Paying the price of HIV in Africa: cash transfers and the depoliticisation of HIV risk

Abstract

Despite biomedical innovation, HIV incidence remains high in some African countries. HIV-related cash-transfer projects propose a solution. However, the author raises concerns about their success from a political economy perspective. Where structural change is invoked by these projects, it is too narrowly conceived. Some cash-transfer projects focus solely on ‘nudging’ choices about risky sex, without considering the wider set of factors that increase HIV incidence. Consequently, the promise of HIV-related cash transfers is dangerously exaggerated. Instead they obscure the underlying causes of high HIV prevalence, by focusing on individual behaviour and a limited, neoliberal-friendly menu of options.

[Payer le prix du VIH en Afrique : les transferts de liquidités et la dépolitisation du risque lié au VIH.] Malgré l’innovation biomédicale, les cas de VIH restent élevés dans certains pays africains. Les projets de transfert de liquidités liés au VIH proposent une solution. Cependant, l’auteur émet des réserves quant à leur succès à partir d’une perspective politico-économique. Lorsque le changement structurel est invoqué par ces projets, ils sont conçus de manière trop étroite. Certains projets de transfert de liquidités se concentrent seulement sur les choix « encouragés » sur les relations sexuelles risquées, sans considérer l’éventail plus large de facteurs qui augmentent les cas de VIH. Par conséquent, les impacts potentiels des transferts de liquidités liés au VIH sont exagérés de manière dangereuse. Plutôt, ces transferts dissimulent les causes sous-jacentes de la prévalence élevée du VIH en se concentrant sur le comportement individuel, et sur un menu d’options limité proche du néolibéralisme.

Keywords:

• HIV/AIDS
• cash transfers
• Africa
• political economy
• behavioural economics
• libertarian paternalism

Mots-clés:

• VIH/SIDA
• transfert de liquidités
• Afrique
• économie politique
• économie comportemental
• paternalisme libéral

Acknowledgements

I wish to thank Ben Fine and Kevin Deane for discussions on these issues, as well as anonymous reviewers for their comments. I also wish to thank participants at a workshop held in SOAS in 2012, ‘The Political Economy of HIV’, for their helpful comments on an early draft. All the usual disclaimers apply.

Note on contributor

Deborah Johnston is a Reader in Development Economics in the Department of Economics, at SOAS, University of London.

ORCID

Deborah Johnston http://orcid.org/0000-0003-0065-1105

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1. There are dissenting voices. For example, see Perrey et al. (2012) for a discussion of the controversial construction of the public health consensus on male medical circumcision.

2. HIV incidence is a measure of the new acquisition of HIV over time in a given population. It is expensive to measure and HIV prevalence is used in its place, itself being the percentage of people (usually aged 15–49) who are HIV positive.

3. Cash transfers may be perceived to be better than standard methods where there are compounded problems of both a deeply ingrained health problem (e.g. drug addiction, overeating, alcohol abuse and smoking cessation) and the character of the target population (e.g. those with chaotic lifestyles, or suffering a range of social problems) (Medlin and de Walque 2008).

4. The discussion is related only to those projects that have publicly available evaluation material. There was no such material for the two South African projects identified. The Swa Koteka project will have its last evaluation visits only at the end of 2014, but aims to measure HIV, HSV, sexual behaviour, mental health, school outcomes, socio-economic status and other key social factors. The CAPRISA 007 RHIVA project will measure HIV incidence rates, academic performance, substance use, pregnancy rates and contraceptive use in girls, participation in extra-curricular activities and sexual behaviour.

5. There are two small-area studies of HIV incidence in South Africa that also provide relevant evidence – the drawback being their limited representation. Bärnighausen et al. (2007), working in one area of South Africa, reported that educational attainment reduced the hazard of HIV seroconversion. Hargreaves et al. (2007) report on a study in another area of South Africa, finding that HIV seroconversion was negatively associated with education amongst women (but not men).