Publication: Evolving Strategies, Opportunistic Implementation: HIV Risk Reduction in Tanzania in the Context of an Incentive-Based HIV Prevention Intervention
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2012-08-27
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2015-12-03
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Behavior change communication (BCC) interventions, while still a necessary component of HIV prevention, have not on their own been shown to be sufficient to stem the tide of the epidemic. The shortcomings of BCC interventions are partly due to barriers arising from structural or economic constraints. Arguments are being made for combination prevention packages that include behavior change, biomedical, and structural interventions to address the complex set of risk factors that may lead to HIV infection.
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Publication Incentivising Safe Sex(BMJ Publishing Group, 2012-02-08)The authors evaluated the use of conditional cash transfers as an HIV and sexually transmitted infection prevention strategy to incentivise safe sex. Conditional cash transfers used to incentivise safer sexual practices are a potentially promising new tool in HIV and sexually transmitted infections prevention.Publication Incentivising Safe Sex : A Randomised Trial of Conditional Cash Transfers for HIV and Sexually Transmitted Infection Prevention in Rural Tanzania(2012-02-08)Objective The authors evaluated the use of conditional cash transfers as an HIV and sexually transmitted infection prevention strategy to incentivise safe sex. Design An unblinded, individually randomised and controlled trial. Setting 10 villages within the Kilombero/Ulanga districts of the Ifakara Health and Demographic Surveillance System in rural south-west Tanzania. Participants The authors enrolled 2399 participants, aged 18–30 years, including adult spouses. Interventions Participants were randomly assigned to either a control arm (n=1124) or one of two intervention arms: low-value conditional cash transfer (eligible for $10 per testing round, n=660) and high-value conditional cash transfer (eligible for $20 per testing round, n=615). The authors tested participants every 4 months over a 12-month period for the presence of common sexually transmitted infections. In the intervention arms, conditional cash transfer payments were tied to negative sexually transmitted infection test results. Anyone testing positive for a sexually transmitted infection was offered free treatment, and all received counselling. Main outcome measures The primary study end point was combined prevalence of the four sexually transmitted infections, which were tested and reported to subjects every 4 months: Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium. The authors also tested for HIV, herpes simplex virus 2 and syphilis at baseline and month 12. Results At the end of the 12-month period, for the combined prevalence of any of the four sexually transmitted infections, which were tested and reported every 4 months (C trachomatis, N gonorrhoeae, T vaginalis and M genitalium), unadjusted RR for the high-value conditional cash transfer arm compared to controls was 0.80 (95% CI 0.54 to 1.06) and the adjusted RR was 0.73 (95% CI 0.47 to 0.99). Unadjusted RR for the high-value conditional cash transfer arm compared to the low-value conditional cash transfer arm was 0.76 (95% CI 0.49 to 1.03) and the adjusted RR was 0.69 (95% CI 0.45 to 0.92). No harm was reported. Conclusions Conditional cash transfers used to incentivise safer sexual practices are a potentially promising new tool in HIV and sexually transmitted infections prevention. Additional larger study would be useful to clarify the effect size, to calibrate the size of the incentive and to determine whether the intervention can be delivered cost effectively. Trial registration number NCT00922038 ClinicalTrials.gov.Publication Female Sex Workers Use Power Over Their Day-to-Day Lives to Meet the Condition of a Conditional Cash Transfer Intervention to Incentivize Safe Sex(Elsevier, 2017-05)Female Sex Workers are a core population in the HIV epidemic, and interventions such as conditional cash transfers (CCTs), effective in other health domains, are a promising new approach to reduce the spread of HIV. Here we investigate how a population of Tanzanian female sex workers, though constrained in many ways, experience and use their power in the context of a CCT intervention that incentivizes safe sex. We analyzed 20 qualitative in-depth interviews with female sex workers enrolled in a randomized-controlled CCT program, the RESPECT II pilot, and found that while such women have limited choices, they do have substantial power over their work logistics that they leveraged to meet the conditions of the CCT and receive the cash award. It was through these decisions over work logistics, such as reducing the number of workdays and clients, that the CCT intervention had its greatest impact on modifying female sex workers’ behavior.Publication Stimulating Demand for AIDS Prevention : Lessons from the RESPECT Trial(2012-02-01)HIV-prevention strategies have yielded only limited success so far in slowing down the AIDS epidemic. This paper examines novel intervention strategies that use incentives to discourage risky sexual behaviors. Widely-adopted conditional cash transfer programs that offer payments conditioning on easily monitored behaviors, such as well-child health care visits, have shown positive impact on health outcomes. Similarly, contingency management approaches have successfully used outcome-based rewards to encourage behaviors that are not easily monitored, such as stopping drug abuse. These strategies have not been used in the sexual domain, so this paper assesses how incentives can be used to reduce risky sexual behavior. After discussing theoretical pathways, it discusses the use of sexual-behavior incentives in the Tanzanian RESPECT trial. There, participants who tested negative for sexually transmitted infections are eligible for outcome-based cash rewards. The trial was well-received in the communities, with high enrollment rates and more than 90 percent of participants viewing the incentives favorably. After one year, 57 percent of enrollees in the "low-value" reward arm stated that the cash rewards "very much" motivated sexual behavioral change, rising to 79 percent in the "high-value" reward arm. Despite its controversial nature, the authors argue for further testing of such incentive-based approaches to encouraging reductions in risky sexual behavior.Publication Rewarding Safer Sex : Conditional Cash Transfers for HIV/STI Prevention(World Bank Group, Washington, DC, 2014-11)Incentive-based policies have been shown to be powerful in many areas of behavior, but have rarely been tested in the sexual domain. The Rewarding Sexually Transmitted Infection Prevention and Control in Tanzania (RESPECT) study is a randomized controlled trial testing the hypothesis that a system of rapid feedback and positive reinforcement that uses cash as the primary incentive can be used to reduce risky sexual activity among young people, male and female, who are at high risk of HIV infection. The study enrolled 2,399 participants in 10 villages in rural southwest Tanzania. The intervention arm received conditional cash transfers that depended on negative results of periodic screenings for sexually transmitted infections, an objectively measured marker for risky sexual behavior. The intervention arm was further divided into two subgroups, one receiving a high value payment of up to $60 over the course of the study ($20 payments every four months) and the other receiving a lower value payment of up to $30 ($10 payments every four months). At the end of the one year of intervention, the results showed a significant reduction in sexually transmitted infections in the group that was eligible for the $20 payments every four months, but no such reduction was found for the group receiving the $10 payments. The effects were stronger among the lower socioeconomic and higher risks groups. The results of a post-intervention follow-up survey conducted one year after discontinuing the intervention indicate a sustained effect among males, but not among females.
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