Exploring the potential of a conditional cash transfer intervention to reduce HIV risk among young women in Iringa, Tanzania

PEERNaija-a mobile health platform incentivizing medication adherence among youth living with HIV in Nigeria: study protocol for a randomized controlled trial

BACKGROUND

Poor medication adherence is a major barrier to HIV control among youth living with HIV (Y-PLWH). The PEERNaija application (app) is an adapted smartphone app grounded in social cognitive and contigency management theories and designed to harness peer-based social incentives and conditional financial incentives to promote medication adherence. The app delivers a multifaceted medication adherence intervention including (1) peer-based social incentives, (2) financial incentives, (3) virtual peer social support, and (4) early clinic-based outreach for non-adherent Y-PLWH. A pilot trial of the app will be conducted in Nigeria, Africa's most populous country with the 4th largest HIV epidemic, and home to 10% of the world's four million Y-PLWH.

METHODS

In this randomized controlled trial, we will compare implementation outcomes (feasibility, acceptability, appropriateness measured via validated scales, enrollment and application installation rates, feedback surveys and focus group discussions with participants, and back-end application data), and preliminary efficacy (in improving medication adherence and viral suppression) of the PEERNaija app at 6 months. Participants in Arm 1 (PEERNaija) will receive daily medication reminders, peer-based social incentives, and virtual peer social support. Participants in Arm 2 (PEERNaija +) will additionally receive a conditional financial incentive based on their adherence performance. Eligibility for Y-PLWH includes (1) being aged 14-29 years, (2) being on ART, (3) owning a smartphone, (4) being willing to download an app, and (5) being able to read simple text in English.

DISCUSSION

This study will serve as the basis for a larger intervention trial evaluating the PEERNaija app (and the integration of mHealth, incentive, and peer-support-based strategies) to improve HIV outcomes in a critically important region of the world for Y-PLWH.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT04930198. First submitted date: May 25, 2021. Study start: August 1, 2021, https://clinicaltrials.gov/ .

PROTOCOL VERSION

January 21, 2022.

Experiences of conditional and unconditional cash transfers intended for improving health outcomes and health service use: a qualitative evidence synthesis

BACKGROUND

It is well known that poverty is associated with ill health and that ill health can result in direct and indirect costs that can perpetuate poverty. Social protection, which includes policies and programmes intended to prevent and reduce poverty in times of ill health, could be one way to break this vicious cycle. Social protection, particularly cash transfers, also has the potential to promote healthier behaviours, including healthcare seeking. Although social protection, particularly conditional and unconditional cash transfers, has been widely studied, it is not well known how recipients experience social protection interventions, and what unintended effects such interventions can cause.   OBJECTIVES: The aim of this review was to explore how conditional and unconditional cash transfer social protection interventions with a health outcome are experienced and perceived by their recipients.  SEARCH METHODS: We searched Epistemonikos, MEDLINE, CINAHL, Social Services Abstracts, Global Index Medicus, Scopus, AnthroSource and EconLit from the start of the database to 5 June 2020. We combined this with reference checking, citation searching, grey literature and contact with authors to identify additional studies. We reran all strategies in July 2022, and the new studies are awaiting classification.

