With these questions in mind, many people believe that
incentive programmes need to work with the real determinants of vulnerability
to HIV. This has led to the development of a number of programmes which aim to
encourage girls to remain in education.
Outside the HIV field, there have been several
well-documented programmes that have rewarded school attendance, often in Latin America. A large programme, which provides financial
incentives to poor Mexican families to send their children to school and to use
health services, has found that the programme increases school enrolment
(especially for girls) and has had a long-term impact on various indicators of
– height, cognition, vocabulary and behavioural problems.
The programme has also had a long-term impact on smoking and alcohol use, but
not on sexual behaviour.
More generally, economic research in low- and middle-income
countries has found that child support grants and pension payments reduce child
labour, increase schooling, and improve child health and nutrition.
Commenting on the epidemiology of HIV in South Africa, Dr Audrey Pettifor of the University of North Carolina at Chapel Hill noted firstly that HIV
rates in young women are double those in men of the same age.
“And what’s really striking is the rapid increase in
infection in a really short period of time,” she added. Whereas 4% of 15-year-old girls have HIV, by the time they reach their early twenties, a quarter to a
third are infected.
Moreover, there are striking differences in infection rates
according to educational status. For example, women who haven’t completed high
school have quadruple the risk of infection, compared to better educated peers. What's more, teenagers who are not in school are more likely to have ever had sex, had
sex at a young age, been pregnant, have an older partner or recently had
Why does attending school make a difference? Pettifor
suggested that schooling may have a beneficial effect on self-esteem,
self-efficacy and understanding of HIV risks. It may also influence the social
and sexual networks that an individual joins
– girls in school tend to have
sexual partners who are closer to their own age (and so less likely to have
But barriers to attending school include the costs of school
fees, uniforms, books and transport. Moreover, girls are often taken out of
school in order to earn money to support the family or to take care of younger
children. Can cash transfers that are conditional on attending classes help
keep girls in education?
A study in the Zomba district of Malawi
– an area where both HIV rates and school drop-out rates are high in adolescent
– offered financial incentives to households with unmarried schoolgirls
aged 13 to 22. Some of the payments were conditional on regular school attendance,
while others were unconditional (i.e. regardless of school attendance). The
payments included cash transferred to the parents, cash directly to the girl,
and direct payment of school fees.
Eighteen months after the programme began, the HIV
prevalence among those getting payments was 60% lower than in the control
group. Similarly, the prevalence of herpes (HSV-2) was 75% lower.
Importantly, no significant differences were detected
between those offered conditional and unconditional payments. This raises the
question of whether the programme worked not by incentivising particular
behaviours, but by reducing poverty.
“There’s ongoing debate about the role of conditionality as
part of these interventions,” commented Professor Charlotte Watts of the London
School of Hygiene and Tropical Medicine. “There’s good evidence that
conditionality is very important in influencing uptake of services, but I think
there’s less evidence at the moment about its impact on rates of partner change
or maintaining reduced risk behaviours.”
Girls receiving payments reported fewer sexual partners and
fewer sexual acts than other girls, but no more condom use. The researchers
believe that the main reason for the lower HIV infection rate was that girls
receiving payments had sex with partners closer to their own age and were less
likely to have exchanged sex for money. It may be that the additional income made
the girls less dependent on using sex as a way to get essential resources.
The intervention was provided for two years (2008 to 2009),
and the researchers will return to Zomba in 2012 to collect final data and see
whether the health benefit is sustained.
Other important evidence will come from two ongoing trials
which are providing cash transfers to rural South African teenagers as long as
they attend school.
Quarraisha Abdool Karim is leading a CAPRISA study
which has randomised 14 schools to either provide standard life-skills lessons
or to provide the lessons plus cash incentives (both to boys and girls). The
led by Audrey Pettifor, is randomising girls either to receive conditional cash
transfers or not. In both studies, the primary objective is to reduce the rate
of HIV infection. Results are likely to be reported in 2013 and 2015