Financial incentives linked to education help Eswatini to find an innovative way of preventing HIV infections and pregnancy among adolescent girls and young women (AGYW) in a country with one of the highest HIV prevalence globally, and one of the highest rates of new infections.
According to a study that evaluated the impact of conditional financial incentives for adolescent girls and young women in Eswatini over a 3-year period, participants in the education incentive intervention group were 23% less likely to acquire HIV, and participants in both the education and raffle sub-group were 37% less likely to acquire HIV.
“We see that the financial incentives for staying and completing school or other forms of education have a significant bearing on risk to new HIV infections and pregnancy among adolescent girls and young women in our country,” said Health Minister Lizzy Nkosi. “Efforts to keep young people in education need to work alongside biomedical HIV interventions like PrEP and Treatment as Prevention.”
This new large-scale impact evaluation study involved 4,389 randomly-selected adolescent girls and young women and provided different kinds of financial incentives, conditional on either attending education or on being negative for sexually transmitted infections.
“There is no single magic bullet for preventing new HIV infections,” said Khanya Mabuza, national executive director of the National Emergency Response Council on HIV/Aids (NERCHA). “This study gives us another tool to use in reaching the last mile of ending Aids in Eswatini, with the added benefit that it supports the reduction of HIV and simultaneously tie into the improvement of human capital in the country.”
The study was led by NERCHA in Eswatini, with funding support from UKAid, the Global Fund to Fight AIDS, TB and Malaria, the World Bank and UNAIDS. The World Bank also provided technical assistance for the impact evaluation. It was implemented with the support from the Ministry of Health, Ministry of Education and Training including the National Reference Laboratory, the Institute for Health Measurement Southern Africa (IHM) and the Swaziland Action Group Against Abuse.
“This study confirms an effective approach in stepping up the fight against the HIV epidemic,” said Osamu Kunii, head, strategy, investment & impact division at the Global Fund. “We will continue to explore more opportunities to invest in such measures that seek to build a firm foundation for healthy women with equal opportunity”.
For three consecutive school years, starting in 2016 and ending in 2018, participants in the intervention group of the study were paid E1,400 ($100) per year for enrolling and attending school, or for being in university-level education, upgrading classes, or doing short courses. In 2018 only, education fees of up to E2,900 ($200) was paid to institutions where previously out-of-school participants chose to pursue education opportunities.
In addition, 50% of study participants were eligible to form part of a raffle conditional on being negative for syphilis and trichomonas. Seven of these raffle rounds were held, and in each round 80 raffle winners, who tested negative, were drawn. It showed the biggest impact in those who were in the intervention sub-group that were eligible for both the raffle cash incentive and the cash payment for staying in school. The raffle incentive provided E1,000 ($72) prize money to the raffle winners.
“This Impact Evaluation result has shown that being in school, effective years of learning, HIV prevention, health, pregnancy, job creation, poverty, productivity and economic growth are all closely intertwined,” said Education and Training Minister, Lady Howard Mabuza. “We are pleased for partners’ support in the efforts of the government of Eswatini to invest in its people through education and health which are critical to skilling young people, growing the economy, creating employment and poverty reduction.”
The study also significantly contributed to pregnant participants going back to school after they had their babies, and to reductions in teenage pregnancy. It found that the main reasons for not enrolling in school included the lack of school fees, and the need to care for their babies. It also pointed to the real lack of opportunity to return to school after dropping out, resulting in a large proportion of participants at home “doing nothing”.
“Social and structural factors clearly increase a person’s vulnerability to HIV in Eswatini,” said Paul Noumba Um, World Bank country director for Eswatini. “This study shows us that solutions for adolescents and young people will need to be integrated, personalised and comprehensive.
Background: Eswatini still has the highest HIV prevalence globally, and very high HIV incidence among AGYW. Cash transfers linked to school attendance were protective against HIV (Baird et. al 2012), but subsequent studies have not shown impact on HIV incidence (Karim et al. 2015; Pettifor et al. 2016).
Methods: From Nov2015 to April2016, the Sitakhela Likusasa Impact Evaluation enrolled 4389 HIV-negative AGYW aged 15-22 — 50% of whom were not in education — in a cRCT of periodic financial incentives for HIV prevention, with HIV incidence as the main outcome. Using a 2×2 factorial design to create 4 sub-arms, 50% of participants were eligible for financial incentives conditional on education enrollment and attendance, and 50% were eligible for periodic raffle prizes conditional on periodic random selection into the raffle, on negative tests for syphilis and Trichomonas vaginalis (TV) if selected, and on being a periodic raffle winner. Education data were collected throughout. The endline survey, 3 years later, included behavioral and risk profile data, and HIV, syphilis and TV testing.
Results: HIV incidence among participants in the education incentive arm was statistically significantly lower compared to those not eligible for the education incentive, 6.34% vs 8.08% (p=0.041); OR: 0.770 [0.599-0.989]; aOR: 0.751 [0.579-0.974]. HIV incidence in the sub-arm offering both the education and raffle incentive was significantly lower than incidence in the control arm (participants not eligible for any of the two incentives), OR: 0.634 [0.442-0.910]; aOR: 0.618 [0.429-0.889].
Conclusions: The financial incentives conditional on education participation significantly reduced odds of HIV infection among AGYW in Eswatini. Raffle incentives on their own did not lead to a statistically significant impact, but it amplified the effect: the combination of both incentives statistically significantly further reduced the odds of HIV infection. Financial incentives can be useful for HIV prevention among AGYW in high prevalence settings.
M Gorgens, S Ketende, V Tsododo, W Heard, M Mabuza, A Longosz, T Chiperera, L Shongwe, M Sacolo, M Nkambule, G Maphalala, L Dlamini, D Wilson, D De Walque, K Mabuza, Sitakhela Likusasa Impact Evaluation Study Group