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CAPRISA is the UNAIDS Collaborating Centre forHIV Research and Policy
Impact of conditional cash incentives on HSV-2 and HIV in rural high school students in South Africa
Quarraisha Abdool Karimon behalf of the CAPRISA 007 team
Associate Scientific Director: CAPRISAProfessor in Clinical Epidemiology, Columbia University
Adjunct Professor in Public Health, University of KwaZulu-Natal
CAPRISA 007 matched-pair cluster randomized controlled trial
Background• Conditional cash incentives have been effective for a
range of behaviours such as smoking cessation, vaccination uptake and drug rehabilitation
• Promising data that incentives may reduce risky sexual behaviours and impact HIV transmission:
– Baird et al: incentivized school attendance reduced HIV and HSV-2 prevalence in Malawi
– Duflo et al: incentivized later sexual debut reduced pregnancy rates & increased age at sexual debut in Kenya
– Björkman-Nyqvist et al – community lotteries reduced HIV incidence in Lesotho
• Ongoing high HSV-2 and HIV rates in adolescent girls in Africa, with few prevention options…
Age Group (years)
Prevalence of HIV infection% (95% Confidence Interval)
Male (n=1252) Female (n= 1423)
15 1.0
16-17 1.118-19 1.5
≥ 20* 1.8
HIV & HSV-2 prevalence in students by age
Prevalence of HSV-2 (Herpes simplex virus type-2)
15 0.7
16-17 2.018-19 6.6
≥ 20* 3.5
2.6
6.1
13.6
24.7
3.5
9.3
30.2
43.3*Small sample size in the > 20 year sub-group
Purpose
To assess the impact of
conditional cash incentives on the
incidence of HSV-2 and HIV infection
in rural high school students
in South Africa
Study design and Data analysis• 14 schools matched as 7 pairs: by school enrolment
size, geographical proximity & school pass rates
• Grade 9 & 10 students (n = 3,217 students)
• Parental consent with student assent
• HIV and HSV-2 testing (serology): Baseline; 12 months (91% retained) & 24 months (85% retained)
Baseline HSV-2 prevalence: Intervention: 9.0% Control: 7.3%
Baseline HIV prevalence: Intervention: 4.7% Control: 3.7%
• Analysis performed at the cluster level using paired t-tests (Inter-cluster correlation = 0.01)
Students enrolled, followed & analysed for HSV-2 incidence analysis
Intervention
• All 14 rural schools participated in a local Lifeskills (incl. HIV education) Program - My Life! My Future!
• One school in each of 7 pairs randomly assigned to receive, in addition, cash incentives for any combination of 4 conditions being met:
– 80% quarterly participation in My Life! My Future! (4/year)
– Attaining passing score in 6-monthly academic tests (2/yr)
– an annual HIV test (1/yr)
– Submit report on their community project at end (once off).
• Maximum incentive possible is R1,750 ($1=R10), equivalent to half the local child care grant
Most cash incentives were for HIV testing & the Lifeskills Program attendance – no impact on school performance & few completed report
Incentivized Conditions
InterventionGroup
ControlGroup
HIV Counselling and Testing (Annual)Early in study 51.8 (689) 40.4 (560)Mid-study 59.2 (787) 36.6 (507)Close to end of the study 45.2 (601) 8.9 (124)
“My Life! My Future!” Lifeskills & HIV educational Program (Quarterly)1st quarter in study 37.6 (500) 30.6 (424)Mid-study quarter 41.4 (551) 26.8 (372)Final quarter in study 45.1 (600) 27.0 (374)
Academic School Performance (6 monthly)First semester in study 18.6 (248) 22.7 (314)Last semester in study 37.2 (495) 45.4 (629)
Community project report 12.0 (159) 3.3 (46)
Effectiveness of conditional cash incentives in preventing HSV-2 and HIV
HSV-2 Incidence rate ratio*: 0.70 (CI: 0.57 to 0.86); p = 0.007
Intervention Group Control Group
# HSV-2 infections 136 183
Person-years (# students) 2091 (1329) 2132 (1384)
HSV-2 incidence/100 py 6.2 8.7
* Note: Analysis based on matched-pairs of schools & not individual students
Effectiveness of conditional cash incentives in preventing HSV-2 and HIV
HSV-2 Incidence rate ratio*: 0.70 (CI: 0.57 to 0.86); p = 0.007
Intervention Group Control Group
# HSV-2 infections 136 183
Person-years (# students) 2091 (1329) 2132 (1384)
HSV-2 incidence/100 py 6.2 8.7
HIV incidence / 100 py 1.8 1.5
* Note: Analysis based on matched-pairs of schools & not individual students
Too few HIV infections (n=75) to assess impact on HIV
Effectiveness of conditional cash incentives in preventing HSV-2 and HIV
HSV-2 Incidence rate ratio*: 0.70 (CI: 0.57 to 0.86); p = 0.007
30% lower HSV-2 incidence with cash incentives
Intervention Group Control Group
# HSV-2 infections 136 183
Person-years (# students) 2091 (1329) 2132 (1384)
HSV-2 incidence/100 py 6.2 8.7
HIV incidence / 100 py 1.8 1.5
* Note: Analysis based on matched-pairs of schools & not individual students
Too few HIV infections (n=75) to assess impact on HIV
Kaplan-Meier survival probability for HSV-2 and HIV infection
* Note: Analysis based on individual students
*
HSV-2 risk: Control students
HSV-2 risk: Interventionstudents
HIV risk: Intervention students
HIV risk: Control students
p = 0.007
p = 0.419
HSV-2 incidence by incentive levels
* Note: Analysis based on individual students
*
*
• CCI boys had 40% lower HSV-2 incidence (p = 0.042)
• CCI girls had 24% lower HSV-2 incidence (p = 0.035)
• Too few HIV endpoints for HIV sub-group analyses. HIV
incidence lower than expected - need a sample size 3-5 times
larger for adequate power to assess 30% impact on HIV prevention
Students who got > $95 had71% lower HSV-2 Incidence
(p = 0.034)
Conclusions• Cash incentives: 30% reduction in HSV-2 incidence
• Context for cash incentives important:– This study is in poor rural high school students in S. Africa– Few (< 1/3) conditions met, hence median cash incentive = $60– Cash incentives for school performance made little impact– Impact: ↑ uptake of HIV tests and lifeskills program attendance– Incentive dose-response should be interpreted with caution
• Could not establish impact of cash incentives on HIV – lack of statistical power due to lower than expected HIV
incidence (?background trend, ?community interventions ?
study-related interventions)
• Structural interventions in the real world - Challenging!
Acknowledgements KwaZulu-Natal Department of Education Provincial and District and
Circuit Offices Pietermaritzburg and Vulindlela
School Governing Boards, students and staff at the schools
MiET Africa
CAPRISA 007 study team: Quarraisha Abdool Karim, Kerry Leask, Ayesha Kharsany, Hilton Humphries, Fanele Ntombela, Natasha Samsunder, Cheryl Baxter, Janet Frohlich, Lynn van der Elst & Salim S. Abdool Karim
This material is based upon work supported by the Embassy of the Kingdom of Netherlands (EKN) under activity number 20336 through a subcontract with MiET Africa.
Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and therefore the EKN does not accept any liability in regard thereto.