Concept note:
The impact of short-term financial incentives on sexual behavior and HIV incidence
among youth: Evidence from a randomized controlled field trial in Lesotho
June 25 th, 2009
Table of Contents
1. Summary
2. Background
3. Research Objective and Motivation
4. Methods and Evaluation Design
4.1 Evaluation Design
4.2 Sequence of events
4.3 Target Population
4.4 Sample Size
4.5 Data Collection
5. Ethical Issue
5.1 Protecting privacy and autonomy
5.2 Confidentiality
5.3 Informed Consent
6. Organization
6.1 Timeframe
6.2 Principal Investigator
6.3 Responsibility
6.4 Capacity Building
6.5 Target Audience and communication plan
7. Appendix
7.1 Short bio of World Bank team
7.2 Related Literature
7.3 Village List
1. Summary
The HIV/AIDS epidemic is a major concern in many countries. The epidemic is especially acute in
Lesotho where roughly one quarter of the population is infected by HIV/AIDS. In Lesotho, and
elsewhere, new innovative approaches to induce safer sexual behavior have been desperately called
for, particularly in view of the limited impact that existing prevention schemes have had on the
trajectory of the HIV/AIDS epidemic.
One of the key questions is to understand why individuals get involved in short-term risky sexual
behavior when the potential long-term cost of becoming HIV infected is so high? A follow-up
question, which will be more directly addressed by this study, is what replicable and feasible
interventions can affect this trade-off between short and long run returns? On the first question there
are several possible answers. People may not be aware of the long-term benefits of safe sexual
behavior. Or they give a lot of weight to short-term gains, either because they discount the future
heavily or have preferences that might be inconsistent over time, with a strong preference for the
present.
The primary aim of this study is to evaluate whether the use of short-term financial incentives can
affect this trade-off, thereby influencing young individuals’ decisions with respect to sexual and
1
reproductive health behavior, and thus in the end reduce HIV incidence rates. We will study this
question using a sample of population attending New Start Voluntary Counseling and Testing
(VCT) sites that a local NGO, Population Service International (PSI), has already implemented in
Lesotho.
We propose to conduct a randomized controlled trial to test whether adding a financial incentive to
remain STI-negative in the form of a lottery can promote safer sexual activity. The lotteries will
work as follows: if the individual is tested negative on a set of curable STIs, she will get a lottery
ticket with the chance to win a “big” prize. If she is tested positive, she will receive free treatment,
but no lottery ticket. If an individual who tested positive is cured, she can come back in the lottery
system and get a later chance to win the lottery ticket if she remains STI-negative. The outcome will
be to measure the impact of financial incentives on HIV incidence after two years. Because lotteries
are inexpensive, we think we are testing a model that could be relatively easy to replicate.
As a second step, the project will also explore spillover effects. A higher number of STI and HIV
negative individuals within a community is a potential source of positive externalities for all
members who did not participate in the project. We might have externalities through two main
channels: first, the diffusion of information regarding HIV/STI prevention and second, a lower
probability to be involved in sexual relationships with positive partners.
Information about the cost of the information will also be collected so that we will be able to
measure the cost-effectiveness of the intervention and compare it with other HIV prevention
interventions.
The results of this research project will be disseminated through academic and non-academic
conferences, workshops, publications in academic journals, and also in policy journals with the aim
to reach out to policy makers outside the research community.
2. Background
Lesotho has the third-highest HIV prevalence in the world at 23.2% (DHS, 2004). Many HIV
prevention initiatives are currently going on in the country. The proposed impact evaluation
responds to the urgent need to find innovative approaches to promote safer sexual behaviors among
youths in Lesotho. In particular, the project will be implemented through the New Start Voluntary
Counseling and Testing (VCT) sites established by PSI in the country.
PSI, the implementing agency, has 5 static New Start VCT sites nationally in 5 out of the 10
districts in Lesotho. They are located in the main camp town of the following districts: Maseru,
Mafeteng, Qacha’s Nek, Maputsoe, Butha-Buthe. Each of these sites has vehicles and tents that are
used for outreach services. Outreach activities aim at targeting more specific groups of the
population who are generally at higher risk of HIV infection. For example, urban and semi-urban
villages (within 30 km radius from the static VCTs, working places (garment factories, phone
companies, etc.)) and schools. The present randomized evaluation aims at targeting youths in urban
and semi-urban villages (see section 4.3 for details).
PSI Lesotho has an extensive experience of working in the HIV prevention sector and it is currently
involved in various HIV prevention activities, including, in particular, condom distribution.
3. Research objective and Motivation
The result of traditional information campaigns (like ABC-Abstinence, Be Faithful and use
Condom) on sexual behavioral changes is not conclusive. Although, anecdotal evidence shows that
it has resulted in some changes, for example, interventions focusing on condoms use have resulted
2
in increasing condoms during commercial and sexual encounters, there is no rigorous evidence
actually showing a significant reduction in HIV prevalence in Southern Africa countries.1
Perhaps the reason for this resides in some differences in sexual behavior in Africa (e.g. it is much
more common to have concurrent partnerships that can overlap for significant time) and so the
information campaigns are not focusing on the right messages and thus not affecting behavior
where it matters the most. Or maybe, as recent literature suggests people tend to delay activities that
are a little bit unpleasant in the present (like protecting themselves) even if they have very large
returns in the future.2 People may not be aware of the long-term benefits of safe sexual behaviors.
Alternatively, they give a lot of weight to short-term gains, either because they discount the future
heavily or have preferences that might be inconsistent over time, with a strong preference for the
present.
What replicable and feasible interventions can affect this trade-off between short and long run
returns? Can the introduction of a small but "short term" reward promote safer sexual behaviors?
This intervention aims at contrasting the difference between a reward in the next 4 months (a lottery
ticket) and a reward 10 years later (being HIV negative). The main issue, is the interval between
the sexual activity and the lottery. To gauge the extent of participation in the lottery, the correct
interval time among lottery draws, and the impact on behavioural changes, we plan to do a short
qualitative study a couple of months before the beginning of the project.
