Evaluating the effectiveness of incentives to improve HIV prevention outcomes for young females in Eswatini: Sitakhela Likusasa impact evaluation protocol and baseline results

Marelize Gorgens,Vimbai Tsododo,Muziwethu Nkambule,Mbuso Mabuza,Andrea Low,Sosthenes Ketende,Pandu Harimurti,Kelvin Sikwibele,Tengetile Dlamini,Khanya Mabuza,David Wilson,Andrew F Longosz,Futhie Dennis-Langa,Wendy Heard,Mthokozisi Dlamini,Damien De Walque

doi:10.1186/s12889-020-09680-8

Marelize Gorgens, Vimbai Tsododo + Show 14 more

Open Access

https://doi.org/10.1186/s12889-020-09680-8

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Abstract

BackgroundEswatini continues to have the highest prevalence of HIV in the world, and one of the highest HIV incidences among adult populations (aged 15–49). This analysis reports on both key elements of study design/protocol and baseline results from an impact evaluation of an intervention incentivizing (i) initiation, enrolment, attendance or completion of some form of education, and (ii) lower risk sexual behaviour.MethodsThe impact evaluation employs a two by two factorial design in which participants are enrolled in either the incentive for education arm (‘education treatment arm’ providing a conditional cash incentive) or the control arm (‘education control arm’). In each of these arms, 50% of participants were randomized to also be eligible for selection – three times a year – to participate in a conditional raffle conditional on testing negative for curable STIs (syphilis and Trichomonas vaginalis).ResultsBaseline recruitment and screening occurred in 2016 when a total of 6055 individuals were screened of which 4863 participated in the baseline survey, and 4819 individuals were randomized into one of the study arms. The baseline prevalence of HIV, Trichomonas vaginalis, and syphilis among adolescent girls and young women 8.20% (397/4840), 3.31% (150/4533) and 0.17% (8/4830) respectively.ConclusionsAn educational cash incentive and raffle incentive impact evaluation that addresses adolescent girls and young women who are in-education and out-of-education has the potential to reduce HIV risk in adolescent girls and young women in Eswatini.Trial registrationName of the registry: Pan African Clinical Trials Registry.Trial registration number: PACTR201811609257043.Date of registration: May 11, 2018 ‘Retrospectively registered’.URL of trial registry record: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=4685

Highlights

Eswatini continues to have the highest prevalence of HIV in the world, and one of the highest HIV incidences among adult populations
The highest rates of HIV infection are in southern Africa, with more than 1% of the population per year becoming infected in Botswana, Lesotho and Eswatini.[1]. There are 6 countries (Botswana, Lesotho, Namibia, Eswatini, South Africa, and Zimbabwe) that have HIV prevalence of more than 10% of the entire population.[1]. In 2015, Eswatini had an estimated 13,910 new HIV infections, 263,040 people living with HIV (PLHIV), and 5,890 HIV/AIDS related deaths.[2]. Some of the main factors associated with transmission of HIV in Eswatini include: low prevalence of male circumcision; multiple, long-term concurrent sexual relationships; early sexual debut and intergenerational sex; low condom use, especially in long-term sexual partnerships; lack of family and community support; and multiple structural factors. [3,4]
The three main structural factors that influence HIV incidence include income inequality, gender inequality, transactional sex and education.[4,5,6,7] Income inequality has been shown to be a major contributor to sexual risk in women in Eswatini.[8]. Eswatini is classified as a lower Middle Income country by the World Bank.[9]. Yet, Eswatini has one of the highest levels of income inequality in the world: despite it being a lower middle income country, 63% of the population living on less than $2 per day.[9]. The poor economic prospects for young women contribute to the increasing prevalence of intergenerational and transactional sex, as young women develop desires and needs consistent with modern expectations of lifestyle

Summary

Introduction

Eswatini continues to have the highest prevalence of HIV in the world, and one of the highest HIV incidences among adult populations (aged 15-49) This analysis reports on both key elements of study design/protocol and baseline results from an impact evaluation of an intervention incentivizing (i) initiation, enrolment, attendance or completion of some form of education, and (ii) lower risk sexual behaviour. Evidence obtained from cash incentive studies show that cash incentives may reduce HIV[11,12] and STI (sexually transmitted infection) or HSV-2 (herpes simplex virus 2) incidence[11,12,13,14] but not all studies demonstrate significant reductions.[15] few studies currently focus on out-of-education young women[11] while this group could benefit greatly from cash incentives for HIV prevention as well as more broadly to improve their wellbeing. Raffles have not been evaluated in addition to education incentives to determine if there is a compound effect of these cash incentives

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