Sandra Tembo walks past a billboard on her way to Mbare vegetable market in Harare, Zimbabwe, that gives advice she says friends can’t afford to follow: “Your future is brighter without a sugar daddy.”
“I’m sure they realize the risk,” Tembo, a 20-year-old dressmaking student, said of the friends. “But they say being broke all the time also has its dangers, as you could starve.”
African girls who sell themselves for sex to older men, known as sugar daddies, are fueling an AIDS epidemic in Sub-Saharan Africa, home to two-thirds of all people infected with the HIV virus. Young women in the region have HIV infection rates three times higher than young men: 3.4 percent of women aged 15 to 24 and 1.4 percent for men in the same age group.
Now the World Bank is proposing to pay girls like Tembo’s friends as an incentive to keep them in school and prevent AIDS. Cash may be the “ethical policy instrument” of the 21st century, said Mead Over, a health economist at the Center for Global Development, a research organization in Washington.
“It is obvious, but it never occurred to anybody to give girls cash to help prevent transactional sex,” Mayra Buvinic, the World Bank’s director of gender and development, said in an interview. “They needed money and, you know, since they got money, they didn’t need to interact with older men.”
The World Bank led a study in Malawi, where about one in eight adults has the incurable illness. About 3,800 schoolgirls and school dropouts aged 13 to 22 were enrolled.
One group got an average of $10 a month and payment for school fees if they regularly attended class. The others got nothing. A year and a half after the program began, infection rates were 60 percent lower among schoolgirls who got cash: 1.2 percent, compared with 3 percent.
Buvinic said the payouts are the first non-biomedical approach to AIDS prevention that she knows of that had a “significant effect.” Biomedical techniques like male circumcision have been shown to reduce the risk of infection.
In the Malawi study, 25 percent of the girls who were sexually active at the start of the program said they had relationships because they “needed his assistance” or “wanted gifts/money.” Nine out of 10 of the sexually active schoolgirls said they got an average of $6.50 a month from male sexual partners. Malawi’s gross domestic product per person was $339 in 2009, compared with $45,934 in the U.S., according to the IMF.
The program found a delay in the onset of sexual activity among beneficiaries and a reduction in the number of partners among those who remained sexually active. The frequency of sexual activity was also reduced among beneficiaries, according to the World Bank report. After a year, schoolgirls receiving payments had men as partners who were two years older on average, rather than three years for the control group.
HIV prevalence rises from less than 5 percent among 15 to 19-year-old Malawian and Zimbabwean males to about 20 percent among 30 to 34-year-old Malawian men and about 30 percent among Zimbabwean men in that age group, according to the U.S. Agency for International Development.
The World Bank wants to repeat the test elsewhere in Africa, Buvinic said: “The potential could be huge to reduce HIV rates in teenage girls.”
The bank announced at the International AIDS Conference in Vienna last July that it had carried out cash-incentive programs to prevent AIDS in Malawi and Tanzania. While the Malawi test compensated girls for staying in school, the Tanzania test incentivized adults by paying cash when they tested negative for a group of sexually transmitted diseases.
Berk Ozler, the World Bank economist who worked on the Malawi project with Sarah Baird of George Washington University and Craig McIntosh at the University of California, San Diego, declined to comment for this story because a peer-reviewed journal is assessing the results, spokeswoman Jane Zhang said.
Girls who have sex with older men “contribute significantly” to the spread of AIDS because they have a much greater risk of infection, said Esther Etkin of loveLife, South Africa’s biggest AIDS-campaigning organization. Men who have multiple partners, prostitution and women forced to have sex against their consent are also causes of infection, she said.
Some girls also have relationships with older men because of peer pressure from friends “who seem to be enjoying” such partnerships, said Chrissie Gondwe, a nurse who works in Malawi for Canadian non-profit Dignitas International.
Rosemary Zulu recalls how married men in her native Zambia would show up at the end of the day at high school in Lusaka to chauffeur away teenage girls who were sleeping with them in exchange for gifts of clothes, cash and mobile phones.
“It takes a very strong teenager to take the pressure,” said Zulu, 26, who trains young Zambians to teach sexual and reproductive health for Restless Development, a London-based non-profit. “Even taxi drivers come with gifts for girls in return for sleeping with them.”
Zulu and loveLife’s Etkin are wary of financial incentives.
“We try to get people to tap into their own sense of self worth and intrinsic motivation rather than wait for handouts,” Etkin said.
The subject draws strong feelings on both sides. More than 350 people viewed a Feb. 14 online debate at the World Bank entitled “The Ethics of Material Incentives for HIV Prevention.”
Cash incentives may be cost-effective when measured against the estimated $500 billion that donors have committed to treat the AIDS epidemic through 2050, the Center for Global Development’s Over said.
“Material incentives can bring the rewards of the distant future more tangibly into the present,” said Julia Kim, an expert at the United Nations Development Programme. “Money matters.”
Peter Lamptey from Ghana in West Africa disputed Kim and Over’s view. Lamptey, a public health physician at the non-profit group Family Health International, said Africa can’t afford cash payouts.
“Medical incentives aren’t for us,” Lamptey said. “You can keep them in Washington. We could end up creating an environment of dependency that cannot be sustained.”
Using money to achieve health and educational goals has been employed in countries from Mexico to Brazil and has won unlikely advocates, including Dambisa Moyo, the Zambian former World Bank and Goldman Sachs Group Inc. economist.
In Moyo’s 2009 book “Dead Aid,” she challenged the African aid lobby, led by rock stars such as Bono and Bob Geldof, by arguing that trade rather than handouts will lift Africans from poverty. This kind of payout, she says, may be different.
“There are a lot of reasons why we would find such a system abhorrent,” Moyo said of so-called conditional cash transfers at a Feb. 1 lecture in London. “Given where we’ve got today, nothing is off the table.”
Applying the incentive to influence sexual behavior may be “massively dangerous,” according to Sophie Harman, a senior lecturer in international politics at London’s City University who has studied World Bank AIDS policies.
Harman was visiting the World Bank’s office in Dar es Salaam, Tanzania, in 2009 where she saw a confidential report on the Tanzanian test to incentivize adults.
“I was shocked,” Harman said. “Paying people to influence their sexual behavior won’t solve the wider problems of abuse, esteem, neglect and inequality that cause them to get HIV.”
The Zimbabwe billboard near the densely populated township of Mbare was put up by Washington-based non-profit group Population Services International. “Only you can stop the sexual network. You can do it,” the advertisement says.
Advertising the problem isn’t enough, said Tembo, the Zimbabwean dressmaking student.
“They only show that sugar daddies are a problem, without offering solutions to the problems that make the sugar daddies attractive to the girls,” she said.