Behavioral Economics Matters for HIV Research: The Impact of Behavioral Biases on Adherence to Antiretrovirals (ARVs)

Applying behavioural economics principles to increase demand for free HIV testing services at private doctor-led clinics in Johannesburg, South Africa: A randomised controlled trial

Expanding free HIV testing service (HTS) access to include private clinics could increase testing rates. A donor funded programme, GP Care Cell, offered free HIV testing at selected private doctor-led clinics but uptake was low. We investigated whether HTS demand creation materials that used behavioural economics principles could increase demand for HIV testing at these clinics. We conducted a randomised controlled trial in Johannesburg, South Africa (January-April 2022) distributing brochures promoting HTS to adults in five private doctor-led clinic catchment areas. Individuals were randomised to receive three brochure types: (1) "Standard of care" (SOC) advertising a free HIV test and ART; (2) "Healthy lifestyle screening" promoted free low-cost health screenings in addition to HTS; and (3) "Recipient of care voucher" leveraged loss aversion and the endowment effect by highlighting the monetary value of free HTS. The primary outcome was presenting at the clinic following exposure to the brochures. Logistic regression compared outcomes between arms. We found that of the 12,129 brochures distributed, 658 were excluded because of errors or duplicates and 11,471 were analysed. About 59% of brochure recipients were male and 50,3% were aged 25-34 years. In total, 448 (3.9%) brochure recipients presented at the private doctor-led clinics of which 50.7% were males. There were no significant differences in clinic presentation between the healthy lifestyle screening and SOC arm (Adjusted Odds Ratio [AOR] 1.02; 95% CI 0.79-1.32), and similarly between the recipient of care voucher and SOC arm (AOR 1.08; 95% CI 0.84-1.39). Individuals were more likely to attend centrally-located clinics that had visible HTS branding (AOR = 5.30; 95% CI: 4.14-6.79). Brochures that used behavioural insights did not increase demand for HTS at private doctor-led clinics. However, consistent distribution of the brochures may have potential to increase HIV testing uptake at highly visible private doctor-led clinics.

The NUDGE Framework: Application to Address Behavioral Barriers to Antiretroviral Therapy in Adolescents Living With HIV in Eswatini

Behavioral economics offers a unique opportunity to understand the social, cognitive, and psychological nuances that may influence health behavior. The purpose of this article is to demonstrate the application of NUDGE, a novel behavioral economics and design thinking framework, to address barriers to antiretroviral therapy adherence among adolescents living with HIV in eSwatini. NUDGE comprises five steps: (1) Narrow the focus to a specific target behavior, (2) Understand the context of the behavior through inquiry, (3) Discover behavioral insights related to the target behavior, (4) Generate intervention design features to address behavioral barriers to the target behavior, and (5) Evaluate the design features through iterative pilot testing. This article demonstrates the application of the Discover and Generate steps using qualitative data. In showing the utility of the NUDGE framework, we provide a practical tool for creating interventions informed by behavioral insights.

Behavioral Economic Incentives to Support HIV Care: Results From a Randomized Controlled Trial in Uganda

BACKGROUND

This study tests behavioral economics incentives to improve adherence to antiretroviral treatment (ART), with 1 approach being low cost.

SETTING

Three hundred twenty-nine adults at Mildmay Hospital in Kampala, Uganda, on ART for at least 2 years and showing adherence problems received the intervention for about 15 months until the study was interrupted by a nation-wide COVID-19 lockdown.

METHODS

We randomized participants into 1 of 3 (1:1:1) groups: usual care ("control" group; n = 109) or 1 of 2 intervention groups where eligibility for nonmonetary prizes was based on showing at least 90% electronically measured ART adherence ("adherence-linked" group, n = 111) or keeping clinic appointments as scheduled ("clinic-linked"; n = 109). After 12 months, participants could win a larger prize for consistently high adherence or viral suppression. Primary outcomes were mean adherence and viral suppression. Analysis was by intention-to-treat using linear regression. This trial is registered with ClinicalTrials.gov, NCT03494777 .

RESULTS

Neither incentive arm increased adherence compared with the control; we estimate a 3.9 percentage point increase in "adherence-linked" arm [95% confidence interval (CI): -0.70 to 8.60 ( P = 0.10)] and 0.024 in the "clinic-linked" arm [95% CI: -0.02 to 0.07 ( P = 0.28)]. For the prespecified subgroup of those with initial low adherence, incentives increased adherence by 7.60 percentage points (95% CI: 0.01, 0.15; P = 0.04, "adherence-linked") and 5.60 percentage points (95% CI: -0.01, 0.12; P = 0.10, "clinic-linked"). We find no effects on clinic attendance or viral suppression.

CONCLUSIONS

Incentives did not improve viral suppression or ART adherence overall but worked for the prespecified subgroup of those with initial low adherence. More effectively identifying those in need of adherence support will allow better targeting of this and other incentive interventions.

Increasing the use of telemedicine: A field experiment

Patients are reluctant to use telemedicine health services, compared to its substitute in-person visits. One reason is that telemedicine can be accurately evaluated and compared to its substitute only after the product has been adopted and experienced. As such, an intervention that increases the probability of a first experience can have lasting effects. This article reports the results of a randomized field experiment conducted in collaboration with a health insurance company. During the intervention, half of the households out of 3,469 in the sample received periodic e-mails with information about the available services. It effectively increased the take-up and demand for telemedicine. Within the first 8 months of the experiment, patients assigned to the treatment group were 6 percentage points more likely to have used the service at least once (and had about five times the odds of using telemedicine compared to those in the control group). Eight months after the start of the intervention, the number of virtual consultations by the treatment group was six times larger than that of the control group. These results, even if limited by the sample and context in which the intervention took place, provide additional evidence about how information interventions can increase technological take-up within the health sector and could serve as the stepping stone for evaluating the impact of telemedicine on health outcomes causally.

