Are students being coerced into testing for HIV? Ethical considerations related to offering incentives for HIV counselling and testing at tertiary institutions in South Africa

David Alan Cameron; Hanlie Van der Merwe

SAJBL 197

Are students being coerced into HIV testing? Ethical considerations related to offering incentives for HIV counselling and testing at tertiary institutions in South Africa

D Cameron, H van der Merwe

Foundation for Professional Development and the Department of Family Medicine at the University of Pretoria.

D Cameron, MB ChB, M Prax Med, M Phil, FCFP(SA)

Foundation for Professional Development

H van der Merwe, B Cur, CAHM

Corresponding author: D Cameron (davidc@foundation.co.za)

A social marketing strategy, including substantial prizes, was used to promote HIV testing at 17 institutions of higher learning in South Africa. Over 20 000 students with a mean age of 19 years were counselled and tested for HIV. The majority were being tested for the first time. Afterwards they signed a public pledge: ‘We, the class of 2010, pledge to know our status, to stop HIV/AIDS stigma and to contribute to the struggle against HIV/AIDS.’ The students’ opinion of the campaign was surveyed and they were found to be overwhelmingly in favour of it. The issue of whether the prizes unduly influenced the students’ participation is investigated and an approach to resolving ethical dilemmas is presented. The potential of incentives to undermine ‘moral sentiments’ is reviewed.

S Afr J BL 2012;5(2):95-97. DOI:10.7196/SAJBL.197

Students attending university for the first time are inclined to indulge in high-risk behavior such as excessive alcohol consumption and unprotected sex.1 , 2 , 3 The motivations underlying human behaviour are complex; encouraging a healthy lifestyle requires strategies that are widespread and sustained.3 , 4 One such strategy is to help students establish their HIV status by undergoing counselling and testing, which is one of the first steps in self-protection.5 , 6 , 7 , 8

On World AIDS Day, 1 December 2009, President Jacob Zuma called on every South African to ‘act decisively and act together’ to tackle the growing AIDS epidemic. In April 2010 the Minister of Health, Dr Aaron Motsoaledi, launched a campaign to encourage 15 million people to go for HIV counselling and testing. In response to this call, an association of pharmaceutical companies, together with a private institution of higher learning, funded, planned and implemented a mass voluntary HIV counselling and testing campaign, called First Things First, at most of the public higher educational institutions across South Africa.

The First Things First campaign

The marketing strategy for creating maximum awareness and interest included an innovative educational multimedia presentation, flyers, banners and posters, as well as colourful T-shirts and waving hands worn by promoters. Drawstring give-away bags contained branded condoms, armbands, HIV- and AIDS-related leaflets, copies of the DVD First Things First, a list of nearby health facilities and services and a competition entry form. After testing, students were encouraged to sign the Pledge Wall which stated: ‘We, the class of 2010, pledge to know our status, to stop HIV/AIDS stigma and to contribute to the struggle against HIV/AIDS.’ After signing the pledge wall, first-year students had the opportunity to enter a competition.

Although the effort was initially aimed at first-year students, senior students and even some staff were later offered counselling and testing. Members of the university faculty, peer educators and NGO staff were trained to support students in 5 regional hubs.

The campaign was conducted at 17 of the 23 institutions of higher education that were invited to participate. Some academics questioned the value of a mass campaign and suggested that it would disrupt the normal process of voluntary testing at the student health centres, which would struggle to cope with the increased numbers.

The campaign travelled around the country spending 4 - 5 days at each campus. They tested an average of 222 students per day over a period of 94 days. In total, 20 953 students with a mean age of 19 years were counselled and all but 529 were tested. One third of the students were first-years, and twice as many females as males tested. During the campaign, 315 (1.5%) out of the 20 953 students tested positive for HIV infection and were referred to healthcare facilities for further management and support. In addition, 15 668 students were screened for TB and 45 were referred for further investigation.

This was the first countrywide HIV counselling and testing campaign for higher education institutions in South Africa. The response of the committee of university vice-chancellors has been very positive, and they have requested that the First Things First campaign should be repeated annually.

Incentives and ethical concerns

As an incentive to participate, first-year students could enter a lucky draw at each campus. The first name drawn went into the national draw for a motor car (fully sponsored by Toyota SA) at the end of the campaign; second prize was a laptop computer or an android smart phone; and third prize was book vouchers to the value of R200.

Social marketing

Social marketing uses the same strategies that were developed for commercial marketing to promote public health.9 These include careful analysis of the target audience; tailoring the message; branding; developing favourable thoughts about the message’s arguments (message elaboration); and the use of incentives.

While free pens and bags don’t generate much concern, substantial prizes such as computers and a car raise the question of whether such incentives put undue pressure on students to volunteer for testing. Is this a form of coercion, or are they truly able to give voluntary consent?

Resolving ethical dilemmas

There are numerous approaches to resolving apparent ethical dilemmas. Traditionally, the approach has been to examine the options from two perspectives. Firstly, what are the consequences of the action (the consequentialist or teleological perspective)? The second is to consider the action itself and ask if it is a morally right action (the deontological approach).

In this case, the issue is whether offering significant incentives interferes with freedom of choice. Has the student’s freedom of choice been curtailed or manipulated by the incentives, and has the student thus been coerced?