The research objective is to test and rigorously evaluate whether the introduction of small financial
rewards in the short term can promote safer sexual behaviour in general, and reduce HIV incidence
in particular, in a high risk environment.
The results of the evaluation are expected to be an important input in designing effective HIV
prevention in Lesotho. Furthermore, a credible impact evaluation is also a global public good in the
sense that it can offer reliable guidance to international organizations, governments, donors, and
nongovernmental organizations in their ongoing search for effective HIV prevention programs.
4. Methods and Evaluation Design
4.1 Evaluation Design
We are proposing to conduct a randomized controlled field trial to rigorously test whether shortterm financial incentives in the form of lotteries have an impact on sexual behavior and the
incidence of HIV and a small set of curable STIs of youths coming in to outreach sessions of New
Start VCT in Lesotho.
The underlying question for the study is why individuals get involved in short-term risky sexual
behavior when the potential long-term cost of becoming HIV infected is so high, which clearly is
the case in Lesotho. It appears like individuals, to the extent that they have not been coerced into
having sex (which unfortunately is also a common problem); put a lot of weight on short-term gains
at the expense of long run benefits. If this is the case, short run financial incentives may affect
individual’s trade-off between short and long run returns. In fact, there exists some preliminary
evidence that small (financial) incentives associated with activities that have very high returns in the
1
An exception for this is Uganda that experienced a large drop in HIV prevalence in the 1990s, which is unique among
Sub-Saharan African countries; this drop is generally credited to educational programs, which promoted partner
reduction and to elements of ABC (Green, 2004; Green et al, 2006; Slutkin et al, 2006).
2
For example, Thornton (2008) studies the impact of monetary incentives to maintain HIV status on sexual behavior. In
particular, after testing for HIV, this study randomizes financial incentives to rural Malawians for successfully
maintaining status. Similarly Baird, Chirwa, McIntosh and Ozler (2009) assess the impact of a more traditional CCT
program, conditioned on school enrollment, on sexual and reproductive health outcomes.
3
future can result in significant change in behavior (Emont and Cunnings (1992), Kane (2004)
Krishnan-Sarin et al. (2000)). However, there is little (no) evidence that such an incentive scheme
will work when it comes to sexual behavior.
Thus, the main hypothesis to be tested is that a system of rapid feedback and positive reinforcement
using cash as an incentive can effectively lower risky sexual activity and reduce rates of HIV
transmission. The primary outcomes for evaluating impact will be a sub-set of sexually-transmitted
infections (STIs), Syphilis, Chlamydia, Gonorrhea,3 that are prevalent in the population and have
been incontrovertibly linked to risky sexual activity. Each of these STIs is curable. This is a critical
point, since enrollees who test positive for an STI can continue to participate in the study after they
have been treated and cured of the infection. Thus, learning is encouraged through positive
reinforcement, and mistakes can be corrected and overcome.
We will test study participants for HIV at baseline and after one year and two years to assess the
impact of the intervention on HIV transmission, but we will not condition participation to the
lotteries to HIV status.
We propose to test this hypothesis through the introduction of financial incentives in the form of a
lottery to remain/become STI-negative, which we believe is both replicable and relatively easy to
scale-up. Indeed, using a lottery system decreases the cost of the project compared with a
conditional cash transfer transferring a fixed sum of money to all individuals who remain STI
negative. Thus, the project might be easier to scale up with limited resources. Lotteries are also
more valued by risk-takers and these individuals might also be the ones with the most risky sexual
behavior, thus providing additional incentives would reach the most important group. The
presumption is that the financial incentive will influence individuals’ trade-off between short and
long run returns with respect to sexual behavior.4
The sample population will consist of youth aged 18-30 targeting through outreach activities in
urban and semi-urban villages implemented by the VCT centers in Lesotho We aim at a study
population of about 6,000 (see section 4.3 for details). To the extent demand will exceed supply; we
will randomly choose the participants.
In a clustered randomized controlled field trial the sample population is randomly divided into a
treatment group (individuals that will have a chance to participate in the lottery) and a comparison
(individuals that will not take part in the lottery) group. Here, the randomization will be at the
village level and therefore the analysis will cluster the standard errors at the village level Half of the
villages will be assigned to the treatment group and half to the control group. Since treatment has
been randomly assigned, and provided that the sample contains a sufficiently large number of
individuals, units assigned to the treatment and comparison groups are similar in expectations
before the intervention. The analysis will also control for observable characteristics. The causal
effect of the intervention can therefore be gauged by comparing mean outcomes in the treatment
and comparison groups after the intervention.
3
The study will remain open for testing other STIs, such as Trichonomasis and MGen, depending on budget, prevalence
and testing technology.
4
Raffles and other contests similar to lotteries are often advertised in the newspapers and on radio in Lesotho. It is
difficult to have detailed information on them (i.e. what are the chance to winning commercial lotteries or how many
people buy it), but the concept of lottery is common enough that most study participants will be familiar with it.
4
The random assignment to the control and treatment groups will be done in a transparent way, for
example by drawing from an urn which villages will be in the treatment and in the control group5.
Not only does randomization guarantee internal validity, it is also typically a fair way to allocate
participants across the treatment and the comparison groups.
Individuals both in the treated and in the control villages will receive free sexual health discussion
sessions as part of the PSI prevention and treatment program, free HIV/STI testing, free STI
treatment (for individuals tested positive), and free counseling before and after each STI/HIV test.
PSI also will provide free condoms in the VCTs.
Individuals in the treatment group villages will be eligible to participate in a lottery if they are
tested STI negative. There will be testing and lottery draw every four months. Participants will
know in advance the amount of the lottery reward. Suggestively, the amount of the reward will be
around 1000-2000 Rands and the lottery will be drawn among all the STI negative people in each
villages6. There will be 2 winners (i.e. one man and one woman) in each village. The exact details
on the type and the size of the reward will be more precisely decided during the pilot of the project.
The focus on STI status as a condition for participation in the lottery, rather than on HIV status, is
primarily based on ethical consideration. By focusing on STIs that are curable, we can also study
how the intervention affects behavior of both HIV-positive and HIV-negative participants. STIpositive individuals, who receive treatment and are cured, will be eligible to participate in future
lottery draws.
