The Demand for and Impact of Learning HIV Status in MalawiPDF version
As of December 2007, over two-thirds of the 33 million people living with HIV/AIDS were in sub-Saharan Africa1. In the absence of significantly expanded prevention and treatment programs, the epidemic is expected to worsen in many other parts of the world. Nearly one-quarter of new cases are due to unprotected sex2. Testing and counseling could impact sexual behaviors, offering a chance to slow the spread of the disease. Some governments have suggested implementing universal testing programs, sending nurses door-to-door. However, low uptake can make testing programs expensive, and additional evidence is needed to determine the specific barriers which prevent people from getting tested, and changing sexual behavior.
Nearly 12 percent of Malawian adults are infected with HIV/AIDS, giving the country the 9th highest prevalence in the world3. In the face of this epidemic, government officials and NGOs face an urgent need to develop effective programs to halt the transmission of the disease, including testing and counseling interventions. Underlying the emphasis on HIV prevention through testing are two assumptions – that those diagnosed HIV-positive will take precautions to protect others, and that it is naturally difficult to get people to learn their HIV status, possibly due to psychological or social barriers. Because of this second assumption, expenditures on social marketing to de-stigmatize infection and promote treatment are generally assumed to be necessary.
Researchers evaluated a field experiment in rural Malawi designed to address these assumptions. Examining a program initiated by the University of Pennsylvania, researchers randomly selected 120 villages in 1998 for the evaluation. Approximately 25 percent of all married households in each village were randomly selected to participate in 1998, and an additional sample of young-adults aged 15-24 was added to the sample in 2004.
Between May and August 2004, respondents were offered a free door-to-door HIV test and were given randomly assigned vouchers for between zero and three dollars, redeemable upon obtaining their results at a nearby voluntary counseling and testing (VCT) center. The location of each HIV results center was also randomized to evaluate the impact of distance, and thus travel time for participants, on VCT attendance. The evaluation sample was comprised of those who accepted an HIV test, consisting of 2,812 individuals. Several months later, follow-up interviews were conducted and respondents were given the opportunity to purchase condoms.
Impact of Monetary Incentives and Distance: While only 34 percent of those who received no monetary incentive attended clinics to learn their results, monetary incentives were highly effective at increasing result-seeking behavior. On average, respondents who received any cash-value voucher were twice as likely to go to the VCT center to obtain their HIV test results as those who received no cash incentive. Although the average incentive was worth about a day’s wage, even the smallest amount, about one-tenth of a day’s wage, resulted in large attendance gains. Distance was also an important factor, as living over one kilometer from the VCT center reduced result-seeking by 6 percent.
Impact on Sexual Behavior: Receiving an HIV positive diagnosis significantly increased the likelihood of purchasing condoms among those who were sexually active. On average, those who were sexually active who learned they were HIV-positive purchased two more condoms than those HIV-positives who did not learn their results. Learning HIV status had no impact on condom purchases among those who were HIV-negative or those who were not sexually active. Because changes in sexual behavior, evidenced in condom purchase, were contained within the small proportion of sexually active HIV-positive individuals who chose to learn their status and the costs of door-to-door testing is quite high – $44.06 for testing per person – a better targeted intervention may be more cost-effective.
[1] World Health Organization, “HIV/AIDS Epidemiological Surveillance Report for the WHO African Region, 2007 Update,” http://www.afro.who.int/aids/publications/OMS%20HIVAIDS%20in%20Africa%20... (accessed August 31, 2009).
[2] Pascaline Dupas, “Do Teenagers Respond to HIV Risk Information? Evidence from a Field Experiment in Kenya,” Economics Department, UCLA, January 2009. (Accessed December 16, 2009)
[3] CIA World Factbook, “Malawi,” https://www.cia.gov/library/publications/the-world-factbook/geos/mi.html (accessed August 31, 2009).
