The authors have declared that no competing interests exist.
Conceived and designed the experiments: WHD DD RN. Performed the experiments: LP SM. Analyzed the data: LP AK WHD DD SM. Wrote the paper: LP AK WHD DD.
Behavior change communication (BCC) interventions, while still a necessary component of HIV prevention, have not on their own been shown to be sufficient to stem the tide of the epidemic. The shortcomings of BCC interventions are partly due to barriers arising from structural or economic constraints. Arguments are being made for combination prevention packages that include behavior change, biomedical, and structural interventions to address the complex set of risk factors that may lead to HIV infection.
In 2009/2010 we conducted 216 in-depth interviews with a subset of study participants enrolled in the RESPECT study - an HIV prevention trial in Tanzania that used cash awards to incentivize safer sexual behaviors. We analyzed community diaries to understand how the study was perceived in the community. We drew on these data to enhance our understanding of how the intervention influenced strategies for risk reduction.
We found that certain situations provide increased leverage for sexual negotiation, and these situations facilitated opportunistic implementation of risk reduction strategies. Opportunities enabled by the RESPECT intervention included leveraging conditional cash awards, but participants also emphasized the importance of exploiting new health status knowledge from regular STI testing. Risk reduction strategies included condom use within partnerships and/or with other partners, and an unexpected emphasis on temporary abstinence.
Our results highlight the importance of increasing opportunities for implementing risk reduction strategies. We found that an incentive-based intervention could be effective in part by creating such opportunities, particularly among groups such as women with limited sexual agency. The results provide new evidence that expanding regular testing of STIs is another important mechanism for providing opportunities for negotiating behavior change, beyond the direct benefits of testing. Exploiting the latent demand for STI testing should receive renewed attention as part of innovative new combination interventions for HIV prevention.
Traditional behavior change communication interventions, while still a necessary component of HIV prevention, have not in and of themselves been shown to be sufficient to stem the tide of the epidemic
The shortcomings of behavioral change interventions are at least in part due to barriers arising as a result of structural or economic constraints on behavior change
Qualitative data from one such structural intervention in Tanzania, the RESPECT trial
We know from previous research that individuals are frequently employing risk reduction strategies, but often not in the ways that dovetail with the traditional sexual behavior change messages
Risk reduction strategies such as condom use and reducing the number of sexual partners may be implemented inconsistently as a result of structural and cultural factors including gender inequality
Less research has been conducted on behavior change barriers that might exist for men, in large part because the epidemiology shows higher HIV prevalence among women. Notably, one recent exception from the comparative anthropology perspective discusses in detail the “opportunity structures” in place that perpetuate the benefits that men derive from having multiple and extramarital partners
Using qualitative data from a trial of economic incentives for testing STI negative, in this paper we explore how a cash incentive, in combination with regular STI testing, influenced strategies for risk reduction. This is important to understanding behavioral mechanisms through which the RESPECT trial led to reduced STIs. The cash awards are a type of structural intervention, which we hypothesized could lead to behavioral change by both men and women, but it was a priori unclear what type of behavioral change strategies would be adopted and how. In addition, the study's provision of regular STI testing (in an environment in which STI testing was generally not available on demand) allowed analysis of the mechanisms through which STI testing could operate. STI testing is understood to reduce risks through epidemiological pathways by identifying treatment needs, but in this paper we explore whether the expanded health status knowledge from STI testing led RESPECT participants to change sexual behaviors, and if so, how. Our investigation also helps to understand how the structural cash intervention and the testing component could work synergistically as part of a combination prevention package that can assist men and women with opportunities to better act on behavioral change intentions, thus potentially increasing the effectiveness of traditional behavior change interventions.
The data reported on in this paper come from the qualitative component of the RESPECT study. Detailed methods of the RESPECT study have been reported elsewhere
The use of cash incentives to encourage sexual behavioral change is an innovative approach, but not without controversy. The background and justification of the RESPECT design are discussed in more detail
The qualitative study participants were recruited from four of the ten villages that were participating in the RESPECT study. The four qualitative villages represented a range of semi-urban to more rural, and ranged from 15 minutes to a 2-hour drive to Ifakara, the main urban center in the district. We used stratified random sampling to select the qualitative study participants at baseline. In each village, the strata of interest were gender, marital status, and intervention/control group. We over-sampled from the treatment group as we were interested in hearing more experiences relating to how the money did or did not motivate sexual behavior change. This analysis utilizes data from in-depth interviews conducted at the baseline, 4-month and 8-month study visits. At baseline, we randomly sampled 92 trial enrollees (43 men, 49 women) from four of the ten study villages to be interviewed. Of these 92, 80 showed up at the study site to pick up their STI results at the next study visit three weeks later, at which time the qualitative interviews were conducted. Those who did not show up to the study site were more likely to be male (p = 0.08), but there were no other significant differences. Of these 80 that were interviewed, 66 transcripts were received (14 transcripts were lost through data management error–either the recordings were inadvertently deleted or the electronic version of the transcript was inadvertently deleted).
