Monetary incentives and peer referral in promoting secondary distribution of HIV self-testing among men who have sex with men in China: A randomized controlled trial

Abstract

Background Digital network–based methods may enhance peer distribution of HIV self-testing (HIVST) kits, but interventions that can optimize this approach are needed. We aimed to assess whether monetary incentives and peer referral could improve a secondary distribution program for HIVST among men who have sex with men (MSM) in China. Methods and findings Between October 21, 2019 and September 14, 2020, a 3-arm randomized controlled, single-blinded trial was conducted online among 309 individuals (defined as index participants) who were assigned male at birth, aged 18 years or older, ever had male-to-male sex, willing to order HIVST kits online, and consented to take surveys online. We randomly assigned index participants into one of the 3 arms: (1) standard secondary distribution (control) group (n = 102); (2) secondary distribution with monetary incentives (SD-M) group (n = 103); and (3) secondary distribution with monetary incentives plus peer referral (SD-M-PR) group (n = 104). Index participants in 3 groups were encouraged to order HIVST kits online and distribute to members within their social networks. Members who received kits directly from index participants or through peer referral links from index MSM were defined as alters. Index participants in the 2 intervention groups could receive a fixed incentive ($3 USD) online for the verified test result uploaded to the digital platform by each unique alter. Index participants in the SD-M-PR group could additionally have a personalized peer referral link for alters to order kits online. Both index participants and alters needed to pay a refundable deposit ($15 USD) for ordering a kit. All index participants were assigned an online 3-month follow-up survey after ordering kits. The primary outcomes were the mean number of alters motivated by index participants in each arm and the mean number of newly tested alters motivated by index participants in each arm. These were assessed using zero-inflated negative binomial regression to determine the group differences in the mean number of alters and the mean number of newly tested alters motivated by index participants. Analyses were performed on an intention-to-treat basis. We also conducted an economic evaluation using microcosting from a health provider perspective with a 3-month time horizon. The mean number of unique tested alters motivated by index participants was 0.57 ± 0.96 (mean ± standard deviation [SD]) in the control group, compared with 0.98 ± 1.38 in the SD-M group (mean difference [MD] = 0.41),and 1.78 ± 2.05 in the SD-M-PR group (MD = 1.21). The mean number of newly tested alters motivated by index participants was 0.16 ± 0.39 (mean ± SD) in the control group, compared with 0.41 ± 0.73 in the SD-M group (MD = 0.25) and 0.57 ± 0.91 in the SD-M-PR group (MD = 0.41), respectively. Results indicated that index participants in intervention arms were more likely to motivate unique tested alters (control versus SD-M: incidence rate ratio [IRR = 2.98, 95% CI = 1.82 to 4.89, p-value < 0.001; control versus SD-M-PR: IRR = 3.26, 95% CI = 2.29 to 4.63, p-value < 0.001) and newly tested alters (control versus SD-M: IRR = 4.22, 95% CI = 1.93 to 9.23, p-value < 0.001; control versus SD-M-PR: IRR = 3.49, 95% CI = 1.92 to 6.37, p-value < 0.001) to conduct HIVST. The proportion of newly tested testers among alters was 28% in the control group, 42% in the SD-M group, and 32% in the SD-M-PR group. A total of 18 testers (3 index participants and 15 alters) tested as HIV positive, and the HIV reactive rates for alters were similar between the 3 groups. The total costs were $19,485.97 for 794 testers, including 450 index participants and 344 alter testers. Overall, the average cost per tester was $24.54, and the average cost per alter tester was $56.65. Monetary incentives alone (SD-M group) were more cost-effective than monetary incentives with peer referral (SD-M-PR group) on average in terms of alters tested and newly tested alters, despite SD-M-PR having larger effects. Compared to the control group, the cost for one more alter tester in the SD-M group was $14.90 and $16.61 in the SD-M-PR group. For newly tested alters, the cost of one more alter in the SD-M group was $24.65 and $49.07 in the SD-M-PR group. No study-related adverse events were reported during the study. Limitations include the digital network approach might neglect individuals who lack internet access. Conclusions Monetary incentives alone and the combined intervention of monetary incentives and peer referral can promote the secondary distribution of HIVST among MSM. Monetary incentives can also expand HIV testing by encouraging first-time testing through secondary distribution by MSM. This social network–based digital approach can be expanded to other public health research, especially in the era of the Coronavirus Disease 2019 (COVID-19). Trial registration Chinese Clinical Trial Registry (ChiCTR) ChiCTR1900025433

Optimizing Peer Distribution of Syphilis Self-Testing Among Men Who Have Sex with Men in China: A Multi-City Pragmatic Randomized Controlled Trial

“…We observed that indexes and alters in both intervention arms were more likely to provide test kits to their peers than those in the standard-of-care arm. This is consistent with the results in studies of secondary distribution of HIVST in China (Sha et al, 2022 ; Zhou et al, 2022 ) and in Uganda (Okoboi et al, 2020 ). We found a higher distribution rate for face-to-face distribution of self-testing kits (S-SST) than the other two arms and a higher rate of returned verified test kits amongst alters in this study arm at primary level.…”

“…This finding differs from the findings in studies on peer distribution of HIVST, which required indexes to order self-testing kits themselves (Lu et al, 2020 ; Wu et al, 2021 ). We did note that the RL-SST arm resulted in a higher numbers of peers being reached compared to the S-SST arm, which aligns with some literature on online peer referral resulting in wider coverage for HIVST (Zhou et al, 2022 ). Subgroup analysis results showed that indexes who were 30 years old or below were more likely to pass along the syphilis testing kits to their peers when compared with standard of care.…”

“…Current peer distribution models take place in person and may result in a lack of privacy (Zhou et al, 2022 ), potential for coerced testing (Dovel et al, 2020 ), and inconvenience (Choko et al, 2019 ). Some of these problems might be alleviated by online network distribution.…”

The Practice and Potential Role of HIV Self-testing in China: Systematic Review and Meta-analysis

“…Therefore, raising awareness of the accuracy and reliability of HIVST in a web-based digital manner might be desirable. In addition, monetary incentives combined with peer referral in the MSM population is also an effective manner to encourage first-time testing [ 73 ]. However, it is essential that other novel and inventive approaches for the promotion of first-time HIV testing are further explored.…”

Participatory approaches to delivering clinical sexually transmitted infections services: a narrative review

“…Approaches that co-opt members of the community in the delivery of health services through their networks [43][44][45]90,91 Evaluation Community scorecards and quality improvement processes that are led by communities 46,47 Scale-up Approaches that involve training and certification of community members, and allow for shared leadership with community members in the delivery of comprehensive clinical STIs services [48][49][50][51][52][53][54] C where communities are either consulted or lead the development of intervention material or processes, shape clinical service processes or digital health interfaces for STIs, and design research study protocols and workflows. 38 For example, clinical guidelines for STIs services delivery, such as treatment and prevention, have been developed alongside and in consultation with key populations, including MSM and sex workers, in many settings.…”