View as:|
1 of 5

Cash Incentives in HIV

Intuitively, it makes sense that cash incentives can influence behavior. In Sub-Saharan Africa, where poverty is tied to high rates of HIV infection, cash could be a strong motivator to change behavior, such as condom usage (prevention), or adherence to antiretroviral therapy (treatment).

As described by Audrey Pettifor, M.P.H., Ph.D., University of North Carolina Department of Epidemiology, at the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015), the concept of cash incentives has recently generated a lot of "buzz." Mainstream media and researchers alike have been discussing the idea that cash incentives could be an effective alternative to behavior change programs.

Two Main Theories

In 2012, Pettifor's team conducted a review of 16 cash-incentive studies. They found that two main approaches exist.

The first is what Pettifor called an "upstream" approach -- offering cash to alleviate poverty, which hopefully improves the recipients' overall well being and reduces their likelihood of contracting HIV later in life. The second "downstream" approach offers cash incentives for behavioral change, such treatment adherence or male circumcision.

Pettifor cautioned that although both models make sense at the outset, the impact of cash incentives may be more complex than researchers initially anticipated. The view that cash incentives are an "easy fix," might be oversimplified, she said.

Girls and Education

Pettifor was particularly interested in the plight of young girls in Sub-Saharan Africa. Poverty, traditional gender roles and inequality are all forces detrimental to the health of young women, increasing their risk of contracting HIV.

It's possible to imagine many ways in which cash incentives might reduce the risk of HIV for young girls, Pettifor said. Cash might reduce poverty and the likelihood that a girl would be willing to offer sex in exchange for cash.

Three separate World Bank studies suggest that HIV risk is reduced with cash incentives. Other studies, such as one in South Africa by Lucie Culver, show that girls in households with less cash are more likely to engage in sex work.

Inconclusive Results

Pettifor designed a controlled experiment to test her hypothesis that cash incentives to keep girls in school would reduce their risk of contracting HIV. Approximately 2,500 young South African women enrolled in the study. Some girls were given cash, as were their parents, in exchange for school attendance at least 80% of the time; the other girls were not given cash. Yet an unexpected number of girls stayed in school for the entirety of the study, regardless of their cash incentive.

"We did not see a reduction in HIV incidence," Pettifor said. However, she noted that those girls who did drop out of school had a greater risk of contracting HIV than those who stayed in school. Still, the results were unexpected, she said.

Moving Forward With Cash Incentives

During her IAS 2015 presentation, Pettifor admitted that creating an impact through cash incentives is "more complicated than we thought." An important take-away from her results is the need to be thoughtful when designing future cash incentive studies.

"We need to understand context when thinking of structur[al] interventions," she said. For example, which patient population is being targeted for intervention? How long does the cash need to be given in order to make a real difference? Is there a specific period in a woman's life when cash incentives would be the most effective? Are there other economic incentives that might work better?

The answers to each of these questions will differ depending on social context. Every society is different, and cash incentives are a complex behavioral motivator, including in HIV treatment and prevention.