Are self-reported fertility preferences biased? Evidence from indirect elicitation methods.

Desired fertility measures are routinely collected and used by researchers and policy makers, but their self-reported nature raises the possibility of reporting bias. In this paper, we test for the presence of such bias by comparing responses to direct survey questions with indirect questions offering a varying, randomized, degree of confidentiality to respondents in a socioeconomically diverse sample of Nigerian women ([Formula: see text]). We find that women report higher fertility preferences when asked indirectly, but only when their responses afford them complete confidentiality, not when their responses are simply blind to the enumerator. Our results suggest that there may be fewer unintended pregnancies than currently thought and that the effectiveness of family planning policy targeting may be weakened by the bias we uncover. We conclude with suggestions for future work on how to mitigate reporting bias.

Optimising the public health benefits of sex work regulation in Senegal: Results from qualitative interviews with policy stakeholders.

CONTEXT: There is compelling evidence that eliminating sexually transmitted infections (STIs) among female sex workers (FSWs) is a cost-effective approach to reducing the spread of HIV/AIDS. Although many countries recognise sex work as a public health issue, few have implemented public health policies specifically aimed at controlling the transmission of HIV/AIDS among FSWs. In particular, Senegal stands out as the only African country to regulate sex work through a specific public health policy that requires FSWs to register with a health centre. Despite the potential health and legal benefits associated with registration, a staggering 80% of FSWs in Senegal remain unregistered. This low registration rate hinders the realisation of the policy's full potential for public health benefits. The reluctance of FSWs to register is due to inherent flaws in the policy design, where the disadvantages of registration outweigh the benefits for FSWs. OBJECTIVE: To identify which modifications to the current registration policy have the potential to increase uptake of registration by FSWs and to assess their feasibility in the context of Senegal. METHOD: We conducted a qualitative policy research study using semi-structured in-depth interviews with 22 national stakeholders in this policy, including representatives from the police, government and non-governmental organisations (NGOs) in Dakar, Senegal, as well as FSWs' leaders. The interview data were thematically coded using the interview topic guide and other recurring themes and analysed using thematic analysis on Nvivo 12. RESULTS: A total of 20 relevant themes were selected, focusing primarily on assessing the feasibility of potential interventions and identifying potential barriers and associated risks. We found that, without changing current legislation, improving relationships between FSWs and police officers, providing accurate and accessible information about the rules and benefits of the policy, and offering psychosocial support have the potential to improve both the registration rate of FSWs and their wellbeing. Policy features designed to increase registration by improving FSWs' confidentiality, and thus their confidence in the services offered, were also discussed. CONCLUSIONS: The study highlighted that several national public health policies could be changed to increase the registration rate of FSWs and improve their wellbeing without overturning constitutional law.

Trading HIV for sheep: Risky sexual behavior and the response of female sex workers to Tabaski in Senegal.

We use a cohort of female sex workers (FSWs) in Senegal to show how large anticipated economic shocks lead to increased risky sexual behavior. Exploiting the exogenous timing of interviews, we study the effect of Tabaski, the most important Islamic festival celebrated in Senegal, in which most households purchase an expensive animal for sacrifice. Condom use, measured robustly via the list experiment, falls by between 27.3 percentage points (pp) (65.5%) and 43.1 pp (22.7%) in the 9 days before Tabaski, or a maximum of 49.5 pp (76%) in the 7 day period preceding Tabaski. The evidence suggests the economic pressures from Tabaski are key to driving the behavior change observed through the price premium for condomless sex. Those most exposed to the economic pressure from Tabaski were unlikely to be using condoms at all in the week before the festival. Our findings show that Tabaski leads to increased risky behaviors for FSWs, a key population at high risk of HIV infection, for at least 1 week every year and has implications for FSWs in all countries celebrating Tabaski or similar festivals. Because of the scale, frequency, and size of the behavioral response to shocks of this type, policy should be carefully designed to protect vulnerable women against anticipated shocks.

Reforming the registration policy of female sex workers in Senegal? Evidence from a discrete choice experiment.

