Preventing HIV By Paying People to Maintain Safe Sex Practices

Finding an HIV prevention strategy that works is one of the Holy Grail's of public health policy. Indeed, poor evidence of the epidemic quelling effects of most prevention programs (outside of biomedical interventions such as circumcision) have driven many to accept that treatment may actually be the best preventive device we have.

That may be true, but I do not think that all modes of prevention have been exhausted. One margin where there is some growing evidence is in providing cash transfers for people who maintain a given set of behaviors over a period of time. For example, one could pay people for every month they do not test positive for HIV. Such methods have been tried in the substance abuse world, apparently to good effect. Could it work with HIV/AIDS?

In a great new NBER working paper, Damien de Walque, William H. Dow, Carol Medlin, and Rose Nathan argue that the answer is a resounding yes (ungated version here). From the abstract:

[W]e discuss the use of sexual-behavior incentives in the Tanzanian RESPECT trial. There, participants who tested negative for sexually transmitted infections are eligible for outcome-based cash rewards. The trial was well-received in the communities, with high enrollment rates and over 90% of participants viewing the incentives favorably. After one year, 57% of enrollees in the “low-value” reward arm stated that the cash rewards “very much” motivated sexual behavioral change, rising to 79% in the “high-value” reward arm. Despite its controversial nature, we argue for further testing of such incentive-based approaches to encouraging reductions in risky sexual behavior.

The abstract undersells some of the evidence they cite in the paper, so I would go ahead and read the entire thing. While people may somehow find it reprehensible to pay people to do the right thing, there is already a great precedent in education and yearly doctor visits (i.e., conditional cash transfers for those things are all the rage in the Americas) as well as (as mentioned above) with getting people to stop using illicit/recreational drugs.