There are issues to consider before an HIV test. In the event of a positive result, one will have to endure major emotional distress, as well as possible discrimination and stigma. However, there are also major advantages including accessing treatment and preventing further spread of the virus to one’s sexual partner/s. From the consequentialist perspective, the advantage of finding out one’s status outweighs the disadvantage of the emotional distress.

To determine the students’ views of the campaign and whether they felt pressurised into being tested, an independent survey organisation, Partners in Research, conducted a satisfaction survey using touch-screen technology. As the survey was commissioned after the campaign had already started, it was only possible to survey 1 436 students at the remaining 3 campuses. The survey was not limited to first-year students. The results are presented in Table 1.

Table 1. The results of the survey of students’ views of the campaign at 3 university campuses
Question	Response
Is this your first HIV test?
Yes	58%
No	42%
What prompted your decision to take an HIV test?
Promotional activity of campaign	42%
Friends having a test	24%
Opportunity to win a prize	17%
Viewing the multi-media presentation	2%
Other/no reason supplied	15%
Based on today’s experience, would you encourage your friends to take an HIV test?
Yes	99%
No	1%
Before your arrival on campus, had you received information on HIV?
Yes	86%
No	14%

Some of the 354 comments received were:

• Job well done/continue the good work

• Awesome – will support it again

• Excellent work to build a healthy world free of HIV and AIDS

• Made me think deeply about HIV and AIDS, thanks guys

• Well-organised and a great initiative

• First Things First, you rock

• Speedy and convenient being held on campus, otherwise I wouldn’t go

• Competition was a good advertising strategy

• Felt honoured to be part of this campaign

• Loved the freebies

• It’s awesome to see society caring for people like with this campaign – thanks.

It is obvious that the overwhelming majority of the students surveyed were in favour of the campaign and the use of incentives. When asked why they chose to get tested, students’ responses show that the energy and ‘buzz’ around the campaign, plus the encouragement of their friends, were the main reasons. Even though the thought of winning a prize did encourage many students, none of them felt they were being coerced. They were acting in what they perceived as their own best interests.

From the deontological or moral perspective, there appears to be no real issue. The only complaint received was that the senior students felt that they should also have had a chance to enter the competition. The exclusion of the senior students had been a deliberate strategy on the part of the organisers as the campaign was focused on first-year students.

Societal concerns

There is, however, a more subtle concern around the issue of incentives. Do incentives undermine moral values that form an important foundation of our open society? Samuel Bowles argues that caution is needed:10 ‘High-performance organisations and economies work on the basis not only of material interests but also of Adam Smith’s “moral sentiments.” Well-designed laws and public policies can harness self interest for the common good. However, incentives that appeal to self interest may fail when they undermine the moral values that lead people to act altruistically or in other public-spirited ways.’

Now, what did Adam Smith (1723 – 1790), the Scottish social philosopher and father of modern economics, have in mind when he used the term ‘moral sentiments’? Smith regarded human relationships as the source of our ability to form moral judgements. This ability counters our natural inclination to self-interest and allows us to act for the common good. But what does this have to do with incentives and HIV tests? Here the issues get a little confused but Bowles illustrates the importance of Smith’s argument with numerous examples that support the notion that incentives undermine ethical motives.

According to Bowles, incentives affect key aspects of how we acquire our motivations and may induce subtle long-term change in motivations. Incentives have been shown to degrade performance and may even be perceived as an indication of distrust.11 , 12 , 13 , 14 For many, the intrinsic motivation to act for the common good is closely tied to their belief that they are moral beings. Incentives, big or small, may degrade that notion and may subtly undermine the intended good. Consider an example such as payment for blood donation. Currently in South Africa there is no financial incentive to donate blood, and we rely on ‘moral sentiments’ to supply the blood needed for medical emergencies. The feel-good factor (the sense that ‘I’ve done the right thing’) is a strong incentive to respond to appeals from worthy causes.

There is, however, ample evidence that financial incentives have achieved better health outcomes.15 The factors for and against the use of incentives are complex and include the need to consider not only effectiveness but also feasibility, scalability and sustainability. These issues were considered in a series of recent debates on emerging issues in HIV prevention.16 A major concern is that behavior may be short-lived if the incentive is no longer available.17

It is interesting to note that during the First Things First campaign, more senior students than first-years came for testing even though they were not eligible for the prizes. Signing the Pledge Wall after testing further reinforced their personal commitment to be aware of their HIV status and to continue the struggle against HIV and its stigma.

In the 2009 Reith Lectures,18 philosopher Professor Michael Sandel of Harvard pointed out that economic forces leave their mark on social norms: ‘We need to recognise that there are some things than money can’t buy and other things that money can buy but shouldn’t.’ It is the extent and impact of this mark that should continually concern us.

The real ethical issue is thus both a moral and a teleological one. Do financial incentives to encourage an HIV test cloud the moral sentiments of our first-year students in a less obvious but more serious and long-term way? Should such a clouding be viewed as a ‘cost’? If yes, it would be important for organisers to reflect on this matter very carefully in future campaigns and consider how the overarching good can be maintained in future campaigns, but at limited ‘cost’.

Post script. The First Things First campaign won the award for the Best Mass Media intervention, campaign or production at the annual African Network for Strategic Communication in Health and Development (AfriComNet) awards ceremony held in Ethiopia in December 2011.

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