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This study investigates how the landscape of sex work in Dar es Salaam, Tanzania, evolved in the context of the COVID-19 epidemic. Using a mixed-methods approach, the analysis triangulates data from quantitative and qualitative sources to quantify shifts in income, demand, and client frequency and describe female sex workers' perspectives on their work environment. The COVID-19 restrictions introduced in early 2020 resulted in dramatic decreases in sex work income, leading to extreme financial vulnerability, food insecurity, and challenges in meeting other basic needs such as paying rent. However, in a 2021 follow-up survey, sex workers reported the summer of 2021 as a key turning point, with the demand for sex work rebounding to closer to pre-pandemic levels. Notably, despite the average number of unique weekly clients not yet having fully rebounded, by 2021 the price per client and the total monthly sex work income had returned to pre-pandemic levels. This may potentially be explained by an increased number of repeat clients, which represented a larger proportion of all clients during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

This scoping review assesses the use of conditional cash transfer (CCT) interventions – direct distribution of money to individuals conditional on their compliance to certain requirements – in randomised controlled trials, quasi-experimental studies and large community-based randomised trials with health-focused outcomes. Five databases were searched to identify 68 records published 2004–2021 from 25 countries (8 low- (32%), 5 lower middle- (20%), 6 upper middle- (24%) and 6 high-income (24%), according to the World Bank Categorisation (2017). Forty-six studies were unique (after excluding multiple publications on a single study). The most common outcomes assessed were infectious diseases (30%); maternal health (24%); vaccination rates (17%); and childhood developmental measures (17%). The number of participants receiving CCT in each study ranged from 47 to 5,788, with a median of 487 individuals. The number of total participants ranged from 72 to 14,000, with a median of 1,289 individuals. Fifteen percent of studies involved mobile CCT disbursement. More than a quarter of payments were greater than 50 USD (29%), and most payments were 20 USD or less (58%). Seventy-eight percent of unique full-length studies reported statistically significant CCT effects. Although CCTs remain controversial, a growing evidence base is emerging for their potential impact in specific health conditions. [ABSTRACT FROM AUTHOR]

The author offers insights on the research methodology to calculate the estimated death toll of the 1994 Rwandan genocide. Topics discussed include the use of the sibling mortality schedule to obtain a reasonable estimate of relative mortality rate, research questions which may be addressed through the study of relative mortality in genocide, and the need for further investigation into the distribution of excess mortality in this genocidal event.

Abstract The quality of care is a crucial determinant of good health outcomes, but is difficult to measure. Survey vignettes are a standard approach to measuring medical knowledge among health care providers. Given that written vignettes or knowledge tests may be too removed from clinical practice, particularly where “learning by doing” may be an important form of training, we developed a new type of provider vignette. It uses videos presenting a patient visiting the clinic with maternal/early childhood symptoms. We tested these video vignettes with current and future (students) health professionals in Burkina Faso. Participants indicated that the cases used were interesting, understandable and common. Their performance was consistent with expectations. Participants with greater training (medical doctors vs. nurses and midwives) and experience (health professionals vs. students) performed better. The video vignettes can easily be embedded in computers, tablets and smart phones; they are a convenient tool to measure provider knowledge; and they are cost-effective instruction and testing tools. Highlights • To measure health worker knowledge, we tested a new type of provider vignette using videos. • The videos presented a patient with maternal/childhood symptoms visiting the clinic. • Results displayed significant variance in performance, consistent with expectations. • Participants expected to perform better (doctors, experienced professionals) did perform better. [ABSTRACT FROM AUTHOR]

Paying for performance provides financial rewards to medical care providers for improvements in performance measured by utilization and quality of care indicators. In 2006, Rwanda began a pay for performance scheme to improve health services delivery, including HIV/AIDS services. Using a prospective quasi-experimental design, this study examines the scheme's impact on individual and couples HIV testing. We find a positive impact of pay for performance on HIV testing among married individuals (10.2 percentage points increase). Paying for performance also increased testing by both partners by 14.7 percentage point among discordant couples in which only one of the partners is an AIDS patient. [ABSTRACT FROM AUTHOR]

