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South Africa: Cash Rewards Could Encourage HIV Testing

Tamar Kahn

1 August 2008

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Johannesburg — High-profile public education campaigns about HIV seem to be having a limited effect in SA.

SA is awash with information about the dangers of HIV, yet only a small proportion of the population has ever taken a test to find out whether they are infected, increasing the chance they will unwittingly spread the virus.

Less than a third of South Africans have taken an HIV test, according to the Human Sciences Research Council.

Since high-profile public education campaigns have clearly had limited effect, a Cape Town-based nonprofit organisation - Men on the Side of the Road - has taken the radical step of offering cash rewards to unemployed day labourers who volunteer to take an HIV test.

Men on the Side of the Road has for the past decade helped thousands of unemployed men aged between 15 and 55 find semiskilled jobs in fields such as construction and gardening.

Like many men, they are often reluctant to seek help for health problems, be it a bothersome cough or an aching back. But being poor makes it even less likely that they will do so.

"Unemployed men are intent on earning a living, making ends meet, and simply surviving. AIDS is a huge side issue for them," says Men on the Side of the Road founder Charles Maisel.

Women tend to have more contact with clinics and hospitals than men do because they bear children and are usually the family's primary care giver: as a result more women than men know their HIV status, says Maisel.

"I looked at lots of HIV prevention programmes, and realised people were not testing, particularly men, because there was no incentive to do so."

After a series of pilot programmes to determine how much money would persuade men to forgo work for a day and take an HIV test, Men on the Side of the Road settled on offering a cash reward of R75, roughly the price of a day's labour. The testing and requisite counselling is provided by the Desmond Tutu HIV Foundation, a research institute at the University of Cape Town.

If the men test positive, they are referred to local clinic services. If they are negative, they are invited to return three months later for another test: this time they get the R75 cash reward only if they are still free of the virus.

The idea behind the scheme is to encourage men to change their sexual behaviour - for example by reducing their sexual partners and using condoms whenever they have sex - says Maisel. "We don't just want people to test - we want to keep them negative," he says.

Men on the Side of the Road hopes to reach 5000 men this year, and then expand the incentive scheme to include their families.

Maisel is not alone in thinking that incentives could be the way to spark action from people who might ordinarily be reluctant to take an HIV test: SA's biggest medical scheme Discovery Health, which pioneered a complex series of incentives to encourage its members to be healthier, has recently teamed up with the Sunday Times to offer a monthly cash prize of R100000 to a reader who takes an HIV test.

"We know incentives work, but they have to be of sufficient scale to get people to change their behaviour," says Discovery's head of HIV strategy, Elaine McKay.

Discovery runs an incentive programme called Vitality that offers members rewards such as discounted gym membership, cheap airline tickets, and reduced life insurance premiums if they take steps to safeguard their health.

Members can earn points for going to the gym, signing a non-smokers declaration, joining a weight loss programme, or undergoing tests for diseases such as cervical and prostate cancer, and HIV.

Discovery's research shows active Vitality members who have belonged to the programme for three years claim on average 15% less in rand terms than members who do not belong to the programme.

So what is it about human nature that seems to make cash rewards a better incentive than the knowledge that taking an HIV test, or quitting smoking, will benefit one's long-term health?

Behavioural scientists suggest a much higher value is placed on an immediate reward than one that is deferred, says Vitality's head Craig Nossel.

Economists sometimes refer to this as "discounting the future". It also helps explain why a sex-worker who needs to feed her children might agree to unprotected sex with a client she suspects is infected with HIV, effectively mortgaging her future to deal with the demands of the present.

Aside from Discovery Health's Vitality programme and similar initiatives launched by its rivals, health-related incentives are not widely used in SA. Yet a host of projects around the world suggest they can persuade people to stay off drugs, take their medication, or keep their children in school.

During the 1990s, for example, Mexico launched a programme called Progresa that gave cash to poor families to enrol their children in school, and make sure they had regular health check ups: a family could supplement its income by about 20% of a family's average spending. Within a few years, clinics were reporting 60% more visits from families with babies, illness among children dropped 12%, and the number of girls in school increased 14%.

In Windhoek, a nonprofit organisation called Penduka has achieved an almost 100% cure rate among tuberculosis patients by training them in craft work, and only giving them the money from the sale of the goods they produce once they have completed their six months of treatment.

So far incentive schemes in SA are limited to the private sector. Perhaps it's time for politicians to consider whether such projects could work in the public sector too, complementing the slew of awareness campaigns.

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