SELECTION CRITERIA

We included primary studies, using qualitative methods or mixed-methods studies with qualitative research reporting on recipients' experiences of cash transfer interventions where health outcomes were evaluated. Recipients could be adult patients of healthcare services, the general adult population as recipients of cash targeted at themselves or directed at children. Studies could be evaluated on any mental or physical health condition or cash transfer mechanism. Studies could come from any country and be in any language. Two authors independently selected studies.  DATA COLLECTION AND ANALYSIS: We used a multi-step purposive sampling framework for selecting studies, starting with geographical representation, followed by health condition, and richness of data. Key data were extracted by the authors into Excel. Methodological limitations were assessed independently using the Critical Appraisal Skills Programme (CASP) criteria by two authors. Data were synthesised using meta-ethnography, and confidence in findings was assessed using the Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach.  MAIN RESULTS: We included 127 studies in the review and sampled 41 of these studies for our analysis. Thirty-two further studies were found after the updated search on 5 July 2022 and are awaiting classification. The sampled studies were from 24 different countries: 17 studies were from the African region, seven were from the region of the Americas, seven were from the European region, six were from the South-East Asian region, three from the Western Pacific region and one study was multiregional, covering both the African and the Eastern Mediterranean regions. These studies primarily explored the views and experiences of cash transfer recipients with different health conditions, such as infectious diseases, disabilities and long-term illnesses, sexual and reproductive health, and maternal and child health. Our GRADE-CERQual assessment indicated we had mainly moderate- and high-confidence findings. We found that recipients perceived the cash transfers as necessary and helpful for immediate needs and, in some cases, helpful for longer-term benefits. However, across conditional and unconditional programmes, recipients often felt that the amount given was too little in relation to their total needs. They also felt that the cash alone was not enough to change their behaviour and, to change behaviour, additional types of support would be required. The cash transfer was reported to have important effects on empowerment, autonomy and agency, but also in some settings, recipients experienced pressure from family or programme staff on cash usage. The cash transfer was reported to improve social cohesion and reduce intrahousehold tension. However, in settings where some received the cash and others did not, the lack of an equal approach caused tension, suspicion and conflict. Recipients also reported stigma in terms of cash transfer programme assessment processes and eligibility, as well as inappropriate eligibility processes. Across settings, recipients experienced barriers in accessing the cash transfer programme, and some refused or were hesitant to receive the cash. Some recipients found cash transfer programmes more acceptable when they agreed with the programme's goals and processes.   AUTHORS' CONCLUSIONS: Our findings highlight the impact of the sociocultural context on the functioning and interaction between the individual, family and cash transfer programmes. Even where the goals of a cash transfer programme are explicitly health-related, the outcomes may be far broader than health alone and may include, for example, reduced stigma, empowerment and increased agency of the individual. When measuring programme outcomes, therefore, these broader impacts could be considered for understanding the health and well-being benefits of cash transfers.

Developing and testing unconditional cash transfer strategies among young adults with first-episode psychosis in South Africa: a study protocol for a pilot randomised control trial (PRS-FEP trial)

INTRODUCTION

Access to mental health services is a challenge, especially for young people who are over-represented in the unemployment and poverty index in South Africa. Therefore, continuing care is a problem after hospital discharge for young people with first-episode psychosis (FEP) due to a lack of clinical engagement and follow-up, for which they need support, including financial, to improve their outcomes. This pilot randomised control trial (RCT) aims to assess the feasibility and acceptability of financial support, in the form of an unconditional cash transfer (UCT), among young patients with FEP to prevent relapse.

METHODS AND ANALYSIS

This study will use a 1:1 ratio two-arm open-label pilot RCT of 60 young participants (18-29 years) with FEP in remission, who will be recruited from specialised psychiatric facilities in KwaZulu-Natal Province, South Africa. This study will implement an UCT and assess its feasibility, acceptability and preliminary clinical outcomes (ie, medication adherence, relapse, quality of life, personal and social function). The follow-up time will be 3 months, the outcomes being measured at baseline, months 1 and 3. Descriptive and conventional content analysis will be done for quantitative and qualitative data, respectively.

ETHICS AND DISSEMINATION

The study obtained provisional approval from the Biomedical Research Ethics Committee at the University of KwaZulu-Natal(#BREC/00004117/2022). Also is registered on the South African National clinical trial registry (#DOH-27-092022-5894) and approved by the KwaZulu-Natal department of health (#NHRD Ref: KZ_2002209_033). The results from this investigation will be actively disseminated through peer-reviewed journal publications, conference presentations and stakeholder engagement.

TRIAL REGISTRATION NUMBER

DOH-27-092022-5894.

Tackling barriers to collective action for effective vaccination campaigns: rabies in rural Africa as an example

Vaccine-based protection in populations that are vulnerable to infectious diseases represents a public good, whose successful attainment requires collective action. We investigated participation in mass domestic dog vaccination against dog-mediated human rabies endemic in Tanzania as a prototypical example of these issues. We employed advertising interventions, text messaging and/or engagement through community leaders, as well as operational adjustments to increase the saliency of rabies risks and reduce barriers to participation in vaccination campaigns. Neither advertising strategies were effective on their own, however, when taken together, the two advertising strategies substantially improved vaccination coverage. Operational interventions, such as increasing vaccination stations and extending time windows of delivery, greatly enhanced participation. Our experimental and theoretical findings highlight the importance of both salience and context: sparking successful collective action requires decision-making bodies to understand and respond to the challenges encountered by intended beneficiaries in their local contexts.