This randomized controlled trial investigates the impact of four demand-side interventions on health screening for diabetes and hypertension among Armenian adults. The interventions are 1) personalized invitations from a physician, 2) personalized invitations with information about peer screening behavior, 3) personalized invitations with a labeled but unconditional financial incentive, and 4) personal invitations with a conditional financial incentive. Compared with the control group, interventions 1 to 3 led to a significant increase in the screening rate of about 15 percentage points for diabetes and hypertension. The highest impact was measured for intervention 4 leading to a 31.2 percentage point increase in both screenings. • Personal invitations increased screening for diabetes and hypertension in Armenia. • Peer information and unconditional incentives did not augment the invitation impact. • Incentives conditional on screening doubled the impact. • Conditional incentives were more expensive to implement. • Personal invitations alone and with conditional incentives were equally cost-effective. [ABSTRACT FROM AUTHOR]

We combine data from 84 Demographic and Health Surveys from 46 countries to analyze trends and socioeconomic differences in adult mortality, calculating mortality based on the sibling mortality reports collected from female respondents aged 15-49. The analysis yields four main findings. First, adult mortality is different from child mortality: while under-5 mortality shows a definite improving trend over time, adult mortality does not, especially in sub-Saharan Africa. The second main finding is the increase in adult mortality in sub-Saharan African countries. The increase is dramatic among those most affected by the HIV/AIDS pandemic. Mortality rates in the highest HIV-prevalence countries of southern Africa exceed those in countries that experienced episodes of armed conflict. Third, even in sub-Saharan countries where HIV prevalence is not as high, mortality rates appear to be at best stagnating, and even increasing in several cases. Finally, the main dimension along which mortality appears to differ in the aggregate is by sex. Adult mortality rates in sub-Saharan Africa have risen substantially higher for men than for women-especially so in the high HIV-prevalence countries. On the whole, the data do not show large gaps by urban/rural residence or by school attainment. [ABSTRACT FROM AUTHOR]

Separated, divorced, and widowed individuals in Africa are at significantly increased risk for HIV infection. Using nationally representative data from 13 sub-Saharan African countries, this study confirms that finding and goes further by examining those who have experienced a marital dissolution and are now remarried. Results show that remarried individuals form a large portion of the population and have a higher-than-average HIV prevalence. HIV-positive remarried individuals are at risk of transmitting the infection to their spouse, because many of the couples are serodiscordant. The large number of high-risk remarried individuals is a source of vulnerability and further infection, and should be acknowledged and taken into account by prevention strategies that rarely address this population. [ABSTRACT FROM AUTHOR]

Using nationally representative data from 13 sub-Saharan African countries, we reinforce and expand upon previous findings that men report using condoms more frequently than women do and that unmarried respondents report that they use condoms with casual partners more frequently than married individuals report using them with their spouses. Based on descriptive, bivariate, and multivariate analyses, we also demonstrate to a degree not previously shown in the current literature that married men from most countries report using condoms with extramarital partners about as frequently as unmarried men report using them with casual partners. Married women from most of the countries included in the study reported using condoms with extramarital partners less frequently than unmarried women reported using them with casual partners. This result is especially troubling because marriage usually ensures regular sexual intercourse, thereby providing more opportunities for a person to pass HIV infection from an extramarital partner to his or her spouse. These findings about high-risk behaviors can be used to better target future HIV-transmission-prevention efforts. [ABSTRACT FROM AUTHOR]

