Effect of a Cash Transfer Programme for Schooling on Prevalence of HIV and Herpes Simplex Type 2 in Malawi: A Cluster Randomized Trial

Publication Details

The Lancet, Early Online Publication, February 2012. Available From:

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Sarah Baird,Richard S. Garfein,Craig McIntosh,Berk Ozler
Sub-Saharan Africa (includes East and West Africa)
Education, Health Nutrition and Population, Multisector, Social Protection
Girl's Education, HIV and AIDS, Preventive Health and Health Behavior, Primary Health- including reproductive health, Sexual Behavior, Conditional Cash Transfers, Social Assistance
Equity Focus
Evaluation design
Randomised Control Trials (RCT)
Journal Article


This study examines the impact of a cash transfer programme on the prevalence of human immunodeficiency virus (HIV) and herpes simplex virus type 2 (HSV-2). The study also assesses impacts on syphilis prevalence, school enrolment, self-reported marriage, pregnancy and sexual behaviour. Lack of evidence of the impact of behaviour change interventions on HIV infection and the identification of poverty as a major risk factor for HIV have led researchers to design and evaluate structural interventions such as conditional and unconditional cash transfers to protect young women against HIV in sub-Saharan Africa.
To test this hypothesis, the authors designed and implemented an intervention in 176 enumeration areas in Zomba district in Malawi between January 2008 and December 2009.The study population consists of all never-married girls aged 13 to 22 years. They are separated into two cohorts: in school and out of school. After completion of the baseline surveys, 88 enumeration areas were randomly assigned to the intervention group and the other 88 to the control group. In the intervention group, conditional and unconditional cash transfers were given to guardians and girls. In the conditional group, cash transfers were given when girls attended school regularly during the previous month. The monthly amount received by guardian was randomly chosen amongst US$4, US$6, US$8 or US$10. For girls, the monthly amount was randomly chosen amongst US$1, US$2, US$3, US$4 or US$10. To measure spill-overs of the intervention on untreated schoolgirls in treatment areas, the authors randomly chose the percentages of schoolgirls participating in the cash transfer intervention in treatment areas.
Data were collected from 3,796 individuals. The survey captures information on age of individuals, whether mother and father are alive, highest grade attended and mobile phone access. Finally, to evaluate the impact of the intervention, the authors calculate adjusted odds ratios with a logistic regression model of individual data.

Main findings

Combination intervention (conditional and unconditional cash transfers) reduces significantly HIV and HSV-2 prevalence. Eighteen months after the baseline surveys, in the cohort of baseline school girls, weighted HIV prevalence was 1.2 per cent in the intervention group and 3.0 per cent in the control group. Weighted HSV-2 prevalence was 0.7 per cent in the intervention group and 3.0 per cent in the control group. There is no significant difference between conditional and unconditional intervention groups regarding HIV and HSV-2 prevalence. Furthermore, 12 months after baseline, the outcomes related to self-reported sexual activity are significantly lower in the intervention group, particularly for ‘had sexual intercourse once per week’ with at least one partner and for ‘having a sexual partner aged 25 years or older’. However, there is no significant impact on other outcomes (e.g., the likelihood of marriage, pregnancy, sexual debut and intercourse without consistent use of condoms with at least one partner). For baseline dropouts from the intervention group, the intervention has a significant positive impact on reenrolment at school; enrolment rates were 57 per cent in the intervention group and 12 per cent in the control group. However, prevalence of HIV or HSV-2 was not different for the two groups. For self-reported sexual activity, there is no difference between the two groups except for intercourse at least once a week with at least one partner, which is lower in the baseline dropouts group.
The intervention has no impact on untreated girls in treatment enumeration areas. Furthermore, the analysis of heterogeneity of the intervention by transfer size shows that the effect on the prevalence of HIV and HSV-2 does not vary by the amount of cash offers to participants. This study shows that cash transfers to unmarried school girls can help reduce risky sexual activities and the likelihood that young women will be infected with HIV and HSV-2. Further studies are needed to examine whether this intervention works in other settings.

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