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Enhancing Social Protection for HIV Prevention

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Treatment, Care & Support - The State of the Evidence

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What is Social Protection &
Why is it Important for HIV While many existing social protection schemes were not set
up with HIV as a primary focus, their potential to contribute
Outcomes? to a comprehensive HIV response is increasingly
recognised.
Over the past decade, there has been growing recognition
of the importance of social protection to respond to a range The UNAIDS Business Case on social protectionii shows
of challenges faced by developing countries, including food how HIV-sensitive social protection can reduce vulnerability
insecurity, chronic poverty and the HIV pandemic. to HIV infection, improve and extend the lives of people
living with HIV, and support individuals and households.
HIV and AIDS can push people and households into Under the Outcome Framework 2009–2011, UNAIDS will
poverty, in part by reducing household labour capacity and focus its efforts on achieving results in nine priority areas.
increasing medical expenses. In some cases, HIV-related Among these is the commitment to “enhance social
stigma and discrimination marginalises people living with protection for people affected by HIV”. Achieving social
HIV (PLHIV) and households affected by the virus and protection for people and households affected by HIV is a
excludes them from essential services. critical step towards the realisation of universal access to
prevention, treatment, care and support. The business case
Despite increased access to life-saving treatment, HIV and explains why this is the case, what needs to be done, and
AIDS can increase individual and household vulnerabilities - the role of UNAIDS in this endeavour.
hampering governments’ effort to meet the Millennium
Development Goals.
Social protection is often described as “all public and private
In the face of rising HIV prevalence rates and the initiatives that provide income or consumption transfers to the
aftershocks of the recent economic crisis, few developing poor, protect the vulnerable against livelihood risks, and
countries outside of Latin America have national social enhance the social status and rights of the marginalised; with
protection systems and large scale coverage. Social the overall objective of reducing the economic and social
protection systems are especially limited in sub-Saharan vulnerability of poor, vulnerable and marginalised groups.”
Africa, with the notable exception of a few southern African (Devereux &, Sabates-Wheeler 2004)
countries.
Box 1:
Linking social protection with Universal Access outcomes: indicative instruments & populations
Adapted from Edstrom, J. IDS 2010
HIV Prevention Treatment Care & Support
for those most vulnerable to HIV for people living with HIV for people living with and affected
infection by HIV
Financial protection Transfers for the very poor to Transfers to poor PLHIV for Transfers to mitigate the impact of
 Social assistance support HIV prevention better HIV treatment access & AIDS on individuals & households
protection for very poor adherence

 Livelihoods support Income generation or micro-credit Economic empowerment for Income generating activities,
for poor and vulnerable to reduce HIV risk for poor key PLHA to prolong & improve life livelihoods strengthening, micro-
population groups finance for affected
Access to affordable quality Social insurance to prevent HIV Social health protection to Preventive insurance measures
services risk (social security, public finance ensure access to health care appropriate for those affected
 E.g., Social Health Protection of RH, MH & HIV prevention & to prevent erosion of (pension schemes, funeral clubs
for vulnerable services etc.) savings etc.)
Laws, policy, regulation Legal reform, policy process, and Protection of rights to health, Legal protection for affected
 Social justice for the protection regulation to reduce HIV treatment and work to improve (widow’s and orphans’ property
marginalised risk (decriminalisation) life for PLHA (anti-discrim) rights, birth registration etc.)
The contents of this brief were extracted from a longer paper, HIV-Sensitive Social Protection: What Does the Evidence Say?
by Miriam Temin, UNICEF, forthcoming 2010.

