Using a blue pen, Sityhilelo Mandlingana enters a client's name, sex and age into a register next to the date and time that he saw her. He removes a new HIV test kit from a box behind his consulting table under a baby-blue awning in the middle of a field in the rural Eastern Cape and takes a deep breath. "Next!" he shouts.
He is ready for the 39th villager from Magweni, near Elliotdale. They are here to be tested for HIV.
In the background, the music is pumping and a marquee tent has been erected. Mamas are peeling carrots and cooking chickens in massive cast-iron pots over smoking fires.
Mandlingana looks up as someone settles into the chair alongside his table. "No! Not you again!" he exclaims. "You were here just the other day!"
"Come on, man!" says the young man, easing into the chair. "I need another chance to win the phone and I also need one of those bags. I need to keep in touch with my family!"
There are another 56 people waiting in the searing heat to get tested.
"I won the phone a few months ago, but I gave it to my aunt. Now I am here to win it for myself," says a 22-year-old man wearing a T-shirt bearing the image of Che Guevara.
A woman with a baby girl tied to her back adds quickly: "We are aware of the raffle and the gift, but it's not those things that are drawing us to the queue; it's our bodies and that we want to be healthy."
The "gift" is a handmade cotton bag containing toothpaste, soap and condoms. You receive it only once you have been tested for HIV. Then there is the "raffle": the chance to have your name placed in a hat to win a Nokia cellphone worth R200.
No one wanted to get tested
Two years ago, no one wanted to be tested for HIV here, and young people refused to attend the "health days" set up by Bulungula Incubator, a nongovernmental organisation in the Eastern Cape that works to improve living conditions there.
"We were all very disappointed and started to think of gimmicky things and novelty factors that would draw young people," says the NGO's director, Réjane Woodroffe. "In addition to a free lunch, we needed incentives that young people just wouldn't be able to stay away from. That's when we came up with the idea of a cellphone raffle, because people here love cellphones; they're most villagers' only link with the outside world."
As a result, HIV testing has tripled in the four villages – Nqileni, Magweni, Folokhwe and Chezi – where health days are being held.
According to the Joint United Nations Programme on HIV and Aids, only 50% of people who have HIV know they are infected. Human Sciences Research Council figures show that less than half of South Africans were aware of their HIV status in 2012.
But at Magweni, many villagers now present themselves for repeated testing. "It's good to get regular tests because, if you're sexually active, you can get infected at any time – a one-off test isn't good enough," explains Mandlingana. "So this drive is really working well."
Mandlingana – a pensive man in his early 30s – works for the government's Madwaleni Hospital. It is the closest hospital to Magweni village, yet it takes four hours to get there in a minibus taxi over dirt roads.
Out of the 95 people Mandlingana and his colleagues tested today, four tested positive for HIV. "We can now put them on antiretroviral treatment that will not only keep them healthy, but also make them much less infectious," he says.
The health department aims to get 80% of adult South Africans to test for HIV at least once a year by 2016.
But Magweni's "incentivised HIV testing" is a contentious subject in South Africa: when Western Cape Premier Helen Zille, for instance, tried to get people to test for HIV in 2011 by offering cash lottery prizes, the ANC accused her of implementing an "outrageously ill-advised plan" and health activists called her strategy "questionable".
Zille's not the only one who has used lotteries to prompt South Africans to test for HIV. In 2009 the Sunday Times and medical aid scheme Discovery Health ran a yearlong competition offering a R100 000 cash prize that one reader could win each month in a lucky draw. They inspired more than 50 000 people to test in that way. And when the national health department launched its HIV testing campaign among tertiary institutions in the country, it offered a car, laptop computer and book vouchers that could be won in a lottery to attract students to test.
Opponents of incentivised testing argue that "prizes" undermine people's "intrinsic motivation" or understanding of why they need to get tested. "My concern is that if people get incentivised to test for HIV, they would expect the same for diabetes, hypertension, vaccinations and to stay in school. Where does it end?" asks the deputy director general for health, Yogan Pillay. "You also run the risk of only attracting people who are interested in the specific prize that you offer."
But Woodroffe says she sees no harm in the initiative: "When children go to the dentist or doctor, they get lollipops or sweets. What's the difference? In fact, I see lots of harm when there aren't any incentives and people [don't test and] die."
Incentives have also been used in developed countries, albeit not for HIV. A 2008 study published in the open access journal BioMed has shown that that the use of daily, small cash lottery prizes can significantly improve patients adherence to take the "blood-thinning" medication warfarin which has potentially severe side effects. Canadian studies have proved that lottery prizes encourage people to test their cholesterol levels and US research has found that cash lotteries helped Americans to lose weight.
One of the most cited "lottery examples" is the Glasgow story: In 1957 Glasgow had the highest death rate from lung TB in Britain. The government wanted to get people to go for lung x-rays so that people with TB could be identified during an early state of the disease. It aimed to get 250 000 people over a five week period, but ended up with almost three times that amount through a weekly prize draw.
A study in 2013 by the Automotive Industry Development Centre Eastern Cape, conducted among four car factories in Port Elizabeth and Uitenhage, found that lottery incentive systems in fact "reinforced people's intrinsic motivation to test for HIV" at their places of work rather than weakened it.
"Qualitative interviews with employees showed that lotteries, which were advertised through posters and pamphlets two weeks before HIV testing days, facilitated discussions about HIV in the build-up to the testing day. This increased workers' understanding about why they needed to get tested. In the end, they went to get tested because of the benefits of knowing their status that they learned about through these discussions, rather than to win a prize," says Martin Weihs, adviser to the Automotive Industry Development Centre.
Bulungula Incubator health co-ordinator Nomzingisi Hopisi says her project has experienced similar results: "Our raffles and goodie bags make people talk about HIV. And the more they talk about it, the more normal the condition becomes and the more willing they become to take steps, such as getting tested for HIV, to prolong their lives."
Offering prizes also reduces the stigma around HIV testing, Weihs says, as it provides "psychological cover". Hopisi agrees. "People can say: 'Well, I'm just going to try to win a cellphone.' They don't have to say: 'Well, I'm going because I think I may have HIV.'"
Public health system failing
The head of activist organisation Section27 , Mark Heywood, says that the need for incentives shows that South Africa's public health system is failing. "People's reluctance to seek HIV testing is indicative of the weakness of the health system to persuade people to pursue health-seeking behaviour. Ultimately, we need far more public and continuous messaging about HIV testing and the advantages of it. We need to put our energy into that rather than quick fixes."
The big question, opponents of incentives say, is what happens when the incentive is taken away. Will people still go to get tested for HIV?
"We don't have to test that question yet," says Woodroffe. "We still have the funding to pay for the phones and goodie bags. As long as we have the money, we will pay for it."
Back at Magweni, the time for the raffle draw has arrived. Yandisa Mbobana – a 21-year-old man in a navy-blue Chelsea football shirt – jumps to his feet when his name is announced.
"I'm thanking you that I've won this phone! I was the lucky one!" He dances in small circles, waving his hands above his head with villagers cheering and clapping hands. Then he stops and thinks for a while. "I would have come anyway, but knowing that I would win the phone, it was something extra that really made me feel like this is an occasion I should not miss," he says.
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