Evolving Strategies, Opportunistic Implementation: HIV Risk Reduction in Tanzania in the Context of an Incentive-Based HIV Prevention Intervention

"Behavior change communication (BCC) interventions, while still a necessary component of HIV prevention, have not on their own been shown to be sufficient to stem the tide of the epidemic....Arguments are being made for combination prevention packages that include behavior change, biomedical, and structural interventions to address the complex set of risk factors that may lead to HIV infection."

Because, in part, the shortcomings of BCC may involve structural or economic constraints and because there is evidence that incentive-based interventions can stimulate demand for HIV testing and medical male circumcision (MCC) and HIV treatment, the authors sought to test the hypothesis that "an economic incentive to avoid unsafe sex, along with regular testing for sexually transmitted infections (STIs), may work in combination with traditional behavior change messages to overcome some of the barriers inherent in sexual behavior change, especially for women." In particular, this study explores how different components of the RESPECT intervention in Tanzania may have created new leverage in sexual negotiations, as well as increased opportunities for exercising that leverage.

"Using qualitative data from a trial of economic incentives for testing STI negative, in this paper we explore how a cash incentive, in combination with regular STI testing, influenced strategies for risk reduction. This is important to understanding behavioral mechanisms through which the RESPECT trial led to reduced STIs. The cash awards are a type of structural intervention, which we hypothesized could lead to behavioral change by both men and women, but it was a priori unclear what type of behavioral change strategies would be adopted and how. In addition, the study's provision of regular STI testing (in an environment in which STI testing was generally not available on demand) allowed analysis of the mechanisms through which STI testing could operate." In 2009/2010, the authors "conducted 216 in-depth interviews with a subset of study participants enrolled in the RESPECT study - an HIV prevention trial in Tanzania that used cash awards to incentivize safer sexual behaviors."

Interviews were conducted with 111 individuals in Kiswahili from an interview guide. The guide was revised for each follow-up visit (months 4, 8, and 12) and included questions about respondent's experiences being enrolled in the study over the previous four months, what strategies they tried, and why or why not these strategies were successful.

The study revealed that women, who may in typical circumstances lack sexual decision-making ability, can and often do take advantage of situations that present added leverage with which to negotiate. In this case, the cash award combined with testing added leverage. "In fact, the repeated testing became part of the strategy in some cases as the combination of targeted condom use, testing and treatment was sometimes implemented as a three-pronged approach to decreasing risk of infection. Having a back-up for condom use is important in a society where condom use carries with it such strong meaning about the type of relationship....The data presented here suggest that abstinence is a favored strategy over condom use in certain situations - among young single people, among women who have just had children, and among women who can argue that they have been put at risk by their husbands. Married women seem to be more likely to be able to abstain from sex with their husbands in order to at least temporarily reduce their risk of infection than they are to insist on condom use."

The study demonstrates that this kind of intervention can bring about behaviour change, even if temporary, and suggests further study at what stymies women who would choose to change behaviours surrounding sexual relations.