At the 4 and 8-month study visits new qualitative participants were purposively sampled in order to increase the number of participants interviewed who had tested positive for an STI. In addition, we intentionally conducted fewer overall interviews at 8 months because we had reached saturation with the number of participants we had already enrolled. As a result, some participants who were interviewed in 4 months were purposely not interviewed in 8 months. The decision of which participants to drop was not random; transcripts were reviewed to screen out the least cooperative respondents who were not deemed to be particularly candid, and consideration was given also to gender, intervention group, and STI status of the participant. Transcripts were not reviewed for content when making the decision to keep or drop a respondent; rather the text was reviewed for coherency of responses and a willingness to talk at relative length about the subject matter. No participants who were recruited for the qualitative study from those coming to the study station to pick up test results refused to be interviewed, however, some targeted qualitative respondents did not return to the study station for the follow up visits at months 4 (4.6%) and 8 (1.8%).
Qualitative participants received a small cash payment equal to approximately $3 USD at the end of each interview to reimburse them for transport and extra time spent at the study station. Interviews took place at the study station in tents or secluded areas.
All interviews were audio-recorded, transcribed in Kiswahili, and then translated into English. The interviews were conducted using an interview guide. The main topic areas covered during the interviews were opinions about the study, community perceptions about the study, strategies and/or steps for avoiding STI and getting the cash award, perceptions of the cash incentive, and future plans generally and for use of the cash incentive if received. The guide was revised for each follow-up visit (months 4, 8 and 12) and included questions about respondent's experiences being enrolled in the study over the previous four months, what strategies they tried, and why or why not these strategies were successful.
Following a methodology developed by Watkins and Swidler termed conversational journals, we also hired ten diarists who were “cultural insiders” in all of the communities in which the RESPECT trial took place
Qualitative analysis was conducted using a phenomenological approach – relying on in-depth descriptions by study participants to derive meaning and understanding of experience
The study was approved by the Institutional Review Boards of the Ifakara Health Institute, the University of California at Berkeley, and by the Tanzania National Institute for Medical Research. All participants provided written informed consent.
Variable | All Study Participants at Baseline (%) | Qualitative Participants at Baseline (%) | Qualitative Participants at 4-month (%) | Qualitative Participants at 8-month (%) |
(N = 2399) | (N = 66) | (N = 95) |
(N = 55) |
|
Female | 50.3 | 57.6 | 61.1 | 56.4 |
Age (mean) | 26.4 (se: 0.12) | 25.4 (se: 0.51) | 25.5 (se: 0.43) | 26.6 (se: 0.53) |
Marital Status | ||||
Single | 21.0 | 30.0 | 26.9 | 18.2 |
Married | 63.5 | 48.5 | 48.4 | 54.5 |
Living Together | 11.7 | 12.1 | 15.1 | 16.4 |
Divorced | 4.1 | 6.1 | 7.5 | 7.3 |
Widowed | 0.2 | 3.0 | 2.2 | 3.6 |
Education Level | ||||
No Education | 11.0 | 9.1 | 11.6 | 14.5 |
Some Primary School | 77.2 | 80.3 | 74.7 | 81.8 |
Some Secondary School | 11.9 | 10.6 | 13.7 | 3.6 |
Religion | ||||
Muslim | 38.2 | 47.0 | 41.9 | 38.2 |
Catholic | 43.7 | 43.9 | 48.4 | 45.5 |
Other/None | 18.1 | 9.1 | 9.7 | 16.4 |
Intervention Group | ||||
High Value | 25.6 | 31.8 | 30.9 | 18.2 |
Low Value | 27.5 | 33.3 | 33.0 | 41.8 |
Control | 46.9 | 34.9 | 36.2 | 40.0 |
HIV/STI status at baseline | ||||
HIV-pos at baseline | 3.5 | 3.0 | 6.3 | 3.6 |
STI-pos at baseline |
16.1 | 7.6 | 12.6 | 16.4 |
59 of the 95 qualitative participants interviewed at 4 months were also interviewed at baseline
37 of the 55 qualitative participants interviewed at 8 months were also interviewed at baseline and 4 months, 9 were also interviewed only at 4 months
Based on STI tests for Chlamydia, Gonorrhea, Syphilis and Trichomonas
The qualitative coding resulted in several categories of strategies to avoid unsafe sex, mentioned both at baseline and at the follow-up interviews. These included abstinence or periodic abstinence, having one partner who has tested and not using condoms, having one partner only and using condoms with this partner, convincing your spouse to use condoms outside of the marriage, convincing your spouse not to go outside the marriage, using condoms with your spouse, avoiding situations and circumstances that might lead to unsafe sexual behavior, filling time with other activities, reducing the number of sexual partners overall, having less risky partners, using the money to help convince a partner to stay safe, and separating or divorcing a current partner.
