Conditional cash transfers to affect sexual behaviour are increasingly popular in HIV prevention research and rhetoric. This consists in paying mostly young people money if they do not get a sexually transmitted infection (STI), which is a marker for unprotected sex and, therefore, HIV risk.
The intriguingly titled RESPECT study (Rewarding Sexually Transmitted Infection Prevention and Control in Tanzania) has been described in a World Bank working paper as creating significant reduction in STIs in one of the intervention groups.
Participants received US$20 every four months if they tested negative for STIs.
The effects were stronger among lower socioeconomic and “higher risk” groups, that is, those who had an STI at the start of the research. The cash transfer had an equal protective effect for males and females at the end of the study. However, a survey of participants one year later showed a sustained effect among males only.
Some interesting aspects of the findings:
– The researchers wondered if the cash transfers for females worked in the short term not because they changed something intrinsic to the person, but because they protected against transactional sex on an immediate day to day basis
– Self reported changes in sexual behaviour were not consistent with STI prevalence, suggesting self report is unreliable in measuring change
– STI treatment-seeking behaviours did not change, suggesting that money influences some aspects of behaviour but not others.
Complex dynamics at play
All of this starts to paint a complex and interesting picture. The researchers suggest a number of overlapping factors could be at play.
“Price effects” essentially influence a participant to weigh the “price” of risky sex as they could lose cash if they tested STI positive.
But this can itself be affected by the fact that getting an STI from unprotected sex is not automatic; a lot depends on the risk profile of one’s sexual partners. As a result, this “price” calculation is an ongoing balancing act, with unpredictable outcomes.
“Income effects”, a weighing up of benefit as opposed to cost, might account for some females seeing the cash transfers as offsetting monies and goods they might get from transactional sex.
But, since more money could also make males more likely to have sex (money as sexual pulling power), this “income effect” is not inevitable.
The researchers wondered if some participants could make the necessary calculations to weigh up risks and benefits. In some cases, participants overestimated HIV prevalence and possible financial loss, and so their behavioural adjustments were not always congruent with risk.
It seemed that participants were also more likely to consider short term (losing the money) rather than long term (being HIV positive) costs, suggesting perhaps that cash transfers work for some people because they are “present-focused”.
Paying for sex, paying not to have sex
On the other hand, if behaviour change is to be sustained, how do we help people think more long term?
A meta-analysis found that conditional cash transfers suggest promise but context, purpose and population were key to effectiveness. Most of the studies were with young people. This fact, along with the ideas above, raises many interesting questions.
In focusing on sexual risk, STIs and HIV, are we unconsciously reinforcing a bleak and pessimistic view of young people, only seeing them as “risk units”, needing extrinsic reinforcement to be safe, as opposed to helping them develop internally generated – and consistent – agency, which is supported by the context they live in and is “wired” into them for life?
Is it respectful to young people to challenge transactional sex by saying “paying for sex is wrong but we will pay you not to have sex”?
Are we not cynically re-commodifying sex, and what are the unintended consequences of this?
Where is there space in this conversation for ideas around desire, pleasure, intimacy and love? Is this not an excessively instrumental view of human behaviour, devoid of meaning, connection and community?
Or can it be argued that these are irrelevant, or less urgent, in the middle of an epidemic?
I worry that we are “atomising” young people; losing the opportunity, firstly, to ask more interesting and complex questions about networks of positive social and sexual capital; and secondly, to find ways to make sexual and reproductive health a natural and pro-social part of who we are, not just a conditioned response to an external stimulus.
Pierre Brouard, director of the Centre for the Study of AIDS at the University of Pretoria, South Africa, is a clinical psychologist interested in sexualities, gender, human rights, and finding just the right word to grace a sentence, convey empathy or complete a crossword.
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