Treatment News

Compiled by Gus Cairns

Paying for prevention: World Bank rewards women who remain STD-free

In an innovative and controversial HIV pilot prevention programme, the World Bank and three other sponsors will pay 3,000 Tanzanian women aged 15-30 45 US dollars every time they attend for a scheduled sexual health checkup over a three-year period – as long as they remain free of sexually transmitted infections.

The STI and HIV incidence results in the 3000 women will be compared with 3000 comparable women who have the same checkups but are not given the cash.

The payments are equivalent to a quarter of the annual income of some participants.

The theory behind the so-called ‘conditional cash transfer’ study is that the promise of financial reward will give women more bargaining power in the bedroom: “Use a condom, we need the money”.

One of the researchers, Carol Medlin, commented: “We hope this ‘reverse prostitution’ will make people think hard about the long-term consequences of their short term behaviour.”

Financial rewards are not new in public health. They have been used in Latin America to persuade poor parents to send their children to school and have them vaccinated, and in New York to encourage drug addicts to stay clean. But no programme has offered such a relatively large financial gain to participants who stay healthy.

The programme will include women with HIV, and an HIV test is not a condition of entry; the primary STI tested for will be gonorrhoea, which is seen as the most reliable ‘marker disease’ for unprotected sex.

The Financial Times, in an editorial, supported the Tanzanian study enthusiastically, saying “It is not often that the phrase ‘new and daring’ is paired with the words ‘healthcare intervention’, but this goes beyond eye-catching.”

However it questioned what would happen if the programme was successful. “The pilot would need to be scaled up to the tune of many millions of dollars a year in Tanzania alone. How would health systems cope?”

HIV advocates greeted the idea with mixed feelings. Jo Robinson of the Terrence Higgins Trust commented that the programme might work for sex workers and in casual sex, but would it work for long term partners where ‘love, trust and intimacy’ were stronger disincentives to use condoms than the fear of STIs?

Anna Forbes of the Global Campaign for Microbicides asked what would happen when the study stopped. “I think we are kidding ourselves if we assume that people who use condoms because they are paid to do so will necessarily be able to continue condom use once the programme stops,” she commented.

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