Comparison of two cash transfer strategies to prevent catastrophic costs for poor tuberculosis-affected households in low- and middle-income countries: An economic modelling study

BACKGROUND:Illness-related costs for patients with tuberculosis (TB) ≥20% of pre-illness annual household income predict adverse treatment outcomes and have been termed "catastrophic." Social protection initiatives, including cash transfers, are endorsed to help prevent catastrophic costs. With this aim, cash transfers may either be provided to defray TB-related costs of households with a confirmed TB diagnosis (termed a "TB-specific" approach); or to increase income of households with high TB risk to strengthen their economic resilience (termed a "TB-sensitive" approach). The impact of cash transfers provided with each of these approaches might vary. We undertook an economic modelling study from the patient perspective to compare the potential of these 2 cash transfer approaches to prevent catastrophic costs. METHODS AND FINDINGS:Model inputs for 7 low- and middle-income countries (Brazil, Colombia, Ecuador, Ghana, Mexico, Tanzania, and Yemen) were retrieved by literature review and included countries' mean patient TB-related costs, mean household income, mean cash transfers, and estimated TB-specific and TB-sensitive target populations. Analyses were completed for drug-susceptible (DS) TB-related costs in all 7 out of 7 countries, and additionally for drug-resistant (DR) TB-related costs in 1 of the 7 countries with available data. All cost data were reported in 2013 international dollars ($). The target population for TB-specific cash transfers was poor households with a confirmed TB diagnosis, and for TB-sensitive cash transfers was poor households already targeted by countries' established poverty-reduction cash transfer programme. Cash transfers offered in countries, unrelated to TB, ranged from$217 to $1,091/year/household. Before cash transfers, DS TB-related costs were catastrophic in 6 out of 7 countries. If cash transfers were provided with a TB-specific approach, alone they would be insufficient to prevent DS TB catastrophic costs in 4 out of 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between$3.8 million (95% CI: $3.8 million-$3.8 million) and $75 million (95$50 million-$100 million) per country. If instead cash transfers were provided with a TB-sensitive approach, alone they would be insufficient to prevent DS TB-related catastrophic costs in any of the 6 countries, and when increased enough to prevent DS TB catastrophic costs would require a budget between$298 million (95% CI: $219 million-$378 million) and $165,367 million (95$134,085 million-$196,425 million) per country. DR TB-related costs were catastrophic before and after TB-specific or TB-sensitive cash transfers in 1 out of 1 countries. Sensitivity analyses showed our findings to be robust to imputation of missing TB-related cost components, and use of 10% or 30% instead of 20% as the threshold for measuring catastrophic costs. Key limitations were using national average data and not considering other health and social benefits of cash transfers. CONCLUSIONS:A TB-sensitive cash transfer approach to increase all poor households' income may have broad benefits by reducing poverty, but is unlikely to be as effective or affordable for preventing TB catastrophic costs as a TB-specific cash transfer approach to defray TB-related costs only in poor households with a confirmed TB diagnosis. Preventing DR TB-related catastrophic costs will require considerable additional investment whether a TB-sensitive or a TB-specific cash transfer approach is used

Impacts of intimate partner violence and sexual abuse on antiretroviral adherence among adolescents living with HIV in South Africa

OBJECTIVE: We are failing to reach 95-95-95 for adolescents living with HIV (ALHIV). Sexual abuse and intimate partner violence (IPV) may impact antiretroviral therapy (ART) adherence, with high rates of 17.4 and 29.7%, respectively, across the southern sub-Saharan African region. However, evidence on their associations with adolescent ART adherence remains limited, with only three cross-sectional studies globally. DESIGN: A prospective cohort of ALHIV (sample N = 980, 55% female individuals, baseline mean age 13.6 years) were recruited from 53 health facilities in South Africa's Eastern Cape Province and responded to a structured questionnaire at 18-month and 36-month follow-up (2015-2016, 2017-2018). METHODS: A repeated-measures random effects model assessed multivariable associations of self-reported sexual abuse and IPV with past-week ART adherence, controlling for individual, socioeconomic, and HIV-related factors. Past-week adherence was defined based on currently taking ART and not having missed any doses in the past 7 days (including weekends). We further fitted a moderation model by sex. RESULTS: Fifty-one percent of adolescents reported consistent ART adherence at both time points. Exposure to IPV was associated with lower odds of self-reported ART adherence (aOR 0.39, 95% CI 0.21-0.72, P = 0.003), as was sexual abuse (aOR 0.54, 95% CI 0.29-0.99, P = 0.048). The marginal predicted probability of ART adherence for adolescents with no exposure to either IPV or sexual abuse was 72% (95% CI 70-74%) compared with 38% (95% CI 20-56%) for adolescents with exposure to both IPV and sexual abuse. Moderation results showed similar associations between sexual violence and ART adherence by sex. CONCLUSION: Sexual violence prevention and postviolence care may be essential components of supporting adolescent ART adherence. Integration of HIV and violence prevention services will require accessible services and simple referral systems

