World AIDS Day DREAMS Made Real: How Cash Transfers for Girls Can Work

This year, my colleagues and I made our small contributions to the ongoing and epic battle against HIV/AIDS: a working group on powering-up grant agreements to deliver greater efficiency and impact with the Global Fund to Fight AIDS, Tuberculosis and Malaria (out December 14), a set of recommendations to PEPFAR under a new administration, and an analysis of the costs and cost-effectiveness of alternative strategies to expand HIV/AIDS treatment in South Africa, in addition to our usual fare of blog posts and events.

We also looked at a solution that wasn’t typically linked to HIV/AIDS, but which ended up front-and-center in the ongoing fight: cash transfers. Specifically, we looked at cash transfers as a way to reduce HIV and risky behaviors among adolescent girls and young women who are most vulnerable and who, in many settings, seem to be driving the epidemic despite the gains to date.

Recognizing this new reality where girls are at the forefront of the epidemic, PEPFAR, the Bill & Melinda Gates Foundation, and Girl Effect announced a new partnership in September called DREAMS, with an ambitious goal: to reduce new HIV infections by 40 percent among adolescent girls and young women by 2017. Among the program’s objectives is to keep girls in secondary school. Enter cash transfers.

Back in 2012, I wrote that cash transfers were good for HIV/AIDS, too. Direct cash transfers can offer a substitute (immediate cash benefits) or incentive (reward for declining risks) that can alter adolescent valuations of benefits and costs. And last month, as part of our tribute to Nancy Birdsall’s leadership on women and development, we invited some of the key cash transfer evaluators to CGD: Carolyn Heinrich who evaluates South Africa’s massive Child Support Grant program, Berk Ozler and Sarah Baird who evaluate the Malawi Zomba transfer, and Damien de Walque whose evaluations of cash transfers in Lesotho and Tanzania have yielded interesting results.

Evident through these evaluations is that, across many settings, conditional and sometimes unconditional cash transfers pretty unambiguously keep girls in school longer. And girls who remain in school are less likely to engage in risky behaviors—early sexual debut, sex with older men, alcohol and drug consumption—which significantly reduces their chance of contracting HIV and sexually transmitted infections (STIs). The program in South Africa, with more than 12 million children enrolled, is particularly encouraging: the longer kids were in the program, the larger the effect on their well-being as adolescents. Findings from scaled-up programs in Kenya and Mexico also confirm how important cash transfers might be for young girls.

The findings from Malawi Zomba are more complicated. While there were massive positive effects on schooling, HIV and STI rates held steady during the two-year transfer program. But once transfers were stopped, HIV rates spiked and, worse, girls had only “poorer quality husbands” left to marry. Yet given the impact of programs that are longer-running and larger-scale, perhaps the policy message is that cash transfers need to be sustained from childhood into the young adult years if we want to decisively interrupt the spread of risks and disease. 

Of course, cash transfers are no silver bullet and transfers may not always be the most cost-effective, but they are among the best-evaluated programs (after sexuality education) for adolescent girls at risk of contracting HIV risk—and they are a worthy use of DREAMS funding.