The proposal calls for two follow-up surveys, one after a 12-month period and one after a 24 month
period. We aim at surveying twice the sample of around 6,000 participants. To generate more
precise estimates of the impact of the intervention, a baseline survey will also be implemented. The
information from the baseline survey will also assist in stratifying the sample and will be used to
study heterogeneous effects. We are planning to study heterogeneous effects by gender and HIV
status and the power calculations have taken into account this stratification. In order to minimize
attrition during the project, we will collect data on names, addresses and phone numbers of the
participants in a way to preserve confidentiality and not to decrease their willingness to participate
(see section 5 for details). Further, we will provide small incentives (e.g. air time vouchers) for
participants to report to the study station
The design of this experiment avoids the usual complications of selection and reporting bias
because it randomized individual incentive to learn STIs status. However, there will be selfselection of people who choose to decide to participate in the study, because, for example, they are
more motivated and aware and perhaps knowledgeable about their options (in case they are HIV
positive) compared to someone who have tested. Those are mainly problems of external validity.
We are aware of these problems but in practice, they are difficult to avoid, since we cannot impose
this study on a representative sample of the population..
4.2 Sequence of events
The first thing would be to randomly allocate the villages between the control and treatment group.
We will randomly select villages from the list of villages with more that 150 youths from the list of
normal outreach activities of PSI. If the number of villages selected will not be enough to reach the
target sample size we will pick up additional villages from the Lesotho Census 2006. Individuals in
5
Because the randomization will be done in a transparent way, in public, it will not be possible to have the organization
administering the intervention blinded to the randomization.
6
We will study the possibility - once we have established in the first rounds that the lotteries are well accepted in the
study population - to randomly allocate different levels of prize over time and across village, moving away from a
simple binary treatment and providing richer variation in the level of treatment.
5
the target villages (both control and treatment) will be informed about the project through the
village chief.
Month 1
In each village, individuals in the target group, coming to the VCT outreach event, will be
registered and they will sign an informed consent. A survey will be conducted. We will collect data
on names, phone numbers, and addresses of the participants that will be kept in a separate file. We
will thus able to re-contact them during two years (see Section 5 for details). There will be the pre
and post test counselling, free sexual health discussion sessions as part of the PSI prevention
activities, free HIV/STI testing, free STI treatment (for individuals tested positive). PSI will also
provide free condoms. Each individual will receive a card with an ID number and they have to
present every time they will be tested. Informed consent will be required, so refusing HIV or STI
tests is a possibility. But we should only recruit individuals who, if they have provided informed
consent, are willing to take all tests.
We will provide an incentive, such as a grocery voucher to all the youths who agree on be part of
the project. Participants will be informed that PSI will come back after four months to test them
again and to provide them another grocery voucher for the value of about 25 Rands.
Month 5
Three or four days before the due date at month 5, a SMS firm will send to each participant a quick
reminder for their test. For those without cell phone, the reminder will be sent to the village chief.
Individuals in both the lottery and control villages will receive free sexual health discussion
sessions as part of the PSI prevention and treatment program, free STI testing, free STI treatment
(for individuals tested positive), and free counseling before and after each STI/ test. PSI will also
provide free condoms.7 Note that we will do HIV test only every year, at baseline, after 12 months
and after 24 months.
Individuals in the treatment group will be eligible to participate in a lottery if they are tested STI
negative. Every time clients will be tested, the enumerator will register the id number of that client
and provide her a Grocery voucher both in the treated and in the control villages.
After we target 150 youth per village, STI negative youth will be eligible to participate to a lottery
draws. A couple of participants will be called to do the lottery draw. The winner’s ID number will
be advertised in the village and we will ask to the winner to come and claim the prize. There will be
one lottery draw per village every four months.
Month 9, Month 16, Month 20
Same events as in month 5.
Month 12
Same events as in month 5 plus follow-up survey and HIV testing.
Month 24
Follow-up survey and HIV-testing
4.3 Target Population
HIV/AIDS is by far the leading cause of death for young people in sub-Saharan Africa (WDR
2007). While preventing new infections at any age is an important public health goal, achieving
7
We may decide to provide free STI testing in a subsample of the control villages in order to also test the effect of free
STI testing.
6
significant reductions in risky behavior among young people, aged 18-30, has the added attraction
of addressing a major concern about the impact of the AIDS epidemic on the demographic profile
of the most affected countries.
Adolescence and young adulthood corresponds to a period of identify formation, sexual identify
formation, and increased risk-seeking behaviors, but it is precisely this phase of life when
individuals are most receptive to changing norms, attitudes, and practices with regards to sexual
behavior. Thus, by offering the correct incentives during the critical transition to adulthood, it may
be possible to intervene before risky behaviors become firmly entrenched. The present project aims
at targeting youth aged 18-30 reached by New Start mobile VCT established by PSI.
There are 5 New Start VCT sites nationally, located in the main camp town of the districts Maseru,
Mafeteng, Qacha’s Nek, Maputsoe, Butha-Buthe. Each of these sites has vehicles and tents that are
used for outreach in their own catchment area. This project will focus on urban and semi urban
villages. In appendix, a list of the villages (from the Lesotho Census 2006) with an estimate of more
than 150 youth per village.
The project aims at targeting about 50 villages, of which half will be in the treatment group. We are
going to target about 12-13 villages per months in the all country and about 100-150 youths per
village. This would involve a total of 6,000-7,000 participants.
Table 1: Statistics on the target population:
No. of villages No. of villages in No. of villages in No
of No of youths tested and
in total
total per months
total per months youths per survey per villages per
per VCT
villages per day
(counting
20
month
working days per month)
50
12-13
2-3
150
7-8
Each VCT will have two outreach teams, composed by two nurses and two enumerators. To reach
our sample size, the two outreach teams will spend about 10-15 days in the first village and then
they will move together to the second and third villages for other 10-15 days. This means that each
nurse and each enumerator should roughly test and interview 7-8 youth per day. When they will
reach about 100-150 youth per villages they will move to the second village. 8 We also plan to target
villages during weekends to reach a higher number of youth.