surmise that sexually active beneficiaries reduced their risky behaviour. such as gender inequality. testing. legislation and regulation to meet HIV. shifted What can Social Protection from older. The intervention also led to a significant Understanding risk and vulnerabilities from an HIV decline in early marriage. transfers of cash or food for those risk of infection. particularly the poor and non-conditional cash transfers for adolescent girls in Malawi marginalised.Enhancing Social Protection for HIV Prevention. Malawi: The Zomba Cash Transfer Experiment for Adolescent Girls Ideally a social protection strategy is comprehensive. The existing evidence on some social protection instruments is strong. revealed substantially increased school attendance among beneficiaries. at different stages of their lives. there was no HIV effect among the girls who inequitable) can be integrated into broader national social returned to school as a result of the transfers. Box 1 groups typical social protection categories Box 2: and relevant beneficiary populations. from which it is possible to infer likely impacts on HIV – but © UNICEF/NYHQ2009-1912/Pirozzi where more operational research is required. and access to treatment and care. (Baird et al. It appears that they did not cease having sex. which exacerbate interventions: financial marginalisation and vulnerability faced by key populations at higher protection through predictable key populations at higher risk of infection. For other instruments. health and education from being affected by AIDS to becoming vulnerable to services. pregnancy. and policies. and AIDS. a range of initiatives that are HIV sensitive (as at the intervention’s start than amongst the control group. better-off partners to peer partners. who were Contribute to Universal Access? less likely to be HIV infected. which have had a demonstrable impact on mitigating the impact of AIDS on vulnerable households and children. with national coverage. Care & Support Social protection measures are HIV Social protection has shown to play a critical role sensitive when they are inclusive in helping people overcome structural of people who are either at risk Social protection is inequalities that drive the epidemic and serve of HIV infection or susceptible particularly relevant to HIV as barriers to treatment.which can be stigmatizing and However. such as cash transfers. stigma into three broad categories of and vulnerability faced by and discrimination. and self-reported perspective means understanding the epidemic stage. There is an emerging evidence base showing social protection’s contribution to HIV prevention and treatment uptake and adherence. sexual activity amongst beneficiaries in both conditional and drivers of the epidemic and different groups’ exposure to non-conditional arms.groups. stigma Social protection is particularly relevant to HIV sensitive social and discrimination. The evidence also suggests an important access to affordable quality services potential of social protection to interrupt the cycle including treatment. evidence specific to their use in an HIV context is more limited. Based on significantly lower among girls who were enrolled in school this. which HIV because of its potential to address protection can be grouped exacerbate marginalisation issues. Additionally. to the consequences of HIV because of its potential to and other essential services. it is important that polices and programming are backed by robust evidence. HIV-affected and most vulnerable. but rather with the cash in hand from the transfer. . opposed to HIV exclusive . 2009) The State of the Evidence Whilst there is growing interest in HIV-sensitive social protection. as well as studies showing the impact of social protection on related outcomes such as access to primary health care and women’s empowerment. such as gender inequality. preliminary findings indicate that the incidence of new HIV infections was infection risk. Researchers protection strategies. address issues. and built upon a sound understanding of One of the few programme evaluations comparing the the range of risks and vulnerabilities facing different relative benefits of conditional (on school attendance) and population sub. Treatment. schooling. the needs and uphold the rights of the most vulnerable and excluded.