Evidence suggests that treating sexually transmitted infections (STIs) amongst female sex workers (FSWs) is a cost-effective strategy to reduce the spread of HIV/AIDS. Senegal is the only African country where sex work is regulated by a public health policy which aims to monitor and routinely treat STIs. The law requires FSWs to be at least 21 years old, register with a health centre and the police, carry an up-to-date registration booklet, attend monthly health check-ups, and test negative for STIs. Despite health and legal benefits of registration, 80% of FSWs in Senegal are not registered. Hence, the potential health benefits of the policy have not materialised. To understand why FSWs do not want to register and to define policy changes that would increase the registration rate of FSWs in Senegal, we designed and implemented a discrete choice experiment (DCE) completed by 241 registered and 273 non-registered FSWs. Participants made choices between a series of hypothetical but realistic registration policy changes. Conditional logit models were used to analyse the DCE data. The results highlighted that confidentiality at the health facility was an important element, registered and non-registered FWs were respectively 26.0 percentage points (pp) and 22.1 pp more likely to prefer a policy that guaranteed confidentiality at the health centre. Similarly, both groups preferred a policy where their health record was only held at the health centre and not with the police. Several interventions to increase FSW registration rate and improve their wellbeing may be implemented without modifying the law. For example, the introduction of psychosocial support in the registration policy package, replacing the registration booklet by a QR code, the use of electronic medical files and the integration of FSWs routine visits with maternal health appointments to increase confidentiality have the potential to encourage registration of FSWs.

Can Self-affirmation Encourage HIV-Prevention? Evidence from Female Sex Workers in Senegal.

We test an intervention aiming to increase condom usage and HIV testing in a stigmatized population at high risk of contracting HIV: female sex workers (FSWs) in Senegal. Some sex work is legal in Senegal, and condoms and HIV tests are freely available to registered FSWs-but FSWs may be reluctant to get tested and use condoms, in part because doing so would entail acknowledging their risk of contracting HIV and potentially expose them to stigma. Drawing on self-affirmation theory, we hypothesized that reflecting on a source of personal pride would help participants acknowledge their risk of HIV, intend to use condoms more frequently, and take an HIV test. Prior research suggests that similar self-affirmation interventions can help people acknowledge their health risks and improve their health behavior, especially when paired with information about effectively managing their health (i.e., self-efficacy information). However, such interventions have primarily been tested in the United States and United Kingdom, and their generalizability outside of these contexts is unclear. Our high-powered experiment randomly assigned participants (N = 592 FSWs; N = 563 in the final analysis) to a self-affirmation condition or a control condition and measured their risk perceptions, whether they took condoms offered to them, and whether (after randomly receiving or not receiving self-efficacy information) they took an HIV test. We found no support for any of our hypotheses. We discuss several explanations for these null results based on the stigma attached to sex work and HIV, cross-cultural generalizability of self-affirmation interventions, and robustness of previous findings.

From a drought to HIV: An analysis of the effect of droughts on transactional sex and sexually transmitted infections in Malawi.

Each year there are over 300 natural disasters globally with millions of victims that cost economic losses near USD$100 billion. In the context of climate change, an emerging literature linking extreme weather events to HIV infections suggests that efforts to control the HIV epidemic could be under threat. We used Demographic and Health Survey (DHS) data collected during the 2015-2016 harsh drought that affected several areas of Malawi to provide new evidence on the effect of an unanticipated economic shock on sexual behaviours of young women and men. We find that amongst women employed in agriculture, a six-months drought doubles their likelihood of engaging in transactional sex compared to women who were not affected by the drought and increases their likelihood of having a sexually transmitted infections (STI) by 48% in the past twelve months. Amongst men employed outside of agriculture, drought increases by 50% the likelihood of having a relationship with a woman engaged in transactional sex. These results suggest that women in agriculture experiencing economic shocks as a result of drought use transactional sex with unaffected men, i.e. men employed outside agriculture, as a coping mechanism, exposing themselves to the risk of contracting HIV. The effect was especially observed among non-educated women. A single drought in the last five years increases HIV prevalence in Malawi by around 15% amongst men and women. Overall, the results confirm that weather shocks are important drivers of risky sexual behaviours of young women relying on agriculture in Africa. Further research is needed to investigate the most adequate formal shock-coping strategies to be implemented in order to limit the negative consequences of natural disasters on HIV acquisition and transmission.