PSI would like to expand the program to the whole population if funds will be provided by the
Lesotho Government or by other institutions. Furthermore, PSI will carry on their ordinary
activities in the static VCTs and in the villages out of the target villages.
4.4 Sample size
The protocol requires an 80% power of detecting a 50% reduction of annual incidence of HIV
infection in the core group of young individuals (18-30 years old) from 1% in the comparison group
to 0.5% in the treatment group. This gives us a sample of roughly 5,000 individuals in 50 villages.
The sample size calculations take into account the clustering within villages. As the invitation to
participate in the experiment, for both analytical and ethical reasons, will not be limited to only the
young HIV-negative individuals (HIV-positive individuals will also be allowed to participate), and
since we also want to be able to test if the sexual behavior of HIV-positive individuals can be
affected through financial incentive, the sample size was expanded to 7,000 individuals. This
8
From the data collected by previous Client Intake Forms at VCT level, this is seems reasonably.
7
sample size will ensure that we have enough core participants (HIV-negative individuals), while at
the same time it gives us enough power to detect a 50% reduction of annual incidence of sexually
transmitted infections (STIs) in the group of young HIV-positive individuals from 2.5% in the
comparison group to 1.25% in intervention group over two years.
Since expanding the sample size has obvious budget implications, an alternative evaluation strategy
has been developed that gives us less precision, or power, to detect a reduction of annual incidence
of STIs in the group of young HIV-positive individuals. This alternative strategy requires roughly
6,000 individuals in 50 villages.9
4.5 Data Collection and analysis.
In order to rigorously evaluate the impact of the program, we will conduct both a baseline survey of
participants prior to the start of the intervention and at least one post-survey (when the project has
been running for two years) of the participants. In addition to these two major surveys, the
participants in the treatment group will be tested for STI every quarter (since the lottery will be
based on the STI test result) and for HIV every year.
The survey and the data entry will be conducted by PSI. PSI will thus be responsible for the quality
of the data collection. The World Bank will provide funds to expand PSI capacity for the data
collection. Roughly, 10 enumerators are needed.
The research proposed will create new datasets. A survey among VCTs clients will be carried out
longitudinally, i.e. before the launch of the intervention (baseline) and after its launch (follow-up).
The survey of individuals/workers will contain general and more specific questions on health and
STIs/HIV.
Examples of modules to include in the surveys are:
1. Socio-demographic information
2. Life style risk factors (i.e. alcohol consumption)
3. Relationships and sexual behavior (i.e. age of sexual debut, condom use and other
preventative methods, age of partners, extra-marital relationships and concurrent partners,
sexual economic exchange)
4. HIV/AIDS and STIs knowledge
5. History of HIV testing and obtaining results (i.e. test before the survey, main reasons for
testing)
6. Perception of own risk of being HIV positive
7. Knowledge of people infected and who have been HIV tested
8. Violence and sexual abuse
9. Birth and Pregnancy history
10. Family situation (i.e. number of kids, how often do you see your partner, sources of income
for the family)
In both the baseline and in the follow-up surveys, we will test participants for STI and HIV. The
biological markers that have been selected for the study have been selected from a list of STIs that
are commonly used within the epidemiological literature as proxies for risky sexual behavior, and
that are known to be prevalent in the area where we will be working.
9
Details of the sample size calculations are available upon request from the lead investigators.
8
We have opted to include HIV testing, but we will not condition on it the participation to the lottery.
In any case, the study is sufficiently powered without including HIV as an outcome, and free HIV
testing is already available through VCT clinics in the area for anyone who wants it. We plan to
collect data on the following: Chlamydia; Gonorrhea; Syphilis through rapid tests.
To evaluate the program effect on the treated individuals, or the Average Treatment Effect (ATE),
we want to measure the difference between the potential outcome (Y1i) for individuals (Pi = 1) in a
treated village (Ti = 1) in the presence of the treatment and the potential outcome (Y0i) individuals in
a treated village in the absence of the treatment: ATE  E(Y1i Ti  1, Pi  1)  E(Y0i Ti  1, Pi  1) .
However, since we do not observe the potential outcome for individuals in a treated village in the
absence of the treatment, (Y0i), we use the individuals in control villages (Ti = 0) as the
counterfactual. We assume the potential outcome for individuals in a treated village in the absence
of the treatment in the village would be the same as the potential outcome for individuals in the
absence of the treatment in control villages, E (Y T  1, P  1)  E (Y T  0, P  1) . Therefore, the ATE
0i i
i
0i i
i
is given by, ATE  E(Y1i Ti  1, Pi  1)  E(Y0i Ti  0, Pi  1)
.
The following equation is estimated to find the ATE for individuals:
Yi   0  1Ti   2 X i   3 Z i   it
(1)
where Yi is an outcome for individual i (HIV or other STI status), Ti is the treatment indicator, Xi is
a vector of individuals characteristics (gender, age, education) and household characteristics
(wealth, parent education and literacy) and Zi is a vector of village level characteristics (village
infrastructure, school quality, village social capital)10. The direct impact of the treatment program
on the treated individuals, or ATE, is measured by 1.
5. Ethical Issues
No work on this study will begin prior to approval by all ethical oversight committees. Applications
will be submitted to a recognized academic ethical review acceptable to PSI and the World Bank
and if approved, to the Ethic Committee at the Ministry of Health and Social Welfare in Lesotho.
Notwithstanding these formal review procedures, the research team is aware of the ethical concerns
relevant to this research project. There is sensitivity around the idea that it may be possible to “buy”
and “reward” specific behaviors, and there is apparent concern that the proposed intervention
represents unwarranted interference in a matter of personal rather than public concern.
