“What is the role of social protection in addressing and reducing negative coping strategies with a focus on HIV?.” EPRI DIASPS Global Webinar on HIV-Sensitive and epi-Smart Social Protection: Leaving no one behind. Convened by Economic Policy Research Institute (EPRI) for course on “Designing and Implementing Adaptive Social Protection Systems.” March 24, 2022.

1. ROLE OF SOCIAL PROTECTION
IN ADDRESSING NEGATIVE
COPING STRATEGIES: FOCUS
ON HIV
Tia Palermo, Ph.D.
Epidemiology & Environmental Health
University at Buffalo, State University of New York

2. NEGATIVE
COPING
STRATEGIES

3. 3
Poverty, food insecurity,
and economic shocks
(drought, flood,
pandemic, etc.)
Migration, loans,
reduced expenditures
on health/education,
selling off assets & land,
sending children to
work, transactional sex,
etc.
Disinvestment in human
capital, reduced income,
and lower ability to deal
with future shocks
Negative coping
strategies

4. 4
Gendered
coping
strategies
• Boys
- sent into hazardous work
• Girls
- married off earlier
- transactional sex
- age-disparate relationships
• Both
- taken out of school
- reduced investment in health

5. 5
Related risks
• Increased stress from poverty and economic shocks can lead to:
- Increases in intimate partner violence
- Dysregulation of the immune system, leading to earlier
onset of chronic disease, including cardiovascular disease
(Oliveira et al. 2016; McEwen and Seeman 1999)

6. HIV RISKS

7. 7
HIV risk & ART adherence
- Coping strategies & related risks associated with HIV:
- Lower schooling attainment (Psaki et al. 2019)
- Transactional sex (Wamoyi et al. 2016)
- Intimate partner violence (Durevall and Lindskog 2015)
- Early marriage (?) (Petroni et al. 2019)
- Food insecurity is associated with sub-optimal ART
adherence (Singer et al. 2015)
Negative
coping
strategies
increase HIV
risk
Risks are
gendered

8. SOCIAL
PROTECTION’S
ROLE IN
MITIGATING RISKS

9. 9
Social
protection’s
role
Social protection (SP) can reduce risk factors
and negative coping strategies, particularly
when SP programmes pay attention to gender
and vulnerable populations, such as PLHIV

10. 10
Social protection programs
Social services
Insurance schemes
Labor market policies
Social safety nets
Public works,
Subsidies, School
feeding,
Economic transfers
Cash
Transfers
~11% coverage in
LMICs, as of 2018
Sources: World Social Protection Report 2017-2019: Universal social protection to achieve the SDGs, ILO, Geneva,
2017; Ivashchenko et al. 2018. The state of social safety nets 2018 (English). Washington, D.C. : World Bank Group
Cash transfers operate at large
scale – and have potential for
continued scale-up
• As of 2018, CTs were a substantial and
growing share of SSNs globally (including in
LMICs)
• Reach a large share of poor populations
within countries
• Robust interest from stakeholders, given
broad impacts and cost-effectiveness for
reducing poverty and food insecurity
• Scale makes it important to understand
impacts on HIV risk factors

11. 11
COVID-19 has dramatically increased social protection
measures
11
Gentilini et al. (February 2022). Social Protection and Jobs Responses to COVID-19: A Real-Time Review of Country Measures. World Bank and
ILO.
40% of these social
protection measures were
cash transfers, with
average duration of 4.5
months

12. 12
The evidence: strong
• Strong evidence that CTs :
• reduce poverty (Bastagli et al. 2019; Davis et al. 2016)
• reduce food insecurity (Hidrobo et al. 2018)
• Reduce negative coping strategies like borrowing money for consumption (AIR 2016)
• increase school attendance and enrolment (Baird et al. 2014)
• reduce sexual exploitation and abuse among adolescent girls (Peterman et al. 2017)
• reduce intimate partner violence (Buller et al. 2018; Baranov et al. 2021)
• delay sexual debut (Handa et al., 2014; Heinrich et al., 2017)
• reduce transactional sex & age disparate relationships (Cluver et al. 2013; Rosenberg et al. 2014)

13. 13
The evidence: mixed or limited
• reduce early marriage (Mathers 2021; Hodinott & Mekasha 2020)
• reduce morbidity and increase health-seeking; depends on context, conditions, and quality of health
services (Novignon et al. 2022; Pega et al. 2017)
• reduce HIV incidence (Baird et al. 2012; Pettifor et al. 2016)

