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More is Not Always Merrier: Evaluating the Provision of Concurrent Sexual Partnership Risk Information on the Incidence of HIV/AIDS In Botswana

Gabarone, Botswana

Organizations

This work will be carried out as a Fulbright research project by MIT alumnus Noam Angrist in conjunction with:

The Challenge

Botswana was one of the poorest countries in the world in 1965, with just 12 km of paved road and only 22 college graduates in its entire history. But between 1965-2000, the story changed: Botswana had the highest GDP growth rate per capita in the world - a sign of remarkable economic progress. However, despite its relative economic success, 25% of people in Botswana live with HIV/AIDS, landing it 2nd highest in the world after Swaziland. This presents a large puzzle for development economists, who once theorized that poor health outcomes are strictly a result of poverty. In Botswana, the trend is flipped. Relative to other Sub-Saharan African countries, Botswana is stable and prosperous, yet at any given time, a quarter of people suffer from an imminent death sentence. Thus, new theories have emerged to explain the spread of HIV/AIDS.

One such theory is that perhaps all this prosperity is in fact causing the spread of HIV. Botswana has good hospitals, and lots of access to Anti-Retroviral Drugs (ARVs). In fact, over 80% of people in Botswana have access to ARVs, making it so that HIV/AIDS is no longer the death sentence it once was. At first glance, this is a wonderful outcome. However, this generates perverse effects: the risk of dying from HIV is lower in Botswana, so people don’t need to be as careful. They have more risky sex, resulting in higher rates of HIV. Thus, ironically, access to good drugs might lead to risker decision-making. This is a classic case of moral hazard.

To this end, conventional medicine-based interventions might be improving the lives of those already infected with HIV/AIDS, but generating perverse incentives for young adults who behave riskier than they otherwise would, guarded with the knowledge that ARVs could save them. Thus, a new focus has been pushed on education-based interventions instead of conventional health-based approaches. These include targeted school-based information programs, such as promoting condom use. However, condom programs have met with weak results. They fail to account for cultural norms and are often deemed imposing and undesirable.

One creative program that has worked is the "Sugar Daddies" intervention, evaluated by MIT's Jameel Poverty Action Lab in Kenya. In this intervention, young girls in Kenya were informed that older men were in fact riskier sexual partners than young men. Previously girls thought younger hot-headed and immature men were riskier. However, older men have had more years to contract HIV, and are probabilistically much less safe. The results of the program were stark: simply providing girls specific risk information reduced childbearing by 28 percent overall, and by 61% with men five years or older. 

The unique challenges in Botswana, coupled with J-PAL's findings in Kenya, motivate my project: an evaluation of another targeted sex ed message.

In particular, researchers have observed that youth in Botswana are by some accounts less promiscuous than youth in the western world. They have fewer partners on average over the course of their lifetime. However, the big difference between western youth and youth in Botswana is that relationships in the western world are held serially — meaning that they are held one after another. In contrast, relationships are often held concurrently in Botswana. Under this paradigm, and since the spread of HIV/AIDS is probabilistically much higher right at infection, and sexual networks overlap, HIV/AIDS can sweep across a nation like wildfire.

To this end, the program will examine the effects of informing youth on the risks of holding multiple concurrent partnerships at once. The goal is to equip youth for safer sexual decision-making so as to reduce the spread and incidence of HIV/AIDS.

Background

In conjunction with funding from the Fulbright program and the U.S. State Department, I will be conducting an independent evaluation of a program that will examine the effects of informing youth on the risks of holding multiple partnerships at once. The program itself is being implemented by the Baylor Pediatric AIDS Initiative in Gabarone, the capital of Botswana, and is funded by the World Bank.

My role involves coordinating the experimental design of the evaluation, including randomly selecting partner schools and determining our outcome metrics, data collection software and protocol.

To this end, I have also partnered with a professor at the University of Botswana, who is well connected in the ministry of education. Professor Pansiri will help build school partnerships and implement the program throughout the capital. After the program is launched, we will be collecting data on health and educational outcomes. Ultimately, the goal is produce a paper evaluating the program's effectiveness. If found to be effective, the World Bank aims to scale the program domestically and, eventually, globally.

In addition, Stepping Stones International works with orphans in rural areas and will also be implementing a supplementary component of the concurrent partnerships program. They are further running and evaluating a literacy program, which I am co-leading with their director of research.

Qualifications, Preferences, and Assets

I'm looking for 4-5 undergraduates who can help with the following pieces of the project:

Time Constraints

Any amount of time and energy invested full-time over IAP and/or the summer.

Contact

Noam Angrist, Principal Investigator
857.225.0882.
nangrist@mit.edu; nangrist@gmail.com