Empowering sex workers in particular through access to leading the researchers to conclude that “Modest cash economic assets. A larger number adherence in Uganda (see Box 3) and transfers in increasing school VCT uptake in Malawi indicates the of studies demonstrate the enrolment and attendance. Box 3: Social protection instruments targeted at girls and women Uganda: Cash Transfers for Transportation have the potential to level the economic playing field. when pre- existing under-nutrition has often been compounded by wasting caused by HIV. reduce gender inequality and empower women to better Improve Adherence & Retention in Care in an negotiate their sexual relations and reduce their risk of HIV HIV Treatment Program infection. Care & Support SOCIAL PROTECTION & HIV much food contributes to nutritional PREVENTION “Social Vaccine” of improvements versus the medication. The relevant instruments include In rural Uganda. Food transfers have been shown to be effective in reducing under-nutrition in people living with HIV . micro-credit. and the removal of user fees have the potential to increase Voucher schemes are more effective when they cover treatment of sexually transmitted infections. Presently.but. Treatment. peers. education.” This important study shows promising results that warrants further investigation. 2010) There is evidence of the positive impact of social transfers for nutritional recovery of patients receiving HIV and TB treatment. it is critical to ensure access to the right food. While it is unclear how . small loans and often financial training. increasing school enrolment and attendance. particularly micronutrient rich and high energy density foods. for participants. People who start treatment in low income countries often do so at very low CD4 counts. social mobilisation and legislation has transfers of $5-8 per month to defray the costs of been shown to reduce HIV risk in a key population. prevention potential include social transfers. economic and social empowerment revealing their potential to and outcomes. researchers tested the hypothesis that providing patients with cash transfers to cover transportation cash transfers and micro-credit programmes that provide costs would increase ART adherence and retention in care. HIV infection. impact of social protection. education against HIV under-nutrition is a predictor for mortality. exemptions. The results of the randomized control trial showed better adherence scores in the intervention than the control group. few empirical studies have explored these causal pathways. programmes with demonstrated impacts voucher and fee exemption schemes sheds light on their on health service access. A small number of studies infection have measured the direct Emerging evidence on the role of cash Studies show the transfers to increase treatment HIV prevention role of social effectiveness of cash and food protection. including social health show the effectiveness of cash and food transfers in insurance. policies and regulation. (Emenyonu et al. social health protection. who in a number of sub-Saharan African studies. patients better tolerate ART and therefore food availability can be a critical enabler of Social protection instruments with HIV adherence. and The range of social health protection measures that transformative laws.Enhancing Social Protection for HIV Prevention. voluntary transport costs along with medical expenses and when counselling and testing uptake. such as maternity care vouchers potential for ART and other HIV-related health services. expand access to the “social which may also have indirect vaccine” of education against Availability of food can help also help impacts on HIV prevention. vouchers. and user-fee elimination. transportation may be an important strategy to reduce costs and improve treatment outcomes in rural. This is particularly Social health insurance (for example. potential to improve treatment uptake health. fails to reduce financial were at greater risk of unsafe sex than their non-orphaned barriers for those who need it the most – the ultra-poor. Many studies expand health care access. community-based important for adolescent girls and children orphaned by health insurance) does cover some health care expenses AIDS. and prevention of mother to providers are reimbursed for appointments covered with child transmission services access. Evidence from the maternal health field on the benefits of In a similar vein. vouchers. resource-limited SOCIAL PROTECTION & TREATMENT treatment settings. revealing their are also relevant to treatment. potential to expand access to the “social vaccine” of education against HIV infection. but on the whole.

South Africa: The Role of Social Grants in The main targets for impact mitigation are the ultra-poor Mitigating the Socio-Economic Impact of AIDS and vulnerable. Provide health care for those marginalised due to poverty. it can also contribute to an enabling environment and transform individual prospects. poverty. but that eligible poorest were left out. 2003) labour. such as members of labour constrained South Africa has several large national granting schemes that households and children affected by AIDS. Comprehensive home based care has documented benefits to potentially impact on the following aspects of HIV-sensitive social protection: . ART expansion may increase the relevance of livelihood approaches for people living with While ensuring access to free and decentralised HIV HIV and their households. . and reliance on child grants decreased. income generating activities. shedding light on an important question requiring further research. Home based care for people living with HIV and their caregivers can play a role here as well. and . HIV or other stigmatised status. In addition. protection programmes actually reaching AIDS-affected households?’ Anecdotal evidence on this varies. Link clients and caregivers with legal support and livelihood opportunities. In fact. A few studies – such as that described in Box 4 – systematically SOCIAL PROTECTION. Treatment. these schemes can increase households’ ability to withstand shocks and reduce poverty. particularly Households grappling with the uncertainty and medical when it comes to eliminating fees for the ultra-poor. Provide food and economic support to members of affected households. as eligibility increased. noting the success in a number of programmes in light of the risks associated with starting countries piloting free HIV services. Promote treatment adherence. small businesses. . The role of social protection for care and support – particularly AIDS impact mitigation – is better documented Box 4: than for the other HIV outcomes considered. poverty levels as non-affected households. Results revealed relatively high levels of access to Disability and Foster Care grants amongst AIDS-affected households. such as food and transport A key question for care and support is ‘are ongoing social expenses and stigma may still persist. Many of the documented benefits of social transfer The research also found that the five large national grant programmes address the very vulnerabilities that AIDS schemes bring AIDS-affected households up to the same exacerbates: reduced education and health care access. Livelihoods promotion can also play a role here. including public works. A study in the Free State Province looked at prospects for those less poor including AIDS-affected their reach and impact for households affected by AIDS. (Booyson. Many expenses related to HIV and AIDS may not always be experts advocate for free ART as the only way to massively appropriate targets for certain types of livelihood increase access. regulation and policy changes to reduce stigma and protect the rights of people living with HIV. ©UNICEF/NYHQ2010-0578/Pirozzi Although specific HIV-related impacts are rarely measured. CARE & SUPPORT explore this question.Enhancing Social Protection for HIV Prevention. . include. Social protection to mitigate the impact of HIV and AIDS serves not only to prevent deprivation. but do not explicitly target. widows. households with labour potential. other economic and social barriers. AIDS-affected individuals social protection can play a role in transforming the and households. Legislative. Care & Support Exemption schemes have a more mixed record. and affected children are important components of care and support. But. Combining transfer schemes with social work and child protective services can reduce exclusion errors and expand coverage to those commonly excluded. services remove important barriers to access. F. and micro-credit. access to household food insecurity.