Summary: Background: Most couples affected by HIV/AIDS in sub-Saharan Africa live in discordant relationships. Men are thought to be the index case in most relationships, and most social marketing and awareness campaigns are focused on men. We investigated serodiscordance in stable relationships to establish the gender balance of index-case infections. Methods: We did a systematic review, random-effects meta-analysis, and meta-regression of published and unpublished studies enrolling discordant couples and assessed the proportion of men and women that were index cases. We repeated the analysis with data from demographic and health surveys (DHS) from the 14 countries that have documented the HIV status of couples. Our primary outcome was the total number of HIV discordant couples, including the proportion of HIV-positive women. Findings: We included data from 27 cohorts of 13 061 couples and DHS data from 14 countries of 1145 couples. The proportion of HIV-positive women in stable heterosexual serodiscordant relationships was 47% (95% CI 43–52), which shows that women are as likely as men to be the index partner in a discordant couple. DHS data (46%, 41–51) and our sensitivity analysis (47%, 43–52) showed similar findings. Meta-regression showed that urban versus rural residence (odds ratio 0·31, 95% CI 0·22–0·39), latitude (β coefficient 0·02, 0·023–0·034), gender equality (β coefficient −0·42, −0·56 to −0·27), HIV prevalence (β coefficient −0·037, −0·04 to −0·030), and older age (β coefficient 0·20, 0·08–0·32) were associated with the proportion of female index cases. Interpretation: Our study shows the need to focus on both sexes in HIV prevention strategies, such as promotion of condom use and mitigation of risk behaviours. Funding: None. [ABSTRACT FROM AUTHOR]

Abstract: This paper tests the hypothesis that education improves health and increases people''s life expectancy. It does so by analyzing the effect of education on smoking behaviors. To account for the endogeneity of smoking, the analysis develops an instrumental variable approach which relies on the fact that during the Vietnam War college attendance provided a strategy to avoid the draft. The results indicate that education does affect smoking decisions: educated individuals are less likely to smoke, and among those who initiated smoking, they are more likely to have stopped. [Copyright &y& Elsevier]

Most analyses of the determinants of HIV infection are performed at the individual level. The recent Demographic and Health Surveys, which include results from HIV tests, allow the study of HIV infection at the level of the cohabiting couple. This article exploits this feature of the data for Burkina Faso, Cameroon, Ghana, Kenya, and Tanzania. The analysis yields two findings about the dynamics of the HIV/AIDS epidemic that have important implications for policy. First, at least two-thirds of the infected couples are sero-discordant, that is, only one of the two partners is infected. This implies scope for prevention efforts among infected couples. Second, among 30–40 percent of the infected couples only the woman is infected. This is at odds with levels of self-reported extramarital sex by women and with the common perception that unfaithful men are the main link between high-risk groups and the general population. These findings are confirmed by tests of robustness. These results indicate that extramarital sexual activity among women in union is a substantial source of vulnerability to HIV that should be, as much as male extramarital activity, targeted by prevention efforts. [ABSTRACT FROM AUTHOR]

The study presented in this paper is an examination of the long-term impact of genocide during the period of the Khmer Rouge regime (1975–79) in Cambodia. The very high and selective mortality of the period had a major impact on the population structure of Cambodia. Fertility and marriage rates were both very low under the Khmer Rouge, but recovered immediately after the regime's collapse. Because of the shortage of eligible men, the age and education differences between partners tended to decline. The period also had a lasting impact on the educational attainment of the population. The school system collapsed during the period and therefore individuals—especially men—who were of school age at the time have a lower educational attainment than those from the preceding and subsequent birth cohorts. [ABSTRACT FROM AUTHOR]

Female sex workers (FSW) across the world are at high risk for HIV infection and much work is needed to scale up HIV prevention programs among this group. Conditional cash transfer (CCT) programs have been used successfully in recent years to encourage behavior change. We report the results of a CCT intervention among FSW in Tanzania. We conducted a randomized controlled trial (N = 100) of a CCT intervention among FSW in Dar-es-Salaam, Tanzania in 2013. A respondent-driven sampling approach recruited women and randomized them into two groups based on the value of the cash incentive ($20 vs. $40 per visit). All women received testing for 2 curable sexually transmitted infections (STIs), trichomonas and syphilis, free treatment for those STIs and counseling. Women attended study visits at 0, 2 and 4 months and were tested for STIs and received counseling at each visit. Women testing negative for both STIs at the 2- and 4-month visits received a cash reward. Eighty-four women were retained in the study through all three visits. Participants reported significant reductions in the number of clients per week, and increases in the proportion of clients that they used condoms with over the course of the study. STI results showed decreases in prevalence from baseline to final study visit for syphilis and trichomonas. While this study was not powered to determine if the incentive resulted in statistically significant increases in condom use or decreases in STI prevalence, the results show the acceptability of the intervention, the feasibility of the recruitment methods, and the ability to retain FSW participants across multiple study visits. A follow-up randomized study with a larger number of participants is planned to test the efficacy of the intervention among high-risk populations of women engaging in transactional sex. • We show feasibility and acceptability of a cash incentive among FSW in Tanzania. • Participants reported significant reductions in the number of clients per week. • Participants reported significant increases in condom use. • STI prevalence decreased significantly from baseline to the final study visit. • STI testing and cash were both motivators for behavior change. [ABSTRACT FROM AUTHOR]