Gender and sociocultural factors in animal source foods (ASFs) access and consumption in lower-income households in urban informal settings of Nairobi, Kenya.

BACKGROUND: Gender shapes household decision-making and access for nutritious diets, including animal source foods (ASFs) that impact on child health and nutrition status. However, research shows that the poorest households in the urban informal settlements of Nairobi have low ASFs consumption. This study was conducted to explore further from a qualitative perspective the gender, sociocultural factors affecting household ASF consumption this study. METHODS: To explore further on the topic of study, an exploratory qualitative study was carried out to establish the factors that influence access, allocation and consumption of animal source foods (ASFs) by households in urban informal settings of Nairobi. Nineteen focus group discussions with men and women were conducted to enable in-depth exploration of ASFs consumption. RESULTS: Gender influences decision-making of household ASFs dietary intake. Gendered power dynamics prevail with men as breadwinners and household heads often determining the food access and consumption of ASFs. Women are increasingly accessing short-term waged-based incomes in urban informal settings and now play a role in food and nutrition security for their households. This enforces the idea that women's decision-making autonomy is an important aspect of women empowerment, as it relates to women's dietary diversity and subsequently, better household nutritional status. As evidenced in this study, if a woman has bargaining power based on accessing incomes to support their household food needs, she will not jeopardize food security. The mobile digital money platform was key in enabling access to resources to access food. Use of trust to access food on credit and purchasing smaller packaged quantities of food were also enablers to access of food/ASFs.

The long-term effects of free care on birth outcomes: Evidence from a national policy reform in Zambia.

As women in many countries still fail to give birth in facilities due to financial barriers, many see the abolition of user fees as a key step on the path towards universal coverage. We exploited the staggered removal of user charges in Zambia from 2006 to estimate the effect of user fee removal up to five years after the policy change. We used data from the birth histories of two nationally representative Demographic and Health Surveys to implement a difference-in-differences analysis and identify the causal impact of removing user charges on institutional and assisted deliveries, caesarean sections and neonatal deaths. We also explored heterogeneous effects of the policy. Removing fees had little effect in the short term but large positive effects appeared about two years after the policy change. Institutional deliveries in treated areas increased by 10 and 15 percentage points in peri-urban and rural districts respectively (corresponding to a 25 and 35 percent change), driven entirely by a reduction in home births. However, there was no evidence that the reform changed the behaviours of women with lower education, the proportion of caesarean sections or reduced neonatal mortality. Institutional deliveries increased where care quality was high, but not where it was low. While abolishing user charges may reduce financial hardship from healthcare payments, it does not necessarily improve equitable access to care or health outcomes. Shifting away from user fees is a necessary but insufficient step towards universal health coverage, and concurrent reforms are needed to target vulnerable populations and improve quality of care.

Sexuality-based stigma and access to care: intersecting perspectives between healthcare providers and men who have sex with men in HIV care centres in Senegal.

Men who have sex with men (MSM) in Senegal face a challenging socio-legal context, marked by homophobia and the illegality of homosexuality. In addition, human immunodeficiency virus (HIV) prevalence among MSM is 27.6%, 46 times greater than the one in the general population (0.5%). Nevertheless, access to healthcare by MSM may be hampered by stigmatizing attitudes from health facility staff (medical and non-medical). This article describes the health facility staff/MSM relationship and analyses its effects on access to healthcare by MSM. The data used were collected through a field survey based on observations and qualitative interviews conducted in 2019 and 2020 with 16 MSM, 1 non-governmental organization (NGO) staff and 9 healthcare providers in Dakar (the capital city) and Mbour (secondary city on the West Coast) hospitals. The data were subject to a thematic analysis assisted by the ATLAS software. The relationship between MSM and healthcare providers is ambiguous. On the one hand, healthcare providers are torn between their professional duty to treat MSM and the cost of being stigmatized by other colleagues. Therefore, they often limit their empathy with MSM within the hospital context. On the other hand, MSM, trusting in the confidentiality of healthcare providers, feel safe in the care pathway. However, we identify the following stigmatizing factors limiting access to care include (1) fear of meeting a relative, (2) difficult relationships with non-medical support staff (mainly security guards), (3) HIV status disclosure and (4) potential conflicts with other MSM. This study is unique as it includes non-medical staff in its respondents. It shows that hospitals are divided into several areas, based on the stigma perceived by MSM. It is important to map out MSM's care trajectories and spaces and to identify all types of staff working within them, including non-medical staff, and enrol them in stigma reduction interventions.

