The Wisdom of Whores

Malawian civil servants who are not infected with HIV are claiming to be positive to increase their salaries, thus demonstrating that the monster of stigma can be slain with cash.

Malawi is suspending its payments to HIV-infected civil servants because so many uninfected people are trying to cash in, according to AFP (via Cryton Chikoko). A third of Malawi’s 120,000 civil servants have registered as HIV positive. That puts HIV prevalence among government workers at twice the national rate of 14 percent.

Infected civil servants top up their salaries by US$ 35 a month –that’s a 50% slab on top of their average earnings — enough to make many of us change our behaviour. Obviously enough to overcome the stigma that is so often said to stand in the way of any effective HIV programming. It reminds me of stories that surfaced in China when the government started providing free schooling for the kids of people with HIV. China being China, it wasn’t long before there was a secondary market in HIV-infected blood.

Stigma exists because we allow it to, because we reinforce it by tiptoeing around it. The bulldozer of personal incentives can break through stigma in exactly the same way as it can break through corruption, poor productivity and other areas of human endeavour. If we have to bribe our way into greater openness about HIV, why not?

Well, maybe because peverse incentives are a dangerous thing. We want to make it worth people’s while to be more open about their HIV status, without making it worth their while to be infected with HIV. And we don’t want to do anything to reduce the motivation that uninfected people have to protect themselves (which, judging from high rates of new infections in many populations, it already pretty slim). This came up in an interesting discussion I had with the Oxford Global Health group recently. One person mentioned that people in South Africa who get disability payments linked to their TB infection are reluctant to be fully cured, because they don’t want to lose the payments. I’m all for using bribery to change attitudes and behaviour. But one does have to remember that the sword of incentives can have many edges.