We are proposing to conduct an intervention study testing the use of financial incentives for HIV prevention among high-risk women in Dar es Salaam. The intervention has been developed from multiple prior pilot phases and builds on results of the RESPECT study that was conducted by the study team in Ifakara, Tanzania. The RESPECT study in Ifakara used financial incentives to motivate safer sex among men and women ages 18-30 in the general population. Participants in the higher value incentive group of that study were found to have a significantly lower prevalence of STIs after one year of study enrollment. This new study will test a similar intervention among female sex workers in Dar es Salaam. We will enroll approximately 2,156 (but request approval to recruit up to 4,000) HIV-negative female sex workers into the study for 2 years. They will be screened for sexually transmitted infections (STIs) at baseline enrollment and offered free treatment if positive. All women tested will also receive pre/post-HIV and STI counselling, as well as extended counselling on safe sex practice and negotiation with partners. They will then be re-screened after 2 years, with counseling at each screening. They will also receive weekly text messages, which will include counseling on safe all for all women, and will be asked to complete a short phone survey after 1 year. Women will be randomized into one of two study arms: the Basic Test group and the Random Test group. Both groups will receive all of the intervention components described above. In addition, in the Random Test group we will randomly draw 10 women each week for random STI testing. If a woman’s random STI tests are negative then the woman will receive an award that day of Tsh100,000 (approximately US$50); if one of the tests is positive then the participant will not receive the reward but she will receive free treatment and further counseling as well as continue to be eligible for future drawings.
This is a population that is a critical node in the HIV epidemic, with HIV positive sex workers potentially causing many more infections among their clients. We hypothesize that providing reward incentives for sex workers to avoid sexually transmitted infections can increase condom use, thus reduce their probability of contracting HIV. In a recent survey of sex workers in Dar es Salaam, 65% reported always using a condom with one-time clients and 32% with steady partners. The report further states that, "among those who did not use condoms, the most common reason was either the client objected or paid more in order not to use them (68.2%)," thus condom price is not a primary reported barrier to use. Based on our own pilot testing we believe that the likelihood of behavior change is promising, and the study is powered to detect a significant reduction in combined new incidence of HSV2 and HIV, two incurable sexually transmitted infections.