The Ethics of Material Incentives for HIV Prevention

I am one of four panelists who will debate on Monday morning whether it is ethical for a government to offer material incentives in order to prevent HIV infections.UPDATE 2/17/2011: The videocast has now been posted. To view it, click here, scroll to “DEBATE 5” and click on the phrase “Click here for videocast".A theme of my work since an early paper with Peter Piot has been the public economic rationale for government to shoulder the responsibility for HIV prevention. In my book with Martha Ainsworth, Confronting AIDS, and subsequently in a chapter entitled “The public interest in a private disease,” I have argued that the extraordinarily large negative external effects of one person’s risky behavior on the rest of society justify the government’s intervention in what would otherwise be private transactions, whether for sex or needle sharing.  But in these arguments, my justifications have been based on the economic calculus of the greatest good for the greatest number.  Although I have not appealed directly to ethics, I believe that the prevention of spread of infectious disease in general, and of HIV in particular, is one of the most ethical activities that a government can undertake.Followers of CGD health activities will know that the second chapter of my forthcoming book is entitled “Using Incentives to Prevent HIV Infections” and is posted here on our website.  In that chapter, and in a background paper jointly authored by Tim Hallett of Imperial College, which is posted here, I have urged the expanded use of incentives in order to encourage behavior by health care providers, by risk takers and by governments that is in the public interest.I have been somewhat surprised at the response I’ve received to these suggestions.  Many people are so concerned about the potential unintended consequences of the use of incentives that they prefer to leave this potentially useful tool aside, continuing to strive for HIV prevention through other means.This always makes me wonder:  Assuming that using incentives could enhance the effectiveness of HIV prevention as much as early indications suggest, eschewing their use means allowing more new HIV cases.  How many additional HIV cases would those who oppose the use of incentives be willing to accept as the cost of leaving this important potential tool unused?  On Monday perhaps we will hear the answer to that question.