Image from the CAPRISA 007 study in a school in rural KwaZulu-Natal. Image supplied by CAPRISA (www.caprisa.org)
The conditions attached to a cash transfer, and the way in
which it is supported by other school-based interventions, may affect the
efficacy of the intervention. Some studies of economic incentives have made
receipt of the cash incentive conditional on remaining free of sexually
transmitted infections, rather than making a straightforward cash transfer.
A second school-based study from South Africa presented at
IAS 2015 reported on the efficacy of a school-based educational intervention
and cash incentives for achieving behavioural and educational outcomes. The
CAPRISA 007 study recruited both young women and young men in Years Nine and
Ten in 14 schools in the Vulindlela district of KwaZulu-Natal province. Schools
were matched in pairs and randomised to receive either an educational
intervention (My Life! My Future!) alone, or to receive the educational
intervention and to receive cash incentives of up to R1750 over two years for
fulfilling any combination of four conditions; annual HIV testing, pass performance
in 6-monthly school tests, 80% quarterly participation in the My Life! My
Future! life skills and HIV educational
programme, and a written report on their community involvement project.
The study randomised 1447 young people to the intervention
arm and 1502 to the control arm, of whom 116 in the intervention arm and 116
in the control arm were lost to follow-up due to school drop-out, relocation or
were otherwise untraceable. Participants were followed for 24 months and
underwent baseline and annual tests for HIV and HSV-2.
Cash incentives had a greater impact on HIV testing and
participation in the life skills course, but little impact on school
The study was unable to detect any difference between arms in
HIV incidence owing to lower-than-expected HIV incidence (1.6 infections per
100 person years of follow-up). Dr Qurraisha Abdool Karim of CAPRISA said that
at this level of HIV incidence, the study would have needed to be three to five
times larger to detect any effect of the study intervention on HIV incidence.
It’s unclear why incidence was so low, although Dr Karim speculated that a
combination of treatment availability in the district, a microbicides trial and
medical male circumcision may all have contributed to lowering incidence.
HSV-2 incidence was reduced by approximately 30% in the
intervention arm (RR 0.70, 95% confidence interval 0.57-0.86, p = 0.007). The
incidence reduction was more pronounced in boys (40%) than in girls (24%) and
those who received more than R950 in incentives during the study showed a 71%
lower incidence of HSV-2 compared to the control group. Dr Karim cautioned
against reading too much into this apparent dose response (the median incentive
received during the study was R600).
Dr Karim noted that apart from the issue of sample size,
interventions to explore the impact of education need to take into account
other factors such as the quality of education and the amount of investment in
school facilities and text books when trying to enhance the protective effect
“All these data are arguments for expanding national social
protection and safety nets,” concluded David Wilson of the World Bank’s HIV
programme, “but we need to look more carefully at the targeting of cash
Audrey Pettifor suggested that intervention designers need
to think about what they are trying to achieve with a cash transfer when they
attach conditions to the transfer. Whereas offering conditional cash for HIV
testing may be effective because it is conditional on performing a single
time-limited action, conditionality may be less successful in achieving
consistent change over time.