The Demand for and Impact of Learning HIV Status in Malawi

 

Nearly 12 percent of Malawian adults are infected with HIV/AIDS, giving the country the 9th highest prevalence in the world.³ In the face of this epidemic, government officials and NGOs face an urgent need to develop effective programs to halt the transmission of the disease, including testing and counseling interventions. Underlying the emphasis on HIV prevention through testing are two assumptions – that those diagnosed HIV-positive will take precautions to protect others, and that it is naturally difficult to get people to learn their HIV status, possibly due to psychological or social barriers. Because of this second assumption, expenditures on social marketing to de-stigmatize infection and promote treatment are generally assumed to be necessary.

 

Eleven percent of adults in Malawi are infected with HIV/AIDS, giving the country the 9th highest prevalence in the world.¹ Although the HIV prevalence rate in the sample area was considerably lower than the national rate, at 6.3 percent , it was comparable to, or greater than, the prevalence rate in much of sub-Saharan Africa. For comparison, in 2009, the HIV prevalence rate in Kenya and Sierra Leone was 6.3 percent and 1.6 percent, respectively.¹

 

Although the national HIV prevalence rate has decreased over the past decade in Malawi, hundreds of people are still infected each day. In 2009, there were 73,000 new HIV infections in Malawi.¹ In the face of this epidemic, policymakers and NGOs face an urgent need to develop effective prevention programs, including voluntary counseling and testing (VCT) interventions. Although surveys in several African countries report that over two-thirds of individuals who did not know their HIV status would like to get tested, the proportion of adults who actually utilize the available testing services is much lower, below 15 percent in some areas. Even when individuals choose to have an HIV test, many do not return for their results. In clinics across Africa, only about 65 percent of individuals returned to learn their result after being tested.

 

Impact of Monetary Incentives and Distance: The demand for HIV test results among those who received no monetary incentive was fairly low, with only 35 percent  of those tested collecting their results. However, monetary incentives were highly effective in increasing result-seeking behavior. On average, respondents who received any cash-value voucher were twice as likely to go to the VCT center to obtain their HIV test results as those who received no cash incentive. Although the average incentive was worth about a day’s wage, even the smallest amount, about one-tenth of a day’s wage, resulted in large attendance gains. Distance also had a significant impact on the likelihood of obtaining HIV test results. Those living more than 1.5km from the VCT center were 3.8 percentage points, or 6 percent, less likely to collect their results than those living within 1.5km.

 

Peer Effects: The presence of social networks had a significant impact on the likelihood of learning one’s HIV status. Specifically, a 10 percentage point increase of the percentage of neighbors (approximately 2.4 individuals) learning their HIV test results increased the probability of learning HIV results by 1.1 percentage points. This effect was greatest for neighbors living within close geographic proximity and for those living further away from the HIV results centers. In contrast, religious networks had no significant impact on learning HIV results.

 

Impact on Sexual Behavior: Learning HIV status did not significantly affect condom purchasing behavior for most people. Overall, 24 percent purchased at least one condom; among those who purchased any, the average number purchased was 3.7. Among sexually active individuals, on the other hand, receiving an HIV positive diagnosis significantly increased the likelihood of purchasing condoms. However, the overall magnitude of the effect was small. On average, sexually active individuals who learned they were HIV-positive purchased only two more condoms than HIV-positive individuals who did not learn their results.

 

Impact on Subjective Beliefs and Economic Behavior: Although learning HIV results had a short-term effect on subjective beliefs about the likelihood of HIV infection, it had no long-term impact. Accordingly, obtaining either HIV-positive or negative results had few significant effects on longer-term economic behavior. Two years after receiving their results, there were few significant differences between HIV-positive and HIV-negative individuals in propensity to save, amount worked in the past 6 months, income, or expenditures.

 

In 2006, 92 percent of respondents agreed to be tested, of whom 98 percent received their results. This compares to the VCT program in 2004, where 91 percent of respondents agreed to be tested, but only 69 percent of all respondents ever received their results, and only 34 percent of respondents receiving no monetary incentives collected their results. Semi-structured interviews with a subset of the sample and observational data suggest that the large proportion of respondents who consented to be tested in both 2004 and 2006 was likely due to respondents’ strong preference for door-to-door testing, because it was convenient and confidential. Door-to-door testing removed the obstacle of travel, which is time-consuming and costly, and provided much more privacy than a hospital. The VCT counselors also came from areas outside of the sample villages and were, therefore, not familiar with the respondents prior to testing.

 

Both of these factors – convenience and confidentiality – can also help to explain the significant increase in the proportion of respondents who received with results in 2006. In addition, respondents reported that they highly preferred the rapid blood test. The rapid test ensured that their results had not been tampered with and/or confused with someone else's; it also eliminated the anxiety of the waiting process. Respondents also favored the rapid blood test because it convinced them of the accuracy of their test result. The red line(s) on the test kits allowed respondents to see their test result with their own eyes, rather than having to trust that the counselor was reporting the correct results. Furthermore, the method of disposing the test kits in front of the respondent was also seen as an advantage, as it ensured that the evidence of the test itself was removed permanently.

 

¹  UNAIDS (2010) “UNAIDS Report on the Global AIDS Epidemic.”

 

Angotti, Nicole, Agatha Bula, Lauren Gaydosh, and E. Yeatman. 2009. "Increasing the Acceptability of HIV Counseling and Testing with Three C's: Convenience, Confidentiality, and Credibility." Social Science & Medicine 68(12): 2263-70.

Godlonton, Susan and Rebecca Thornton. 2012. “Peer Effects in Learning HIV Results.”Journal of Development Economics 97: 118-129.

Godlonton, Susan, and Rebecca Thornton. "Marital Investment under Uncertainty: Couples HIV Testing and Marital Stability." Working Paper, April 2013.

Godlonton, Susan, and Rebecca L. Thornton. 2013. "Learning from Others' HIV Testing: Updating Beliefs and Responding to Risk." American Economic Review Papers and Proceedings 103(3): 439-44.

Thornton, Rebecca L. 2008. "The Demand for, and Impact of, Learning HIV Status." American Economic Review 98(5): 1829-63.

Thornton, Rebecca. 2012. “HIV Testing, Subjective Beliefs and Economic Behavior.” Journal of Development Economics 99(2012): 300-13.