Have halted by 2015 and begun to reverse the spread of HIV/AIDS
Achieve by 2010 universal access to treatment for HIV/AIDS for all those who need it
Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases
Some impact evaluations have forced a rethinking of our assumptions about HIV/AIDS. Development interventions are often designed on the basis of certain assumptions, particularly for HIV/ AIDS—an area where knowledge has grown by leaps and bounds, especially over the past decade. Impact evaluations have contributed to that learning, and some evaluations have shown how erroneous these assumptions can be. Here are a few examples.
Assumption: Promoting Knowledge of HIV/AIDS Will Reduce Risky Behavior
Information and education campaigns have been the main focus of HIV/AIDS prevention campaigns. Although they have improved knowledge and self reported behavior, their apparent impact on behaviors may actually be the result of a reporting bias fueled by the people’s greater knowledge of what they would need to do to reduce their risk, rather than a reflection of substantial changes in actual behaviors. Two recent meta-analytic reviews show that only a small fraction of behavior change interventions had an impact on HIV or other sexually transmitted infections. Information needs to be better targeted and packaged to have an impact on actual behavior. Nor is more information necessarily better. Consider a program that sent text-message reminders concerning adherence to antiretroviral treatment: weekly reminders improved adherence, daily reminders did not. People got habituated to them or perhaps considered them intrusive.
Assumption: More HIV Testing Will Lead to Declines in Risky Behavior
HIV testing is one of the key policy responses to the HIV/AIDS epidemic in Africa, but there is little rigorous evidence on how individual sexual behavior responds to testing. Impact evaluations from East Africa produce three findings. First, individuals surprised by an HIV-positive test are more than five times more likely to contract a sexually transmitted infection than are members of a similar untested control group, indicating an increase in risky sexual behavior. Second, individuals who believed they were at high risk for HIV have a 60 percent decrease in their likelihood of contracting a sexually transmitted infection following an HIV-negative test, indicating safer sexual behavior. Third, when HIV tests agree with a person’s belief of HIV infection, there is no statistically significant change in contracting a sexually transmitted infection. Using the distribution of beliefs of HIV infection and prevalence from the study, the evaluation finds the overall number of HIV infections to increase by 25 percent when people are tested, compared with when they are unaware of their status—an unintended consequence of testing.
Assumption: It is Usually Stigma that Prevents People from Picking Up HIV Test Results
It is often argued that getting people to learn their HIV status is crucial for fighting HIV/AIDS, but that stigma and fear of obtaining a positive result create a major barrier preventing people from picking up their results at testing centers. An impact evaluation in Malawi found, however, that small incentives and deadlines were enough to induce people to do this.c Distance to the center was also a key determinant of attendance. These findings suggest that procrastination and the inconvenience of travel, rather than stigma, explain much of the problem.
Assumption: People Who Test Positive Will Reduce Their Risky Behavior
Although people can behave altruistically once they know they are HIV-positive, they may also show disinhibition behavior because they have less to lose when engaging in risky behavior. A recent study in Mozambiqued found that risky sexual behaviors increase in response to the perceived changes in risk associated with greater access to antiretroviral therapy. So, scaling up access to antiretroviral therapy without prevention programs may not be optimal if the objective is to contain the disease because people would adjust their sexual behavior in response to the perceived changes in risk.