Applying behavioural economics principles to increase demand for free HIV testing services at private doctor-led clinics in Johannesburg, South Africa: A randomised controlled trial

Background

Expanding free HIV testing service (HTS) access to include private clinics could increase testing rates. A donor funded programme, GP Care Cell, offered free HIV testing at selected private doctor-led clinics but uptake was low. We investigated whether HTS demand creation materials that used behavioural economics principles could increase demand for HIV testing at these clinics.

Methods

We conducted a randomised controlled trial in Johannesburg, South Africa (January-April 2022) distributing brochures promoting HTS to adults in five private doctor-led clinic catchment areas. Individuals were randomised to receive three brochure types: (1) "Standard of care" (SOC) advertising a free HIV test and ART; (2) "Healthy lifestyle screening" promoted free low-cost health screenings in addition to HTS; and (3) "Recipient of care voucher" leveraged loss aversion and the endowment effect by highlighting the monetary value of free HTS. The primary outcome was presenting at the clinic following exposure to the brochures. Logistic regression compared outcomes between arms.

Results

Of the 12,129 brochures distributed, 658 were excluded because of errors or duplicates and 11,471 were analysed. About 59% of brochure recipients were male and 50,3% were aged 25-34 years. In total, 448 (3.9%) brochure recipients presented at the private doctor-led clinics of which 50.7% were males. There were no significant differences in clinic presentation between the healthy lifestyle screening and SOC arm (Adjusted Odds Ratio [AOR] 1.02; 95% CI 0.79-1.32), and similarly between the recipient of care voucher and SOC arm (AOR 1.08; 95% CI 0.84-1.39). Individuals were more likely to attend clinics that were centrally located with visible branding for HTS (AOR=5.30; 95% CI: 4.14-6.79).

Conclusion

Brochures that used behavioural insights did not increase demand for HTS at private doctor-led clinics. However, consistent distribution of the brochures may have potential to increase HIV testing uptake at highly visible private doctor-led clinics.

A virtual pilot optimization trial for African American/Black and Latino persons with non-suppressed HIV viral load grounded in motivational interviewing and behavioral economics

Introduction

Virtual and low-touch behavioral interventions are needed for African American/Black and Latino persons living with HIV (PLWH) with barriers to HIV viral suppression, particularly during COVID-19. Guided by the multiphase optimization strategy, we explored three components for PLWH without viral suppression, grounded in motivational interviewing and behavioral economics: (1) motivational interviewing counseling, (2) 21-weeks of automated text messages and quiz questions about HIV management, and (3) financial rewards for viral suppression (lottery prize vs. fixed compensation).

Methods

This pilot optimization trial used sequential explanatory mixed methods to explore the components' feasibility, acceptability, and preliminary evidence of effects using an efficient factorial design. The primary outcome was viral suppression. Participants engaged in baseline and two structured follow-up assessments over an 8-month period, and provided laboratory reports to document HIV viral load. A subset engaged in qualitative interviews. We carried out descriptive quantitative analyses. Then, qualitative data were analyzed using directed content analysis. Data integration used the joint display method.

Results

Participants (N = 80) were 49 years old, on average (SD = 9), and 75% were assigned male sex at birth. Most (79%) were African American/Black, and the remainder were Latino. Participants were diagnosed with HIV 20 years previously on average (SD = 9). Overall, components were feasible (>80% attended) and acceptability was satisfactory. A total of 39% (26/66) who provided laboratory reports at follow-up evidenced viral suppression. Findings suggested no components were entirely unsuccessful. The lottery prize compared to fixed compensation was the most promising component level. In qualitative analyses, all components were seen as beneficial to individual wellbeing. The lottery prize appeared more interesting and engaging than fixed compensation. However, structural barriers including financial hardship interfered with abilities to reach viral suppression. The integrated analyses yielded areas of convergence and discrepancy and qualitative findings added depth and context to the quantitative results.

Conclusions

The virtual and/or low-touch behavioral intervention components tested are acceptable and feasible and show enough potential to warrant refinement and testing in future research, particularly the lottery prize. Results must be interpreted in the context of the COVID-19 pandemic.

Trial registration

NCT04518241 (https://clinicaltrials.gov/ct2/show/NCT04518241).

Assessing behavioral economic biases among young adults who have increased likelihood of acquiring HIV: a mixed methods study in Baltimore, Maryland

BACKGROUND

Behavioral economic (BE) biases have been studied in the context of numerous health conditions, yet are understudied in the field of HIV prevention. This aim of this study was to quantify the prevalence of four common BE biases-present bias, information salience, overoptimism, and loss aversion-relating to condom use and HIV testing in economically-vulnerable young adults who had increased likelihood of acquiring HIV. We also qualitatively examined participants' perceptions of these biases.

METHODS

43 participants were enrolled in the study. Data were collected via interviews using a quantitative survey instrument embedded with qualitative questions to characterize responses. Interviews were transcribed and analyzed using descriptive statistics and deductive-inductive content analyses.

RESULTS

56% of participants were present-biased, disproportionately discounting future rewards for smaller immediate rewards. 51% stated they were more likely to spend than save given financial need. Present-bias relating to condom use was lower with 28% reporting they would engage in condomless sex rather than wait one day to access condoms. Most participants (72%) were willing to wait for condom-supported sex given the risk. Only 35% knew someone living with HIV, but 67% knew someone who had taken an HIV test, and 74% said they often think about preventing HIV (e.g., high salience). Yet, 47% reported optimistically planning for condom use, HIV discussions with partners, or testing but failing to stick to their decision. Most (98%) were also averse (b = 9.4, SD  ±.9) to losing their HIV-negative status. Qualitative reasons for sub-optimal condom or testing choices were having already waited to find a sex partner, feeling awkward, having fear, or not remembering one's plan in the moment. Optimal decisions were attributed qualitatively to self-protective thoughts, establishing routine care, standing on one's own, and thinking of someone adversely impacted by HIV. 44% of participants preferred delayed monetary awards (e.g., future-biased), attributed qualitatively to fears of spending immediate money unwisely or needing time to plan.

