Publication: Incentivising Safe Sex : A Randomised Trial of Conditional Cash Transfers for HIV and Sexually Transmitted Infection Prevention in Rural Tanzania
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Date
2012-02-08
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Published
2012-02-08
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Dow, William H.
Nathan, Rose
Abdul, Ramadhani
Abilahi, Faraji
Gong, Erick
Isdahl, Zachary
Jamison, Julian
Jullu, Boniphace
Krishnan, Suneeta
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Abstract
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.
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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 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 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 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 Effects of a Lottery Incentive on Sexually Transmitted Infections and HIV Incidence among Female Sex Workers in Tanzania(World Bank, Washington, DC, 2023-09-26)Female sex workers are a key population who experience a disproportionately high burden of HIV and sexually transmitted infections. A growing body of evidence suggests that financial incentives can reduce risky sexual behavior and the incidence of HIV and sexually transmitted infections; however, few studies have examined a lottery-based incentive mechanism or been conducted with female sex workers. This paper examines the effect of a lottery intervention on the combined incidence of HIV and herpes simplex virus 2 among female sex workers in Tanzania. The RESPECT II trial was an unmasked, two-arm, parallel group randomized controlled trial conducted in Dar es Salaam, Tanzania among 2,206 enrollees from 2018 to 2021. Participants were randomized in a one-to-one ratio to the basic test control group or to the lottery intervention group. The basic test group received testing and counseling for HIV and biweekly text messages with information on safe sex practices. The lottery group received the basic test group intervention plus entry into a weekly lottery with a 100,000 Tanzanian shilling (US$50) reward offered to 10 randomly selected participants, conditional on negative test results for syphilis and trichomonas. The primary outcome was combined HIV and herpes simplex virus 2 incidence after 36 months. The results showed no statistically significant effect on this primary outcome. Thus the study finds no evidence that the lottery-based incentives reduced the incidence of HIV and sexually transmitted infections among the female sex worker population. However, the results may have been affected by disruption from the COVID-19 pandemic, and unexpectedly high study attrition levels made it impossible to statistically rule out possible moderate-sized effects.
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