Summary

By 2008, 12 million children in sub-Saharan Africa were orphaned by AIDS. Research on children and young people affected by AIDS in Africa, led by Professor Lucie Cluver FAcSS, has led to major systemic social change at the interface of health, poverty, education, behaviour and policy.

‘Cash plus care’ services were found to substantially reduce the risk of HIV infection in both boys and girls, with these services being delivered to over 2.5 million children in more than 10 African countries.  

Cash plus care: improving health outcomes for adolescents in Africa

  • Public health
  • Sociology

University of Oxford 

Social science research has substantially reduced the risk of HIV infection in over 2.5 million children in Africa.

“We looked at child development – what did children need in order to grow up happy and healthy? And the answer from that was so clear, that it wasn’t just cash or money, it was also parenting. It was love and nurture… For boys and for girls the combination of cash plus care was the strongest way of reducing HIV risk.”

Professor Lucie Cluver

The challenge

By 2008, 12 million children in sub-Saharan Africa were orphaned by AIDS, with millions more living with AIDS-affected parents or primary caregivers. In addition, of the subcontinent’s 1.8 million new HIV infections in 2011, 41% were in young people aged between 15-24 years, with the prevalence of HIV infection being up to three times higher in girls than in boys. Over a decade on, in 2022, Sub Saharan Africa still accounts for 85% of children and adolescents living with HIV worldwide.

The research

Prior to 2005, little was known about the effects of AIDS on families – particularly, on young people’s physical and mental health and wellbeing, and on their education.

Researchers at the University of Oxford and University of Cape Town, led by Professor Lucie Cluver FAcSS, conducted the first longitudinal study to understand the enduring psychological effects of AIDS-orphanhood with 1,000 children over four years in Sub Saharan Africa. The results indicated that AIDS-orphaned children showed higher depression, anxiety and post-traumatic stress disorder scores when compared with their peers, with the study recommending that psychosocial support programmes be sustained to support in addressing the negative mental health outcomes amongst AIDS-orphaned children.

This work then informed the Young Carers Study which ran from 2009-2012. This aimed to understand the impact of being a ‘young carer’ on children’s wellbeing and was the largest study on children in AIDS-affected families with over 6,000 children and 2,500 caregivers being interviewed in the South African provinces of Western Cape, Mpumalanga and KwaZulu-Natal.

This research found that children who live with AIDS sufferers suffered as much psychological distress as those who have been orphaned by AIDS, and that this had a direct impact on school attendance. In addition, many teenage girls were living in desperate poverty and felt that they had little choice but to find an older boyfriend to help them pay for food and basic items for their families.

To combat these effects, the team’s research showed that regular small poverty alleviation-focused cash transfers to families (the South African Child Support Grant) substantially reduced the risk of adolescent girls engaging in transactional and age-disparate relationships – which is the region’s main transmission pathway of HIV infection.

Further research found that the combination of these cash transfers with social or family support (‘cash plus care’) further reduced the risk of HIV infection in both boys and girls. With the risk of infection for girls being reduced by up to 50%.

Hear more from Lucie about her research by listening to our We Society podcast.

The impact

The outcomes from this research directly influenced global UN guidance and South African national policy, being cited by a range of UN agencies including UNICEF, UNDP and UNAIDS, to guide the global response to HIV/AIDS.

Cash plus care services have also been delivered to over 2.5 million children and adolescents in over 10 African countries through numerous non-governmental organisations, the U.S Agency for International Development (USAID) President’s Emergency Plan for AIDS Relief (PEPFAR), UNICEF Eastern and Southern Africa Office country partners, and national governments including South Africa, Kenya, Malawi, Mozambique, Zambia and Zimbabwe.

“The concept [‘Cash plus care’] has become an integral part of UN planning and response to the HIV epidemic…At every stage, this research has been a partnership between the academic team, myself and other colleagues within the UN, including UNICEF and the UN Development Programme. They have been successful in building long lasting partnerships with practitioners, policy makers and governmental departments that are having major societal impacts. This really is an example of collaboration to fight the HIV/AIDS epidemic.”

Senior Advisor, UNAIDS

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