CONCLUSION

Mixed methods BE assessments may be a valuable tool in understanding factors contributing to optimal and sub-optimal HIV prevention decisions. Future HIV prevention interventions may benefit from integrating savings products, loss framing, commitment contracts, cues, or incentives.

A novel "HIV salience and Perception" scale is associated with PrEP dispensing and adherence among adolescent girls and young women in Kampala, Uganda

Low perceived HIV risk is a barrier to effective pre-exposure prophylaxis (PrEP) use among African adolescent girls and young women (AGYW). Single-item risk perception measures are stigmatizing and alienating to AGYW and may not predict PrEP use. There is a need for a tool capturing domains of perceived HIV risk and salience that align with PrEP use among AGYW. This HIV PrEP study was conducted in Kampala, Uganda. We developed and piloted the 9-item "HIV Salience and Perception" (HPS) scale (range: 9-36); higher scores indicate beliefs of higher vulnerability to HIV. We administered the scale to Ugandan AGYW participating in an ongoing cohort study at enrollment, one, three and six months. PrEP dispensing was measured quarterly and adherence was measured daily via Wisepill (high adherence: ≥80% of expected pill bottle openings). We assessed scale performance and used generalized estimating equations to determine associations between scale score and PrEP use. Among 499 AGYW, 54.1% of our sample was ≥ 20 years (range:16-25). The median HPS score was 18 (range:8-33; α = 0.77). Higher score was associated with PrEP dispensing (aRR = 1.07 per point increase; 95% CI = 1.01-1.13; p-value = 0.02) in the overall cohort and among only those ≥ 20 years (aRR = 1.10; 95% CI = 1.03-1.19; p-value = 0.01). We did not observe an association between scale score and PrEP adherence. AGYW scoring higher on a novel HPS scale were more likely to initiate and obtain PrEP refills through 6 months. This scale may capture drivers of PrEP dispensing and could inform PrEP delivery and counseling for AGYW.

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

PURPOSE OF REVIEW

This scoping review summarises the literature on HIV prevention and management interventions utilizing behavioural economic principles encapsulated in the MINDSPACE framework.

RECENT FINDINGS

MINDSPACE is an acronym developed by the UK's behavioural insights team to summarise nine key influences on human behaviour: Messenger, Incentives, Norms, Default, Salience, Priming, Affect, Commitment, and Ego. These effects have been used in various settings to design interventions that encourage positive behaviours. Currently, over 200 institutionalised behavioural insight teams exist internationally, which may draw upon the MINDSPACE framework to inform policy and improve public services. To date, it is not clear how behavioural insights have been applied to HIV prevention and management interventions. After screening 899 studies for eligibility, 124 were included in the final review. We identified examples of interventions that utilised all the MINDSPACE effects in a variety of settings and among various populations. Studies from high-income countries were most common (n = 54) and incentives were the most frequently applied effect (n = 100). The MINDSPACE framework is a useful tool to consider how behavioural science principles can be applied in future HIV prevention and management interventions. Creating nudges to enhance the design of HIV prevention and management interventions can help people make better choices as we strive to end the HIV/AIDS pandemic by 2030.

The role of material deprivations in determining ART adherence: Evidence from a conjoint analysis among HIV-positive adults in Uganda

Despite sustained global scale-up of antiretroviral therapy (ART), adherence to ART remains low. Less than half of those in HIV care in Uganda achieve 85% adherence to their ART medication required for clinically meaningful viral suppression, leaving them at higher risk of transmission. Key barriers to ART adherence include poverty-related structural barriers that are inter-connected and occur simultaneously, making it challenging to examine and disentangle them empirically and in turn design effective interventions. Many people living with HIV (PLWH) make tradeoffs between these various barriers (e.g., between expenses for food or transportation) and these can influence long-term health behavior such as adherence to ART. To be able to estimate the distinct influence of key structural barriers related to poverty, we administered a conjoint analysis (CA) to 320 HIV-positive adults currently taking ART at an urban clinic in Uganda between July 2019 and September 2020. We varied the levels of four poverty-related attributes (food security, sleep deprivation, monthly income, and physical pain) that occur simultaneously and asked respondents how they would adhere to their medication under different combinations of attribute levels. This allows us to disentangle the effect of each attribute from one another and to assess their relative importance. We used regression analysis to estimate the effects of each attribute level and found that food security impacts expected adherence the most (treatment effect = 1.3; 95% CI 1.11-1.49, p<0.001), followed by income (treatment effect = 0.99; 95% CI 0.88-1.10, p<0.001. Sleep and pain also impact adherence, although by a smaller magnitude. Sub-group analyses conducted via regression analysis examine heterogeneity in results and suggest that the effects of material deprivations on expected adherence are greater among those with high levels of existing food insecurity. Results from this CA indicate that external factors inherent in the lives of the poor and unrelated to direct ART access can be important barriers to ART adherence. This study applies a CA (typically administered in marketing applications) among PLWH to better understand individual-level perceptions relating to poverty that often occur simultaneously. Policy interventions should address food insecurity and income to improve adherence among HIV-positive adults.

