Impact Brief: Information is Power — An Actionable Lesson in HIV Prevention Scales Up in Africa

The chance conversation in 2004 stopped Pascaline Dupas in her tracks. A colleague in Kenya, where Dupas was doing field work in education, mentioned she had to leave early for the day so she could find her younger sister and give her pocket money.

“These high school girls don’t have money, and I don’t want her to end up with a sugar daddy,” the coworker told Dupas.

In Africa, as in other low-income parts of the world, it’s not uncommon for older men to lure young girls into sexual relationships in exchange for financial support. But these liaisons come at a potentially fatal price in Africa: The risk of contracting HIV from an older male is significantly higher for women than it is from men closer to their own age.

“Why would she get a sugar daddy? That would be crazy,” said Dupas, an associate professor of economics at Stanford, who was then a 28-year-old doctoral student.

Her friend replied that the girls didn’t know about the risks of sex with older men. They were taught that teenage boys were the real danger.

Dupas was stunned by that lack of knowledge—and inspired. Before long, she was surveying young girls in Kenyan schools, where she learned firsthand that her friend had been right. Young girls didn’t know about the strong link between sugar daddies and HIV.

Before long, she developed a 40-minute instruction that included a short video and data on the prevalence of HIV infection by age and gender. As part of their field experiment, Dupas and her team lugged a TV, DVD player, power generator, and cable to some 70 primary schools in rural Kenya. Many of the eighth graders who participated in the session had never seen a television.

“We wanted the moment to be one they wouldn’t forget,” said Dupas, whose intervention also encouraged students to actively participate in a discussion about sugar daddies. For the students, this was quite a change compared to the Kenyan government’s abstinence-only curriculum for HIV prevention.

Even more memorable was the impact the class had on the students. Dupas analyzed pregnancy rates—an objective measure of incidents of unprotected sex and, by proxy, HIV infection—among the 15-year-old girls who heard the lesson and those in a control group who did not.

The results of her randomized field experiment were stunning. Pregnancy rates among girls who received the instruction fell by 28% overall, suggesting a decline in unsafe sex. Pregnancy rates with men five or more years older fell by 61%, with no offsetting jump in childbearing with teenaged boys. The findings formed the basis of Dupas’ PhD dissertation and were published in 2011 in the American Economic Journal: Applied Economics.

“She basically proved that if you empower young women with actionable information about HIV, they will change their behavior,” said Tommy Clark, founder of Grassroot Soccer, a nonprofit that teaches African youth about health that subsequently incorporated Dupas’ data into its HIV prevention curriculum.

A COMPLEX PATH FROM RESEARCH TO PRACTICE

Clark wasn’t the only social entrepreneur who embraced Dupas’ work. In recent years, several nongovernmental organizations have introduced her curriculum to hundreds of schools in countries battling high rates of HIV infections, including Botswana, Ghana, and Nigeria. Four of them were given seed money by the D-Prize, an organization dedicated to scaling existing evidence-based solutions for reducing poverty.

“We thought, ‘Here’s a problem. Here’s a potential solution. Let’s get going.’”

One of the first NGOs to combine Dupas’ data and teaching material was Young 1ove. The charity was founded by an MIT alumnus, Noam Angrist, who heard about Dupas’ work in an undergraduate course on global poverty he took in 2011. He remembers feeling awed by the simplicity and cost-effectiveness of her approach. Three years later, Angrist was working in Botswana when he struck up a conversation about sugar daddies with a coworker. As they talked, he recalled Dupas’ innovation. Young 1ove was born.

Angrist was eager to introduce Dupas’ curriculum in Botswana, which has the world’s second- highest HIV infection rate. Forty-five percent of 40-year-old men have HIV, compared to 5% of teenage boys. When asked which of the two age groups were riskiest, 90% of young students didn’t know it was the older men. Also, the official curriculum advocating abstinence only seemed, like in Kenya, to be having no impact on sexual activity among kids.

“Pascaline’s intervention had already been shown to work in Kenya,” said Angrist. “We thought, ‘Here’s a problem. Here’s a potential solution. Let’s get going.’”

But first the solution needed to be adapted to the local context. In Botswana, it turned out that kids were reluctant to talk openly about sex and the role of sugar daddies in front of their peers. “When we told students about the risk of sugar daddies, they would gasp because the information was so shocking,” said Angrist. This meant the introductory video was not enough. Young 1ove had to find a way make the instruction fun and playful.

28: Percent decrease in pregnancy rates after receiving a 40-minute instruction developed by Dupas

A bigger obstacle arose when Angrist and some collaborators set out in 2014 to rigorously test whether their instruction was having an effect on pregnancy rates similar to what Dupas had found in Kenya. By now, they had plans to scale up as quickly as possible across Botswana and beyond. But first, they had to prove the lesson was working. So, in an innovative move for an NGO, they partnered with the University of Botswana and the country’s Ministry of Basic Education, among others, and set up a randomized experiment covering 42,000 students across 343 schools. When they looked at the results, however, measuring impacts turned out to be “complex,” Angrist said.

He and his team then turned to Dupas. “Her insights were really critical in helping us to interpret our results,” said Angrist, who delayed plans to scale up the intervention to focus on fine-tuning the study results.

Today, nearly three years later, Angrist is gearing up to scale the sugar daddy lesson in Botswana and possibly to Zambia, Zimbabwe, South Africa, and Swaziland. “Pascaline really cares about the research informing the real world,” said Angrist. “She has gone out of her way to make this happen and we continue to learn from her.”

This issue brief describes how teams of researchers and leaders in government, business and nonprofits can work together to generate new ideas, insights, and solutions to make progress on social problems. Stanford King Center on Global Development Faculty Director and Professor of Economics Pascaline Dupas was a co-chair of Stanford Impact Labs’ design team and now serves on the SIL leadership team as associate director. This brief was written prior to the launch of Stanford Impact Labs to show how new evidence and insights developed jointly by scholars and external practitioners can inform policies and programs to improve lives.

Stanford Impact Labs invests in highly motivated teams of researchers and practitioners from government, business, nonprofit organizations, and philanthropy. These teams—impact labs—work together on social problems they choose and where practical progress is possible. With financial capital and professional support from Stanford Impact Labs, they can rapidly develop, test, and scale new solutions to social problems that affect millions of people worldwide.

Learn more about the work Stanford Impact Labs is investing in at impact.stanford.edu.