Financial Incentives & HIV prevention in
Sub-Saharan Africa:
Evidence from Three Experimental
Interventions
Berk Özler & Damien de Walque
Development Research Group (DECRG)
The World Bank
November 10, 2009
PREMISE
 AIDS Treatment: Important, but not the solution to
slow the HIV/AIDS epidemic. Estimation that $1 in
prevention averted $43 in treatment in Thailand (Over
et al. 2007)
 Vaccine technology: Probably still many years in future.
 Existing prevention efforts: Low effectiveness in most
African settings.
 Novel approaches needed! Conditional cash transfers
(CCT) have been promising in other domains … could
they be adapted to help slow the AIDS epidemic?
The SIEF Cluster tests 3 different ways to
apply the CCT concept for HIV prevention
3
 The program in Malawi is a traditional CCT program
for schooling, but evaluates the impact of the
program on the sexual behavior and HIV risk of its
young female beneficiaries.
 In Tanzania, the intervention offers cash transfers
conditional on periodic negative tests for curable
STIs.
 In Lesotho, lottery tickets are offered conditional on
periodic negative tests for curable STIs.
Common features
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 Application of the CCT concept
 Rigorous impact evaluations with baseline and
follow-ups and random allocation of the intervention
 All three evaluations are collecting biomarker data
on HIV and other STIs in addition to self-reported
data on sexual behavior.
 The 3 evaluations are at different stages. One year
impacts will be presented for Malawi, while we will
present the evaluation design for Tanzania and
Lesotho.
Rewarding STI Prevention and Control in
Tanzania (RESPECT Project)
Implementing institutions
Ifakara Health Institute
World Bank Development Economics Research Group
UC-Berkeley
Funding from the World Bank (Research Committee and
Spanish Strategic Impact Evaluation Fund) and Hewlett
Foundation/Population Research Bureau.
OVERVIEW
 What: “Proof of concept” evaluation of randomized
CCT to incentivize reduction in risky sex.
 Why: Goal is to decrease HIV incidence, with potential
subsequent long-run health and economic benefits.
 How: Condition cash incentives on periodic negative
STI tests for young adults aged 18-30.
 Where: Ifakara Demographic Surveillance Site in rural
Tanzania.
CCTs to Reduce Risky Sexual Behavior?
 Conditionality: Increase “price” of risky sex, if
positive STI test causes loss of CCT.
 Time discounting: Bring rewards of risk reduction
closer to present, rather than just avoiding AIDS
many years in future.
 Income effects: Potential direct impact on sexual
behavior, could facilitate behavioral change,
especially for women.
SPECIFIC OBJECTIVES
 Evaluate the impact of the combined CCT/counseling
intervention during the intervention period
(immediate and short-term effects) on STI incidence
overall and by specific subgroups
 Evaluate the economic outcomes of the reward.
 Examine the long-term effects of the intervention –
and its withdrawal – with final round of STI testing
and surveying in the same population 12-months
after the intervention has ended
 Compare the impact of the CCT intervention in the
high-value cash transfer arm to that in the low-value
cash transfer arm
CONDITIONAL CASH TRANSFER
Conditionality: Treatment group
 Testing negative for a set of curable STIs
(Chlamydia, gonorrhea, trichomonas, mycoplasma
genitalium, syphilis).
 Although we are testing for them, we do not
condition on HIV and HSV-2 because they are not
curable.
 Amount:
 USD 20 every four months (high-value)
 USD 10 every four months (low-value)
 We provide free STI treatment if positive, and we allow
returning under CCT once they are negative again

TANZANIA: STUDY DESIGN
The study is a Randomised control trial
Sample drawn from 10 villages, randomization at the individual level.
Participants
3000
Control
group
N= 1,500
Intervention group
(Conditional cash)
N=1,500
High-value
N=750
Low-value
N=750
Counseling and life-skills training, free STI
treatment
The impact of short-term financial incentives
on sexual behavior and HIV incidence among
youth in11Lesotho
 Partnership between the World Bank and PSI
Lesotho
 Same idea as in Tanzania, but instead of getting a
cash transfer for sure if they test negative for a set of
curable STIs, study participants will get a lottery
ticket for a larger prize (500 rands/65 $ or 1000
rands/130$)
 Lottery system might be easier and cheaper to scaleup
 Lottery should be especially attractive to risk takers.
LESOTHO: STUDY DESIGN
The study is a Randomised control trial
Sample drawn from villages where PSI is conducting mobile VCT clinics,
randomization at the individual level
Participants
5000
Control
group
N= 2,000
Intervention group
(Lottery tickets)
N=3,000
High-value lottery
N=1,500
Low-value lottery
N=1,500
Pre and post test counseling, free STI
treatment