Behaviors that are putting people's health at risk are widespread and some of them are on the rise. Some of these behaviors can be prohibited or prevented by taxation. But financial incentives such as conditional cash transfers are also increasingly proposed and tested to discourage such behaviors, in domains as varied as HIV/AIDS, drugs, alcohol, smoking, and obesity. This paper presents the theoretical justification for using such incentives, distinguishing between the price, income effects, and the nudge effects. The growing literature about the effectiveness of financial incentives to prevent undesirable behaviors is reviewed in detail for each type of harmful behavior. Finally, the paper discusses the long-term sustainability of such incentives, a key issue if they are to be scaled up beyond pilot programs and research projects. The current evidence on whether such incentives have an impact after they are discontinued is mixed. Some design features, like lotteries or commitment devices, could induce savings as well as increase effectiveness, therefore improving sustainability. • HIV/AIDS, drugs, alcohol, smoking, and obesity put people's health at risk. • Financial incentives are increasingly tested to discourage such behaviors. • Theoretical justifications for incentives include price, income and nudge effects. • This paper reviews the growing evidence with a focus on incentive design. • Current evidence on effect sustainability after incentive discontinuation is mixed. [ABSTRACT FROM AUTHOR]

Transactional sex is an important risk-coping mechanism and a leading contributor to the HIV/AIDS epidemic in sub-Saharan Africa. We use data from a conditional cash transfer (CCT) experiment in rural Tanzania designed to incentivize safer sexual behavior by conditioning transfers on testing negative for sexually transmitted infections (STIs). For women, we find that negative shocks measured by food insecurity lead to a 36% increase in STIs and increases in self-reported risky sexual behavior. We find no significant effects of negative shocks on either STIs or self-reported sexual behavior for men. This CCT design did not appear to mitigate the behavioral response to shocks that we document in women. We propose that this finding can be explained by binding credit constraints and the relatively infrequent timing of the CCTs. When women experience a negative shock, cash needs are immediate, while transfers linked to a CCT are paid out in a specific point in time. If women are unable to access credit during a shock, they may resort to transactional sex even if they face monetary incentives to do otherwise. [ABSTRACT FROM AUTHOR]

Risky sexual behaviour in PLWHA on antiretroviral therapy threatens both prevention and treatment efforts, but disclosure promises to support safer sexual practices. This paper investigates the association between HIV self-disclosure and consistent condom use in a cohort of public sector patients on antiretroviral (ARV) treatment. Using data from the FEATS cohort study, logistic regression analysis shows that knowledge of your partner's HIV status is positively associated with consistent condom use (OR 2.73, 95% CI 1.37-5.43, p = 0.004) and so too mutual HIV disclosure (OR 3.38, 95% CI 1.60-7.18, p = 0.001). Prevention and treatment programmes, through couple HIV counselling and testing (CHCT) and other assistance programmes, should focus on supporting the mutual disclosure of HIV status among PLWHA on ARV treatment. [ABSTRACT FROM AUTHOR]

HIV/AIDS stigmatizing attitudes and their consequences on preventative behaviors are among the most poorly understood aspects of the AIDS epidemic. This paper analyzes the socioeconomic determinants of discriminating attitudes toward people living with HIV and their implications on the likelihood of HIV testing. These effects are tested using the 2004 and 2009 Demographic and Health Surveys conducted in Lesotho, where HIV/AIDS is a pervasive problem. We find that HIV/AIDS stigmatizing attitudes are negatively associated with education and wealth and positively correlated with Catholic religion for women and traditional circumcision for men. The analysis also shows a negative association between stigmatizing beliefs and the probability of being tested for HIV. [ABSTRACT FROM AUTHOR]

