Adventures of a Retired Armchair Traveler - HIV and conditional cash transfer schemes

sometimes i visit these: Congogirl on Twitter / Bloglines Congogirl link / Congogirl's Links List on My Del.icio.us / Where IS DR Congo, anyway?? / Congo Daily / good summary article on DR Congo / Samantha Power's article, "Bystanders to Genocide" / Dizolele - Eye on Africa / Congo Blog - Ba Leki / Cedric Kalonji's photo blog / Extra Extra / Nayembi / Thirteen Wildlife Blogs from DR Congo / Babycatcher / Global Voices / Helene in RD Congo / ID Land - adventures in international development / John's Blog / Kim Gjerstad in Congo / On Safari with el Jorgito / The Salon of News and Thought / This is Zimbabwe / Bluehaired Mary / African Path / Global Bioethics Blog / Somewhere in Africa / Africa is a Country

December 2009


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	Thu, May. 15th, 2008 03:10 pm

HIV and conditional cash transfer schemes

The other day I read about this scheme in Tanzania, which would essentially give people money for not contracting STIs over a period of time. There is are some thoughts on this with links to a number of articles on the Global Bioethics Blog here.

The concept of conditional cash transfers is new to me, although not to many. Here's a link to a number of papers produced following CCT projects. CCT has been used in a number of contexts, some as a replacement for food supplements or vouchers, and some as a reward for positive health or education based behaviors, i.e. encouragement to mothers to ensure that their children go to school and stay in school.

I think the main objection that resonates with me regarding the Tanzania project, backed by the World Bank, is the idea that this "reverse prostitution" is the only way to reduce transmission of HIV, i.e. that we have to pay Africans to not get HIV because nothing else has worked. What a derogatory thought.

As well, I have heard that emphasis on reduction of partners and faithfulness has actually been very effective, though I don't have a reference at the tips of my fingers. This success could be related to the fact that some studies have shown that the tendency of Africans to have more than one concurrent partner increases the likelihood of transmission to more people because the virus is potent when first transmitted, and multiple concurrent partners means multiple people exposed during this potent period.

Text of Financial Times article:

World Bank backs anti-Aids experiment

By Andrew Jack in London

Published: April 25 2008 22:25 | Last updated: April 25 2008 22:25

Thousands of people in Africa will be paid to avoid unsafe sex, under a groundbreaking World Bank-backed experiment aimed at halting the spread of Aids.

The $1.8m trial – to be launched this year – will counsel 3,000 men and women aged 15-30 in southern rural Tanzania over three years, paying them on condition that periodic laboratory test results prove they have not contracted sexually transmitted infections.

The proposed payments of $45 equate to a quarter of annual income for some participants.

The programme, jointly funded by the World Bank, the William and Flora Hewlett Foundation, the Population Reference Bureau and the Spanish Impact Evaluation Fund, marks an important step in the fight to tackle Aids, which claims 2m lives a year.

In spite of billions of dollars spent annually on treatment and prevention worldwide, there were about 2.5m new HIV infections in 2007, predominantly in Africa.

Carol Medlin from the University of California, San Francisco, one of the researchers, said: “We hope this ‘reverse prostitution’ will make people think hard about the long-term consequences of their short-term behaviour.”

The Tanzanian experiment is a big advance in efforts to test public health ideas more rigorously, with some participants placed in a control arm not offered payment in order to track the effects of the programme precisely.

“Conditional cash transfers” have already been used in Latin America to motivate poor parents to attend health clinics, and have their children vaccinated and schooled. Michael Bloomberg, the mayor of New York, last year unveiled a project to boost school attendance.

The designers of the Tanzanian programme believe that payments of $45 when combined with careful counselling could play an important role in reducing HIV infection, especially for vulnerable young women.

The study will be conducted by the Ifakara Health Research and Development Centre in Tanzania, in conjunction with researchers from the University of California, Berkeley, the University of California, San Francisco and the World Bank.