Consumer perceptions of food safety in animal source foods choice and consumption in Nairobi's informal settlements.

BACKGROUND: Animal-source foods (ASFs) are high-quality nutrient-dense products key to reducing stunting and micronutrient deficiencies. However, their consumption among the poorest households in urban informal settlements is low. Several drivers beyond price, including health considerations have been reported to drive ASF choice and consumption among consumers. This current study explores consumer perceptions of food safety associated with animal source foods (ASFs) consumption in urban informal settlements with a view to unpacking the health considerations driving their choice and consumption. METHODS: Coupled households with children 6-59 months formed the study sample. The Food Environments Working Group (FEWG) Framework of the Agriculture and Nutrition for Health academy (ANH) was used to guide the study which utilized qualitative methods namely, 60 in-depth interviews (IDIs), 19 focus group discussions, and 19 key informant interviews (KIIs) complemented by unstructured observations. Data were transcribed and analysed according to emerging themes. RESULTS: Consumer perceptions of food safety are driven by concerns about food production, processing, handling, storage and the health risks associated with consumption of the ASFs. For all the ASFs, lack of traceability of source, unhygienic environments in which they were sold and health risks around consuming too much or improperly cooked products were key perceptions from the community. To mitigate against food safety risks, consumers used strategies such as boiling the ASFs, purchasing their products from trusted retailers, avoiding vendors in unhygienic environments and reducing the amount and frequency of consumption of ASFs or totally avoiding their consumption. These consumer perceptions are increasingly influencing the ASFs choice and consumption in low-income populations besides other drivers. Notably, given limited incomes that influence their purchasing power and the need for nutritious diets that included ASFs, the dilemma of quality vis-a-vis quantity persists and consumers still accessed and consumed these ASF products to supplement their diets. CONCLUSIONS: To enhance food safety for ASFs, as well as assure consumer access to safe ASFs from informal markets, there is need to contextualize the value chain as informed by consumer perceptions on food safety as these influence their ASFs choice and consumption.

Can we mitigate the effect of natural disasters on child health? Evidence from the Indian Ocean tsunami in Indonesia.

The 2004 Indian Ocean tsunami was an international natural disaster unlike any seen before, killing 166,561 people in Aceh province, Indonesia. It prompted an unprecedented humanitarian response and was a catalyst in ending almost 30 years of civil conflict in Aceh. Since the tsunami was followed by a multitude of events, we first conduct a systematic review to identify those events in Indonesia. We then use a synthetic control method to estimate the combination of those effects on child mortality indicators in Aceh for the 13 years that followed the disaster using data from 258,918 children born between 1990 and 2017. The results show a significant increase in under-5 mortality only the year after the tsunami and no effect in the medium term. However, younger and older children were affected differently in the medium term. In fact, we show a decrease in child mortality among children aged 1-4 years. In contrast, we observe an increase in mortality among children under-1 in 2009 and 2010. Overall, the resilience of Aceh province points to the importance of coordinated international disaster responses after natural disasters.

[Contraceptive use by married women or concubines living in rural areas in Burkina Faso: a qualitative study of free voucher use]. / Utilisation des contraceptifs par les femmes rurales mariées ou en concubinage au Burkina Faso: une analyse qualitative de l'utilisation d'un bon gratuit.

