Follow the Money
AIDS is inextricably linked to inequitable distribution of resources -- money, medications, legal protections, education and more. AIDS activism has long been dedicated to redistribution of all of the above in ways that would make the world a more just place. But does this extend to actually giving people money or other compensation (a gift card, food and so on to change their behavior or get circumcised or keep coming to their clinic visits?)
The answer isn't exactly clear. For many activists and people on the front lines, especially those who are well-versed in the potential coercive impact of financial compensation for trial participation, the idea of offering people money to change behavior is a finger in the dike or a band-aid on the problem of major inequities that need reform at the level of international trade, governance and accountability.
Nevertheless, the issue bears exploration and yesterday's presentations at IAS 2015 added information that will undoubtedly fuel discussions and programming going forward.
NAM provided an excellent summary of data on cash compensation for men coming for VMMC and for women living with HIV attending antenatal services and, in a different write up, a summary of data presented on the use of cash transfers for young women to remain in school (in a study called HPTN 068) and for young men and women conditional on life skills training, educational attainment and HIV testing (a study called CAPRISA 007).
The very brief summary of these findings is that cash offers improved uptake of VMMC and clinic attendance for women in antenatal care, but that it didn't reduce HIV incidence among young women who received the contributions to stay in school -- compared to their age-matched counterparts who were also in school but didn't receive cash bonuses. The CAPRISA 007 study found a reduction in HSV-2 incidence associated with individuals who received cash, but did not find an impact on HIV incidence.
These are not the first studies to investigate the use of such structural interventions on reducing HIV incidence -- Julia Kim and colleagues are one of many teams that did groundbreaking work on this topic over a decade ago in rural South Africa (summaries of some work by Kim and others can be found here and here.) And as Helen Rees has eloquently stated in her discussion of the full spectrum of strategies needed for an effective AIDS response, structural strategies such as girls' education, economic empowerment for women and effective programming to reduce gender-based violence are essential, whether or not they turn up a statistically significant result in a randomized trial.
But these newest data come at a time when cash transfers are getting increasing attention from global leadership seeking to define the package of interventions needed to "end AIDS." And for this reason, it's important to track the findings carefully as they may inform what gets rolled out or called for in the near future.
Most specifically, it's quite possible that cash transfers will turn up in an expanded set of Fast Track goals from UNAIDS. Regular readers of AVAC materials over the past six-plus months are well aware that we've been calling on UNAIDS to release comprehensive targets for prevention and non-discrimination, and that we've also been urging that these targets -- which are available in draft/unofficial form -- are defined in ways that match the intervention. So, for example, VMMC lends itself to numerical and coverage targets -- a certain number of men reached by a specific deadline. Newer strategies like PrEP need targets that reflect how much still needs to be learned about delivery for maximum impact. That's even more true for cash transfers for young women -- an intervention that has turned up in official UNAIDS documents since World AIDS Day, and that has been included -- based on data from World Bank-funded research -- in the modeling that underpins the 90-90-90 goals.
As we stated in AVAC Report 2014/15, the term "cash transfers for young women" isn't nearly specific enough to be operationalized. All sorts of variables are in play -- from the amount of money, to the conditions for receiving it, to the recipient -- whether communities or individuals. And we've clearly stated that defining these variables needs to be part of any target-setting for such an intervention (e.g., the target would be having a clear definition of the intervention, based on evidence, by a specified deadline).
With the new data, and with work we've done over the recent months related to both VMMC and women's access to ART, we want to add a few more questions to this discussion.
- Could -- or should -- cash transfers "for" young women include cash transfers uptake of VMMC?
VMMC programs face funding shortfalls in some places and, in others, are looking for ways to reach men who did not take up the strategy during early, successful roll-out. VMMC is a one-off strategy that reduces individual risk and population level incidence. As Audrey Pettifor, one of the investigators who led the cash transfer study in South African young women observed, it's important to think about the terms of "conditional" cash transfers. VMMC may be suited to this type of offer, since it is a single procedure. Conditional transfers tied to ongoing behavior change could be less successful, she suggested. This doesn't mean that conditional transfers can't work for women, but achieving saturation coverage of VMMC will reduce women's incidence, along with men's. In early versions of at least one PEPFAR Country Operational Plan, money from the DREAMS initiative for reducing incidence in adolescents and young women was earmarked for VMMC. With scant resources for adolescent women and young girls, no one wants to see resources earmarked for women going to young men. But the data on VMMC, including the cash transfer study, are a reminder that both men and women need to be involved and reached to impact women's risk of HIV.
- What is the need for additional research/interventions that focus on pregnant women from third trimester through immediate post-partum -- versus those that encompass many stages of the lifecycle?
A study in the Democratic Republic of Congo found that incrementally increasing cash transfers (starting at USD$5 and adding one dollar at subsequent intervals) significantly increased pregnant women's attendance at clinic visits from roughly 32 weeks pregnant through six weeks post partum. As Option B-plus programs grow, there is also an expanding body of evidence of when and how women are lost to follow up and, arguably, any intervention that improves retention should be considered. But the question should be raised by review committees funding trials, advocates asked to consult on protocols, and agenda-setters at every level working on women's sexual and reproductive health: given all that is known about the complexities of reaching and keeping women in care, should research continue to have a narrow focus on third trimester and early antenatal periods?
- Education reduces HIV incidence. What are UNAIDS, PEPFAR, WHO, GFATM and national governments going to do about it?
In the South African study that didn't find a link between cash transfers and HIV risk, there was a clear link between staying in school and staying HIV negative. This echoes trends detected in Botswana, Zambia and other countries -- where additional years of education are protective in terms of reducing young women's incidence. The structures that need to be in place to support a functioning free and/or accessible secondary education system are quite different from those that need to be in place to deliver cash transfers to selected adolescents and young women. The global and national stakeholders don't need to forgo cash transfers for large-scale structural work on education for girls -- but they ought not imagine that the former will do away with need for the latter.
Finally, on the subject of money, one of the most striking images from activist actions at this conference came from a gathering of women living with HIV, holding handmade signs. Jessica Whitbread, an artist, activist and organizer with ICW Global made a lace-trimmed, hand-lettered blanket that reads: "I am glad my AIDS is paying for your mortgage." AVAC is part of the professional world that now defines much of the response. We work to remind ourselves, our partners and our funders of the very high bar of accountability for all of the resources available in the global fight. And when it comes to eloquence about following the money -- this is exactly the kind of reminder that we need.