Cash plus: exploring the mechanisms through which a cash transfer plus financial education programme in Tanzania reduced HIV risk for adolescent girls and young women

Abstract

Introduction Cash transfers have been promoted as a means to reduce HIV risk for adolescent girls and young women ( AGYW ) in sub‐Saharan Africa. One of the main mechanisms whereby they are hypothesized to reduce risk is by deterring transactional sex. In this paper, we use qualitative methods to explore participant experiences, perspectives and reported behaviours of a cash transfer plus financial education programme among out of school, 15‐ to 23‐year‐old AGYW s in rural Tanzania with a focus on partner choice and transactional sex. Methods We conducted 60 in‐depth interviews ( IDI s) and 20 narrative timeline interviews with participants of the PEPFAR DREAMS Sauti/ WORTH + cash transfer programme between June 2017 and July 2018. Interviews were taped, transcribed and translated from Kiswahili to English. Transcripts were coded and analysed for key themes. Results We found that participants in a cash transfer plus programme discussed behaviours that could reduce HIV risk through decreasing their dependence on male sex partners. There appeared to be two main mechanisms for this. One, young women discussed the cash transfer providing for basic needs (e.g. food, toiletries) which appeared to reduce their dependence on male sex partners who previously provided these goods (e.g. transactional sex). This experience was more pronounced among the poorest participants. Two, young women discussed how the financial education/business development aspect of the programme empowered them to refuse some sex partners; unmarried women discussed these experiences more than married women. Social support from family and programme mentors appeared to strengthen young women's ability to successful start businesses, produce income and thus be less dependent on partners. Conclusions The cash transfer programme may have reduced AGYW engagement in transactional sex that occurred to meet basic needs (one form of transactional sex). The financial education/business development and mentorship elements of the programme appeared important in building AGYW agency, self‐esteem and future orientation which may support AGYW s in refusing unwanted sex partners. Future cash plus programmes should consider adding or strengthening financial education and job skills training, mentorship and future orientation to see stronger and perhaps sustainable outcomes for HIV prevention.

Maximizing the impact of HIV prevention technologies in sub‐Saharan Africa

“…Pettifor and colleagues conducted a qualitative study of a cash transfer project in Tanzania, and propose a conceptual framework for the possible mechanisms for reducing HIV risk . Reduced dependence on transactional sex may be one mechanism, but they also identified the importance of business education and mentorship in building young women's efficacy and self‐esteem, and argue that these may have a greater impact in the long term.…”

HIV risk among young women who sell sex by whether they identify as sex workers: analysis of respondent‐driven sampling surveys, Zimbabwe, 2017

“…Some YWSS may not be formally engaged in sex work while others sell sex occasionally. Unlike transactional sex, which has been associated with implicit exchanges within romantic relationships, and with agency and power , this period of selling sex is likely, in part, driven by economic need . YWSS may later begin to identify as FSW and only then recognize the period before this transition as sex work.…”

Conceptualization of Empowerment and Pathways Through Which Cash Transfers Work to Empower Young Women to Reduce HIV Risk: A Qualitative Study in Tanzania

“…Cash transfers (CT) are encouraged as an intervention that may empower women to make their own decisions and support themselves financially [ 13 ]. They are considered an effective social protection mechanism through provision of cash subsidies to extremely poor households [ 14 ] and sometimes directly to individuals [ 15 – 17 ]. While a few studies, mainly in South Africa, have explored how young women use CT [ 18 ], little has been done to describe how beneficiaries perceive these cash interventions and whether they consider them as empowering in meaningful ways.…”