Protective factors for adolescent sexual risk behaviours and experiences linked to HIV infection in South Africa: a three-wave longitudinal analysis of caregiving, education, food security, and social protection

Background: Structural interventions are endorsed to enhance biomedical and behavioural HIV prevention programmes for adolescents. Aiming to inform future interventions, we evaluated longitudinal associations between six protective factors that link closely to existing structural HIV prevention interventions, and five sexual risk behaviours for HIV transmission in a cohort of adolescents in South Africa. Methods: We used three rounds of data between 2014–2018 on 1046 adolescents living with HIV and 473 age-matched community peers in South Africa’s Eastern Cape (Observations = 4402). We estimated sex-specific associations between six time-varying protective factors − number of social grants, education enrolment, days with enough food, caregiver supervision, positive caregiving, and adolescent-caregiver communication; and five HIV risk behaviours − multiple sexual partners, transactional sex, age-disparate sex, condomless sex, and sex on substances. HIV risk behaviours were analysed separately in multivariable random effects within-between logistic regression models that accounted for correlation of repeated observations on the same individual. We calculated prevalence ratios (PR), contrasting adjusted probabilities of HIV risk behaviours at ‘No’ and ‘Yes’ for education enrolment, and average and maximum values for the other five protective factors. Results: The sample mean age was 15.29 (SD: 3.23) years and 58% were girls. Among girls, within-individuals, increases from mean to maximum scores in positive caregiving were associated with lower probability of transactional sex (PR = 0.79; 95%CI = 0.67–0.91); in caregiver supervision were associated with lower probability of transactional sex (PR = 0.75; 95%CI = 0.66–0.84), and age-disparate sex (PR = 0.84; 95%CI = 0.73–0.95); in adolescent-caregiver communication were associated with higher probability of transactional sex (PR = 1.70; 95%CI = 1.08–2.32); and in days with enough food at home were associated with lower probability of multiple sexual partners (PR = 0.89; 95%CI = 0.81–0.97), and transactional sex (PR = 0.82; 95%CI = 0.72–0.92). Change from non-enrolment in education to enrolment was associated with lower probability of age-disparate sex (PR = 0.49; 95%CI = 0.26–0.73). Between-individuals, relative to mean caregiver supervision scores, maximum scores were associated with lower probability of multiple sexual partners (PR = 0.59; 95%CI = 0.46–0.72), condomless sex (PR = 0.80; 95%CI = 0.69–0.91), and sex on substances (PR = 0.42; 95%CI = 0.26–0.59); and relative to non-enrolment, education enrolment was associated with lower probability of condomless sex (PR = 0.59; 95%CI = 0.39–0.78). Among boys, within-individuals, increases from mean to maximum scores in positive caregiving were associated with lower probability of transactional sex (PR = 0.77; 95%CI = 0.59–0.96), and higher probability of condomless sex (PR = 1.26; 95%CI = 1.08–1.43); in caregiver supervision were associated with lower probability of multiple sexual partners (PR = 0.73; 95%CI = 0.64–0.82), transactional sex (PR = 0.63; 95%CI = 0.50–0.76), age-disparate sex (PR = 0.67; 95%CI = 0.49–0.85), and sex on substances (PR = 0.61; 95%CI = 0.45–0.78), and in days with enough food at home were associated with lower probability of transactional sex (PR = 0.91; 95%CI = 0.84–0.98). Conclusion: Effective structural interventions to improve food security and education enrolment among adolescent girls, and positive and supervisory caregiving among adolescent girls and boys are likely to translate into crucial reductions in sexual risk behaviours linked to HIV transmission in this population