Within these categories of risk reduction strategies that were coded, three prominent themes emerged from the data as participants discussed how they adapted these strategies to avoid risk in the context of their daily lives, and in the context of the RESPECT study. First, we introduce the centrality of regular STI testing as a reliable method of overcoming the barrier of risk assessment and discuss the combination of targeted condom use, STI testing and treatment as a three-pronged approach to decreasing risk of infection. Second, we describe how certain situations provide increased leverage for sexual negotiation. Risk reduction strategies are often opportunistically implemented in these situations. Third, we explore the use of temporary abstinence as a frequently mentioned risk reduction strategy. What emerges from the data is that the barriers described in the previous section are addressed through innovative means of risk reduction. There are difficulties in assessing risk, but frequent and strategic STI testing can be used to ease those difficulties. Furthermore, women who otherwise lack agency in sexual decision-making as a result of marital and/or economic constraints can take advantage of new opportunities where they have leverage (enabled by both the cash awards and the new information about their sexual health from the STI testing) to minimize risk at certain points in time.
The difficulty of assessing risk of a potential or current partner, in conjunction with the generally negative attitudes toward condom use creates a situation in which testing for HIV or STIs becomes an important tool in minimizing exposure to infection. For people who are in the early stages of a relationship, determining when a partner is safe, and when condoms are no longer needed is not straightforward. Testing has helped individuals in the RESPECT trial in making this determination. In fact, one strategy mentioned frequently during the interviews was a combination strategy involving condom use and testing for HIV and/or STIs. For those who are married or in long-term relationships for whom condoms are no longer a realistic option, regular testing provides an opportunity to assess risk and to bring temporary security (or insecurity, depending on the results) to relationships that are often plagued with uncertainty. This 29 year-old divorced woman (R for respondent) describes to the interviewer (I) how she and her partner negotiate risk by relying on the regular STI testing that the RESPECT study provided.
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It should be noted here that repeat testing in the context of the RESPECT study and as mentioned by the study participants during the in-depth interviews refers mostly to STI testing. HIV tests were performed only at the baseline visit and the 12-month visit of the study while STI tests were performed at all study visits (4 times in total). What emerged as particularly important to the study participants was the regular opportunity to learn about their health status. Every four months all study participants received information about their own health and their partner's health if their partner was enrolled in the study and willing to share their results. These results, as the data illustrate, translated into information about the risks participants face in their relationships. So while HIV testing is important, and in some ways the ultimate test of health status and risk exposure, the opportunity to repeatedly check health status using a proxy measure for sexual risk was of paramount importance.
The qualitative data also reveal that condom use is frequently viewed as a temporary strategy for risk reduction until some preferred strategy is made available. Condom use is often situational, sometimes based on objective evidence of the risk level of the partner, and sometimes based on a general feeling of trust. This man in the cash award group discussed how he and his partner use condoms between opportunities to test, especially when one of them has been away from the home for some time.
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Some participants discussed how they find it difficult to trust potential partners when they say they have tested negative, and show concern if the most recent test was several months ago. Others mentioned that they were fine with just a verbally communicated result. . To show how study participants negotiate risk, we illustrate with several examples. The first comes from a 28 year old unmarried man in the low-value cash award group who used condoms with his partner until they could both get tested with good results.
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Testing to assess risk is not a strategy limited to partner selection, but is also used to assess the risk level of a current partner, as is illustrated above, or to prove to a partner that he or she is in fact risky. This interview excerpt is from a 29 year-old married woman enrolled in the RESPECT study.