On the demand for telemedicine: Evidence from the COVID-19 pandemic

Telemedicine can expand access to health care at relatively low cost. Historically, however, demand for telemedicine has remained low. Using administrative records and a difference-in-differences methodology, we estimate the change in demand for telemedicine experienced after the onset of the COVID-19 epidemic and the imposition of mobility restrictions. We find that the number of telemedicine calls made during the pandemic increased by 230 percent compared to the pre-pandemic period. The effects were mostly driven by older individuals with preexisting conditions who used the service for internal medicine consultations. The demand for telemedicine remained relatively high even after mobility restrictions were relaxed, which is consistent with telemedicine being an "experience good." These results are a proof of concept for policy makers to use such relatively low-cost medical consultations, made possible by new technologies, to provide needed expansion of access to health care.

Using the multiphase optimization strategy (MOST) framework to optimize an intervention to increase COVID-19 testing for Black and Latino/Hispanic frontline essential workers: A study protocol

BACKGROUND

Among those at highest risk for COVID-19 exposure is the large population of frontline essential workers in occupations such food service, retail, personal care, and in-home health services, among whom Black and Latino/Hispanic persons are over-represented. For those not vaccinated and at risk for exposure to COVID-19, including frontline essential workers, regular (approximately weekly) COVID-19 testing is recommended. However, Black and Latino/Hispanic frontline essential workers in these occupations experience serious impediments to COVID-19 testing at individual/attitudinal- (e.g., lack of knowledge of guidelines), social- (e.g., social norms), and structural-levels of influence (e.g., poor access), and rates of testing for COVID-19 are insufficient.

METHODS/DESIGN

The proposed community-engaged study uses the multiphase optimization strategy (MOST) framework and an efficient factorial design to test four candidate behavioral intervention components informed by an integrated conceptual model that combines critical race theory, harm reduction, and self-determination theory. They are A) motivational interview counseling, B) text messaging grounded in behavioral economics, C) peer education, and D) access to testing (via navigation to an appointment vs. a self-test kit). All participants receive health education on COVID-19. The specific aims are to: identify which components contribute meaningfully to improvement in the primary outcome, COVID-19 testing confirmed with documentary evidence, with the most effective combination of components comprising an "optimized" intervention that strategically balances effectiveness against affordability, scalability, and efficiency (Aim 1); identify mediators and moderators of the effects of components (Aim 2); and use a mixed-methods approach to explore relationships among COVID-19 testing and vaccination (Aim 3). Participants will be N = 448 Black and Latino/Hispanic frontline essential workers not tested for COVID-19 in the past six months and not fully vaccinated for COVID-19, randomly assigned to one of 16 intervention conditions, and assessed at 6- and 12-weeks post-baseline. Last, N = 50 participants will engage in qualitative in-depth interviews.

DISCUSSION

This optimization trial is designed to yield an effective, affordable, and efficient behavioral intervention that can be rapidly scaled in community settings. Further, it will advance the literature on intervention approaches for social inequities such as those evident in the COVID-19 pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05139927 ; Registered on 11/29/2021. Protocol version 1.0. May 2, 2022, Version 1.0.

"The one who doesn't take ART medication has no wealth at all and no purpose on Earth" - a qualitative assessment of how HIV-positive adults in Uganda understand the health and wealth-related benefits of ART

BACKGROUND

Increases in life expectancy from antiretroviral therapy (ART) may influence future health and wealth among people living with HIV (PLWH). What remains unknown is how PLWH in care perceive the benefits of ART adherence, particularly in terms of improving health and wealth in the short and long-term at the individual, household, and structural levels. Understanding future-oriented attitudes towards ART may help policymakers tailor care and treatment programs with both short and long-term-term health benefits in mind, to improve HIV-related outcomes for PLWH.

METHODS

In this qualitative study, we conducted semi-structured interviews among a subsample of 40 PLWH in care at a clinic in Uganda participating in a randomized clinical trial for treatment adherence in Uganda (clinicaltrials.gov: NCT03494777). Interviews were transcribed verbatim and translated from Luganda into English. Two co-authors independently reviewed transcripts, developed a detailed codebook, achieved 93% agreement on double-coded interviews, and analyzed data using inductive and deductive content analysis. Applying the social-ecological framework at the individual, household, and structural levels, we examined how PLWH perceived health and wealth-related benefits to ART.

RESULTS

Our findings revealed several benefits of ART expressed by PLWH, going beyond the short-term health benefits to also include long-term economic benefits. Such benefits largely focused on the ability of PLWH to live longer and be physically and mentally healthy, while also fulfilling responsibilities at the individual level pertaining to themselves (especially in terms of positive long-term habits and motivation to work harder), at the household level pertaining to others (such as improved relations with family and friends), and at the structural level pertaining to society (in terms of reduced stigma, increased comfort in disclosure, and higher levels of civic responsibility).

CONCLUSIONS

PLWH consider short and long-term health benefits of ART. Programming designed to shape ART uptake and increase adherence should emphasize the broader benefits of ART at various levels. Having such benefits directly integrated into the design of clinic-based HIV interventions can be useful especially for PLWH who face competing interests to increase medication adherence. These benefits can ultimately help providers and policymakers better understand PLWH's decision-making as it relates to improving ART-related outcomes.

Using Personalized Anchors to Establish Routine Meditation Practice With a Mobile App: Randomized Controlled Trial

BACKGROUND

Physical and mental health benefits can be attained from persistent, long-term performance of mindfulness meditation with a mobile meditation app, but in general, few mobile health app users persistently engage at a level necessary to attain the corresponding health benefits. Anchoring or pairing meditation with a mobile app to an existing daily routine can establish an unconsciously initiated meditation routine that may improve meditation persistence.

OBJECTIVE

The purpose of this study was to test the use of either personalized anchors or fixed anchors for establishing a persistent meditation app routine with the mobile app, Calm.