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

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.

Perceived Facilitators and Barriers to Participating in a Combination Income-Generating HIV Risk-Reduction Intervention Among Adolescent Girls and Young Women in Nigeria: A Qualitative Study

Background: Human immunodeficiency virus risk-reduction interventions that include income-generating activities are garnering attention as effective strategies to engage adolescent girls and young women (AGYW) toward HIV risk reduction. To sustain and promote the uptake of these interventions, researchers must understand factors that may encourage or present barriers to AGYW participation in such interventions. This study explores AGYW perceived barriers and facilitators to participation in a school-based combination income-generating HIV prevention intervention in Nigeria.

Methods: A convenience sample of AGYW who participated in a school-based combination income-generating HIV prevention intervention were recruited for the study. Data generated from focus group discussions (FGDs) (eight discussion groups comprising 10–12 participants) were analyzed by inductive thematic analysis.

Results: A total of 93 participants with a mean age of 15.04 years (SD = 0.89) participated in the FGDs. The study participants identified several facilitators and barriers to participation in the intervention. Three main themes that emerged as facilitators were: (1) involvement of young female facilitators in the delivery of intervention components, (2) opportunity for social interaction with peers during the intervention period, and (3) support and approval from school authorities. Two main themes were also identified as barriers: (1) sexual conservatism from society and parents and (2) challenges in sustaining a microenterprise.

Conclusions: Despite the perceived benefits and interest in participation in the intervention, the study participants outlined some challenges that may hinder participation in the intervention components. Addressing barriers, such as stigma associated with the discussion of sexual health-related topics, coupled with the promotion of facilitating factors, such as leveraging context-appropriate intervention delivery modalities, is important for enhancing the engagement of AGYW in HIV risk-reduction intervention. Our findings can guide future research and design of combination income-generating HIV prevention interventions for in-school AGYW in low-resource settings such as Nigeria.

Gender and Power Dynamics of Social Relationships Shape Willingness to Participate in Biomedical HIV Prevention Research Among South African Adolescents and Young Adults

Background: Understanding young women and men's perceived barriers and facilitators to participation in biomedical HIV prevention research is important for designing youth friendly services (YFS) and acceptable technologies, which are necessary for preventing high sustained HIV incidence in South Africa. This study explores the multileveled barriers and facilitators to young men and women's willingness to participate in hypothetical biomedical HIV prevention research. Methods: Eight age- (16-18 and 19-24 years) and gender-stratified focus group discussions (FGDs) were conducted using semi-structured interview guides to explore young South African women and men's willingness, perceived barriers, and facilitators to participating in biomedical HIV prevention research. FGD transcripts were uploaded to NVivo and coded collaboratively with youth study team members. Thematic analysis using Bronfenbrenner's ecological model (individual, inter-personal, community, and societal) was used to guide a deductive coding procedure, which was documented and compared by gender. Results: Thirty-one participants from Durban and 34 from Soweto participated in FGDs. Individual facilitators for participation were discussed more by young men and included financial incentives and altruism. Concerns about side-effects of biomedical products were a common barrier. Interpersonal relationships with peers, intimate partners and caregivers influenced young people's willingness to participate in HIV prevention research, more so among young women. For young women, gendered power dynamics and distrust of intimate partners and parents influenced both communication regarding participation and willingness to participate in research that is often stigmatized, due to societal norms around women's sexuality. On a societal level, participants expressed distrust in medical and research institutions, however a sense of community that was developed with the study staff of this project, was a motivator to participate in future studies. Discussion: At each level of the ecological model, we found participants expressed gendered barriers and facilitators for participation. Gender norms as well as distrust of partners, parents, and health care professionals were key barriers that cut across all levels. At each level participants discussed facilitators that were youth-engaged, underscoring the need to implement YFS, establish trust and address gender inequities within future biomedical HIV prevention studies wishing to engage and retain South African youth.

Supporting Adolescents to Adhere (SATA): Lessons learned from an intervention to achieve medication adherence targets among youth living with HIV in Uganda

INTRODUCTION

Youth in Uganda are disproportionately impacted by HIV and report significant barriers to ART adherence. We asked participants how fixed versus flexible adherence target setting for incentive interventions, in combination with other support systems, could help HIV-positive youth in Uganda reach medication adherence targets.

