HIV/AIDS is the leading cause of death and disability among working-age adults in sub-Saharan Africa. Most HIV transmissions in the region occur through unprotected heterosexual intercourse. One of the key channels through which risky sex is thought to occur in sub-Saharan Africa is transactional sex—the exchange of money or gifts for sexual relations. Conventional approaches to HIV prevention have been important in educating people about risk factors and strategies for reducing risk, but they have had limited success in slowing the AIDS epidemic. This evaluation provided evidence on how cash payments might be used to reduce risky sexual behavior among young men and women.
| Research area: | Health- HIV/AIDS |
| Country: | Tanzania |
| Evaluation Sample: | 2,399 people enrolled in the study |
| Intervention Timeline: | 2009-2010 (Completed) |
| Intervention: | Cash payments |
| Researchers: | Laura Packel, University of California, San Francisco; William H. Dow, University of California, Berkeley; Damien de Walque, The World Bank; Zachary Isdahl, International Labor Organization; Albert Majura, Ifakara Health Institute, Tanzania |
| Partners: | Ministry of Health |
Challenge
Conditional cash transfers have been used successfully to improve education enrollment and attendance, use of health facilities and prenatal care. This evaluation sought to test whether they could also be used to reduce risky sexual behavior, which is a key way in which HIV infections are transmitted in sub-Saharan Africa.
Intervention
In what was known as the RESPECT trial, cash payments offered to young men and women between the ages of 18 and 30 were conditional on testing negative for four curable sexually transmitted infections (Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium) at periodic testing rounds (every four months for one year). Anyone testing positive was offered free treatment, and all received counselling.
Evaluation
The study enrolled 2399 young men and women in 10 villages in rural south-west Tanzania. Participants were divided into a treatment and a control group. People in the treatment group received cash transfers conditional on testing negative when screened for sexually transmitted infections, which is a marker for risky sexual behavior. The treatment group was further divided into two sub-groups – one that qualified for a “high value” payment of $20 for testing negative, and the other that qualified for a “low value” $10 payment. All participants were tested for sexually transmitted infections at baseline and then every four months for one year. Participants in the two treatment arms were eligible to receive the incentive payments if they tested negative for curable infections at the four, eight and 12-month testing rounds. Those who tested positive for any of the conditioned curable infections did not receive the payment, but were eligible to continue in subsequent rounds after having been treated and cured of the infection.
Results
At the end of the one-year intervention, there was a significant reduction in sexually transmitted infections in the group eligible for the $20 payments every four months, but no such reduction in the group eligible for the $10 payments. There was no difference in impact between men and women, but the impact was larger among people who tested positive at baseline for one of the infections. One year after the program ended, there was a continued impact for men but not for women, which may indicate that money may be a factor for women when they are negotiating safe sex with partners.