INTRODUCTION: low levels of contraceptive use in Western Africa are responsible for high fertility rates, which limits economic development. The cost of modern contraceptives is a significant constraint, then the government of Burkina Faso has implemented free family planning. Given this new policy, we provided rural women with a healthcare voucher giving free access to modern contraceptives. We conducted an analysis of the determinants of good free voucher use in order to implement adequate government policy. METHODS: six months after the distribution of vouchers to women living in 30 villages in the Houet Province, we conducted a focus-group study based on individual in-depth health care provider interviews in partner healthcare centers. RESULTS: the benefits of family planning, free contraceptive use, husband's approval and moral obligation were factors facilitating voucher use. The desire to become pregnant, husband's opposition, women's reluctance, women's lack of knowledge of contraceptives and factors associated with the intervention were the leading reasons for not using the vouchers. CONCLUSION: the promotion of modern contraceptive use among married women or concubines requires a holistic approach combining free access to modern contraceptives, effective policies involving men in family planning and the reduction of fertility preferences among the couples.

Nothing but the truth: Consistency and efficiency of the list experiment method for the measurement of sensitive health behaviours.

RATIONALE: Social desirability bias, which is the tendency to under-report socially, undesirable health behaviours, significantly distorts information on sensitive behaviours, gained from self-reports and prevents accurate estimation of the prevalence of those, behaviours. We contribute to a growing body of literature that seeks to assess the performance of the list experiment method to improve estimation of these sensitive health behaviours. METHOD: We use a double-list experiment design in which respondents serve as the treatment group for one list and as the control group for the other list to estimate the prevalence of two sensitive health behaviours in different settings: condom use among 500 female sex workers in urban Senegal and physical intimate partner violence among 1700 partnered women in rural Burkina Faso. First, to assess whether the list experiment improves the accuracy of estimations of the prevalence of sensitive behaviours, we compare the prevalence rates estimated from self-reports with those elicited through the list experiment. Second, we test whether the prevalence rates of the sensitive behaviours obtained using the double-list design are similar, and we estimate the reduction in the standard errors obtained with this design. Finally, we compare the results obtained through another indirect elicitation method, the polling vote method. RESULTS: We show that the list experiment method reduces misreporting by 17 percentage points for condom use and 16-20 percentage points for intimate partner violence. Exploiting the double-list experiment design, we also demonstrate that the prevalence estimates obtained through the use of the two lists are identical in the full sample and across sub-groups and that the double-list design reduces the standard errors by approximately 40% compared to the standard errors in the simple list design. Finally, we show that the list experiment method leads to a higher estimation of the prevalence of sensitive behaviours than the polling vote method. CONCLUSION: The study suggests that list experiments are an effective method to improve estimation of the prevalence of sensitive health behaviours.

Risk aversion and HIV/AIDS: Evidence from Senegalese female sex workers.

HIV/AIDS is the second cause of mortality globally and there are 5000 new infections each day. Globally, sex workers are 13 times more at risk of HIV than the general population and in Senegal they have an HIV prevalence 16.5 times greater. Therefore, it is urgent to encourage behaviour change, which requires a better understanding of the reasons why sex workers engage in risky behaviours. We provide new evidence of the role of risk preferences on sexual behaviours, health behaviours and health outcomes of 600 female sex workers in Senegal in July and August 2017. We measure risk aversion of sex workers using an incentivised Gneezy and Potters task in addition to specific risk-taking scales in four domains (in general, finance, health and sex). Understanding of the experimental task was high despite low literacy level of participants. Using ordinary least squares, we find that risk aversion is an important predictor of sex workers' sexual behaviours. We find that sex workers with higher level of risk aversion have less sex acts with clients, have less clients at risk of HIV, are more likely to engage in protected sex acts and as a result earn less money per sex act. Furthermore, we find that sex workers exhibiting higher level of risk aversion are less likely to be infected with sexually transmitted infections. Results highlight that some associations between risk preferences and sexual and health behaviours are domain specific. To conclude, our results confirm the role of risk preferences in the spread of HIV/AIDS epidemic and suggest the importance of collecting information on self-reported risk aversion to identify individuals who are at a greater risk of HIV/AIDS. Finally, our results provide some rationale in using lottery-based financial incentives to prevent sexually transmitted infections and HIV/AIDS among high-risk populations.