Female Sex Workers are a core population in the HIV epidemic, and interventions such as conditional cash transfers (CCTs), effective in other health domains, are a promising new approach to reduce the spread of HIV. Here we investigate how a population of Tanzanian female sex workers, though constrained in many ways, experience and use their power in the context of a CCT intervention that incentivizes safe sex. We analyzed 20 qualitative in-depth interviews with female sex workers enrolled in a randomized-controlled CCT program, the RESPECT II pilot , and found that while such women have limited choices, they do have substantial power over their work logistics that they leveraged to meet the conditions of the CCT and receive the cash award. It was through these decisions over work logistics, such as reducing the number of workdays and clients, that the CCT intervention had its greatest impact on modifying female sex workers’ behavior. [ABSTRACT FROM AUTHOR]

Intimate partner violence (IPV) is widely prevalent in Tanzania. Inequitable gender norms manifest in men's and women's attitudes about power and decision making in intimate relationships and are likely to play an important role in determining the prevalence of IPV. We used data from the RESPECT study, a randomized controlled trial that evaluated an intervention to prevent sexually transmitted infections in a cohort of young Tanzanian men and women, to examine the relationship between couples' attitudes about IPV, relationship power, and sexual decision making, concordance on these issues, and women's reports of IPV over 12 months. Women expressed less equitable attitudes than men at baseline. Over time, participants' attitudes tended to become more equitable and women's reports of IPV declined substantially. Multivariable logistic regression analyses suggested that inequitable attitudes and couple discordance were associated with higher risk of IPV. Our findings point to the need for a better understanding of the role that perceived or actual imbalances in relationship power have in heightening IPV risk. The decline in women's reports of IPV and the trend towards gender-equitable attitudes indicate that concerted efforts to reduce IPV and promote gender equity have the potential to make a positive difference in the relatively short term. [ABSTRACT FROM AUTHOR]

Some of Adam Wagstsaff's colleagues and research collaborators submitted short reflections about the different ways Adam made a difference through his amazing research output to health equity and health systems as well as a leader and mentor. The Guest Editors of this Special Issue selected a set of six essays related to dimensions of Adam's contributions. The first contribution highlights his role early on in his career, prior to joining the World Bank, in defining and expanding an important field of research on equity in health ("Adam and Equity," by Eddy van Doorslaer and Owen O'Donnell). The second contribution focuses on Adam's early work on equity and health within the World Bank and his leadership on important initiatives that have had impact far beyond the World Bank ("Adam and Health Equity at the World Bank," by Davidson Gwatkin and Abdo Yazbeck). The next contribution focuses on Adam's deep dive into providing support, through research, for country-specific programs and reforms, with a special focus on some countries in East Asia ("Adam and Country Health System Research," by Magnus Lindelow, Caryn Bredenkamp, Winnie Yip, and Sarah Bales). The next contribution highlights Adam's many ways of contributing to the International Health Economics Association, from the impressive technical contributions to leadership and organizational reform ("Adam and iHEA," by Diane McIntyre). The next to last contribution focuses on Adam's long-term leadership in the research group at the World Bank and the long-lasting influence on integrating the research produced into World Bank operations and creating an environment that rewarded producing evidence for action ("Adam the Research Manager," by Deon Filmer and Damien de Walque). The last contribution pulls on the thread found in many of the earlier ones, mentorship with honesty, directness, caring, commitment, and equity ("Adam the Mentor," by Agnes Couffinhal, Caryn Bredenkamp, and Reem Hafez). [ABSTRACT FROM AUTHOR]