Our response to these concerns is several-fold. First, we believe that intervention can be justified on
the basis of market failures that are evident in health and may cause individuals to make privately,
and in particular, socially inferior decisions regarding sexual practices. This relates to the fact that
private markets do not facilitate optimal decision making by individuals for many reasons, and
these market failures may be magnified among youth and young people. Second, there is a sizeable
public cost in addition to the private costs associated with HIV infection. These costs have been
measured and assessed in many different ways and although the magnitude of the public burden
may be disputed, the fact of its existence is not. Third, it is important to emphasize that this is an
intervention of “carrots” (e.g. cash rewards through lottery; and free counseling and treatment) not
“sticks.” Individuals will be counseled prior to enrolment as to the nature of the study, and they
will have the option to decline to participate if they so desire. Finally, the individual’s privacy
regarding all aspects related to study participation, including STI testing, results, and treatment and
10
Alternatively, we will specify equations for the average treatment effect (ATE) that will use village fixed effects, i.e.
controlling for additive heterogeneity.
9
counseling, will be strictly protected according to criteria about informed consent and data use
established by the ethical oversight and review committees.
Thus, the study proposal rests solidly on the premise that risky sexual behavior is a) not in their own
best interest; and b) creates negative public health externalities on other members of society.
Moreover, the study will include all clients at the VCT sites in Lesotho. Although the primary target
is to study people, who have the highest incidence rates, we will not exclude any clients, both HIVpositive and HIV-negative individuals will be taken part of the field trial. Finally, individuals who
receive a positive STI result upon testing will receive free treatment and counseling.
5.1 Protecting privacy and autonomy
At all times, we will take several steps to preserve the subjects’ privacy and autonomy. All
individuals from the sample will be visited and informed of the objective and procedure of the
survey. We will inform the participants of their right to refuse participation in the study. In
addition, we will also assure the subjects that their choice regarding participation in the study will
not impact the care or service they currently receive or hope to receive from affiliated health
providers.
5.2 Confidentiality
We have developed various methods to safeguard against possible threats to confidentiality.
Participants will be informed that all information that they give us during the course of the study
will be strictly confidential, will be used only by the project investigators and will not be available
for other purposes. The results of the study may be published for scientific purposes, but will be
written in such a way that no individual can be identified.
To ensure further confidentiality, each subject will be assigned a unique identification number (ID),
and this code will be the only identification used on all study materials and laboratory specimen
logs. To be able to re-contact people over time, we will collect data on names and phone number of
clients, but the records linking the names and IDs will be kept locked in a secure storage facility.
After data are entered into a computer file, these computer records will be password protected to
limit access. The data files used for analyses will not include information that can be used to
identify individual households or individuals. The latter will be stored separately and will only be
used for re-surveying the study population.
At the follow-up surveys, we plan to re-interview the same individuals that were identified in the
first round. For use with follow-up surveys, only the module of individual roster will be kept in
paper format, which will include numerical identifiers. This part of the survey will be printed in a
different booklet from the remainder of the interview (“data”). The two booklets will be stapled
until the data have been entered. Once the data are entered, the identifying booklet will be separated
from the data booklet. The data booklets will then be destroyed. The identifier booklets will we kept
in a locked and secure place.
During the project we plan to do the STI test. To ensure confidentiality, each subject tested will be
assigned a unique identification number, and this code will be the only identification used. The HIV
testing will require that all information that might be used to identify individual survey respondents
be destroyed prior to the merging of the STI test results with the survey interview data. Therefore,
it will not possible to identify survey respondents.
5.3 Informed Consent
With regard to informed individual consent, we will follow the protocol established by similar
socio-economic surveys carried out in Lesotho. Consent will be obtained by asking to individuals if
10
they would be willing to participate in the survey. We will underline that they can refuse to
participate and that they can drop out from the project whenever they want. This is consistent with
procedures used previously and that constitutes a norm in Lesotho for evaluation surveys.
In addition to asking consent for the general survey, we will ask consent for STIs test. Subjects will
be explicitly asked for their consent before the test, by remembering them that it is a voluntary test.
The consent forms will be written in simple language at a sixth-grade reading level in local
language. The language used in the consent form will be developed in collaboration with PSI who
is familiarized with the procedures used to obtain informed consent for research studies. This was
done with cultural differences and local language patterns being considered. The staff will closely
review the consent form with all participants, and will read the following passage aloud to ensure
understanding. The consent statements are appended as separate documents.
For example, it would be like this:
Good morning/afternoon, Madam/Sir. My name is _____________ and I am here on behalf of the
Ministry of Health and Social Welfare, to collect information your health.
This is a research project, and the findings may be used to design and plan appropriate policies to
fight against HIV/AIDS at a national level in the future. As a participant, you benefit by gaining a
better understanding of the advantages of prevention for HIV and AIDS. The study is expected to
last for around 2 years, so if you accept to cooperate you will probably receive further visits within
the next years.
Everything you tell me will be kept confidential. Under no circumstances will we link your name to
the data during the analysis and dissemination of the study findings. If you choose not to
participate, it will not affect you in anyway.
If you agree to participate, it will take about 30 minute to complete the interview. If you have any
further questions, during the study or in the future, please do not hesitate to contact the research
team using the telephone numbers below.
6. Organization
6.1 Timeframe
October 2008- April 2009: Preparation and design work
April 2009- April 2011: Fieldwork or material/information/data collection phase of study
July 2009-Pilot of the project
August 2009- August 2010: First analysis phase of study, including 4 waves of data collection on a
quarterly basis.
April 2010- September 2010: Writing-up of the research and Preparation of any new datasets for
archiving in STATA format. The data sets will be made available to interested researchers
following the time table and the guidelines of the World Bank Research Committee.
September 2010 – December 2010: Dissemination
6.2 Principal Investigators
The project will be implemented by PSI supported by the Ministry of Health and Social Welfare
(MoHSW) in Lesotho and the World Bank.
The World Bank team is composed of11:
Martina Bjorkman, IGIER, Bocconi University
11
A short biography of each World Bank team is reported in Appendix.
11
Lucia Corno, Institute of Interenational Studies (IIES), Stockholm University.
Damien de Walque, Economist, Development Research Group, The World Bank
Jakob Svensson, Institute of International Economic Studies, Stockholm University.