-Married woman, cash award group, 4 month visit
This passage highlights the centrality of testing as a risk reduction strategy within a marriage, where condom use is not an option. This woman discusses the importance of having the actual test results in hand so that she can use them as leverage to get her husband to test, and as a result of his test results, she can convince him to change his behavior. The power of persuasion in this case lies in the test results and the ability to show a partner that he or she is risky with authority.
Our data reveal that regular testing alone and in combination with condom use is a risk reduction strategy used to facilitate the problematic issue of understanding the risk level of a current or potential partner. The information that test results provide brings some certainty to relationships that, as regards risk of infection, are often filled with ambiguity. The new information and knowledge that comes from test results can also create opportunities for negotiating safer sex where previously little agency in decision-making existed—testing is important both for risk assessment as a bargaining chip in sexual negotiations.
A second insight that came out of the qualitative data and the discussions about strategies to avoid unsafe sex related not to a specific strategy, but rather to how and when strategies were implemented. Risk avoidance was often practiced inconsistently and episodically. This was especially true for women who faced the barriers discussed in the Introductory section; women who much of the time lacked sexual decision-making power in their relationships. During their interviews, these women talked about how they took measures to reduce their risk of infection when they felt they could–if an opportunity arose that temporarily gave them increased agency, they took that opportunity to protect themselves. These opportunities included circumstances or situations that provided women with increased knowledge, and as a result, added leverage with which to negotiate with their partners. Specifically, added leverage arose within the RESPECT study from the cash incentive and STI testing status knowledge. More broadly outside the context of RESPECT, other situations could provide opportunities for women to refuse sex or enforce condom use—such as after having a baby, or when a husband or partner felt guilty about being with another woman. One 19 year-old married woman explained how she is sometimes able to convince her husband to use condoms.
–Married woman, control group, 4 month visit
One possn is taking action when she feels she has leverage to take action. She understands that she can still be infected if she uses a condom today but not tomorrow, but she also understands that she needs to be strategic about when she can implement her prevention efforts. Another possible interpretation is that she is angry about her husband staying out late with other women and when this situation presents itself, it gives her an opportunity to confront him and perhaps to discourage his infidelities.
Some women used the RESPECT award cash to help extract themselves from risky sexual behaviors and relationships that had been driven partly by economic constraints. This woman who lives with her partner talked specifically about how the cash award associated with the study has allowed her to leave other men because the money from the study will help her in her life.
R: Changing men from time to time. All this was because of problems
I: Over the period of four months ago have you had multiple sex partners?
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Others used their enrollment in the study as a leverage point to achieve goals that they had previously (such as getting their husbands to be more faithful), and were able to successfully avoid sex or enforce condom use as a result. Joint strategizing between couples enrolled in the study was also mentioned by both men and women in the cash award groups. If a woman's partner or spouse is enrolled in the study, the couple might discuss staying safe together so that both of them can receive the award, and the woman might have more leverage, backed by the money that they will both receive, to convince her husband to leave outside partners or use condoms with outside partners. This example from a woman in the cash award group illustrates how enrollment in the study and the promise of the reward provided an opportunity for her to discuss the issue of safer sex with her husband.
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Outside of the RESPECT intervention mechanisms, other points of leverage for women to gain some agency in sexual decision-making include recently having had a child, or being infected with an STI. Because it is common not to resume sex for some time after a baby is born, women who have just given birth are in a position of having the ability to refuse sex without consequences, and can then attempt to extend this abstinence—though only temporarily. Having this temporary power to refuse sex with husbands may be especially important for married women who know that their husbands have other partners, but are not sure if he uses condoms with his external partners. Adding the RESPECT STI testing to this situation could further help women convince husbands that there could be real consequences to his own risky behavior during her postpartum abstention.
Temporary abstinence is a risk reduction strategy that, depending on the circumstances, is likely to be limited in its effectiveness in preventing HIV infection. However, what emerges from the data is that given the range of strategies available, individuals in this setting are at least as likely to rely on temporary abstinence as they are on condom use. Temporary abstinence could include divorce (in its most extreme form), temporary physical separation from a partner, enforcing no sex for several months after the birth of a child, enforcing no sex after a positive STI test, or enforcing no sex because of the recognition that a husband has been out with another woman.
