Incentives and phone follow-up could improve healthy behaviour by young people: more research needed

As young people continue to bear the greater proportion of infections, researchers, doctors, educators and social workers are increasingly intent on finding the most effective interventions. A session at the Eighteenth International AIDS Conference in Vienna considered the effectiveness of different youth interventions occurring in resource-limited areas.

Systematic reviews help to determine what works and what doesn’t. A 2006 report, Ready, Steady, Go!, conducted by the World Health Organization (WHO) and several UN agencies, found that curriculum-based interventions led by adults were the most effective, specifically involving teachers and students. Other interventions, including community-wide activities, increased training of healthcare workers, and changes in service delivery, require more research.

Notably, curriculum-based interventions led by peers or older peers have not yet been proven to be effective, according to the report. This was mirrored by a systematic review done by a team of researchers at Brown University, which considered interventions targeting juvenile offenders but found no clear patterns concerning effectiveness of peer education. Additionally, all panelists noted that greater data demonstrating the cost-effectiveness of behavioural interventions was needed.

Charlotte Watts of the London School of Hygiene and Tropical Medicine, and Helen Rees of the Reproductive Health and HIV Research Unit at the University of the Witwatersrand, highlighted the use of incentives to stimulate behaviour change. As of 2007, the World Bank estimated that 29 countries utilised some form of conditional cash transfer (CCT) programme. While traditionally used for the improvement of general health indicators, such as giving a mother money in exchange for having her child vaccinated, there is an increasing interest in tailoring such methods for reproductive health behaviours, specifically by rewarding condom use, low rates of sexually transmitted infection (STI) transmission, and the increased uptake of services such as testing and care.

Watts noted that studies determining STI prevention through CCT have largely been effective, with as many as 60% of participants reporting lower rates of infection than those in control arms. Following this precedent, Rees presented background information on a study to be implemented in South Africa in 2011. Given that several studies have proven that “staying in school [is] protective against HIV”, Rees and her colleagues have created a study in which girls and their heads of households will be given a cash incentive for maintaining attendance. A community arm will also be implemented, with young men receiving training on gender, sexuality and HIV.

There will be four cohorts in the study:

• girls who are given cash transfers in a community which receives training;

• girls who receive cash transfers without community training;

• girls who don’t receive cash transfers but who live in a community which receives training; and

• girls who do not receive cash transfers, while their communities receive no training.

In addition to decreasing rates of HIV infectivity, the study will also consider outcomes concerning gender norms and herpes infection. Preliminary results are expected in 2014.

Despite their proven efficacy, CCT programmes remain contentious. Questions regarding whether the interventions undermine individual autonomy, are top-down, and are “selective poverty alleviation”, are of central concern. Long-term effects also need further research. “Incentives are very successful…in terms of [short-term] behaviour,” Watts notes. “I think there’s more contention as to whether this can lead to long-term behaviour change.”

Other types of incentives have also proven effective. In a groundbreaking new study presented by Ralph DiClemente of the Emory School of Medicine, researchers found that introducing an HIV and STI education programme followed by a total of nine 15-minute calls occurring at six-month intervals reduced the rate of new chlamydia infections by 40% in young African-American women.

As part of the study, so-called 'health coaches' called participants to discuss condom use, avoiding risky situations, negotiating and refusing sex, HIV and STI transmission, and the joys and challenges of being an African-American woman. DiClemente noted that since the coaches were the same throughout the study, they were able to offer “personalised tailoring [of] HIV prevention”. Eighteen months later, these brief calls were also effective in enhancing condom use and reducing the frequency of sex while drinking or using drugs.

DiClemente considers this a “highly cost-effective intervention, with 1.5 hours of time reducing chlamydia rates by 40%”. He suggests that the study be translated to a different setting and used amongst a different population in order to test the potential for widespread use.

DiClemente R et al. Brief cellphone-delivered counseling as a novel strategy to enhance the maintenance of HIV behavioral intervention efficacy: results from a supplemental treatment effectiveness trial. Eighteenth International AIDS Conference, Vienna, abstract WEAC0204, 2010.

Doyle AM et al. HIV prevention in young people in Sub-Saharan Africa: a systematic review and update of the evidence. Eighteenth International AIDS Conference, Vienna, abstract WEAC0201,  2010.

MacPhail CL et al. An innovative multi-level intervention for HIV prevention in young South African women: pilot of a randomized controlled trial. Eighteenth Annual International AIDS Conference, Vienna, abstract WEAC0203, 2010.

Underhill KA and Operario D. Preventing HIV among juvenile offenders: evidence from randomized and quasi-randomized controlled trials. Eighteenth International AIDS Conference, Vienna, abstract WEAC0205, 2010.

Watts C Incentivising behaviour change. Eighteenth International AIDS Conference, Vienna, abstract WEAC0202, 2010.

View abstract and slides from this session on the official conference website.