The PSI team is composed of:
Michele Bradford, Country Representative, PSI/Lesotho
Mankhala Lerotholi, VCT Project Manager, PSI/Lesotho
Adam Smith, PSI, Program Officer, PSI/Lesotho
Mosele Machitje, MIS research Officer
New Start Site managers in the 5 VCTs
The MoHSW team is composed of:
Mrs M. Moteetee- Director General, MOHSW
Mr Katito Campbell - Operations Manager. Health Sector Reforms Programme, MOHSW
Mrs. M. Makhakhe – Director Health Planning, MOHSW
Mr.J. Nkonyana – Epidemiologist Heath Planning, MOHSW
Ms Senate Matete, Doctor, Ethic Committee, MOHSW
Mr. M. Khobotlo – Acting Chief Executive, NAC
6.3 Responsibility
PSI will be responsible for planning and implementing the intervention. The World Bank Team in
consultation with other partners will be responsible for the evaluation design, including randomly
sampling the clients included in the intervention, questionnaire design and data analysis. The two
parties will discuss and coordinate their plans and activities.
More specifically PSI will be responsible for:
- Organization of clients’ incentives (Grocery vouchers)
- Promotion activities on the project (Agreements with the village chiefs, posters)
- Localization of villages for outreaches with the higher number of individuals aged 18-30.
- Training of counselors on STIs
- Data collection and data entry
- Follow and re-contact individuals every four months for a two years window (through SMS).
More specifically The World Bank will be responsible for:
- Provide funds for the project
- Designing questionnaires for the baseline survey and the follow-up survey
- Analysing the data and writing a report on the results.
- Dissemination of the results
- Monitoring and supervising constantly the project with close interactions with PSI
6.4 Capacity building
This project will be conducted in collaboration with a local partner, Population Services
International (PSI). PSI, at global level, has already many platforms that run STI programs and has
extensive experience on how to run a STI program.
However, in Lesotho, while PSI has been involved in several HIV prevention activities and it is the
main provider of condoms in the country, they do not provide STI testing and treatment.
12
Participation in this study would help PSI Lesotho to open a new area of promoting safer sexual
behavior through STI prevention and treatment and to consolidate their capacity in all facets of HIV
research, from collection of biological specimens, to evaluation and assessment.
First, participants in both randomized and control groups will indeed receive free sexual health
discussion sessions by PSI workers, free HIV/STI testing, free STI treatment and free counseling
before and after each STI/HIV test. Since the project will be carry on a broad scale in the whole
country, this would increase the number of trained workers involved in the project in term of HIV
prevention. This would be a precious source with potential spillover to spread information on
HIV/AIDS in the whole country.
Second, even if PSI field workers have extensive experience in conducting visits and interviews,
they have had less experience with the evaluation of their work. They will be able to gain
experience in project evaluation. They will be involved in the random allocation of the villages and
in the lottery draw. They will be also trained for the data collection. It is very relevant for the
success of a project to understand what works and what does not, especially for targeting resources
toward projects that are really effective in HIV prevalence reduction.
Third, PSI members has been involved in designing and in writing the present proposal, thus,
through the involvement in this project, they will be able to run other randomized experiment in the
future by their own. It is very relevant for the success of a project to understand what works and
what does not, especially for targeting resources toward projects that are really effective in HIV
prevalence reduction.
6.5 Target Audience and Communication Plan
The primary target audience for this project includes the Government of Lesotho (the National
AIDS Commission, the Ministry of Health and Social Welfare (MoHSW)) and policymakers
working on HIV/AIDS prevention in Lesotho. However, as we are studying a simple intervention
that is both relatively easy to scale-up and replicate, the results should be of general interest to both
government, non-government, and the donor community in their effort to identify efficient ways to
fight HIV/AIDS.
The results of this research project will be disseminated through academic and non-academic
conferences, workshops, publication in academic journals, and also in policy journals with the aim
to reach out to policy makers outside the research community.
7. Appendix
7.1 Short Biography of The World Bank Team
The World Bank team is composed of:
Martina Bjorkman, IGIER, Bocconi University
Martina Björkman obtained her PhD in Economics from the Institute for International Economic
Studies at Stockholm University in 2006. She is an Assistant Professor of Economics at Bocconi
University in Milan. She is currently Research Affiliate of the Centre for Economic Policy Research
(CEPR), the Innocenzo Gasparini Institute for Economic Research (IGIER) and the Fondazione
Rodolfo Debenedetti (fRDB). Her fields of interests are development economics, economics of
education and health, economics of gender and political economics. Martina Björkman is currently
working on research projects in Uganda, Lesotho and South Africa. Most of her field-based
research relates to randomized experiments within the health and education sector. At Bocconi
University she teaches undergraduate macro economics and undergraduate and graduate courses in
development economics.
13
Lucia Corno, Institute of Interenational Studies (IIES), Stockholm University.
Lucia Corno is a Post-Doctoral research fellow at Stockholm University. She is close to obtain her
Ph.D. in Economics at Bocconi University in Milan, Italy. Her fields of interests are mainly
development economics and health economics. She has been involved in research studies on the
health seeking behavior in Tanzania, the determinants of HIV/AIDS in Lesotho (using of
Demographic Health Survey 2004). Her most recent research includes the relationship between
homelessness and crime.
Damien de Walque, Economist, Development Research Group, The World Bank
Damien de Walque is an Economist in the Development Research Group (Human Development and
Public Services Team) at the World Bank. He received his Ph.D. in Economics from the University
of Chicago in 2003. His research interests include health and education and the interactions between
them. He has been involved in a study on the relationship between schooling and HIV infection in
Uganda, as well as analyzing the effect of education on other health outcomes, like smoking
behaviors. He is working on evaluating the impact of HIV/AIDS interventions and policies in
several African countries. He also developed a research agenda focusing on the analysis of the longterm consequences of mortality crises. He has participated in several World Bank missions in
Lesotho and has survey work experience in many African countries.
Jakob Svensson, Institute of International Economic Studies, Stockholm University.