The social determinants of national tuberculosis incidence rates in 116 countries: a longitudinal ecological study between 2005-2015

BACKGROUND: Accelerating declines in tuberculosis (TB) incidence is paramount for achieving global goals set for 2030 by the Sustainable Development Goals and the End TB Strategy. The aim of this study was to identify key country-level social determinants of national TB incidence trends. METHODS: This longitudinal ecological study used country-level data extracted from online databases from the period 2005-2015. We used multivariable Poisson regression models allowing for distinct within- and between-country effects to estimate associations between national TB incidence rates and 13 social determinants of health. The analysis was stratified by country income status. RESULTS: The study sample included 48 low- and lower-middle-income countries (LLMICs) and 68 high- and upper-middle income countries (HUMICs), with a total of 528 and 748 observations between 2005-2015, respectively. National TB incidence rates declined in 108/116 countries between 2005-2015, with an average drop of 12.95% in LLMICs and 14.09% in HUMICs. Between LLMICs, higher Human Development Index (HDI), social protection spending, TB case detection, and TB treatment success were associated with lower TB incidence. Higher prevalence of HIV/AIDS was associated with higher TB incidence. Within LLMICs, increases in HDI over time were associated with lower TB incidence rates. Between HUMICs, higher HDI, health spending, and diabetes prevalence were associated with lower TB incidence, whereas higher prevalence of HIV/AIDS and alcohol-use were associated with higher TB incidence. Within HUMICs, increases in HIV/AIDS and diabetes prevalence over time were associated with higher TB incidence. CONCLUSIONS: In LLMICs, TB incidence rates remain highest in countries with low human development, social protection spending and TB programme performance, and high rates of HIV/AIDS. Strengthening human development is likely to accelerate declines in TB incidence. In HUMICs, TB incidence rates remain highest in countries with low human development, health spending and diabetes prevalence, and high rates of HIV/AIDS and alcohol use. Here, slowing rising rates of HIV/AIDS and diabetes is likely to accelerate declines in TB incidence

Cash transfers to enhance TB control: lessons from the HIV response

Background: The World Health Organization prioritises a more holistic global response to end the tuberculosis (TB) epidemic by 2030. Based on experiences in the HIV response, social protection, and in particular cash transfers, show promise for contributing to this. Currently, individual-level evidence for the potential of cash transfers to prevent TB by addressing the structural social determinants of disease is lacking. To identify priority actions for the TB research agenda, we appraised efforts by the HIV response to establish the role of cash transfers in preventing HIV infection. Main body The HIV response has evaluated the effects of cash transfers on risky sexual behaviours and HIV incidence. Work has also evaluated the added effects of supplementing cash transfers with psychosocial support. The HIV response has focused research on populations with disproportionate HIV risk, and used a mix of explanatory evaluations, which use ideal conditions, and pragmatic evaluations, which use operational conditions, to generate evidence that is both causally valid and applicable to the real world. It has always collaborated with multiple stakeholders in funding and evaluating projects. Learning from the HIV response, priority actions for the TB response should be to investigate the effect of cash transfers on intermediary social determinants of active TB disease, and TB incidence, as well as the added effects of supplementing cash transfers with psychosocial support. Work should be focused on key groups in high burden settings, and look to build a combination of explanatory and pragmatic evidence to inform policy decisions in this field. To achieve this, there is an urgent need to facilitate collaborations between groups interested in evaluating the impact of cash transfers on TB risk. Conclusions The HIV response highlights several priority actions necessary for the TB response to establish the potential of cash transfers to prevent TB by addresing the structural social determinants of disease

Violence prevention accelerators for children and adolescents in South Africa:A path analysis using two pooled cohorts