HIV infection risk and condom use among sex workers in Senegal: evidence from the list experiment method.

Social desirability bias, which is the tendency to under-report socially undesirable health behaviours, significantly distorts information on sensitive behaviours that is gained from self-reports. As a result, self-reported condom use among high-risk populations is thought to be systematically over-reported, and it is impossible to identify the determinants of condom use. The main objective of the article is to elicit unbiased information on condom use among female sex workers (FSWs) using the double list experiment method to analyse the role of HIV infection and exposure to HIV prevention methods in condom use. More specifically, the difference in levels of condom use between HIV-positive and HIV-negative FSWs is estimated. In addition, the role of FSWs' registration and participation in a pre-exposure prophylaxis (PrEP) demonstration project in condom use is considered. A list experiment was designed to elicit condom use information from 786 FSWs in Senegal who were surveyed in 2015 and 2017. Using the list experiment method, participants were randomly assigned to one of two groups (treatment or control) and were asked to report the number of statements they agreed with. Respondents assigned to the control group were presented with three non-sensitive items, whereas those allocated to the treatment group were presented with the same three statements plus the sensitive item (e.g. 'I used a condom during my last intercourse with a client'). Comparing the average number of sentences that were agreed with in both groups provides an estimation of the condom use rate in the treatment group and estimating such prevalence for several sub-groups allows the role of HIV infection risk in condom use to be identified. The percentage of FSWs using condoms in their last sexual intercourse with a client was 80% in 2015 and 78% in 2017, which was significantly lower than the 97% obtained in the face-to-face surveys in both waves. When estimating condom use among sub-groups with the list experiment method, we found that condom use among HIV-positive FSWs was only 34%, which was 47 percentage points lower than condom use among HIV-negative FSWs. We also found that registered FSWs are more likely to use condoms than clandestine FSWs. However, we did not find any difference in condom use between FSWs who were enrolled in the PrEP demonstration project and those who were not enrolled. Health policies should therefore aim to increase condom use among HIV-positive FSWs.

The cost of safe sex: estimating the price premium for unprotected sex during the Avahan HIV prevention programme in India.

There is some evidence that female sex workers (FSWs) receive greater earnings for providing unprotected sex. In 2003, the landscape of the fight against HIV/AIDS dramatically changed in India with the introduction of Avahan, the largest HIV prevention programme implemented globally. Using a unique, cross-sectional bio-behavioural dataset from 3591 FSWs located in the four Indian states where Avahan was implemented, we estimate the economic loss faced by FSWs who always use condoms. We estimate the causal effect of condom use on the price charged during the last paid sexual intercourse using the random targeting of Avahan as an instrumental variable. Results indicate that FSWs who always use condoms face an income loss of 65% (INR125, US$2.60) per sex act compared to peers providing unprotected sex, consistent with our expectations. The main finding confirms that clients have a preference for unprotected sex and that policies aiming at changing clients' preferences and at improving the bargaining power of FSWs are required to limit the spread of HIV.

HIV self-testing alone or with additional interventions, including financial incentives, and linkage to care or prevention among male partners of antenatal care clinic attendees in Malawi: An adaptive multi-arm, multi-stage cluster randomised trial.