If discussions of condom use, either within the marriage or with external partners, were ineffective, one option is to physically separate themselves from their husbands temporarily to lower risk. In the case of this 27 year-old married woman, simply the threat of separating their beds convinced her husband of the importance of avoiding having external partners.
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The negative test results were enough to convince this woman that her husband had listened to her and was not “moving around” (engaging in sexual relationships with other women). This example again illustrates the importance of the test results in establishing trust with a partner—either for partner selection, or building trust with a current partner. For others though, a test result is not enough to convince a partner to change his or her behavior, or even to get tested. In this case, physical separation from a partner is sometimes the only option.
This passage from one of the diaries in May of 2009 documents a conversation between two women, one of whom is convinced she has an STI and wants her husband to get tested so they can both take treatment.
This example uncovers two alternative strategies–physical separation from an uncooperative husband, but also using social networks and connections to help with convincing a partner to understand the consequences of his actions and perhaps change as a result.
The next step after temporary separation is permanent separation or divorce–another form of temporary abstinence, in many cases a more realistic strategy for risk reduction, for both the wife and the husband, than convincing a partner to use condoms within the marriage. Work done in Malawi has shown that divorce has increasingly become more common overall, and marital dissolution has increasingly been implemented as a strategy to protect oneself from an unfaithful spouse and from HIV
Both women and men enrolled in the RESPECT study discussed having used this strategy in the past to separate themselves from a partner they perceived as risky. Female participants in the cash award groups also sometimes discussed divorce as an extreme strategy they might need to implement in order to stay safe within the context of the RESPECT trial, and to ensure that they would be eligible to receive the award—though this seems unlikely given that participants were only enrolled in RESPECT for one year. Other women are clear that they do not see divorce as an option at all, and are resigned to the reality that facing risk from their husband is part of the marriage experience. This 29 year-old woman left her first husband (in the past, prior to the RESPECT trial) because she was worried that he would bring infection into their marriage.
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This next woman also appears serious in considering divorce as an option as she exploits the new opportunity arising from RESPECT′s STI testing program to convince her husband to either leave his external partners, use condoms with his external partners, go for testing, or use condoms within the marriage. This married woman discusses her frustration in trying to convince her husband to either use condoms with her in the marriage or to go for testing.
–Married woman, cash award group, 4 month visit
It is notable that safe sex in this excerpt, and often in the interview transcripts, refers not to sex using a condom, but sex with someone who has proven through testing or through verbal acknowledgment that they are safe.
Another woman discussed her difficulty in trying to convince her husband to use condoms even though she knew that he had other women. Part of the difficulty, as she mentions, had to do with the expectations around having children and how using a condom when more children were expected was not an option.
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For other women, divorce or separation is not part of the menu of available strategies. They may be financially constrained from leaving their husbands, or because of the emotional attachment leaving may be too difficult.
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Younger, single men often discussed exercising sexual control through avoidance—either avoidance of sex or avoidance of situations that might lead to risky sex, for example those with alcohol. Another path of avoidance mentioned frequently was keeping oneself occupied with other activities, such as exercise, studying, and or working on their farm, so that little time remained to focus on meeting women and sex. Such avoidance was preferable to consistently using condoms with partners–these men found it more realistic to avoid sex than to trust themselves that they would use a condom every time. This excerpt from a single man enrolled in the RESPECT study illustrates these strategies.
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What emerges from these data are that in this context, while episodic use of condoms and abstinence are likely similar in their limited effectiveness in HIV prevention, individuals in this setting are at least as likely to rely on temporary abstinence than they are on temporary condom use. Temporary abstinence is not a reliable means of preventing infection. However, refusing or avoiding sex at certain opportune moments or under specific circumstances is an intermediate strategy that over time might lead to more permanent strategies for risk reduction. If, for example, enforcing temporary abstinence by sleeping in separate beds or refusing sex if a partner comes home late at night is perceived as punishment, this intermediate strategy could eventually lead to a partner changing his behavior. Sexual behavior change is slow at best, and implementation of intermediate strategies such as temporary abstinence is both a means of gaining transient control, and perhaps a method of pushing for change through increased control.