Background: Non-communicable diseases account for a growing proportion of deaths in Armenia, which require early detection to achieve disease control and prevent complications. To increase rates of screening, demand-side interventions of personalized invitations, descriptive social norms, labeled cash transfers, and conditional cash transfers were tested in a field experiment. Our complementary qualitative study explores factors leading to the decision to attend screening and following through with that decision, and experiences with different intervention components.Methods: Informed by the Health Belief Model as our conceptual framework, we collected eighty in-depth interviews with service users and twenty service providers and analyzed them using open coding and thematic analysis.Results: An individual's decision to screen depends on 1) the perceived need for screening based on how they value their own health and perceive hypertension and diabetes as a harmful but manageable condition, and 2) the perceived utility of a facility-based screening, and whether screening will provide useful information on disease status or care management and is socially acceptable. Following through with the decision to screen depends on their knowledge of and ability to attend screenings, as well as any external motivators such as an invitation or financial incentive.Conclusions: Personalized invitations from physicians can prompt individuals to reconsider their need for screening and can, along with financial incentives, motivate individuals to follow through with the decision to screen. The effect of descriptive social norms in invitations should be further studied. Efforts to increase preventive screenings as an entry point into primary care in Armenia may benefit from implementation of tailored messages and financial incentives.Trial Registration: The protocol was approved on January 11, 2019 by the Institutional Review Board of the Center of Medical Genetics and Primary Health Care in Armenia (02570094). https://www.socialscienceregistry.org/trials/3776 . [ABSTRACT FROM AUTHOR]

Background: Eswatini continues to have the highest prevalence of HIV in the world, and one of the highest HIV incidences among adult populations (aged 15-49). This analysis reports on both key elements of study design/protocol and baseline results from an impact evaluation of an intervention incentivizing (i) initiation, enrolment, attendance or completion of some form of education, and (ii) lower risk sexual behaviour.Methods: The impact evaluation employs a two by two factorial design in which participants are enrolled in either the incentive for education arm ('education treatment arm' providing a conditional cash incentive) or the control arm ('education control arm'). In each of these arms, 50% of participants were randomized to also be eligible for selection - three times a year - to participate in a conditional raffle conditional on testing negative for curable STIs (syphilis and Trichomonas vaginalis).Results: Baseline recruitment and screening occurred in 2016 when a total of 6055 individuals were screened of which 4863 participated in the baseline survey, and 4819 individuals were randomized into one of the study arms. The baseline prevalence of HIV, Trichomonas vaginalis, and syphilis among adolescent girls and young women 8.20% (397/4840), 3.31% (150/4533) and 0.17% (8/4830) respectively.Conclusions: An educational cash incentive and raffle incentive impact evaluation that addresses adolescent girls and young women who are in-education and out-of-education has the potential to reduce HIV risk in adolescent girls and young women in Eswatini.Trial Registration: Name of the registry: Pan African Clinical Trials Registry.Trial Registration Number: PACTR201811609257043 . Date of registration: May 11, 2018 'Retrospectively registered'. URL of trial registry record: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=4685. [ABSTRACT FROM AUTHOR]

Background: Behavior change communication (BCC) interventions, while still a necessary component of HIV prevention, have not on their own been shown to be sufficient to stem the tide of the epidemic. The shortcomings of BCC interventions are partly due to barriers arising from structural or economic constraints. Arguments are being made for combination prevention packages that include behavior change, biomedical, and structural interventions to address the complex set of risk factors that may lead to HIV infection. Methods: In 2009/2010 we conducted 216 in-depth interviews with a subset of study participants enrolled in the RESPECT study - an HIV prevention trial in Tanzania that used cash awards to incentivize safer sexual behaviors. We analyzed community diaries to understand how the study was perceived in the community. We drew on these data to enhance our understanding of how the intervention influenced strategies for risk reduction. Results: We found that certain situations provide increased leverage for sexual negotiation, and these situations facilitated opportunistic implementation of risk reduction strategies. Opportunities enabled by the RESPECT intervention included leveraging conditional cash awards, but participants also emphasized the importance of exploiting new health status knowledge from regular STI testing. Risk reduction strategies included condom use within partnerships and/or with other partners, and an unexpected emphasis on temporary abstinence. Conclusions: Our results highlight the importance of increasing opportunities for implementing risk reduction strategies. We found that an incentive-based intervention could be effective in part by creating such opportunities, particularly among groups such as women with limited sexual agency. The results provide new evidence that expanding regular testing of STIs is another important mechanism for providing opportunities for negotiating behavior change, beyond the direct benefits of testing. Exploiting the latent demand for STI testing should receive renewed attention as part of innovative new combination interventions for HIV prevention. [ABSTRACT FROM AUTHOR]