibility.ConclusionsThe VOICE risk score demonstrated low utility to predict HIV incidence in the HPTN 068 sample. Findings highlight the need for an age and developmentally appropriate tool for assessing risk for HIV infection among adolescents. Use of the VOICE risk score for determining PrEP eligibility in younger populations should be carefully considered.