14. 14
“Paying attention” to gender & vulnerability
• HIV-sensitive social protection addresses vulnerabilities of PLHIV, including:
- Increased health costs
- Stigma
- Labor constraints
- Otherwise reduce risk of HIV or mitigates social & economic impacts
• Gender-responsive social protection addresses gendered vulnerabilities & may address:
- Reduced access to social & health services
- Reduced access to formal employment
- Difficulties accessing payment points or mobile phones
- Unpaid care burdens
- Gender norms & violence risks

15. 15
Contextual factors limiting effectiveness
of cash transfers
• Gender norms
• Stigma
• Supply-side constraints
- Quality of and distance to health facilities
- Quality of and distance to schools
- Availability of economic opportunities
• Other: inflation, pandemics, environmental shocks

16. INTEGRATED
SOCIAL
PROTECTION OR
CASH PLUS

17. 17
Integrated social protection or “cash plus”
Cash transfers combined with one or more types of
complementary support, and these may consist of integral
elements (e.g., additional benefits, in-kind transfers, information,
behaviour change communication or psychosocial support); or
external components (e.g., direct provision of access to services or
facilitating linkages to services) (Roelen et al., 2017).

18. 18
Examples of cash plus
• Livelihoods strengthening training and asset transfers
• Case management to identify children/individuals at risk of
abuse, child marriage, malnutrition, etc. & link to services
• Food transfers (on top of cash)
• Behaviour change communication on nutrition, contraception,
and more
• Linkages to health services via:
- Premium fee waivers for health insurance enrolment
- Behavior change communication & information
- Health services strengthening
• Gender norms interventions?

19. 19
Evidence on cash plus
• Increases health insurance enrolment in Ghana (Palermo et al. 2019)
• May improve nutrition (acute malnutrition, stunting) (Little et al. 2021)
• Reduces intimate partner violence in Ghana and Bangladesh (Peterman et al. 2022; Barrington
et al. 2021; Roy et al. 2019)
• Reduces violence against children and youth:
- sexual violence against adolescent girls and youth in Tanzania (Palermo et al. 2021)
- physical violence against adolescents & youth in Zimbabwe (Chakrabarti et al. 2020)
- corporal punishment or harsh physical punishment of children in Haiti and Bangladesh
(Roelen and Saha 2021; Roy et al. 2019)
• Reduces physical violence perpetration among adolescent boys and youth in Tanzania
(Palermo et al. 2021)

20. CONCLUSION

21. 21
Conclusion
• Social protection can:
- reduce risk factors for HIV
- Improve food security and health services access, which are important for ART adherence
• Mechanisms are diverse: economic security, food security, schooling, adolescent risk behaviors,
exposure to high-risk environments, girls’ and women’s empowerment, access to health services
• Evidence gaps
- Several new cash plus initiatives are still being evaluated (e.g., child grant in Mozambique linked
with case management)
- Others have not/are not being evaluated (e.g., nutrition plus component in Tanzania’s Productive
Social Safety Net, linkages to national health insurance in Zambia’s Social Cash Transfer, HIV
sensitive linkages/plus components in Mozambique, Malawi, Zambia, etc.)
- Lack of studies able to test plus components separately or synergistic effects

22. 22
Conclusion: opportunity to broaden thinking about
intersectoral linkages to reduce HIV risk & increase ART
adherence
Cash transfers
reduce HIV risk
factors
Cash transfers can
reduce poverty, food
insecurity, intimate
partner violence
transactional sex,
and violence
Emerging evidence
that cash plus can
reduce risk factors
(e.g., violence) &
improve health
access
How do intersectoral
linkages boost these
impacts?
What is the role of
implementation of these
linkages (and key cadres
such as social workers) in
realizing impacts?
What is cost effectiveness
of cash transfers in
reducing HIV risk? How
does this compare to other
HIV-focused interventions?

23. 23
References: 1 of 3
• American Institutes for Research (2016). Zambia’s Child Grant Programme: 48-Month Impact Report Washington, DC, American Institutes for Research.
• Baird, S., et al. (2014). "Conditional, unconditional and everything in between: a systematic review of the effects of cash transfer programmes on schooling outcomes."
Journal of Development Effectiveness 6(1): 1-43.
• Baird, S. J., et al. (2012). "Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial." Lancet
379(9823): 1320-1329.
• Baranov, V., et al. (2021). "Theoretical Underpinnings and Meta-analysis of the Effects of Cash Transfers on Intimate Partner Violence in Low-and Middle-Income Countries."
The Journal of Development Studies 57(1): 1-25.
• Barrington, C., et al. (2021). "‘Poverty can break a home’: Exploring mechanisms linking cash plus programming and intimate partner violence in Ghana." Social Science &
Medicine: 114521.
• Bastagli, F., et al. (2019). "The impact of cash transfers: a review of the evidence from low-and middle-income countries." Journal of Social Policy 48(3): 569-594.
• Buller, A., et al. (2018). "A mixed-method review of cash transfers and intimate partner violence in low- and middle-income countries." World Bank Research Observer 33(2):
218-258.
• Davis, B., et al. (2016). From evidence to action: the story of cash transfers and impact evaluation in sub Saharan Africa, Oxford University Press.
• Durevall, D. and A. Lindskog (2015). "Intimate partner violence and HIV in ten sub-Saharan African countries: what do the Demographic and Health Surveys tell us?" The
Lancet Global Health 3(1): e34-e43.
• Gentilini et al. (February 2022). Social Protection and Jobs Responses to COVID-19: A Real-Time Review of Country Measures. World Bank and ILO.
• Hidrobo, M., et al. (2018). "Social Protection, Food Security, and Asset Formation." World Development 101: 88-103.

