On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.102 n.1 Cape Town Jan. 2012
Critics 'chew' furiously on Zille's HIV/drug-testing 'carrots'
Feisty Western Cape Premier Helen Zille saw out 2011 in a firestorm of protest over pilot and planned provincial lotteries offering potential cash prizes to anyone who tested for HIV and (negative for) drug abuse, claiming 'persuasion' had so far proven to be a blunt instrument.
The fuse to a series of rhetorical explosions by respondents as varied as the public sector committee of the South African Medical Association (SAMA), the Treatment Action Campaign (aka Section 27), and various topical HIV pandemic authors was lit by a keynote speech Zille gave at her health department's first-ever Wellness Summit in early November. Fuel was added to the fire by several incorrect reports of her address (including that she intended refusing ARVs to HIV-positive men who had sex without condoms or without telling their partners). However, it was incentivised testing and South Africans' bedroom behaviour that injected what one celebrated HIV/AIDS author, Helen Epstein, described as 'hopeful openness' into the ongoing local AIDS prevention debate.
Zille claims South Africa is in the grip of a new AIDS denialism that can only be addressed by confronting the 'root causes' of the HIV pandemic: the culture of multiple concurrent sexual partners and inter-generational sex that creates an 'AIDS super-highway'. She's also calling for HIV-positive individuals who knowingly have sex with one or more partners without disclosing their status to be criminally charged. Her administration will investigate ways of requiring people to know their status, she says. Until individuals took their responsibility as seriously as her government, which provided 'one of the most advanced free treatment and condom distribution systems in the world', South Africa could not beat HIV/AIDS. To address this abrogation of personal responsibility, her government was adapting cutting-edge behaviour change strategies based on work by pioneering experts from Duke and Harvard universities, who late last year led 'brainstorming' sessions with her key departmental heads and staff.
The building blocks of Zille's approach
Zille's lottery idea is based mainly on the work of Dan Ariely, Professor of Behavioural Economics at Duke University and author of Predictably Irrational: The Hidden Forces that Shape our Choices,1while her intended criminal crackdown on HIV-positive people (who knowingly have sex without condoms or telling their partners) is based on work by Epstein, author of The Invisible Cure: Why we are Losing the Fight Against AIDS in Africa.2Epstein coined the phrase 'AIDS superhighway' to describe the turbo-boosted spread of HIV through a network of concurrent sexual partnerships - something she believes explains the higher HIV prevalence in eastern and southern Africa. Epstein says that while Americans actually have more partners over a lifetime than Africans, they are 'serially monogamous' and thus have many more partners one after another - so avoiding entrapment in an HIV-positive network. Africans, however, are more likely to have a small number - 'perhaps two or three' ongoing partnerships at a time.
Zille told journalists that until November last year persuasion had met with very limited success in getting people to test for HIV, while with teenagers, both persuasion and 'reality check' or scare tactics (showing the devastating effect of drugs) had failed to have the required impact.
Her health department's brainstorming sessions, facilitated by the Harvard think-tank 'Ideas42', came up with two very large behaviour-change 'carrots', the first a pilot HIV testing lottery timed to coincide with the 'Sixteen Days of Activism for No Violence Against Women and Children' in November/December last year and the second, a drug/alcohol-free testing lottery aimed at schoolgoing teenagers (still in the pipeline at the time of writing).
The former offered Cape Metropole residents a chance at a R50 000 first prize and five runners-up R10 000 each for taking an HIV test at specific provincial health sites, with winners' names released by consent and proper test counselling provided. The latter, due this year, intends to offer school pupils a monthly chance at winning major shopping voucher prizes, provided they rack up an 85% attendance at the growing network of extracurricular Mass Opportunity Development (MOD) centres across the Cape Metropole over six months - and test drug/alcohol free. The MOD centres are intended to offer an alternative to the alltoo prevalent after-school pursuits of drug taking and drinking, sex and violence that shatter communities, but until now have been shunned by those they are designed for.
'Cutting edge' behavioural economics
In her speech Zille said: 'The point is to create a significant incentive to stay drug/ alcohol free. It will be cheap at the price when you see what we spend on drug and alcohol rehabilitation (budget recently doubled to just under R70 million a year). We could use some of these funds for Wellness programmes rather than have these kids cause devastation to themselves, their families and communities'. Zille's address to the Wellness Summit centred on the skewed context in which R2 billion is spent annually on HIV/AIDS as part of South Africa's globally acknowledged prevention and treatment campaign while few people challenge a predominant sexual culture that helps drive the pandemic.
