Why conditional cash transfers matter for HIV
Dr Sophie Harman
Conditional cash transfers have been used as a key policy tool for development and poverty eradication strategies since the mid 1990s. Projects such as Oportunidades in Mexico and Bolsa Familia in Brazil have demonstrated that giving money directly to the poor is an effective means of breaking intergenerational poverty through better education and health. Cash transfers work by regularly giving small sums of money to female heads of households on condition of a specific social goal, such as primary school enrolment and attendance of children. Conditional cash transfers made their name in Latin America, but are also commonplace as tools of behaviour change in Europe and North America to combat a range of issues from obesity to homelessness. Now global policymakers are turning the attention of cash transfers to global health interventions, and one of the thorniest issues of behaviour change: HIV prevention.
The 2010 International AIDS Conference in Vienna was surrounded by buzz over the role of conditional cash transfers as a mechanism of preventing HIV transmission. Two World Bank-sponsored trials in Malawi and Tanzania had shown that cash payments to schoolgirls and youths on condition of school enrolment or non-HIV infection had been an effective tool in efforts to prevent HIV. The purpose of the Malawi trial was to ensure uptake and continuation of girls aged 13-22 in education. Those that regularly attended school would receive $15 a month. The results of the study showed that 95% of those receiving payments stayed in education, compared to 89% of the control group. However, the particularly interesting finding was that HIV transmission rate was at 1.2% compared to the 3% of the control group: a total lower prevalence of 60%. World Bank Senior Economists attributed the causal explanation for this as being a decline in transactional sex, as 90% of the control group had received an average of $6.50 in gifts of money from partners.
The Tanzanian trial cash transfer project differed from Malawi in that its specific focus and objective was the promotion of behaviour change through safe sex. In 2008, the $1.8million Encouraging Safe Sexual Practices among Youth using Rewards project was established to see if cash transfers could act as an effective means of reducing risky sexual behaviour. The project involved 2394 young adults in two districts of Southern Tanzania - Kilombero and Ulanga - with participants aged 18-30 living in HIV 'hotspots.' 3000 participants from 10 villages were monitored for STI transmission over a one year period, those who were STI free received small cash payments, those who tested positive for STIs would stop receiving payment. Crucially, for ethical reasons, the conditional cash transfers would not be tied to HIV status. The Tanzanian trial saw a 25% reduction in the number of participants who had previously engaged in unsafe sex.
The Tanzanian and Malawi trials show that conditional cash transfers matter for HIV prevention as the evidence suggests they work. This evidence is supported by positive affirmations as to the effectiveness of such transfers by global policymakers, the media and academics alike. Cash transfers matter as they provide the economic incentive to alter perceptions of risky behaviour. Moreover, they begin to address those socio-economic factors that can lead to a lack of value of one's life, low self-esteem, and poverty cycles of ill-health, lack of education and employment opportunities. In addressing these socio-economic factors and risk perception, cash transfers provide an alternative incentive to offset risky behaviour as a means of gaining financial reward. In sum conditional cash transfers provide an innovative form of evidence-based policy that attempt to address the key drivers of HIV transmission - transactional sex, perception of risk and socio-economic status. Conditional cash transfers present the future policy paradigm in which HIV will be governed. However, this paradigm will ultimately prove unsuccessful.
Conditional cash transfers matter because they do not provide sustainable, long-term solutions for the prevention of HIV transmission. The use of cash transfers raise normative questions over the utility of giving money to people to do what they should be doing, i.e. protecting themselves from HIV transmission. The purpose of conditional cash transfers is to provide a basic levelling up of all members of society to give individuals the freedom to choose and incentivise rational behaviour, however such levelling up is ultimately selective. Rewarding some with cash incentives can be seen as a disincentive for those who do not receive such cash. This leaves policy-makers reliant on cash transfers in a bind. Not only do they have to prioritise who to give money to, the longer a project is sustained, the longer individuals rely on the money. Once the incentive is there, it is hard to remove it. Whilst behaviour may be learnt, the risk associated with unprotected sex will only be in regard to the long term, with short term problems of nutrition, education and financial loss remaining.
Conditional cash transfers seek to address the drivers of intergenerational poverty, but they do not address the structural determinants of poverty and ill-health such as gender inequality, rather they imbed them. Despite being presented as having a form of emancipatory potential for women, the emphasis placed on women as carers and more likely to invest money in their children perpetuates gendered norms of women-as-carers or women-as-mothers. In this sense, conditional cash transfers perpetuate the notion that women are the solution to the problem of intergenerational and family poverty.
In incentivising unprotected sex only between non-HIV positive couples, conditional cash transfers have significant implications for individual choice, the family and forms of social engineering that restricts childbirth within specific socio-economic demographics. As such, the governance of HIV/AIDS has much to do with the regulation of the body and the construction of appropriate or particular behaviour, and the promotion of a right kind of knowledge. Cash incentives for the prevention of HIV transmission are about regulating the sex lives of others into appropriate, rational behaviour and inappropriate, irrational behaviour without fully engaging in what makes people have unprotected sex: reproduction, pleasure, esteem, fear, lack of choice.
As momentum builds in support of cash transfers, policymakers should be cognizant of these limitations and not see conditional cash transfers as the golden solution to the problem of long term HIV prevention. Institutions that govern HIV have tended to look for the latest, new mechanism of combating the virus, deploying it quickly, in isolation of more structural and personal drivers of the disease. If conditional cash transfers are going to be used to reduce HIV transmission, more careful consideration needs to be given as to how they are used, why and their implications for social demographics, global health governance, and long-term, sustained socio-economic development. Whilst they could be an additional tool into a broad spectrum of interventions, policymakers must continue to address the socio-economic fundamentals of what drives HIV transmission and not rely on short-term, vogue policy incentives which suggest much opportunity but little long-term reward.