By exploring how study participants responded to an economic incentive to remain STI negative, this analysis adds to our current understanding of approaches to risk reduction by highlighting the often opportunistic and episodic implementation of strategies by women who face behavior change constraints
The analysis is particularly helpful for understanding mechanisms through which behavior change occurred in the RESPECT trial. Both the cash awards and the receipt of STI test results through RESPECT provided opportunities for attempting behavior change. Simply being enrolled in a study that repeatedly provided the ability to check one's health status, and the promise of the cash incentive for testing negative for those in the cash award groups, provided participants with added negotiating power in their sexual relationships. In fact, the repeated testing became part of the strategy in some cases as the combination of targeted condom use, testing and treatment was sometimes implemented as a three-pronged approach to decreasing risk of infection. Having a back-up for condom use is important in a society where condom use carries with it such strong meaning about the type of relationship
Temporary abstinence, in its many forms, also emerged as a more prevalent strategy than expected. The apparent popularity of this approach may be a result of the negative associations with and low levels of use of condoms within long-term serious partnerships. The data presented here suggest that abstinence is a favored strategy over condom use in certain situations–among young single people, among women who have just had children, and among women who can argue that they have been put at risk by their husbands. Married women seem to be more likely to be able to abstain from sex with their husbands in order to at least temporarily reduce their risk of infection than they are to insist on condom use. This is of course an imperfect strategy for protecting their own sexual health, thus it will be important for future educational efforts to ensure that women understand the limited situations in which this can protect them from infections.
The present analysis was not designed to definitively establish the relative importance of cash awards versus STI testing in providing opportunities and tools for behavioral change. The quantitative evaluation results previously published indicate that RESPECT′s high value cash award arm did experience 27% fewer STIs than the control arm; since testing was available to both arms, this difference is likely attributable to the cash awards
Lessons for adopting STI testing interventions beyond a RESPECT-style intervention are more difficult to ascertain. Regular, comprehensive STI testing is a costly intervention; alternatively, using a less comprehensive testing regimen could undermine women's ability to use the testing for the purposes of risk assessment (and could even raise risks due to inaccurate infection information). STI testing has often been considered an intervention targeted at identifying positive individuals so as to provide them treatment (or more controversially, to reduce HIV transmission probabilities
A deeper understanding of how cash awards and STI testing was perceived and acted on would help in structuring related new intervention models. The opportunities provided by the RESPECT study may have altered perceived behavioral control and self-efficacy among women enrolled in the trial, thus temporarily facilitating behavior change
This study brings with it some limitations. As with any study that includes self-reported sexual behavior as a data source, there is the possibility that unsafe sexual behaviors were under-reported. Plummer et al report on the validity of the collection of sexual behavior data using five different methods from a study done in Northern Tanzania
An additional limitation relates to the translation and transcription of audio-taped interviews. There is the potential for the content of the interview to lose meaning and nuance during the transcription and the translation process. We addressed this limitation to some degree by having one of our study interviewers (who is bi-lingual) review the transcripts and translations within two weeks of the actual interview, and revise the transcripts as necessary. This method still suffers from a secondary but related limitation; that is the revised translated transcripts are an interpretive process, wholly dependent on the perception of the interviewer. Limitations related to the use of the village diaries should also be noted. The pay for the diarists may have motivated them to seek out situations in which HIV and/or the study is being discussed
Loss of the 14 of the qualitative transcripts during the first round is an additional limitation of the study. The recordings were inadvertently deleted while the team was out in the field and could not be recovered. While this does not pose a problem in relation to bias since there was no systematic loss of data, it is a limitation in that we lost data that would have contributed to our findings and results, but the limitation is minor given the large number of qualitative interviews analyzed. The purposive sampling to select more candid respondents in the subsequent follow-up visits is an additional limitation in that this type of selection may have introduced a bias. By selecting those respondents who were more open to discuss their strategies for avoiding unsafe sex, we may have also selected respondents utilizing particular types of strategies over and above other strategies. This may have systematically influenced our findings, although we have no evidence of this happening.
Our data suggest that when opportunities to implement risk reduction strategies present themselves, they are regularly taken. The qualitative data point to the importance of not only the cash incentive, but also the access to regular, reliable testing and knowledge of health status in opening opportunities to discuss risk reduction strategies with partners and as leverage in negotiating and implementing risk reduction strategies. With the understanding that behavioral change strategies are a necessary but not sufficient means of preventing HIV, the RESPECT approach may have acted as a combination HIV prevention intervention. Our results suggest that RESPECT′s structural cash intervention and the testing component worked synergistically to assist men and women with opportunities to better act on behavioral change intentions, thus potentially increasing the effectiveness of traditional behavior change interventions as well.
We thank Carol Medlin, Ann Swidler, the RESPECT Study Team, and many others for their contributions to the project. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent.