Mapa de Distribución de Especies de Fauna

One of the main reasons that most behavioral interventions have been unsuccessful is due to a focus on targeting individual risk behaviors (i.e., the knowledge, attitudes and practices) related to HIV risk without focusing on the social, political, and organizational factors (i.e., the

structures) which form the risk environment that influences population HIV risk (Ragnarsson et al., 2010). Factors outside of the direct control of individuals drive much of the epidemic in settings like South Africa. Although the complete mechanism by which environmental-level risks and individual-level risk behaviors work in tandem to affect a young woman’s likelihood of HIV acquisition is unknown, the combination of personal and contextual factors warrants further development and study.

In a systematic review of what does work for HIV prevention with youth in South Africa, Harrison et al. (2010) recommends that successful interventions should: 1) intervene on factors beyond individual’s knowledge and related psychosocial factors and focus on context specific HIV-related causal pathways like gender, sexual coercion, alcohol use or economic risk; 2) affect change in the context of young people’s lives that facilitates the spread of HIV such as economic and skills development; 3) work to alter the social norms that otherwise promote risk behaviors while discouraging protective behaviors; and 4) capitalize on schools and education as a prime venue to target young people, but consider delivering school-based interventions in novel ways that look beyond peer education or teacher-delivered curriculum. In evaluating such structural interventions, one aspect of the research will be to understand and document how the

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providing an important opening for research on the individual-level psychosocial targets of a structural intervention, such as hope.

2.5.1 Cash transfers as structural interventions

One novel structural intervention targeting the financial barriers to behavior change is the provision of cash transfers. Cash transfer interventions dispense money to participants that help facilitate a desired behavior, typically to promote health and social welfare. Such interventions are often “conditional”, meaning that the receipt of the money is contingent on enacting a prescribed behavior change. While the impact of conditional cash transfer (CCT) interventions is well known for improving general health, nutrition, and educational outcomes for children, particularly in Latin America (Rawlings & Rubio, 2005), less is known about the effect of CCTs on HIV outcomes (Baird, McIntosh, & Özler, 2011). However, the few CCT interventions that have been conducted for HIV prevention have resulted in reductions to sexual risk behaviors (Pettifor, MacPhail, Nguyen, & Rosenberg, 2012). School-related CCTs have been shown to lead to large increases in school enrollment (Baird, Chirwa, McIntosh, & Özler, 2009). In one trial thus far conducted in Malawi, intervention recipients of a conditional or an unconditional cash transfer were less likely at 18-months follow-up to have HIV or HSV-2, to have a partner 25 years or older, and to have sexual intercourse once per week compared to control participants (Baird, Garfein, McIntosh, & Özler, 2012). Even though these results show promise for the impact of education improvements on HIV risk, the study did not measure the effect of the cash transfer intervention on HIV incidence (Pettifor, McCoy, & Padian, 2012).

2.5.2 Overview of the conditional cash transfer intervention parent study

Swa Koteka (“it is possible”) is an innovative CCT intervention being conducted in Mpumalanga province, South Africa, which aims to alter the social and structural factors in the risk environment that put young women at risk for HIV, particularly by introducing a conditional

cash transfer mechanism to improve education opportunities that have been shown to protect young women from HIV infection. By lowering the financial barriers for young women to obtain a secondary education, the intervention aims to promote a less adverse risk environment that will reduce the HIV incidence and risk behaviors of the young women in the intervention arm of the study.

Swa Koteka is a Phase III, randomized control trial using a 2x2 factorial design to reduce the young women’s incidence of HIV. One intervention arm provides cash transfers to female secondary students, ages 13-20, and their parents conditional on school attendance. The other intervention arm conducts community mobilization activities to equalize masculine gender norms with young men ages 18-35 in 12 out of 24 study communities in which the trial is conducted. The primary objective is to determine whether young women who receive the CCT and live in communities with mobilization activities have lower incidence of HIV over the course of the intervention compared to young women who do not receive the CCT nor live in communities with mobilization activities. The intervention is conducted in 24 rural communities in Agincourt, Mpumalanga, home to an annual research census – called the Agincourt Health and Demographic Surveillance Survey (AHDSS) – which serves as a demonstration site to study the health of and services available to residents in rural settings in South Africa (Kahn et al., 2007). Approximately 2660 HIV negative young women ages 13-20 and enrolled in grades 8-11 will be randomized to the intervention arm in which they will receive a cash transfer conditional on their attendance at school or to the comparison arm. Half of the 24 communities will receive community

mobilization activities targeting young men to build equitable gender norms that encourage the reduction of the high risk of HIV transmission in young women.

CHAPTER 3: HOPE THEORY