Jakob Svensson is a Professor of Economics, Institute for International Economic Studies (IIES),
Stockholm University. He received his Ph.D. in Economics from Stockholm University in 1996 and
spent five years at the Research Department of the World Bank before joining IIES. His research
interests include, among others, health and education. He has been the project leader of several
large surveys in the education and health sectors, and he recently (jointly with Martina Björkman)
managed a large prospective (randomized) evaluation of an accountability intervention in the health
sector in Uganda.
7.2 Backgroud literature
Askew, I and Berer, M (2003). “The contribution of sexual and reproductive health services to the
fight against HIV/AIDS: a review.” Reproductive Health Matters 11(22):51-73.
Bertrand, JR and others (2006). “Systematic review of the effectiveness of mass communication
programs to change HIV/AIDS-related behaviors in developing countries.” Health Education and
Research 21(4):567-97.
Baird, Chirwa, McIntosh and Ozler (2009) “The Impact of a Conditional Cash Transfer Program for
Schooling on the Sexual Behavior of Young Women in Malawi”, working paper
De Janvry, A. and E. Sadoulet. 2004. “Conditional Cash Transfer Programs: Are They Really
Magic Bullets?” Department of Agriculture and Resource Economics: University of California,
Berkeley.
Donatelle, Rebecca and others. 2000. “Randomised controlled trial using social support and
financial incentives for high risk pregnant smokers: Significant other Supporter (SOS) program.
Tobacco Control 9: 67-69.
Emont, S. and K Cummings. 1992. “Using a low-cost, prize-drawing incentive to improve
recruitment rate at a work-site smoking cessation clinic.” Journal of Occupational Medicine
34:771-4.
14
Farrington, John and Rachel Slater. 2006. “Introduction: Cash Transfers: Panacea for Poverty
Reduction or Money Down the Drain?” Development Policy Review 24(5):499-511.
Fiszbein Ariel and Norbert Schady (2008). “Conditional Cash Transfers for Attacking Present and
Future Poverty”, Policy Research Report, forthcoming, The World Bank, Washington, DC.
Gertler, Paul (2004). “Do Conditional Cash Transfers Improve Child Health? Evidence from
PROGRESA’s Control Randomized Experiment” The American Economic Review 94(2): 332-341.
Haug, Nancy and James Sorensen. 2006. “Contingency management interventions for HIV-related
behaviors. Current HIV/AIDS Reports 3(4).
Higgins and others. 1994. “Incentives improve outcomes in outpatient behavioral treatment of
cocaine dependence.” Archives of General Psychiatry 51: 568-76.
Jeffrey, RW and others. 1984. “Effectiveness of monetary contracts with two repayment schedules
of weight reduction in men and women from self-referred and population samples.” Behavioral
Therapy 15:273-9.
Jeffrey RW and others. 1978. “Effects on weight reduction of strong monetary contracts for calorie
restriction or weight loss.” Behavioral Res Therapy 16:363-9.
Kamb, ML and others. 1998. “What about money? Effect of small monetary incentives on
enrollment, retention, and motivation to change behavior in an HIV/STD prevention counseling
intervention. The Project RESPECT Study Group.” Sexually Transmitted Infections 74:253-55.
Kane, Robert, and others. 2004. “A Structured Review of the Effect of Economic Incentives on
Consumers’ Preventive Behavior.” American Journal of Preventive Medicine 27(4):327-52.
Krishnan-Sarin, S. and others. (2006). Contingency management for smoking cessation in
adolescent smokers.” Experimental Clinica Psychopharmacology 14(3):306-10.
Mauldon, Jane Gilbert. 2003. “Providing Subsidies and Incentives for Norplant, Sterilization and
Other Contraception: Allowing Economic Theory to Inform Ethical Analysis.” Journal of Law,
Medicine, and Ethics 31:351-64.
Nigenda, Gustavo and Luz Maria Gonzalez-Robledo. 2005. “Lessons offered by Latin American
cash transfer programmes, Mexico’s Oportunidades and Nicaragua’s SPN: Implications for African
Countries. DFID Health Systems Resource Centre.
O’Donoghue, T. and M. Rabin. 2001. “Risky Behavior Among Youths: Some Issues from
Behavioral Economics” in Risky Behavior Among Youths, J. Gruber, ed. Chicago, University of
Chicago Press: 29-68.
Paul-Ebhohimhen, V. and A. Avenell. 2007. “Systematic review of the use of financial incentive
in treatments for obesity and overweight.” Obesity Reviews 1-13.
Philipson, T. and R.A.Posner (1995). “The Microeconomics of the AIDS Epidemic in Africa.”
Population and Development Review 21(4):835-848.
15
Rawlings, Laura and Gloria Rubio. 2005. “Evaluating the Impact of Conditional Cash Transfer
Programs.” The World Bank Research Observer 20(1): 29-55.
Rawson, R. (2002). “A comparison of contingency management and cognitive-behavioral
approaches during methadone maintenance treatment for cocaine dependence.” Archives of
General Psychiatry 59(9):817-24.
Rosen, M and others. (2007) “Improved Adherence with Contingency Management.” AIDS
Patient Care STDS 21(1):30-40.
Schady Norbert, and José Rosero. (2007). “Are Cash Transfers Made to Women Spent Like Other
Sources of Income?” World Bank Policy Research Working Paper 4282, The World Bank,
Washington, DC.
Schubert, Bernd and Rachel Slater. 2006. “Social Cash Transfers in Low Income African
Countries: Conditional or Unconditional?” Development Policy Review 24:5.
Schuring, Esther. 2005. “Conditional Cash Transfers: A New Perspective for Madagascar?” A
World Bank Report (unpublished).
Silverman, K. and others. 1996. “Sustained cocaine abstinence in methodone-maintenance patients
through voucher-based reinforcement therapy.” Archives of General Psychiatry 53:409-15.
Sindelar, J. and others. 2007. “What Do We Get for Our Money? Cost Effectiveness of Adding
Contingency Management.” Addiction 102(2):309-16.
Stizer, Maxine and Nancy Petry. 2006. “Contingency management for treatment of substance
abuse.” Annual Review of Clinical Psychology 2:411-34.
