Can Money Prevent the Spread of HIV? A Review of Cash Payments for HIV Prevention

"Cash payments to improve health outcomes have been used for many years; however, their use for HIV prevention is new and the impact not yet well understood."

This research provides a brief background on the rationale behind using cash to improve health outcomes, reviews current studies completed or underway using cash for prevention of sexual transmission of HIV, and outlines some key considerations on the use of cash payments to prevent HIV infections. [Footnotes are removed throughout by the editor.]

From the abstract: "We searched the literature for studies that implemented cash transfer programs and measured HIV or HIV-related outcomes. We identified 16 studies meeting our criteria; 10 are completed. The majority of studies have been conducted with adolescents in developing countries and payments are focused on addressing structural risk factors such as poverty."

The article provides a historical overview of the use of cash to improve health outcomes in development, social protections, and psychology (e.g., contingency management, CM - from Wikipedia: "Contingency management or Systematic use of Reinforcement is a type of treatment used in the mental health or substance abuse fields. Patients' behaviors are rewarded (or, less often, punished)."), and focuses on the potential impact on HIV prevention. It divides the programmes studied into two categories with regard to their mechanism of action:

"The majority of studies aim to address upstream, structural barriers that increase HIV risk such as education or poverty. These studies hypothesize that improving the socio-economic situation of vulnerable populations or providing cash payments conditioned on social goods, such as school attendance, will reduce HIV risk (category 1 interventions). Other studies hypothesize that providing cash for specific outcomes like a negative STI [sexually transmitted infection] test will serve as an incentive for individuals not to engage in high risk behavior (category 2 interventions). However, it is unclear whether interventions premised on rewarding specific HIV-related outcomes actually address factors that place individuals at risk."

"Nine studies provide cash on a conditional basis, six provide cash on an unconditional basis, and one examines the effect of both. The purpose of the transfer varies by study (and conditionality or not), but include: school attendance, school completion, poverty alleviation, and completion of health promotion activities, such as STI/ HIV testing.... Studies measure a variety of outcomes, including sexual behaviors and intentions (12/16), STI status (2/16), and HIV status (5/16). Overall, the majority of studies that have measured a change in sexual behaviors found a positive impact (9/10); however, one pilot study found a negative impact in men (Malawi Incentives Project): immediately after receiving their cash incentive, men reported more sex acts (although they also reported more condom use)."

Results show that in most studies, programmes have seen reductions in sexual behaviour, and one large trial has documented a difference in HIV prevalence between young women getting cash transfers and those not. However, the results do not identify amounts of cash that are effective and vary in who gets the cash; thus, the researchers suggest that the complexity of evidence points to the importance of formative and ethnographic research and pilot studies in potential study populations to understand pathways that lead to risk and how cash transfers or incentives might best be structured to reduce risk. "While providing cash to individuals is hypothesized to reduce risk, concerns have been raised that individuals receiving the cash could be placed at risk for negative outcomes, such as violence, bullying, coercion, or using the cash for high-risk activities. Similar concerns were raised when government social welfare programs provided payments to female instead of male heads of households." Though gender-based violence is a concern, as stated here, "evidence shows that payments made to female heads of households have not resulted in increased intimate partner violence...", nor is there evidence of other social harm.

The article concludes: "Cash transfer programs focused on changing risky sexual behaviors to reduce HIV risk suggest promise. The context in which programs are situated, the purpose of the cash transfer, and the population will all affect the impact of such programs... Ongoing research from randomized controlled studies will provide information on whether cash payment programs are a cost-effective strategy for preventing new HIV infections and what role they may play in the larger prevention agenda."