Prevention Pays Off

March 8, 2012

Sarah Baird speaks at podium

By Anna Miller

As consumers, young women and girls in Malawi look a lot like their American counterparts. When given a bit of extra cash, they spend it on handbags, shoes and other “things that any girl would want,” said Sarah Baird, assistant professor of global health and economics and the director of the Doctor in Public Health Program in Global Health at the School of Public Health and Health Services.

Aspects of their love lives are comparable too. “How people in Malawi date is not so different than how we date,” she said. “Women make their own choices about marriage and divorce.” And while a significant portion of female Malawians report committing to relationships for financial support, “they say love too,” said Dr. Baird.

But women in Malawi — and in sub-Saharan Africa, in general — face something American women don’t: a far greater chance of acquiring HIV than their male peers. In sub-Saharan Africa, 60 percent of people living with HIV are women. In the United States, it’s closer to 25 percent.

And despite researchers’ and humanitarian organizations’ best efforts, the “abstinence, be faithful, use a condom,” or ABC, strategy, hasn’t been effective. What’s more, the common beliefs that education acts as a “social vaccine” against HIV infection and that higher income reduces the risk of transmission are not supported by convincing scientific evidence.

“We were reading the literature on HIV prevention and were shocked to find that, outside of male circumcision, nothing is really working in that region,” said Dr. Baird.

So she and three colleagues, who are based across the U.S., decided to try something new. They decided to give girls money — some only if they went to school, others regardless — to see if it reduced the risk of sexually transmitted infections, including HIV and HSV-2, a strain of the herpes virus.

The cash transfer intervention, which was conducted between 2008 and 2009, involved nearly 4,000 never-married women from the Zomba district in Malawi who were between 13 and 22 years old. About 1,300 of the women or their families received payments, the others acted as a control group. The study, which is ongoing, is funded by the Global Development Network, the Bill & Melinda Gates Foundation, the National Bureau of Economic Research Africa Project, World Bank’s Research Support Budget and several World Bank trust funds.

The study participants didn’t know what the researchers were assessing. In other words, they weren’t being paid to change their sexual behavior — they were just being paid.

After 18 months of payments, which ranged in amount and averaged about $10 in U.S. currency a month, the young women were tested for sexually transmitted infections. The researchers found that those who received payments were less than half as likely as those who hadn’t to have acquired HIV, no matter how much they received or whether or not they only got paid for going to school. Similar results were reported for HSV-2.

This study is the first randomized-controlled trial to result in a significant difference in HIV infection among women in sub-Saharan Africa. In February, its results were published online in The Lancet.

“We didn’t know what to expect — it could have gone either way,” said Dr. Baird, who co-authored the article. “So it was exciting to finally get results showing that something works in reducing HIV infection.”

Dr. Baird and her colleagues think the intervention worked in part because it alleviated the participants’ perceived need to turn to men when short on money.

“In order to buy things before, they had to rely on boyfriends, who were usually older men,” said Dr. Baird. “Giving them pocket money sort of widened their box of choices.”

Dr. Baird and her team hope to replicate the study in other countries to see if it the intervention has a similar effect. If it does, it could be scaled up to help reduce HIV rates across sub-Saharan Africa, the home of two-thirds of the world’s HIV-infected population. Cash-transfer programs in the long run are much more cost-effective than treatments for HIV/AIDS, Dr. Baird said.

But it’s not the type of intervention that can — or should — go on forever, she said.

“This idea is to influence both current and future poverty. You hope that this boost now will be enough to get them to a point where they can provide better for their own children in the future,” said Dr. Baird

Dr. Baird’s fellow authors are currently in Malawi conducting follow-up research to see if the temporary payments had any longer-term effects on other factors like parenting techniques, marital choice and financial stability.

While the project raises some controversy — as cash-transfer programs usually do, particularly among public health professionals — Dr. Baird sees it as an opportunity to call for greater collaboration between economists and those involved in public health.

“I think the take away from all of this is that it’s important to think outside of the box when it comes to interventions,” she said. “They may not look like public health, but they can make a difference.”