The Tanzanian trial programme, which is still subject to fine-tuning and ethical approval, will not specifically test for HIV, which is costly and already widely conducted in the country. It will use proxies including gonorrhoea, and guarantees any participant found to be infected receives state treatment.

ETA: Oh right, I meant to post this to

hivnews. I'll leave it here but sorry, you'll see it there too if you're a member.

Tags: africa, hiv, news, public health

delerium69

Bethie of Doom

	Thu, May. 15th, 2008 08:25 pm (UTC)

*scratches head thoughtfully*

Yeah, I really don't know how I feel about this concept. I can see the pros and cons (the big con in my head being its racist and classist). It reminds me of folks here who want to pay poor women who already have several children to become sterilized. It can understand some of the reasoning, but it creates a warning knot in my gut.

congogirl

	Thu, May. 15th, 2008 08:29 pm (UTC)

Re: *scratches head thoughtfully*

I know that people are not being coerced into doing something they might not want to, other than practicing safer sex and visiting the doctor. But still... I think incentivizing any type of behavior with money is just anathema to good behavior change techniques. What happens when the money runs out?

I can see subsidizing health care, but it seems strange that it would happen on an individual level rather than a systemic one.

delerium69

Bethie of Doom

	Thu, May. 15th, 2008 08:44 pm (UTC)

Re: *scratches head thoughtfully*

Yes, it's the notion of placing funds into programs that highlight the "unwanted" behaviour of people living at or near poverty levels who must also deal with their culture's views on sexuality that really makes me uncomfortable. Are they taking into account these various factors?

congogirl

	Fri, May. 16th, 2008 02:37 pm (UTC)

Re: *scratches head thoughtfully*

I wish I knew more, I guess I have to look at their methodology more closely.

apropos

((O))

	Thu, May. 15th, 2008 08:27 pm (UTC)

I mean, the thing that both bothers and intrigues me is how this scheme PRODUCES the rational self-maximizing subject that so much prevention takes for granted.

The thing that bothers me more is that when incidence is a factor of economic inequality, introducing MORE economic inequality between positive and negative individuals seems.... really bad for positive people.

congogirl

	Fri, May. 16th, 2008 02:27 pm (UTC)

Totally agreed.

I think monetizing NOT contracting an infection is ... I don't know, coercive in a really bizarre manner.

apropos

((O))

	Fri, May. 16th, 2008 07:52 pm (UTC)

And since this money is likely to get distributed to family members, it punishes the families/partners of positive people as well, whether they're positive or negative.

Ugh. The more I think about it the less I like it.

sammka

one of those feathery maniacs

	Thu, May. 15th, 2008 10:57 pm (UTC)

1) It seems to be completely unrelated to people's actual behavior, and therefore is sexist in that it completely disregards that there are rape survivors with HIV.
2) It doesn't seem to be tied to education, which further undermines any claim that it's actually influencing behavior.
3) DON'T PEOPLE ALREADY HAVE ENOUGH OF AN INCENTIVE NOT TO GET HIV???? I mean people have complained that in the US people who get really good treatment are living really long lives with HIV and so some people are getting sort of blase about catching it. But I got the impression that Tansania doesn't have this problem so much.

I just sort of dislike the assumption that people are getting HIV because they're not trying hard enough or something, or are just too sex-crazed, and they need to be paid not to have sex.

congogirl

	Fri, May. 16th, 2008 02:26 pm (UTC)

or are just too sex-crazed, and they need to be paid not to have sex.

EXACTLY. This is the assumption that I have problems with. Those crazy Africans, out having unprotected sex all the time! I don't trust that the World Bank has public health advisors working with them - they may, but come on, public health is not their forte, we all know that.

Your other points are spot on - I should probably find out some more about the methodology of the intervention but seems like there are some missing pieces, and they forgot to talk to their SGBV expert...

readkellyuganda
readkellyuganda

	Fri, May. 16th, 2008 08:59 am (UTC)

Uganda Scarlett Lion's thoughts on this

http://ugandascarlettlion.blogspot.com/2008/05/paying-for-safer-sex.html