METHODS

We conducted a randomized controlled trial and randomly assigned participants to one of 3 study groups: (1) a personalized anchor (PA) group, (2) fixed anchor (FA) group, or (3) control group that did not use the anchoring strategy. All participants received app-delivered reminder messages to meditate for at least 10 minutes a day using the Calm app for an 8-week intervention period, and app usage data continued to be collected for an additional 8-week follow-up period to measure meditation persistence. Baseline, week 8, and week 16 surveys were administered to assess demographics, socioeconomic status, and changes in self-reported habit strength.

RESULTS

A total of 101 participants across the 3 study groups were included in the final analysis: (1) PA (n=56), (2) FA (n=49), and (3) control group (n=62). Participants were predominantly White (83/101, 82.2%), female (77/101, 76.2%), and college educated (ie, bachelor's or graduate degree; 82/101, 81.2%). The FA group had a significantly higher average odds of daily meditation during the intervention (1.14 odds ratio [OR]; 95% CI 1.02-1.33; P=.04), and all participants experienced a linear decline in their odds of daily meditation during the 8-week intervention (0.96 OR; 95% CI 0.95-0.96; P<.001). Importantly, the FA group showed a significantly smaller decline in the linear trend of their odds of daily meditation during the 8-week follow-up (their daily trend increased by 1.04 OR from their trend during the intervention; 95% CI 1.01-1.06; P=.03). Additionally, those who more frequently adhered to their anchoring strategy during the intervention typically used anchors that occurred in the morning and showed a significantly smaller decline in their odds of daily meditation during the 8-week follow-up period (1.13 OR; 95% CI 1.02-1.35; P=.007).

CONCLUSIONS

The FA group had more persistent meditation with the app, but participants in the FA or PA groups who more frequently adhered to their anchoring strategy during the intervention had the most persistent meditation routines, and almost all of these high anchorers used morning anchors. These findings suggest that the anchoring strategy can create persistent meditation routines with a mobile app. However, future studies should combine anchoring with additional intervention tools (eg, incentives) to help more participants successfully establish an anchored meditation routine.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04378530; https://clinicaltrials.gov/ct2/show/NCT04378530.

Uncovering a behavioral strategy for establishing new habits: Evidence from incentives for medication adherence in Uganda

Incentives are used to improve many health-related behaviors, but evidence is mixed for their effectiveness both during the incentivization period and, even more so, on the persistence of the behavior after incentives are withdrawn. In this paper, we present the results of a randomized controlled trial that successfully uses incentives to improve medication adherence among HIV-infected patients in Uganda over 20 months, and follows the sample for another 6 months to measure the persistence of these behavioral improvements. Our study contributes to the literature on habit formation by identifying a behavioral strategy that is associated with persistently high medication adherence after controlling for observable individual-level characteristics and the receipt of incentives. We find evidence supporting a psychological theory of habits as reflexive context-behavior associations, which suggests new ways of designing incentive-based interventions for better promoting persistent, healthier behaviors.

Role of temporal discounting in a conditional cash transfer (CCT) intervention to improve engagement in the prevention of mother-to-child transmission (PMTCT) cascade

Background

Temporal discounting, the tendency of individuals to discount future costs and benefits relative to the present, is often associated with greater engagement in risky behaviors. Incentives such as conditional cash transfers (CCTs) have the potential to counter the effects of high discount rates on health behaviors.

Methods

With data from a randomized trial of a CCT intervention among 434 HIV-positive pregnant women in the Democratic Republic of Congo, we used binomial models to assess interactions between discount rates (measured using a delay-discounting task) and the intervention. The analysis focused on two outcomes: 1) retention in HIV care, and 2) uptake of prevention of mother-to-child transmission (PMTCT) services.

Results

The effect of high discount rates on retention was small, and we did not observe evidence of interaction between high discount rates and CCT on retention. However, our findings suggest that CCT may mitigate the negative effect of high discount rates on uptake of PMTCT services (interaction contrast (IC): 0.18, 95% CI: − 0.09, 0.44).

Conclusions

Our findings provide evidence to support the continued use of small, frequent incentives, to motivate improved uptake of PMTCT services, especially among women exhibiting high rates of temporal discounting.

Trial registration

Clinicaltrials.gov number NCT01838005, April 23, 2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10499-0.

Narrative sexual histories and perceptions of HIV risk among young women taking PrEP in southern Africa: Findings from a novel participatory method

Pre-exposure prophylaxis (PrEP) is an important HIV prevention method for adolescent girls and young women (AGYW) in Africa, who are at heightened risk of HIV infection. HIV risk perception is generally a powerful motivator for adoption of HIV prevention behaviours, including PrEP use. While HIV risk perceptions have been evaluated using quantitative measures, these seldom capture how individuals conceptualize and understand risk within local frameworks of meaning. More nuanced understanding may come from qualitative approaches that map these perceptions across the trajectory of sexual histories. Between 2016 and 2018, we implemented a novel participatory method to investigate risk perceptions in interviews with 32 participants in HPTN 082, a study of AGYW's use of PrEP in South Africa and Zimbabwe. Timelines were used to record narrative sexual histories and perceived HIV risk for each relationship. We found that women assessed HIV risk primarily based on their partners' personal qualities and behaviour (especially relating to infidelity); their subjective experience of being treated respectfully; and the practice of perceived 'risk reduction', including younger partners and condoms, even if used inconsistently. A narrative timeline approach grounded in an understanding of young women's sexual histories may increase critical reflection about HIV risks and facilitate risk-reduction counselling with this group.