BACKGROUND: Conventional HIV testing services have been less comprehensive in reaching men than in reaching women globally, but HIV self-testing (HIVST) appears to be an acceptable alternative. Measurement of linkage to post-test services following HIVST remains the biggest challenge, yet is the biggest driver of cost-effectiveness. We investigated the impact of HIVST alone or with additional interventions on the uptake of testing and linkage to care or prevention among male partners of antenatal care clinic attendees in a novel adaptive trial. METHODS AND FINDINGS: An adaptive multi-arm, 2-stage cluster randomised trial was conducted between 8 August 2016 and 30 June 2017, with antenatal care clinic (ANC) days (i.e., clusters of women attending on a single day) as the unit of randomisation. Recruitment was from Ndirande, Bangwe, and Zingwangwa primary health clinics in urban Blantyre, Malawi. Women attending an ANC for the first time for their current pregnancy (regardless of trimester), 18 years and older, with a primary male partner not known to be on ART were enrolled in the trial after giving consent. Randomisation was to either the standard of care (SOC; with a clinic invitation letter to the male partner) or 1 of 5 intervention arms: the first arm provided women with 2 HIVST kits for their partners; the second and third arms provided 2 HIVST kits along with a conditional fixed financial incentive of $3 or $10; the fourth arm provided 2 HIVST kits and a 10% chance of receiving $30 in a lottery; and the fifth arm provided 2 HIVST kits and a phone call reminder for the women's partners. The primary outcome was the proportion of male partners who were reported to have tested for HIV and linked into care or prevention within 28 days, with referral for antiretroviral therapy (ART) or circumcision accordingly. Women were interviewed at 28 days about partner testing and adverse events. Cluster-level summaries compared each intervention versus SOC using eligible women as the denominator (intention-to-treat). Risk ratios were adjusted for male partner testing history and recruitment clinic. A total of 2,349/3,137 (74.9%) women participated (71 ANC days), with a mean age of 24.8 years (SD: 5.4). The majority (2,201/2,233; 98.6%) of women were married, 254/2,107 (12.3%) were unable to read and write, and 1,505/2,247 (67.0%) were not employed. The mean age for male partners was 29.6 years (SD: 7.5), only 88/2,200 (4.0%) were unemployed, and 966/2,210 (43.7%) had never tested for HIV before. Women in the SOC arm reported that 17.4% (71/408) of their partners tested for HIV, whereas a much higher proportion of partners were reported to have tested for HIV in all intervention arms (87.0%-95.4%, p < 0.001 in all 5 intervention arms). As compared with those who tested in the SOC arm (geometric mean 13.0%), higher proportions of partners met the primary endpoint in the HIVST + $3 (geometric mean 40.9%, adjusted risk ratio [aRR] 3.01 [95% CI 1.63-5.57], p < 0.001), HIVST + $10 (51.7%, aRR 3.72 [95% CI 1.85-7.48], p < 0.001), and phone reminder (22.3%, aRR 1.58 [95% CI 1.07-2.33], p = 0.021) arms. In contrast, there was no significant increase in partners meeting the primary endpoint in the HIVST alone (geometric mean 17.5%, aRR 1.45 [95% CI 0.99-2.13], p = 0.130) or lottery (18.6%, aRR 1.43 [95% CI 0.96-2.13], p = 0.211) arms. The lottery arm was dropped at interim analysis. Overall, 46 male partners were confirmed to be HIV positive, 42 (91.3%) of whom initiated ART within 28 days; 222 tested HIV negative and were not already circumcised, of whom 135 (60.8%) were circumcised as part of the trial. No serious adverse events were reported. Costs per male partner who attended the clinic with a confirmed HIV test result were $23.73 and $28.08 for the HIVST + $3 and HIVST + $10 arms, respectively. Notable limitations of the trial included the relatively small number of clusters randomised to each arm, proxy reporting of the male partner testing outcome, and being unable to evaluate retention in care. CONCLUSIONS: In this study, the odds of men's linkage to care or prevention increased substantially using conditional fixed financial incentives plus partner-delivered HIVST; combinations were potentially affordable. TRIAL REGISTRATION: ISRCTN 18421340.

Estimating misreporting in condom use and its determinants among sex workers: Evidence from the list randomisation method.

Social desirability bias, which is the tendency to underreport socially undesirable health behaviours, significantly distorts information on sensitive behaviours gained from self-reports. We applied the list randomisation method to indirectly elicit condom use among female sex workers and tested it among 651 female sex workers in Senegal, a country where sex workers face high social stigma and where the AIDS epidemic is mainly concentrated among this population. On the basis of our list randomisation, we found that the condom use rate in the last sexual intercourse with a client was 78%, which is significantly lower than the 97% obtained when asked directly in the survey. When estimating condom use among the subgroups, we found that female sex workers who are at a higher risk of infection are less likely to use condoms.