Background: The INSPIRE framework was developed by 10 global agencies as the first global package for preventing and responding to violence against children. The framework includes seven complementary strategies. Delivering all seven strategies is a challenge in resource limited contexts. Consequently, governments are requesting additional evidence to inform which ‘accelerator’ provisions can simultaneously reduce multiple types of violence against children. Methods and Findings: We pooled data from two prospective South African adolescent cohorts including Young Carers (2010-2012), and Mzantsi Wakho (2014-2017). The combined sample size was 5034 adolescents. Each cohort measured six self-reported violence outcomes: sexual abuse, transactional sexual exploitation, physical abuse, emotional abuse, community violence victimisation, and youth lawbreaking; and seven self-reported INSPIRE-aligned protective factors: positive parenting, parental monitoring and supervision, food security at home, basic economic security at home, free schooling, free school meals, and abuse response services. Associations between hypothesised protective factors and violence outcomes were estimated jointly in a sex-stratified multivariate path model, controlling for baseline outcomes and socio-demographics, and correcting for multiple hypothesis testing using the Benjamini-Hochberg procedure. We calculated adjusted probability estimates conditional on the presence of no, one, or all protective factors significantly associated with reduced odds of at least three forms of violence in the path model. Adjusted risk differences (ARD) and risk ratios (ARR) with 95% confidence intervals (CI) were also calculated. The sample mean age was 13.54 years and 56.62% were female. There was 4% loss to follow up. Positive parenting, parental monitoring and supervision, and food security at home, were each associated with lower odds of three or more violence outcomes (p Conclusion: In this cohort study, we found that positive and supervisory caregiving, and food security at home are associated with reduced risk of multiple forms of violence against children. The presence of all three of these factors may be linked to greater risk reduction as compared to the presence of one, or none of these factors. Policies promoting action on positive and supervisory caregiving, and food security at home are likely to support further efficiencies in the delivery of INSPIRE.</p

What do adolescents value most and is this affected by HIV status? Aspirations and self-perceptions from a large cohort study in South Africa.

Hundreds of millions of adolescents across Africa face challenges in many areas of their lives, including elevated risk of HIV exposure and acquisition. Understanding the aspirations and self-perceptions of adolescents could play an important role in better targeting effective investments to break the cycle of adversity for adolescents and into their adulthood. Aiming to understand what adolescents value most for themselves and their future, we analysed and summarised cross-sectional data on the aspirations and self-perceptions of 1519 adolescents living in South Africa, overall and by HIV status. Outcomes were coded from participant responses to two open-ended questions: 'What job do you want to do when you grow up?' and 'What are you most proud of about yourself?'. Associations with HIV status were then evaluated using multivariable logistic regression adjusting for six sociodemographic factors measured from the same cohort. The sample had a mean age of 14 years, 55% were female, and 70% were living with HIV. The five most common job aspirations were: 'Health and Medical Science Professionals' (28%), 'Law Enforcement and Public Safety Professionals' (14%), 'Social Work Associate Professionals' (12%), 'Legal Professionals' (9%), and 'Education Institutions Teaching Professionals' (6%). The top five themes for what adolescents were most proud of about themselves were 'School performance' (22%), 'Outward appearance' (15%), 'Sports skills' (12%), 'Personality' (11%), and 'Behaviour at home/with elders' (7%). Adjusted analysis showed no evidence that HIV status was associated with important differences in aspirations or self-perceptions. In conclusion, adolescents facing high levels of adversity in South Africa hold high value for their education and aspirations for their futures. Policies and initiatives should focus on meeting these aspirations as vehicles for development, independent of their HIV status. Therefore, more needs to be done to not just help adolescents survive but thrive into adulthood

Understanding accelerators to improve SDG-related outcomes for adolescents:An investigation into the nature and quantum of additive effects of protective factors to guide policy making