'How is it possible to claim that we are out of the denial of the Thabo Mbeki era when our current president's behaviour exemplifies the AIDS superhighway and nobody says anything? The government's role is to provide preventive and rehabilitative care for AIDS - but every individual has personal responsibility for preventing AIDS and not spreading it,' she added. She cited numerous examples of how money saved through effective behaviour change would help prevent disease and boost the now nationally promoted Wellness approach to healthcare. It was especially 'ironic' that people rejected the 'nanny state' when it asked them to behave responsibly, but ran to it when they couldn't cope with the consequences of their behaviour.
SAMA spokesperson 'out of touch' - Zille
SAMA's public sector committee chief, Dr Poppie Ramathuba, called for a boycott of Zille's campaign, saying it undermined the poor, medical professionals and 'all the hard work that has gone into destigmatising HIV in South Africa'. She labelled what she called the 'Get Tested and Win' campaign as 'inappropriate and medically unethical' and questioned its sustainability. Politicians needed to probe the 'real reasons' that kept people from testing (i.e. stigma). Zille, by implying that HIV was 'only among the poor', was discriminating in the context of a disease that knew no such discrimination, Ramathuba added. Zille hit back, saying medico-legal advice was an integral part of campaign planning while patientpractitioner confidentiality was guaranteed. Zille described SAMA's call for a boycott of testing as 'both outrageous and unethical, adding that Ramathuba and her colleagues were 'clearly unfamiliar with behavioural economics, for which they can be forgiven as this is an emerging field of knowledge at the cutting edge of social innovation'.
Mark Heywood, Director of Section 27 (including the TAC), said creating artificial incentives would not overcome the real reason for people not testing for HIV. Campaigns for HIV testing should run for 365 days, not just 16. Patrick Solomons, director of child rights group Molo Songololo, said the competition 'smacks of cheap publicity' and such money should rather be spent providing testing services in under-served areas. Epstein, in a lengthy article responding to Zille's initiatives, confirmed the sexual partnership theory upon which Zille based her approach but warned that 'partner reduction cannot be coerced'. She said the programmes she had called for in her book were 'precisely the opposite of Zille's'.
'Rather it's a negotiated adjustment that must make sense within a particular culture - the greatest obstacle to such adjustments are shame and denial which inhibit open discussion of sexuality, relationships and risk,' the author wrote. Such discussions needed to take place in an atmosphere of 'compassion, urgency and pragmatism'. Epstein said the hypothesis of her book, based on research by epidemiologist Rand Stoneburner and Daniel Low-Beer, was that in South Africa, where the epidemic and its victims had long been especially stigmatised, such personal, frank discussions had been suppressed, 'with catastrophic results'. Epstein said she was optimistic for South Africa, partly because the response to Zille was so vociferous. 'If it gets people talking about AIDS and other things - that can only be hopeful,' she said.
Incentivised HIV testing using free bread for individuals and a free winter jacket for anyone enrolling 10 others into being tested helped garner Mpumalanga Province's Dr Kolawole Adigun the 2011 South African Rural Doctors Associations' Rural Doctor of the Year award. His carefully crafted, widely consultative campaign has been hugely successful so far.3 The 2008 intervention by the Men By the Side of the Road charity, which offered unemployed men R75 to test for HIV, had a 100% uptake in the group it targeted, along with a waiting list in the thousands. The Discovery Health/Sunday Times Right to Know campaign (July 2008 - June 2009) attracted 55 000 volunteers for testing, thanks to the promise of one person per month becoming R100 000 richer. Longer-term trials such as the three-year J-PAL immunisation intervention in rural India, met with similar success. Offering parents 1 kg of lentils and a set of metal meal plates upon completion of a course of immunisation for their child resulted in a more-than-doubled immunisation rate at half the cost, thanks to economies of scale resulting from increased uptake.4
Whatever the outcome of the latest initiative, Zille, an award-winning former journalist and mayor of Cape Town, has single-handedly moved the locus of the HIV testing debate.
1. Ariely D. Predictably Irrational: The Hidden Forces that Shape our Choices. London: HarperCollins, 2008. [ Links ]
2. Epstein H. The Invisible Cure: Why we are Losing the Fight Against AIDS in Africa. New York: Picador, 2008. [ Links ]
3. Bateman C. Ubuntu values lived out by rural award winner. S Afr Med J 2011;101(12):862. [ Links ]
4. Rousseau J. Get tested: get off the entitlement horses and give it a chance. Daily Maverick, 1 December 2011. [ Links ]