Changes in ART Adherence Relate to Changes in depression as Well! Evidence for the Bi-directional Longitudinal Relationship Between Depression and ART Adherence from a Prospective Study of HIV Clients in Uganda

Studies have documented how levels and change in depression correspond to ART non-adherence. However, few studies have examined how levels of and change in adherence may relate to levels of and change in depression, although one might expect mental health to be related to physical health and how successful one is in managing disease. To assess the bidirectional nature of the association between these two constructs, we examined data from a prospective trial of an ART adherence intervention in Uganda that followed 143 participants over 20 months. Adherence was measured using electronic monitoring caps; non-adherence was defined as missing > 10% of prescribed doses; self-reported depression was measured using the Patient Health Questionnaire (PHQ-9), and PHQ-9 > 4 defined the presence of at least minor depression. Adjusted linear and logistic regression models were used to examine the longitudinal relationships between depression and non-adherence. At baseline, 40.6% had at least minor depression and 37.1% were non-adherent. Time varying change in the classification of depression (e.g., becoming depressed) predicted change in non-adherence status (e.g., becoming non-adherent), and this association remained when examining continuous measures of the constructs. Similarly, time varying measures of increases in non-adherence predicted increases in depression, regardless of whether continuous or binary classification measures were used. A temporal trend of increased non-adherence over time was observed, and this was accelerated by an increase in depression. Furthermore, those who had at least minor depression at baseline were more likely to be non-adherent at follow-up. These findings support the potential benefits of depression care and adherence support for improving adherence and mental health, respectively, and call for further research to examine such benefits.The trial has been registered with ClinicalTrials.gov (NCT02503072).

The influence of value reference point and risk preference on adherence in hypertensive patients in a low-income area of China

Aims: Prevention and control of hypertension can be achieved by improving patient adherence to long-term treatment regimens. Non-adherence is an obstacle to chronic disease management. We studied the impact of value reference point and risk preference on patient adherence and influencing factors from the perspective of behavioral economics so as to offer targeted recommendations to improving patient adherence in low-income areas.Methods: A representative impoverished area, Qianjiang District in Chongqing was selected as the sample district. A cross-sectional survey using questionnaire augmented with an interview was conducted to collect information with 321 patients previously diagnosed with hypertension stage 3. Preference experiments conducted through scenario simulation were used to elicit and measure patients' value and risk preferences. We constructed a structural equation model to verify the impact of value reference points and risk preference on adherence behavior decision-making. Logistic regression models were constructed to analyze other factors that may influence adherence.Results: Adherence was determined by patients' value reference points (path coefficient = 0.876, p < 0.01) and risk preference (path coefficient = 0.715, p < 0.01). The factor loadings of all indicators on the latent variables were significant (p < 0.01). Hypertensive patients in our cohort adhered poorly to health management and were heavily influenced by knowledge of hypertension, expectation, health literacy and opportunity costs. Certainty effect, overconfidence and optimism significantly affected patients' risk preference in decision-making progress. In the face of the uncertain benefits of adherence, patients preferred to delay treatment until condition affected their quality of life, resulting in poor adherence. Satisfaction with current services and relationship with physicians, as well as type of drugs also influenced adherence.Conclusions: Adherence may be improved by changing patients' value reference points and perceptions through health education and better health service resources. One of the key to increasing adherence is through identifying and eliminating bias.

Behavioral Economics Incentives to Support HIV Treatment Adherence (BEST): Protocol for a randomized controlled trial in Uganda

Background

Many HIV-positive patients do not appropriately adhere to their antiretroviral medication (ART). This leads to higher viral loads and greater probability of HIV transmission. Present bias—a tendency to give in to short-term temptations at the expense of long-term outcomes—is a potential driver of low adherence. In this study we test a novel intervention rooted in behavioral economics that is designed to overcome present bias and increase ART adherence.

Methods/design

We will enroll 330 HIV-positive patients at Mildmay Hospital in Kampala, Uganda, into a 2-year randomized controlled trial. Participants will be randomized to one of three groups. The first intervention group (T1, n = 110) will be eligible for small lottery prizes based on timely clinic visits and demonstration of viral suppression. Group 2 (T2, n = 110) will be eligible for the same lottery prizes conditional on high adherence measured by a medication event management system (MEMS) cap. The control group (n = 110) will receive the usual standard of care. Adherence will be measured continuously throughout the intervention period and for 12 months post-intervention to evaluate effect persistence. Surveys will be conducted at baseline and then every 6 months. Viral loads will be measured annually. Primary outcomes are whether the viral load is detectable and MEMS-measured adherence. Secondary outcomes are the log-transformed viral load as a continuous measure and a binary measure for whether the person took at least 90% of their ART pills.

Discussion

Our study is one of the first to investigate the effectiveness of lottery incentives for improving ART adherence, and in addition, it compares the relative efficacy of using electronically measured adherence versus viral load to determine lottery eligibility. MEMS caps are relatively costly, whereas viral load testing is now part of routine clinical care in Uganda. BEST will test whether directly incentivizing viral suppression (which can be implemented using readily available clinic data) is as effective as incentivizing electronically measured adherence. Cost-effectiveness analyses of the two implementation modes will also be performed.

Trial registration

ClinicalTrials.gov, NCT03494777. Registered on 11 April 2018.

Bridging the Efficacy-Effectiveness Gap in HIV Programs: Lessons From Economics

BACKGROUND

Bridging the efficacy-effectiveness gap in HIV prevention and treatment requires policies that account for human behavior.

SETTING

Worldwide.

METHODS

We conducted a narrative review of the literature on HIV in the field of economics, identified common themes within the literature, and identified lessons for implementation science.

RESULTS

The reviewed studies illustrate how behaviors are shaped by perceived costs and benefits across a wide range of health and nonhealth domains, how structural constraints shape decision-making, how information interventions can still be effective in the epidemic's fourth decade, and how lessons from behavioral economics can be used to improve intervention effectiveness.

CONCLUSION

Economics provides theoretical insights and empirical methods that can guide HIV implementation science.

