75718 DIME BRIEF The Effects of Conditional Cash Transfers on the Prevention of STIs in Tanzania The Development Impact Evaluation Initiative is a Policy context broad-based World Bank Using behavior change to tackle HIV/AIDS in the developing world is not easy. program to generate For years, the global community has zeroed in on behavior change as a key to knowledge on the fighting the global HIV epidemic. But so far, the approach has brought only effectiveness of limited success in reducing HIV infections in developing countries. government programs. It supports government The frustrations are especially evident in sub-Saharan Africa, which has two- agencies adopt a culture thirds of the world’s HIV infections. Women and girls, in particular, are at of real time evidence- greater risk, partly because of the biological, social and economic challenges based policy-making on they face. Thus, finding solutions is vital. the basis of rigorous impact evaluation. By A large randomized trial involving cash incentives is showing promise in testing how to make reducing sexually-transmitted infections (STI) in Tanzania. The trial is policies work, it modeled on “conditional cash transfer” programs, which use cash payments contributes to improving policy performance. to encourage good behaviors, such as attending schools or getting basic health care. DIME works with 300 agencies in 72 countries Impact evaluation across 15 thematic The Tanzania study was designed to directly expand conditional transfers to programs to generate encourage the prevention of STIs, and it differs from traditional transfer knowledge, improve quality of operations and programs in two aspects. First, the participants weren’t youth, but adults. strengthen country Second, by conditioning quarterly cash payments to negative tests for curable capacity for evidence- STIs, it didn’t pay participants to do something, but paid them not to do based policy- making. something: engaging in unsafe sex, This impact evaluation is This $1.8 million study in southwest Tanzania was designed to give cash funded by the Spanish payments to adults (men and women between 18 and 30 year old) in 10 Trust Fund for Impact villages to prevent STIs such as chlamydia, gonorrhea, trichomonas, Evaluation cluster on mycoplasma genitalium. The trial only gave payments to those who tested HIV/AIDS, the Population negative for STIs. The cash, up to US$60 per person over 12 months, made a Reference Bureau, and difference in many households as annual earnings of study participants was the William and Flora Hewlett Foundation. around $250. Impact evaluation results The intervention worked. A year into the program, 9% of the 2,399 young enrollees eligible for the $60 award tested positive for the infections, compared with 12% for the control group, which didn’t receive payments. This is equivalent to a 25 percent reduction in prevalence, an encouraging result. The amount of the cash transfer mattered. Half of the cash group was eligible for $30 a year and the other half $60. The study found that the $30 group still DIME Brief on Tanzania CCT STI Prevention 1 Counselors discuss The role of Impact safe sex practices Evaluation in combating the with study HIV/AIDS Epidemic participants What interventions substantially reduce risky sexual behavior? The global AIDS epidemic is fueled by risky sexual behavior. Over 80 percent of HIV infections occur through sexual contact with an infected partner and could have been avoided through the adoption of safe sexual behavior such as condom use, reduction in concurrent partnerships, had the same infection rate as the control group that received no abstinence and type of sexual interaction. Prevention programs payments. appear to have been fairly successful in increasing awareness Not surprisingly, the program is more effective for people from and knowledge but evidence on poorer and rural areas. the link to changes in sexual behavior is weak. The question of Policy recommendations whether HIV prevention is effective and whether the right strategies The impact evaluation in Tanzania provides evidence for using are being implemented is on conditional cash transfers as an effective tool for HIV-prevention. The everyone’s mind. Are the encouraging results from the trial show promising outcomes in economic and behavioral factors that drive risky sexual behavior reducing HIV and STI prevalence rates. being addressed? This is the focus of impact evaluation in HIV Such programs should be applied on a larger scale and in various prevention. settings. However, further study and testing is needed to assess their What interventions are successful effectiveness of such programs for different scales and contexts. What in ensuring patients’ high level of works in rural Africa may not work in other regions. Testing different adherence to ART? On the variations of these programs will help fine-tune the delivery treatment side, the emphasis has mechanism of such programs. been on making Antiretroviral Therapy (ART) available and increasing the number of HIV Conditional cash transfer programs could complement current infected individuals on treatment. programs on behavior change. These programs can be introduced at a However, ART is only beneficial low marginal cost. when patients have very high levels of adherence to the treatment. Without high These innovative studies, if proven to be equally effective on a larger adherence patients could be scale, could help make a dent in reversing the HIV epidemic. harmed by the medication and millions of dollars wasted. Learning how to secure high adherence to Source: de Walque, D., Dow, W., Nathan, R., “Evaluating Conditional Cash treatment is an enduring Transfers for HIV/STI Prevention in Tanzania” (unpublished report) challenge that requires testing and rigorously evaluating multiple competing strategies. This is critical to save lives, increase productivity and ensure the effectiveness of large public expenditures in ART. www.worldbank.org/dime For more information email ddewalque@worldbank.org DIME Brief on Tanzania CCT STI Prevention 2