24. 24
References: 2 of 3
• Hoddinott, J. and T. J. Mekasha (2020). "Social protection, household size, and its determinants: Evidence from Ethiopia." The Journal of Development Studies 56(10):
1818-1837.
• Little, M. T., et al. (2021). "Effectiveness of cash-plus programmes on early childhood outcomes compared to cash transfers alone: A systematic review and meta-analysis
in low-and middle-income countries." PLOS Medicine 18(9): e1003698.
• Mathers, N. (2021). How Cash Transfers Can Contribute to Ending Child Marriage. Washington, DC, Girls Not Brides.
• McEwen, B. S. and T. Seeman (1999). "Protective and damaging effects of mediators of stress: elaborating and testing the concepts of allostasis and allostatic load."
Annals of the New York Academy of Sciences 896(1): 30-47.
• Novignon, J., et al. (2022). "The Impact of Unconditional Cash Transfers on Morbidity and Health Seeking Behaviour in Africa: Evidence from Ghana, Malawi, Zambia and
Zimbabwe." Health policy and planning.
• Oliveira, B. S., et al. (2016). "Systematic review of the association between chronic social stress and telomere length: A life course perspective." Ageing research reviews
26: 37-52.
• Palermo, T., et al. (2021). "Government implemented cash plus model reduces violence experiences and perpetration among adolescents in Tanzania." American Journal
of Public Health 111(12).
• Palermo, T. M., et al. (2019). "Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana’s National Health Insurance Scheme."
BMJ open 9(11): e028726.
• Pega, F., et al. (2017). "Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low‐and
middle‐income countries." Cochrane Database of Systematic Reviews (11).
• Peterman, A.,. Neijhoft A, Cook S, Palermo T. (2017). "Understanding the linkages between social safety nets and childhood violence: a review of the evidence from low-
and middle-income countries." Health policy and planning 32(7): 1049-1071.

25. 25
References: 3 of 3
• Peterman, A., Valli E, Palermo T. (2022). "Government Anti-Poverty Programming and Intimate Partner Violence in Ghana." Economic Development and Cultural Change 70(2).
• Petroni, S., et al. (2019). "Understanding the relationships between HIV and child marriage: conclusions from an expert consultation." Journal of Adolescent Health 64(6): 694-
696.
• Pettifor, A., et al. (2016). "The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial."
The Lancet Global Health 4(12): e978-e988.
• Psaki, S. R., Chuang, E. K., Melnikas, A. J., Wilson, D. B., & Mensch, B. S. (2019). Causal effects of education on sexual and reproductive health in low and middle-income
countries: A systematic review and meta-analysis. SSM-population health, 8, 100386.
• Roelen K., Devereux S, Abdulai AG, Martorano B, Palermo T, Ragno LP. (2017). "How to Make ‘Cash Plus’ Work: Linking Cash Transfers to Services and Sectors." UNICEF
Office of Research.
• Roelen, K. and A. Saha (2021). "Pathways to stronger futures? The role of social protection in reducing psychological risk factors for child development in Haiti." World
Development 142: 105423.
• Roy, S., Hidrobo, M., Hoddinott, J.F., & Ahmed, A. (2019a). "Transfers, behavior change communication, and intimate partner violence: Postprogram evidence from rural
Bangladesh." Review of Economics and Statistics 101(5): 865-877.
• Singer, A. W., et al. (2015). "Does food insecurity undermine adherence to antiretroviral therapy? A systematic review." AIDS and Behavior 19(8): 1510-1526.
• Wamoyi, J., Stobeanau, K., Bobrova, N., Abramsky, T., & Watts, C. (2016). Transactional sex and risk for HIV infection in sub‐Saharan Africa: a systematic review and
meta‐analysis. Journal of the international AIDS society, 19(1), 20992.

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Thank you
@tiapalermo
@TransferProjct
tiapaler@buffalo.edu
https://transfer.cpc.unc.edu/