A distinguished panel of global HIV experts gathered to discuss the ethics of providing material incentives for HIV prevention at a debate hosted by the World Bank and the U.S. Agency for International Development (USAID) on February 23. The debate, one in a series called “Emerging Issues in Today’s HIV Response,” featured different views on both the efficacy and the ethics of offering material incentives for preventing the spread of HIV to people most at risk of becoming infected.
Amie Batson, deputy assistant administrator for Global Health at USAID, moderated the debate and explained that in addition to biomedical interventions, HIV prevention techniques must offer solutions to structural barriers that inhibit people from protecting themselves from the disease – such as poverty, gender discrimination, stigma, and social norms.
Julia Kim, of the United Nations Development Program, explained that offering material incentives to deal with these barriers may be one way to deal with the HIV crisis. She added that because economic limitations prevent women from negotiating the terms of sex, putting money into the hands of women would give them greater control and allow them to protect themselves. She cited an HIV prevention study in Malawi in which school girls and their families were given cash if the girls stayed in school. There was a 60 percent reduction in HIV prevalence in the control group. Kim explained that because participants had some financial autonomy thanks to the monetary compensation they received, they were less likely to receive cash or gifts from older men who would have exposed them to HIV and other STIs, a practice increasingly common in some developing countries.
Also in support, Mead Over of the Center for Global Development went on to say that categorically opposing providing material incentives for HIV prevention would result in more infections. He explained that currently there are perverse incentives for engaging in risky sexual behavior and introducing countervailing incentives can only be beneficial. However, the programs which offer incentives should be designed well and donors must be credible and able and willing to keep their promises, like the President’s Emergency Plan for AIDS Relief.
Peter Lamptey, president of public health programs at FHI, explained that although studies in other parts of the world, such as South America, have shown considerable evidence that incentives can be efficacious, they are not feasible in Africa. He cited one study in Africa that provided vouchers to participants who maintained their HIV-negative status for at least one year. Although most participants did maintain their negative status for one year, the male participants were 8.5 percent more likely to engage in risky sexual behavior after the study was over. Lamptey explained that incentives offered could be used to finance risky practices; for example, men might use monetary incentives to purchase sex or injection drug users may use the money to purchase more drugs.
Daniel Wickler, with the Harvard School of Public Health, when explaining that providing material incentives could have unintended consequences, also cited the African study referenced by Lamptey. He explained that because the male participants received cash as a reward for maintaining their negative status, members of the community knew for sure they were not infected with HIV, which gave the men the freedom to engage in risky behavior as their partners knew they would not become infected.
Wickler was also concerned about the effects such programs could have on participants who fail to comply with the study terms and subsequently don’t receive incentives. He suggested that the negative effects on them could outweigh the positive effects of the program. Participants may not be able to comply due to factors outside their control, such as weak healthcare systems, or lack of understanding.
Lamptey went on to make the point that incentive programs are not sustainable – that it’s hard to stop a program once it has started and the longer a program is sustained, the more money it will cost. He went on to say that public health principles dictate that we must work to empower individuals and that we shouldn’t create an environment of dependency on governments and donor organizations.
Although both sides had divergent opinions on the ethics of providing material incentives to prevent HIV infection, everyone agreed that scaling up prevention programs is key to fighting the epidemic. Prevention programs that offer material incentives to participants must be designed to allow for sustainability and must ensure that the costs of preventing disease are lower than the costs of treating an individual already infected.