Cash Payments can Reduce HIV/Sexually Transmitted Infections in Africa - New Bank Studies. 18/7/10

Two new studies show how young women and men in Malawi and Tanzania who were given cash payments had significantly lower HIV and other STI rates

18 July 2010

Vienna/Washington - On the eve of a global AIDS summit in Vienna, the World Bank today released two new studies that show how young women and men in Malawi and Tanzania who were given cash payments had significantly lower HIV and other sexually transmitted infection (STI) rates than other groups in their communities.

The two studies―‘Schooling, Income, and HIV Risk (SIHR) Malawi,’ and ‘The RESPECT Study: Evaluating Conditional Transfers for HIV/STI Prevention in Tanzania’―are modeled on ‘conditional cash transfer’ programs, like the ‘Oportunidades’ program in Mexico, which use cash payments to encourage children and adults in poor households to improve their education and healthcare.

“The world desperately needs new HIV prevention strategies because for every two people who receive life-saving AIDS treatment, another five become newly infected, which is an impossible situation for many poor countries and their communities,” says Dr. David Wilson, the World Bank’s newly appointed Director for its Global HIV/AIDS Program.

An international authority on HIV prevention, Wilson will head the Bank team at the International AIDS Society summit in Vienna, July 18-23. “These two studies show the potential for using cash payments to prevent people, especially women and girls, from engaging in unsafe sex while also ensuring that they stay in school and get the full benefit of an education,” Wilson says. “They can also boost incomes for poor families and help them escape poverty.”

Schooling, Income, and HIV Risk (SIHR) Malawi

This cash transfer study, which ran for two years between 2008-09, randomly enrolled 3,796 adolescent girls and young women between the ages of 13 and 22 from Zomba, a district in Malawi with high HIV rates and school dropout rates among adolescent girls.

The only condition for receiving cash payments every month was that the girls enrolled in the program had to attend school regularly. As part of the program, their parents received cash payments as well. The girls’ school attendance was checked every month and payment for the following month was withheld for any student whose attendance rate was below 75 percent in the previous month.

Although the cash payments were made purely on the basis of school attendance, the money also made the girls less vulnerable to contracting HIV and other STIs. Eighteen months after the program began, HIV infections among girls in the program were 60-percent lower than those who were part of a control group and did not receive payments. Also significantly, HSV-2 infections (herpes simplex virus – type 2, the most common cause of genital herpes) among girls in the program were 75-percent lower than in the control group.

Girls who received payments not only had less sex, but when they did, they tended to choose younger, safer partners.

The new study suggests that the cash transfers may have led to a drop in so-called ‘transactional sex.’ At the beginning of the study, a quarter of sexually active participants said they started relationships because they ‘needed his assistance’ or ‘wanted gifts/money.’ Meanwhile, among the sexually-active schoolgirls in the control group, 90 percent said that they received an average of US$6.50 a month in gifts or cash from their partners. Given that the country’s per capital yearly GDP in 2008 was US$287.5, the girls considered these gifts very valuable.

After a year, schoolgirls receiving payments from the cash-transfer program seemed to avoid older men, who tend to be wealthier and are much more likely to be HIV positive than schoolboys. The sexual partners were two years older on average than the girls, compared with three years for the control group. More strikingly, less than 2 percent of the sexual partners were 25 or older, compared with 21 percent for the control group.

Conditional cash transfer programs, which immediately boost income among poor families while investing in better health and education prospects for children, have not typically been part of HIV prevention strategies among adolescent girls and young women. Such programs, perhaps designed with an added focus on adolescent girls, could become an important part of effective HIV-prevention strategies at a small marginal cost, complementing interventions that explicitly target ‘behavior change.’

“Programs like these could become an important missing part of effective HIV-prevention strategies,” says Berk Özler, a Senior Economist with the World Bank’s Development Research Group, who conducted the study with researchers from George Washington University and the University of California, San Diego. “These findings suggest that empowering girls financially can also lead to reduced risk—not just by reducing their sexual activity or practicingsafer sex, but also by enabling them to choose partners who are less likely to be infected with HIV in the first place.”

The RESPECT Study: Evaluating Conditional Transfers for HIV/STI Prevention in Tanzania

This $1.8 million study in Tanzania was designed to give cash payments to adults to avoid unsafe sex and prevent STIs such as chlamydia, gonorrhea, trichomonas, mycoplasma genitalium, and syphilis, each of which is preventable and curable. The study enrolled 2,399 participants, males and females between the ages of 18 and 30 in 10 villages, in the Kilombero and Ulanga districts of Southwest Tanzania, located 100 kilometers south of the major highway linking Dar Es Salaam with Zambia and Malawi.

All participants have been monitored on a regular basis (every four months during a 12-month period) for common STIs transmitted through unprotected sexual contact and which therefore serve as a proxy for risky sexual behavior and vulnerability to HIV infection.

Medical teams were sent to each village every four months to conduct STI testing. Individual pre-test and post-test counseling was provided to study enrollees at each testing interval, and monthly group counseling sessions were also made available to all study participants to assist them in their efforts to reduce risky sexual behaviors..

After 12 months of rewarding people for testing negative for STIs, the program recorded a 25-percent drop in the numbers of STIs compared to people in control groups who were not paid to stay STI-free. All participants received free treatment when testing STI positive. But only those who tested negative in the cash group received payments. Cash payments were not tied to HIV status. Those who tested positive first, but negative after four months, also received cash payments.

The cash, up to US$60 per person over 12 months, made a difference in many households. The country’s gross national income per capita was US$496.4 in 2008, and on average, the annual earnings of study participants were half of that amount.

“Using cash payments to reduce STIs by 25 percent over the course of 12 months is encouraging and means that we should further test this idea in other settings and maybe on a larger scale.,” says Damien de Walque, a Senior Economist in the World Bank’s Development Research Group, who carried out the study with researchers from the University of California in Berkeley and the Ifakara Health Institute in Tanzania.”Existing prevention strategies have had limited success so we have to look for creative new approaches to help people change their behavior and finally stop and then reverse the HIV/AIDS epidemic.”

World Bank and HIV/AIDS

The World Bank continues to recognize AIDS as a serious development challenge that has inflicted widespread human tragedy as well as robbed countries of their productive citizens and workers, causing serious economic loss. To date, the Bank has provided US$4.5 billion for HIV prevention, treatment, care and support programs in developing countries. Since 2006, 4.3 million people have received counseling and testing through Bank-supported projects focused on HIV prevention. During the past year alone, the Bank provided US$630 million in funding disbursements and new commitments for HIV and AIDS programs, helping poor countries fill critical gaps in AIDS prevention, treatment, and mitigation.

To make sure that HIV/AIDS programs are more effective and sustainable over the coming years, Global AIDS Director, David Wilson says that the World Bank must continue to integrate its HIV work with its broader mission to help developing countries strengthen their overall health systems to improve the state of people’s health.

“We have to move AIDS treatment away from a purely emergency response towards a sustainable long-term future by folding AIDS prevention, treatment and other health-related HIV services into stronger national health systems that make health and development dollars work reciprocally together for maximum effect,” Wilson says. “The Bank’s record lending for health in FY10—roughly $4 billion, up from $2.9 billion the previous year—reflects a strong demand from countries for Bank support.”

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