Thornton, Rebecca (2006). “The Demand for and Impact of HIV Testing: Evidence from a Field
Experiment”. Processed.
UNAIDS (2001). Global Crisis-Global Action: Preventing HIV/AIDS Among Young People.
Geneva, UNAIDS.
UNAIDS (2007). Report on the global AIDS epidemic. Geneva, UNAIDS.
Weedon, Donald and others. 1986. “An Incentives Program to Increase Contraceptive Prevalence
in Rural Thailand.” International Family Planning Perspectives 12(1):11-16.
Windsor, RA, Lowe JB, Bartlett EE. “The effectiveness of a worksite self-help smoking cessation
program: a randomized trial. Journal of Behavioral Medicine 11:407-21.
Yeh, E (2006). “Commercial Sex Work as a Response to risk in Kenya.” University of California,
Berkeley Disseration in the Department of Economics.
7.3 Background data from the Lesotho Census 200612
Village list with a number of people aged 18-30 higher than 150 in each district
12
Data from the census 2206. We impute 40 percent of the population as aged 18-30 (from the DHS is the 46% but on a
sample of 15-59).
16
Berea
Ha Boose
Ha Buasono
Ha Lebina
Ha Lehlohonolo
Ha Lenkoane
Ha Letsoela
Ha Maritintsi
Ha Mohlaetoa
Ha Mokhameleli (Ha Tjotji)
Ha Moroke
Ha Nkhahle
Ha Patso
Ha Sakoane
Ha Ts'ekelo
Koalabata
Malimong (Ha Mapeshoane)
Maphiring
Mapolateng
Maqhaka
Marabeng
Naleli (Ha Ts'osane)
Sebalabala
Tsipa
Tsokung
Butha Buthe
Ha Mofolo
Ha Kuini (Lithakong)
Liqalaneng
Marakabei
Phahlane
Tebe-tebe
Tlapeng
Leribe
Ha Mathata
Ha Khomoatsana
Ha Lejone
Ha Mahloane
Ha Majara
Ha Maqele
Ha Mathata
Ha Matube
Ha Matumo
Ha Mohlokaqala
Ha Mokati
Ha Molelle
Ha Mositi
Ha Nena
Ha Polaki
Ha Polile
Ha Sekhonyana
17
Ha Simone
Ha Thokoa
Hleoheng
Khanyane
Lekhalong (Ha Mafata)
Lekhalong (Ha Qamo)
Levis Nek
Lisemeng
Lisemeng II
Mamohau
Maqasane
Matukeng
Mokoallong
Naleli
Pitseng (London)
Pote
Qophelo
Soweto
Tabola 1
Tiping 1
Ts'ifalimali
Tsoekereng
Vukazenzela
Mafeteng
Ha Kabai
Ha Konote
Ha Mabatla
Ha Mafa
Ha Mofoka
Ha Ngoale
Ha Petlane
Ha Ramarothele
Ha Sehlabo
Ha Sekhaupane
Haseng
LeCoop
Makeneng
Makhomalong
Maralleng
Mathebe
Methinyeng
Mohlanapeng
Motsekuoa
Tibeleng
Maseru
Bochabela I
Bochabela II 1
Boquate (Ha Majara)
Borokhoaneng2
Fika-le-Mohala (Orlando)
Ha Abia
18
Ha Jimisi
Ha Khoabane
Ha Leqele
Ha Lesia
Ha Leteketa
Ha Mabote
Ha Mabote (Motlakaseng)
Ha Mabote (Nokeng)
Ha Mabote (Thoteng)
Ha Mafefooane
Ha Maja
Ha Makhalanyane
Ha Makhoathi
Ha Malelo
Ha Mantsebo
Ha Matala
Ha Mohasoa
Ha Motemekoane
Ha Motloheloa
Ha Mpo
Ha Paanya
Ha Pita
Ha Ramabele
Ha Ramatekane
Ha Ramokitimi
Ha Ramorakane
Ha Rasetimela
Ha Sekepe
Ha Seleso
Ha Seoli
Ha Shelile
Ha Sofonea
Ha Teko
Ha Thetsane
Ha Tikoe
Ha Tjameli
Ha Tlali
Hata-Butle
Khubetsoana (Ha Nkhala)
Khubetsoana (Nts'irele)
Lekhaloaneng
Leralleng
Letlapeng
Lithabaneng (Ha Keiso)
Lithabaneng (Ha Matala)
Lithoteng (Ha Seleso)
Lower Thamae
Machekoaneng
Mafikaneng
Mafikeng
Mafikeng (Ha Motoko)
19
Mahlabatheng
Mamenoaneng
Maqalika
Maqalika (Litupung)
Maseru Correctional Service
Maseru East
Maseru West
Maseru west
Matukeng
Mohalalitoe
Moshoeshoe II
Motimposo
Naleli
Naleli (Khutsong)
Old Europa
Phahameng
Qoaling (Ha Letlatsa)
Qoatsaneng (Ha Tsautse)
Ratjomose
Seapoint
Selakhapane
Semphetenyane
Thabong
Thetsane West
Thibella
Thoteng
Ts'enola (Majoe-Lits'oene)
Upper Thamae
Total 112
Mohale
Ha Matabane
Ha Moletsane
Ha Phafoli
Ha Potsane
Ha Rakoloi
Ha Sehaula
Quacha
Ha Makoae
Ha Mapote
Ha Matlali
Ha Mosiuoa
Ha Seteleng
Keiting
Leseling
Makhalong
Mosafeleng
Motse-Mocha
TJ
Quithing
None
Thaba
20
Ha Khoanyane
Ha Laka
Ha Motsepa
Ha Rats'iu
Ha Toka
Lebung
Liqonong
Mohlakeng
Ponts'eng
Thabong
th
Maseru, 9 April, 2009
Principal Secretary, MOHSW
--------------------------------
Ms Michele Bradford
PSI Country Representative
------------------------------------
Ruth Kagia
Country Director for Southern African Countries, The World Bank
----------------------------------
21