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22-02-2012 | Gynaecology | Article

Cash intervention can reduce STIs in young African women


Free abstract

MedWire News: Providing cash to unmarried schoolgirls decreases risky sexual activity and reduces their risk for HIV and herpes simplex virus 2 (HSV-2) infection, suggest results of a study conducted in Malawi.

"Lack of education and an economic dependence on men are often suggested as important risk factors for HIV infection in women," explain Berk Özler (The World Bank, Washington, District of Columbia, USA) and colleagues in The Lancet.

As women aged 15-24 years are more than twice as likely to be infected with HIV as men, HIV prevention in girls is essential to reduce the HIV epidemic, they add.

In the present study, Özler and team assessed the effect of a cash-transfer program on rates of HIV and HSV-2 infection in young women.

They explain that cash-transfer programs - where money is provided to poor households with school-aged children - have been shown to increase household income and school enrollment. This may in turn reduce the risk for sexually transmitted infections (STIs) by keeping girls in school or by providing them with an income that allows them to be less economically dependent on male partners, the researchers hypothesize.

They recruited 1289 never-married girls, aged 13-22 years, from 176 enumeration areas in the Zomba district of Malawi to participate in their study. The women were randomly assigned to receive cash payments (intervention group) or nothing (control group) for 2 years.

Participants in the intervention group were further randomly assigned to conditional (school attendance required to receive payment) and unconditional (no requirements to receive payment) payment groups. Monthly payments, assigned by a random lottery, ranged from US$ 1.00 to $ 5.00 for participants, and from $ 4.00 to $10.00 for their parents.

The researchers report that, at 18 months, girls in the combined cash-transfer groups were a significant 64% less likely than girls who did not receive payments to have HIV infection, at respective prevalence rates of 1.2% versus 3.0%.

Participants in the intervention group were also a significant 76% less likely to have an HSV-2 infection than those in the control group, at respective rates of 0.7% and 3.0%.

These differences were possibly due to the fact that, compared with the control group, girls in the intervention group were significantly less likely to have an older male partner (0.5 vs 2.5%) and to have sexual intercourse once per week (3.0 vs 6.5%) at follow up.

Of note, the prevalence of HIV and HSV-2 at follow up did not differ significantly between the conditional and unconditional intervention subgroups, or by transfer amount.

Özler and co-authors estimated that the intervention cost between $ 5000 and $ 12,500 per case of HIV infection averted.

Editorialists Audrey Pettifor (University of North Carolina, Chapel Hill, USA) and colleagues say that this is could be a cost-effective intervention that may be cheaper than biomedical methods such as using antiretroviral treatment in the prevention of HIV.

However, they caution that although the findings are "exciting" they are weakened by the fact that the investigators did not measure HIV or HSV-2 incidence. In spite of this, "the balance of covariates between study groups at baseline and the consistency of effects across outcomes suggest that the intervention was probably effective in reducing HIV and HSV-2 infections," they write.

Pettifor et al conclude that the study "provides a proof of concept that alteration of the structural environment with cash payments can affect HIV risk in young women."

By Laura Cowen

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