A combination intervention addressing sexual risk-taking behaviors among vulnerable women in Uganda: study protocol for a cluster randomized clinical trial

BACKGROUND

Sub-Saharan Africa (SSA) has the highest number of people living with HIV/AIDS, with Nigeria, South Africa, and Uganda accounting for 48% of new infections. A systematic review of the HIV burden among women engaged in sex work (WESW) in 50 low- and middle-income countries found that they had increased odds of HIV infection relative to the general female population. Social structural factors, such as the sex work environment, violence, stigma, cultural issues, and criminalization of sex work are critical in shaping sexually transmitted infection (STI)/HIV risks among WESW and their clients in Uganda. Poverty is the most commonly cited reason for involvement in sex work in SSA. Against this backdrop, this study protocol describes a randomized controlled trial (RCT) that tests the impact of adding economic empowerment to traditional HIV risk reduction (HIVRR) to reduce new incidence of STIs and HIV among WESW in Rakai and the greater Masaka regions in Uganda.

METHODS

This three-arm RCT will evaluate the efficacy of adding savings, financial literacy and vocational training/mentorship to traditional HIVRR on reducing new incidence of STI infections among 990 WESW across 33 hotspots. The three arms (n = 330 each) are: 1) Control group: only HIVRR versus 2) Treatment group 1: HIVRR plus Savings plus Financial Literacy (HIVRR + S + FL); and 3) Treatment group 2: HIVRR plus S plus FL plus Vocational Skills Training and Mentorship (V) (HIVRR + S + FL + V). Data will be collected at baseline (pre-test), 6, 12, 18 and 24-months post-intervention initiation. This study will use an embedded experimental mixed methods design where qualitative data will be collected post-intervention across all conditions to explore participant experiences.

DISCUSSION

When WESW have access to more capital and/or alternative forms of employment and start earning formal income outside of sex work, they may be better able to improve their skills and employability for professional advancement, thereby reducing their STI/HIV risk. The study findings may advance our understanding of how best to implement gender-specific HIV prevention globally, engaging women across the HIV treatment cascade. Further, results will provide evidence for the intervention's efficacy to reduce STIs and inform implementation sustainability, including costs and cost-effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov , ID: NCT03583541 .

Microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices in economically-vulnerable African-American young adults (EMERGE): protocol for a feasibility randomized clinical trial

Background

Economic vulnerability, such as homelessness and unemployment, contributes to the HIV risk among racial minorities in the U.S., who are disproportionately infected. Yet, few economic-strengthening interventions have been adapted for HIV prevention in economically-vulnerable African-American young adults. Engaging Microenterprise for Resource Generation and Health Empowerment (EMERGE) is a feasibility randomized clinical trial of an HIV prevention microenterprise intervention with integrated text messages (“nudges”) that are informed by behavioral economic principles. The trial aims to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors.

Methods/design

In total, 40 young adults who are African-American, aged 18–24, live in Baltimore City, have experienced at least one episode of homelessness in the last 12 months, are unemployed or underemployed (fewer than 10 h per week), are not enrolled in school, own a cell phone with text messaging, and report at least one episode of unprotected or unsafe sex in the prior 12 months will be recruited from two community-based organizations providing residential supportive services to urban youth. Participants will undergo a 3-week run-in period and thereafter be randomly assigned to one of two groups with active interventions for 20 weeks. The first group (“comparison”) will receive text messages with information on job openings. The second group (“experimental”) will receive text messages with information on job openings plus information on HIV prevention and business educational sessions, a mentored apprenticeship, and a start-up grant, and business and HIV prevention text messages based on principles from behavioral economics. The two primary outcomes relate to the feasibility of conducting a larger trial. Secondary outcomes relate to employment, sexual risk behaviors, and HIV preventive practices. All participants will be assessed using an in-person questionnaire at pre-intervention (prior to randomization) and at 3 weeks post-intervention. To obtain repeated, longitudinal measures, participants will be assessed weekly using text message surveys from pre-intervention up to 3 weeks post-intervention.

Discussion

This study will be one of the first U.S.-based feasibility randomized clinical trials of an HIV prevention microenterprise intervention for economically-vulnerable African-American young adults. The findings will inform whether and how to conduct a larger efficacy trial for HIV risk reduction in this population.

Trial registration

ClinicalTrials.gov, NCT03766165. Registered on 4 December 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3529-7) contains supplementary material, which is available to authorized users.

Perceptions of HIV Preexposure Prophylaxis Among Young Pregnant Women from Rural KwaZulu-Natal, South Africa

Young sub-Saharan women are at particularly high risk of HIV acquisition during pregnancy and the postpartum period and would potentially benefit from preexposure prophylaxis (PrEP). From June to August 2016, we interviewed 187 HIV negative pregnant women 18-24 years old in Tugela Ferry, Kwazulu-Natal province, a rural and among the poorest subdistricts in South Africa. Demographic data, HIV and PrEP knowledge, HIV risk, and readiness for oral tenofovir-based PrEP were collected using an information-motivation-behavior model-formatted instrument. Mean age was 20.3 years, 179 (95.7%) were unemployed, and 137 (73.3%) reported sex with one partner in the last month. Most were concerned that their sexual partner (95.2%) potentially had HIV or had other sexual partners in the last month (36.4%). Despite this, only 7 (3.7%) women reported that condoms had been used consistently during sex; most (97.3%) felt powerless to negotiate condom use with their partner. There was widespread interest in taking PrEP (97.3%), and most women (>97%) reported possessing the skills to take pills regularly, would commit to monthly visits, and were motivated to remain HIV negative to take care of their families. Young pregnant rural South African women are cognizant of their HIV risk and interested in prevention. Impending motherhood may portend increased interest in HIV prevention. We identified three potential obstacles to successful PrEP rollout among young pregnant women: hesitation about PrEP effectiveness (46%), perceived HIV stigma (53.5%), and risk compensation through decreased condom use (9.6%). Comparative studies of motivations, skills, and rates of initiation and adherence among pregnant and nonpregnant women are needed to inform optimal implementation efforts.