The effect of demand-side financial incentives for increasing linkage into HIV treatment and voluntary medical male circumcision: A systematic review and meta-analysis of randomised controlled trials in low- and middle-income countries.

INTRODUCTION: Linkage to HIV treatment is a vital step in the cascade of HIV services and is critical to slowing down HIV transmission in countries with high HIV prevalence. Equally, linkage to voluntary medical male circumcision (VMMC) has been shown to decrease HIV transmission by 60% and increasing numbers of men receiving VMMC has a substantial impact on HIV incidence. However, only 48% of newly diagnosed HIV positive people link to HIV treatment let alone access HIV prevention methods such as VMMC globally. METHODS: A systematic review investigating the effect of demand-side financial incentives (DSFIs) on linkage into HIV treatment or VMMC for studies conducted in low- and middle-income countries. We searched the title, abstract and keywords in eight bibliographic databases: MEDLINE, EMBASE, Web of Science, Econlit, Cochrane, SCOPUS, IAS Conference database of abstracts, and CROI Conference database of abstracts. Searches were done in December 2016 with no time restriction. We fitted random effects (RE) models and used forest plots to display risk ratios (RR) and 95% CIs separately for the linkage to VMMC outcome. The RE model was also used to assess heterogeneity for the linkage to HIV treatment outcome. RESULTS: Of the 1205 citations identified from searches, 48 full text articles were reviewed culminating in nine articles in the final analysis. Five trials investigated the effect of DSFIs on linkage to HIV treatment while four trials investigated linkage to VMMC. Financial incentives improved linkage to HIV treatment in three of the five trials that investigated this outcome. Significant improvements were observed among postpartum women RR 1.26 (95% CI: 1.08; 1.48), among people who inject drugs RR 1.42 (95% CI: 1.09; 1.96), and among people testing at the clinic RR 1.10 (95% CI: 1.07; 1.14). One of the two trials that did not find significant improvement in linkage to ART was among people testing HIV positive in clinics RR 0.96 (95% CI: 0.81; 1.16) while the other was among new HIV positive individuals identified through a community testing study RR 0.82 (95% CI: 0.56; 1.22). We estimate an average 4-fold increase in the uptake of circumcision among HIV negative uncircumcised men from our fitted RE model with overall RR 4.00 (95% CI: 2.17; 7.37). There was negligible heterogeneity in the estimates from the different studies with I-squared = 0.0%; p = 0.923. CONCLUSIONS: Overall, DSFIs appeared to improve linkage for both HIV treatment and VMMC with greater effect for VMMC. Demand-side financial incentives could improve linkage to HIV treatment or VMMC in low- and middle-income countries although uptake by policy makers remains a challenge.

The effect of sex work regulation on health and well-being of sex workers: Evidence from Senegal.

Senegal is the only African country where sex work is legal and regulated by a health policy. Senegalese female sex workers (FSWs) are required to register with a health facility and to attend monthly routine health checks aimed at testing and treating sexually transmitted infections (STIs). Compliance to those routine visits is recorded on a registration card that must be carried by FSWs in order to avoid sanctions in case of police arrests. Although this policy was first introduced in 1969 to limit the spread of STIs, there is no evidence so far of its impact on FSWs' health and well-being. The paper aims to fill this gap by exploiting a unique data set of registered and unregistered Senegalese FSWs. Using propensity score matching, we find that registration has a positive effect on FSWs' health. However, we find that registration reduces FSWs' subjective well-being. This finding is explained by the fact that registered FSWs are found to engage in more sex acts, in riskier sex acts, have less social support from their peers, and are more likely to experience violence from clients and police officers. We prove that those results are robust to the violation of the conditional independence assumption, to misspecification of the propensity score model, and that covariate balance is achieved. The results suggest that more efforts should be deployed to reduce the stigma associated with registration and to address the poor well-being of FSWs, which is counterproductive to HIV prevention efforts.