led by sex workers themselves. Participants agreed that it is neither desirable nor feasible While it is too early to see an impact. target new research. care and support. They services. including: improving access to legal and economic services. participants recognised the role use in sex work) with social support. 85% and HIV prevalence among sex workers decreased to 4% compared to rates of 50% reported in other sex work districts Social protection can enable sex workers’ access to of India. including sex workers. criminalisation of homosexuality. that planners adapt the scale up of national social thereby improving STI treatment. The Sonagachi project staff moved from a more traditional and their families. discrimination. The need for participatory approaches that involve potential beneficiaries of social protection In terms of MSM. Condom use in project areas increased to Africa. particularly in Sub-Saharan transmission rates.Enhancing Social Protection for HIV Prevention. VCT. Reducing the barriers they face in public health approach to HIV prevention to one that access to health. and capacity building. identified areas where more research is needed. protection. HIV-sensitive social protection power of sex worker collectives in changing the legislative and is highly relevant to key populations. In light of fiscal constraints. condom promotion. identified the need for better understanding of the advocates recently won a ten year struggle to overturn the cost-effectiveness of different approaches. particular countries. this legal change is to set up parallel HIV-exclusive social protection likely to bring more MSM into health and HIV services. ©UNICEF/INDA2010-00043/Feit . Tackling gender and human rights issues. Yet. Ensuring that national social protection strategies are inclusive of those affected by. However. men who have sex with men (MSM). Involving sex workers in the design. evidence on how to reduce gender issues. the recent economic crisis. This empowering approach. programmes. What More Needs to be Done? Evidence points to the importance of linking specific harm At a recent meeting of development partners working on reducing interventions (like building demand for condom HIV and social protectioniii. and adding training and life . and living with HIV is an essential component of a comprehensive HIV response. and social services is a empowered sex workers. treatment. Care & Support KEY POPULATIONS AT HIGHER RISK OF HIV Box 5: INFECTION India: An Effective Approach to Empowering Sex Workers and Reducing HIV As social protection is about reducing risk and vulnerability. building sex workers’ social capital. we must do more. highly vulnerable to. negotiation skills with clients. approaches. it is important to address both economic and social Calcutta’s Sonagachi Project is an excellent illustration of the determinants of vulnerability. contribute to HIV prevention. Better understanding of the barriers of access to skills education can increase the impact of public health HIV services. In India. and of social protection in the response to HIV and AIDS. protection programmes to HIV-related vulnerabilities in and other essential services for a key population. and for a continuing dialogue between partners working on HIV and social protection. led to a reduction in HIV populations is extremely limited. there is good potential for ensuring which some previously avoided due to fear of prosecution. management and implementation of HIV prevention activities heightens their effectiveness by empowering workers (see Box 5). exclusion and poverty amongst key training. they also decriminalising homosexuality. along with efforts to decriminalise sex work. for example. particularly treatment. people who use drugs. and ensure evidence reaches decision-makers to expand and scale up social protection measures that are HIV-sensitive. (Doupe 2007) essential HIV prevention and treatment services and legal protection. There is an urgent need to interrogate existing programmes. and the ever growing number of people in need of HIV prevention. education. Treatment. including activities to address rights. . particular challenge. socially protective legislation can programmes in their design. social environment as a way of reducing HIV and other risks. care and support by . With growing concern over HIV financing. child care.

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