Environmental fate and ecotoxicological effects of antiretrovirals: A current global status and future perspectives

The therapeutic efficacy of antiretroviral drugs as well as challenges and side effects against the human immunodeficiency virus is well documented and reviewed. Evidence is available in literature indication that antiretrovirals are only partially transformed and become completely excreted from the human body in their original form and/or as metabolites in urine and feces. The possibility of massive release of antiretrovirals through human excreta that enters surface water through surface runoff and wastewater treatment plant effluents is now of environmental concern because the public might be experiencing chronic exposure to antiretrovirals. The primary concern of this review is limited data concerning environmental fate and ecotoxicity of antiretrovirals and their metabolites. The review aims to provide a comprehensive insight into the evaluation of antiretrovirals in environmental samples. The objective is therefore to assess the extent of analysis of antiretrovirals in environmental samples and also look at strategies including instrumentation and predictive models that have been reported in literature on the fate and ecotoxicological effects due to presence of antiretrovirals in different environmental compartments. The review also looks at current challenges and offers possible areas of exploration that could help minimize the presence of antiretrovirals in the environment.

Beliefs in Antiretroviral Treatment and Self-Efficacy in HIV Management are Associated with Distinctive HIV Treatment Trajectories

An online survey was conducted among people living with HIV (PLHIV) in Australia to discern key factors associated with distinctive ART use patterns. The sample (N = 358), was further divided into three groups: those on ART continuously since initiation (n = 208, 58.1%); those on ART intermittently (n = 117, 32.7%); and those not on ART at the time of survey (n = 33, 9.2%). ART non-users were the most likely to hold serious concerns about ART that outweighed perceived necessities (benefits) from ART (AOR = 0.13; 95% CI 0.06-0.29; p < 0.001). They were also the least self-efficacious in HIV disease management (AOR = 0.29; 95% CI 0.09-0.87; p = 0.028). Intermittent ART users were more likely to receive their HIV diagnosis prior to 2003 (AOR = 0.38; 95% CI 0.28-0.53; p < 0.001) and perceive lower HIV management self-efficacy (AOR = 0.50, 95% CI 0.28-0.87; p = 0.015) than continuous users. ART-related beliefs and perceived self-efficacy in HIV self-management play an important role in achieving universal treatment uptake and sustained high levels of adherence.

Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory

Urban slum adolescents and young adults have disproportionately high rates of HIV compared to rural and non-slum urban youth. Yet, few studies have examined youth's perceptions of the economic drivers of HIV. Informed by traditional and behavioral economics, we applied a scarcity theoretical framework to qualitatively examine how poverty influences sexual risk behaviors among adolescents and young adults. Focus group discussions with one hundred twenty youth in Kenyan's urban slums were transcribed, coded, and analyzed using interpretive phenomenology. Results indicated that slum youth made many sexual decisions considered rational from a traditional economics perspective, such as acquiring more sex when resources were available, maximizing wealth through sex, being price-sensitive to costs of condoms or testing services, and taking more risks when protected from adverse sexual consequences. Youth's engagement in sexual risk behaviors was also motivated by scarcity phenomena explained by behavioral economics, such as compensating for sex lost during scarce periods (risk-seeking), valuing economic gains over HIV risks (tunneling, bandwidth tax), and transacting sex as an investment strategy (internal referencing). When scarcity was alleviated, young women additionally described reducing the number of sex partners to account for non-economic preferences (slack). Prevention strategies should address the traditional and behavioral economics of the HIV epidemic.

Behavioral economic incentives to improve adherence to antiretroviral medication

OBJECTIVE

Fixed incentives have been largely unsuccessful in improving adherence to antiretroviral medication. Therefore, we evaluate whether small incentives based on behavioral economic theory can increase adherence to antiretroviral medication among treatment-mature adults in Kampala, Uganda.

DESIGN

A randomized control trial design tests whether providing small incentives based on either attending timely clinic visits (intervention group 1) or achieving high medication adherence (intervention group 2) can increase antiretroviral adherence. Antiretroviral adherence is measured by medical event monitoring system (MEMS) caps.

METHODS

Overall, 155 HIV-infected men and women age 19-78 were randomized into one of two intervention groups and received small prizes of US $1.50 awarded through a drawing conditional on either attending scheduled clinic appointments or achieving at least 90% antiretroviral adherence. The control group received the usual standard of care.

RESULTS

Preliminary results based on pooling the intervention groups showed individuals receiving incentives were 23.7 percentage points more likely to achieve 90% antiretroviral adherence compared with the control group [95% confidence interval (CI), 6.7-40.7%]. Specifically, 63.3% (95% CI, 52.9-72.8%) of participants in the pooled intervention groups maintained at least 90% mean adherence during the first 9 months of the intervention, compared with 39.6% (95% CI, 25.8-54.7%) in the control group.

CONCLUSION

Small prize incentives resulted in a statistically significant increase in antiretroviral adherence. Although more traditional fixed incentives have not produced the desired results, these findings suggest that small incentives based on behavioral economic theory may be more effective in motivating long-term adherence among treatment-mature adults.

A Framework to Inform Strategies to Improve the HIV Care Continuum in Low- and Middle-Income Countries

Reasons for attrition along the HIV care continuum are well described. However, improving patient engagement in care has been a challenge. New approaches to understanding and responding to reasons for attrition are required. Here, with a focus on low- and middle-income countries, we propose a framework that brings together an explanatory model with social ecological levels. Individual action may be based on a conscious or unconscious balance between perceived value and perceived costs. When the balance between value and cost favors value, engagement in care can be expected. Value and cost may be mediated by levels of the individual, interpersonal interactions, the clinic experience, community, society, and policy. We encourage the use of a framework for developing strategies to improve the care continuum and believe that this framework provides a rigorous approach.