Financial incentives and deposit contracts to promote HIV retesting in Uganda: A randomized trial

Abstract

Background Frequent retesting for HIV among persons at increased risk of HIV infection is critical to early HIV diagnosis of persons and delivery of combination HIV prevention services. There are few evidence-based interventions for promoting frequent retesting for HIV. We sought to determine the effectiveness of financial incentives and deposit contracts in promoting quarterly HIV retesting among adults at increased risk of HIV. Methods and findings In peri-urban Ugandan communities from October to December 2018, we randomized HIV–negative adults with self-reported risk to 1 of 3 strategies to promote HIV retesting: (1) no incentive; (2) cash incentives (US$7) for retesting at 3 and 6 months (total US$14); or (3) deposit contracts: participants could voluntarily deposit US$6 at baseline and at 3 months that would be returned with interest (total US$7) upon retesting at 3 and 6 months (total US$14) or lost if participants failed to retest. The primary outcome was retesting for HIV at both 3 and 6 months. Of 1,482 persons screened for study eligibility following community-based recruitment, 524 participants were randomized to either no incentive (N = 180), incentives (N = 172), or deposit contracts (N = 172): median age was 25 years (IQR: 22 to 30), 44% were women, and median weekly income was US$13.60 (IQR: US$8.16 to US$21.76). Among participants randomized to deposit contracts, 24/172 (14%) made a baseline deposit, and 2/172 (1%) made a 3-month deposit. In intent-to-treat analyses, HIV retesting at both 3 and 6 months was significantly higher in the incentive arm (89/172 [52%]) than either the control arm (33/180 [18%], odds ratio (OR) 4.8, 95% CI: 3.0 to 7.7, p < 0.001) or the deposit contract arm (28/172 [16%], OR 5.5, 95% CI: 3.3 to 9.1, p < 0.001). Among those in the deposit contract arm who made a baseline deposit, 20/24 (83%) retested at 3 months; 11/24 (46%) retested at both 3 and 6 months. Among 282 participants who retested for HIV during the trial, three (1%; 95%CI: 0.2 to 3%) seroconverted: one in the incentive group and two in the control group. Study limitations include measurement of retesting at the clinic where baseline enrollment occurred, only offering clinic-based (rather than community-based) HIV retesting and lack of measurement of retesting after completion of the trial to evaluate sustained retesting behavior. Conclusions Offering financial incentives to high-risk adults in Uganda resulted in significantly higher HIV retesting. Deposit contracts had low uptake and overall did not increase retesting. As part of efforts to increase early diagnosis of HIV among high-risk populations, strategic use of incentives to promote retesting should receive greater consideration by HIV programs. Trial registration clinicaltrials.gov: NCT02890459.

Demand creation for HIV testing services: A systematic review and meta-analysis

“…Fourteen RCTs were conducted in Africa [ 11 – 15 , 17 , 18 , 21 , 24 , 25 , 27 , 28 , 30 ], 6 in the Americas [ 16 , 19 , 20 , 22 , 23 , 26 ], and 2 in Asia [ 10 , 29 ]. Seven focused on heterosexual couples [ 12 , 14 , 17 , 20 , 23 , 27 , 30 ], 4 on heterosexual men [ 11 , 15 , 21 , 22 ], 4 on women or caregivers of children [ 14 , 16 , 24 , 25 ], 2 on children and adolescents [ 18 , 28 ], 5 on priority populations including sex workers [ 10 , 13 ], previously incarcerated adults [ 26 ], and transgender women and MSM [ 19 , 29 ].…”

Applying Behavioural Insights to HIV Prevention and Management: a Scoping Review

“…Twenty HIV prevention studies used commitment. Binding commitment contracts, which involved financial deposits made by participants, were used in some studies to encourage participants to attend clinics regularly for HIV testing services [ 139 , 156 , 157 ]. When participants underwent HIV testing regularly for the agreed commitment period, their deposits were returned with interest paid.…”

“…Other examples include text-based ART medication reminders and mindfulness exercises to reduce HIV viral load (Table 2). Culturally relevant and gender-specific messaging to engage in HIV prevention [30,101] Loss framed lottery intervention to encourage dual contraception methods to prevent HIV infection [86] HIV to take PrEP medication [142] HIV management Use of priming stimuli that is empowering or culturally meaningful to improve adherence to ART and retention in care [143,144] Use of financial rewards as priming to improve adherence to ART and to suppress viral load count [49,145] Providing safe sex materials as priming to practice safe sex to prevent HIV transmission [146] Personalised cues and reminder messages for remembering dose times to support ART adherence [72,74,147,148] Affect HIV prevention Creating positive emotion for HIV testing or accessing HIV services [111,139,149,150] Peer-led group sessions to learn skills for self-efficacy and positive sexual health behaviours [31] Increasing risk perception towards HIV to encourage HIV prevention behaviours [99,151] HIV management Creating positive emotion for HIV care retention and ART adherence through social, financial, or non-financial support [99,111,143,146] Group sessions targeting positive affect to increase skills for self-efficacy to encourage ART adherence and viral load suppression [146,[152][153][154] Motivational messages to encourage ART adherence [147,150,155] Commitment HIV prevention Use of binding contracts with financial deposits to encourage HIV testing or clinic visits [139,[156]…”

Randomized Controlled Trial of Automated Directly Observed Therapy for Measurement and Support of PrEP Adherence Among Young Men Who have Sex with Men

“…However, in this study, we did not see improved adherence in the intervention arm compared with the control arm. It is possible that providing the micro-incentives to both arms of the study masked any benefit from the DOT Diary app alone, as incentives have been previously shown to improve some health behaviors [ 50 – 54 ], and approximately 60% of both the intervention and control participants stated that getting a micro-incentive improved their daily pill taking. Nearly all participants also stated that participation in the study improved their self-confidence in taking PrEP, so the counseling provided to both study arms may have similarly obscured differences between the two arms.…”