Who Changes How: Strategies and Motivation for Risk Reduction Behaviors in the Context of an Economic-based HIV Prevention Intervention in Tanzania
The lack of success of traditional, individual-level HIV prevention interventions has contributed to the increase of structural interventions for HIV prevention. One such intervention is the use of conditional cash transfers (CCTs) to motivate sexual behavior change. CCTs have been success-ful in other areas of health behavior change, but have only recently been used to promote safer sex among populations at risk for HIV infection. Drawing on both quantitative and qualitative data from an HIV prevention trial in Tanzania that used cash awards to create incentives to engage in safer sexual behaviors (the RESPECT study), this dissertation--made up of three papers--explores strategies and motivation for risk reduction behaviors among study participants. The first paper explores anticipated and reported sexual behavior change of participants enrolled in the RESPECT study to understand who changes, how they change, and what factors drive such change or lack of change. The second paper draws on in-depth interviews from participants enrolled in the study and diary entries from village diarists RESPECT study in Tanzania to illustrate difficulties inherent in staying faithful to one of the Abstinence-Be Faithful-Condom Use (A-B-C) strategies and to describe the tools that people use in an attempt to avoid infection. The third paper again draws on qualitative data to explore the possible pathways through which the intervention package implemented as part of the CCT study might work to decrease STI prevalence. The three principal conclusions from the three papers are: (1) within the context of the conditional cash transfer trial in Tanzania, perceived risk is an important driver of sexual behavior change; (2) as the level of perceived risk changes for a participant through receipt of HIV test results and repeated STI test results, so does the risk reduction strategy; and (3) exposure to new and unexpected opportunities in the form of receipt of a positive STI test or being eligible for the cash award influences perceived ability to engage in risk reduction behaviors and thus increases the likelihood of reported behavior change.