Recent evidence has shown support for the United Nations Development Programme (UNDP) accelerator concept, which highlights the need to identify interventions or programmatic areas that can affect multiple sustainable development goals (SDGs) at once to boost their achievement. These data have also clearly shown enhanced effects when interventions are used in combination, above and beyond the effect of single interventions. However, detailed knowledge is now required on optimum combinations and relative gain in order to derive policy guidance. Which accelerators work for which outcomes, what combinations are optimum, and how many combinations are needed to maximise effect? The current study utilised pooled data from the Young Carers (n = 1402) and Child Community Care (n = 446) studies. Data were collected at baseline (n = 1848) and at a 1 to 1.5- year follow-up (n = 1740) from children and young adolescents aged 9-13 years, living in South Africa. Measures in common between the two databases were used to generate five accelerators (caregiver praise, caregiver monitoring, food security, living in a safe community, and access to community-based organizations) and to investigate their additive effects on 14 SDG-related outcomes. Predicted probabilities and predicted probability differences were calculated for each SDG outcome under the presence of none to five accelerators to determine optimal combinations. Results show that various accelerator combinations are effective, though different combinations are needed for different outcomes. Some accelerators ramified across multiple outcomes. Overall, the presence of up to three accelerators was associated with marked improvements over multiple outcomes. The benefit of targeting access to additional accelerators, with additional costs, needs to be weighed against the relative gains to be achieved with high quality but focused interventions. In conclusion, the current data show the detailed impact of various protective factors and provides implementation guidance for policy makers in targeting and distributing interventions to maximise effect and expenditure. Future work should investigate multiplicative effects and synergistic interactions between accelerators

Social protection as a strategy for HIV prevention, education promotion and child marriage reduction among adolescents: a cross-sectional population-based study in Lesotho

Background: Lesotho’s government has shown consistent efforts to implement social protection programmes. However, while recent evidence established a positive causal relationship between some of these programmes and food security there is little evidence on the extent to which these initiatives are associated with better educational and sexual and reproductive health outcomes among vulnerable adolescents in Lesotho. Methods and Findings: The study uses cross-sectional, nationally representative data from the 2018 Lesotho Violence Against Children and Youth Survey. Our research examined the association between social protection receipt and educational and sexual and reproductive health outcomes among adolescents and young people (13–24 years) living in poverty. We employed multivariate logistic regression controlling for age, orphanhood, HIV status and sex. Social protection receipt was defined as household receipt of financial support from a governmental, non-governmental, or community-based program that provides income. Additionally, we fitted a marginal effects model by sex. Among the 3,506 adolescent females and males living in the two lowest poverty quintiles, receipt of social protection was associated with improvements in multiple adolescent outcomes: higher odds of consistent condom use (aOR 1.64, 95% CI 1.17–2.29), educational attainment (aOR 1.79, 95% CI 1.36–2.36), and school enrolment (aOR 2.19, 95% CI 1.44–3.34). Stratified analyses by sex showed that social protection receipt was also associated with reduced likelihood of child marriage among females (aOR 0.59, 95% CI 0.42–0.83) and higher odds of educational attainment and school enrolment among males (aOR 2.53, 95% CI 1.59–4.03 and aOR 3.11, 95% CI 1.56–6.19, respectively). Conclusions: Our study provides evidence that social protection programs are associated with improved educational, sexual and reproductive health and child marriage prevention outcomes among adolescents living in poverty. Implementing and expanding such social protection initiatives could prove instrumental in improving the well-being of vulnerable adolescents. Contributions: Social protection programs have been increasing in sub-Saharan African countries, playing a pivotal role in poverty reduction, with Lesotho being no exception. Despite the optimistic outlook brought about by the implementation of the National Social Protection Strategy Lesotho I (2014-19) and II (2021–2031), the impact of these programs on some specific outcomes that concern the lives of the most vulnerable adolescents in Lesotho remains to some extent unexplored. Additionally, Lesotho grapples with high rates of HIV, adolescent pregnancy, child marriage and early school dropout, which can further contribute to poor long-term health and social outcomes among adolescents. In this study, we used data from the 2018 Lesotho Violence Against Children and Youth Survey (VACS) to examine the association between receiving social protection and multiple adolescent outcomes: educational, sexual and reproductive. The findings revealed that social protection programs, particularly the existing government-provided cash transfers, are significantly associated with multiple better outcomes among adolescents living in the poorest households in Lesotho. Such cash transfer schemes in Lesotho are associated with improved sexual and reproductive health outcomes for adolescent females, including reduced child marriage rates, and improved educational outcomes for males. These findings indicate that government-led social protection programmes are positively associated with favourable outcomes that can improve the quality of life for adolescents in resource-limited settings