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
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Published
2017-05
ISSN
0277-9536
Date
2018-03-27
Author(s)
Cooper, Jan E.
Dow, William H.
Keller, Ann C.
McCoy, Sandra I.
Fernald, Lia C.H.
Balampama, Marianna P.
Kalolella, Admirabilis
Packel, Laura J.
Wechsberg, Wendee M.
Editor(s)
Abstract
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.
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Publication Sexual Behavior Change Intentions and Actions in the Context of a Randomized Trial of a Conditional Cash Transfer for HIV Prevention in Tanzania(2012-03-01)Information, education, communication and interventions based on behavioral-change communication have had success in increasing the awareness of HIV. But these strategies alone have been less successful in changing risky sexual behavior. This paper addresses this issue by exploring the link between action and the intention to change behaviors. In Africa, uncertainty in the lives of those at risk for HIV may affect how intentions are formed. Characterize this uncertainty by understanding the reasons for discrepancies between intentions and actions may help improve the design of HIV-prevention interventions. Based on an incentives-based HIV prevention trial in Tanzania, the longitudinal dataset in this paper allows the exploration of intended strategies for changing sexual behaviors and their results. The authors find that gender, intervention groups and new positive diagnoses of sexually transmitted infections can significantly predict the link between intent and action. The paper examines potential mediators of these relationships.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 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.Publication Potential Applications of Conditional Cash Transfers for Prevention of Sexually Transmitted Infections and HIV in Sub-Saharan Africa(World Bank, Washington, DC, 2008-07)A growing number of developing countries have introduced conditional cash transfer programs that provide money to poor families with certain contingencies attached - such as requiring school attendance or regular immunization and health check-ups. As the popularity of conditional cash transfer programs has grown, experimentation with potential applications in other areas of health, such as sexual and reproductive health, and HIV prevention, in particular, has also increased. Evaluations of conditional cash transfer programs have focused almost exclusively on uptake of health and educational services, which make relatively low demands of participants compared with more complex interventions, which require the cessation of risky behaviors, such as smoking, obesity, and substance abuse. The literature on contingency management - based on the principle that behavioral change occurs when appropriate behaviors are reinforced and rewarded - provides a richer picture of the complexity of the use of conditionality to encourage healthy behavioral change. This paper examines developing countries' experiences with conditional cash transfer programs and the results of trials in clinical settings on the efficacy of contingency management, and addresses their relevance for designing conditional cash transfer programs to address risky sexual behavior and promote the prevention of sexually transmitted infections and HIV in Sub-Saharan Africa.Publication Effect of a Lottery Intervention on Gender-Based Violence among Female Sex Workers in Dar es Salaam, Tanzania(World Bank, 2023-10-02)Financial incentives are a promising approach for HIV prevention. Some studies have shown that financial incentive interventions aimed to promote positive health and social behaviors have mixed or harmful effects on gender-based violence, and little is known about their effects among higher risk groups such as female sex workers. To address this gap, this study investigated the relationship between a lottery-based incentive and gender-based violence among female sex workers in Dar es Salaam, Tanzania. Data were analyzed from the RESPECT II trial, which enrolled 2,206 female sex workers in Dar es Salaam, Tanzania, to evaluate the effect of a lottery-based incentive on HIV and sexually transmitted infections. Participants were randomized in a one-to-one ratio to: (1) the basic test group (control), which provided baseline testing and counseling for HIV and sexually transmitted infections and bi-weekly text messages on safe sex practices; or (2) the lottery group, which included the basic test group intervention plus entry into a weekly random lottery for an award of 100,000 Tanzanian shillings conditional on negative tests for sexually transmitted infections (syphilis and trichomonas vaginalis). An intent-to-treat analysis was conducted to estimate differences in physical and sexual gender-based violence (overall), and intimate partner violence and non-partner violence between treatment arms at endline, with estimates expressed as unadjusted prevalence differences with 95 percent confidence intervals. Adjusted estimates controlled for baseline reports of violence. Multiple imputation and inverse-probability of treatment weighting were used to account for missing data. Causal, population-level impacts were estimated using g-computation. Gender-based violence, intimate partner violence, and non-partner violence declined in both treatment arms over the study period among the sample of 1,117 female sex workers retained at endline. The lottery group had a lower prevalence of gender-based violence overall, intimate partner violence, and non-partner violence compared to control at endline; however, the differences were not statistically significant. The results indicate that the lottery intervention had no effect on violence outcomes among endline participants in the RESPECT II trial. These results suggest that this economic approach does not pose additional risks of violence in the context of sex work; however, they must be interpreted with caution due to high attrition in the study sample. Additional research is warranted to examine how this incentive mechanism impacts violence for female sex workers.
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