By the time he was 21, Sandile had had sex with at least seven women. Now 23, the father of one says he doesn’t keep track any more “as I have more important things to worry about”.
His childhood friend, Litha, 22, has been more cautious, with three sexual partners. But one thing the young men from Khayelitsha, Cape Town, have in common is that they have not had HIV tests and don’t plan to.
“I don’t think that I could cope with knowing I have HIV,” said Sandile, while Litha is worried about stigma. “HIV tests at clinics are done in special cubicles, away from everybody,” he said.
“The mere fact that I’m seen at that cubicle means people conclude I must be HIV-positive. The testing area is also full of women, so as a man you feel out of place and alienated.”
It is young men such as these who are the target of research in rural KwaZulu-Natal, which has found that paying people to be tested could be key to getting them to overcome reluctance.
A team from the Africa Health Research Institute and universities in the UK and US offered 4,000 teenage boys R50 each to take a test. Another group was offered counselling in an attempt to motivate them to do so.
A year later the cash-incentive group recorded a 55% increase in testing, while counselling had no impact.
Great strides have been made in fighting HIV in SA, but men’s reluctance to get tested and treated remains a key driver of new infections among women.
Writing in the Journal of the International Aids Society, lead researcher Prof Frank Tanser said the new findings provided “strong evidence that the relatively small once-off micro-incentives can play an important role in overcoming a barrier for accepting HIV testing at a home environment among men”.
One of the authors, Dr Hae-Young Kim, said the financial incentive was well received because of its immediate benefits. “Perhaps those who received the counselling might have needed more time to process the information they received and make a decision to take an HIV test. On the other hand, a financial incentive is a very immediate and tangible incentive.”
The next step would be quantifying the cost-effectiveness of the financial incentive.
In countries such as Malawi and Zimbabwe, small cash incentives tripled the uptake of HIV testing among adolescents, but lottery-type incentives didn’t make a difference, a result replicated in the Western Cape in 2011.
A campaign led by then-premier Helen Zille offered people who took an HIV test the chance to win cash prizes of up to R50,000, but civil society and public health experts said it was not scientifically based and could encourage stigma.
Provincial health spokesperson Byron la Hoe said the campaign had not made an impact and incentives were not sustainable. “The emphasis now is more on promoting behaviour change and thus making testing more of a lifestyle issue,” he said.
“We have also adopted the national ‘men’s health’ approach that seeks to address men as men as opposed to see them as recipients of specific health services, such as medical male circumcision.”
University of Cape Town (UCT) public health specialist professor Leslie London said while cash transfers had worked to promote healthy behaviours such as breastfeeding or child vaccination, there were no guarantees HIV testing would change men’s behaviour.
“This is especially if the reason for testing is financial. The motivation of the testee may be less about the test result, but about the process and reimbursement. The study did not do anything further about seeing whether testing translated into anything of value, such as use of condoms, changed sexual practices, or reduced sexually transmitted infections, including HIV rates,” he said.
“With any preventive measure, there may be a paradoxical increase in risk if people think they are safe. So young men tested negative may be less likely to ensure safe sex and so increase risk. We don’t know if that is likely to be the case.”
Prof Sinead Delany-Moretlwe, director of the Wits Reproductive Health and HIV Institute, said in addition to stigma, men were reluctant to test and seek treatment due to a perception that health services had been “feminised”, with most staff being women.
“This study is important for showing what would work to incentivise men to overcome some of their concerns about testing,” she said.
“I know people have had trouble with thinking about how these incentives might be operationalised at scale, but there are models where cash vouchers are made contingent on health interventions. It would be important to understand the acceptability of that.
“It may not be a strategy that needs to be universally applied for prolonged periods of time, but may be an important way to kick-start and normalise testing in men.”
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