METHODS

Four focus groups conducted in Luganda were audiotaped, transcribed, and translated into English; the transcriptions were then coded using Dedoose software. Two members of the research team read the text and identified the basic topics covered. A codebook was developed that detailed inclusion and exclusion criteria for each topic area, as well as typical entries for each code. A directed content analysis was used to identify key themes.

RESULTS

Several themes were common across groups. Participants consistently maintained that they preferred to set their own adherence targets. But regardless of how adherence targets were assigned, participants noted that missing their target was disappointing. They commented positively on the use of Medication Event Monitoring System (MEMS) caps, noting that knowing their adherence information was being tracked often encouraged them to take their medications. Participants reported that receiving text messages further motivated them to take their medications; however, on occasions when they reported not doing well, they wanted intensive follow-up by staff. Participants said that the prize drawing alone did not motivate their ART adherence and that receiving 'zero' in the drawing was disheartening.

CONCLUSION

We found that participants preferred to set their own adherence targets and that doing so increased a sense of ownership in achieving them. All participants enjoyed using MEMS caps and expressed disappointment at needing to return the device at the study's completion. Participants noted that text message reminders may be a useful way to help patients stay motivated between clinic visits; however, ongoing engagement and support are needed from providers and counselors. Finally, our participants stressed the importance of including incentives with a small, positive value rather than 0 when designing the lowest prize.

Education and HIV incidence among young women in KwaZulu-Natal: An association but no evidence of a causal protective effect

We examine the relationship between school attendance and HIV incidence among young women in South Africa. Our aim is to distinguish a causal effect from correlation. Towards this end, we apply three methods to population-based longitudinal data for 2005–2012 in KwaZulu-Natal. After establishing a negative association, we first use a method that assesses the influence of omitted variables. We then estimate models with exclusion restrictions to remove endogeneity bias, and finally we estimate models that control for unobserved factors that remain constant over time. All the three methods have strengths and weaknesses, but none of them suggests a causal effect. Thus, interventions that increase school attendance in KwaZulu-Natal would probably not mechanically reduce HIV risk for young women. Although the impact of school attendance could vary depending on context, unobserved variables are likely to be an important reason for the common finding of a negative association between school attendance and HIV incidence in the literature.

Can cash break the cycle of educational risks for young children in high HIV-affected communities? A cross-sectional study in South Africa and Malawi

BACKGROUND

Household cash grants are associated with beneficial outcomes; enhanced if provided in combination with care.

OBJECTIVES

This study describes the impact of cash grants and parenting quality on 854 children aged 5-15 (South African and Malawi) on educational outcomes including enrolment, regular attendance, correct class for age and school progress (controlling for cognitive performance). Consecutive attenders at randomly selected Community based organisations were recruited. The effects of cash plus good parenting, HIV status and gender were examined.

RESULTS

Overall 73.1% received a grant - significantly less children with HIV (57.3% vs 75.6% (χ2 = 17.21, P < 0.001). Controlling for cognitive ability, grant receipt was associated with higher odds of being in the correct grade (odds ratio (OR) = 2.00; 95% confidence interval (CI) = 1.36, 2.95), higher odds of attending school regularly (OR = 3.62; 95% CI = 1.77, 7.40), and much higher odds of having missed less than a week of school recently (OR = 8.95; 95% CI = 2.27, 35.23). Grant receipt was not associated with how well children performed in school compared to their classmates or with school enrolment. Linear regression revealed that grant receipt was associated with a significant reduction in educational risk (B = -0.32, t(420) = 2.84, P = 0.005) for girls.

CONCLUSION

Cash plus good parenting affected some educational outcomes in a stepwise manner, but did not provide additive protection.

Cash transfers for HIV prevention: what do young women spend it on? Mixed methods findings from HPTN 068

Background

Social grants have been found to have an impact on health and wellbeing in multiple settings. Who receives the grant, however, has been the subject of discussion with regards to how the money is spent and who benefits from the grant.

Methods

Using survey data from 1214 young women who were in the intervention arm and completed at least one annual visit in the HPTN 068 trial, and qualitative interview data from a subset of 38 participants, we examined spending of a cash transfer provided to young women conditioned on school attendance.

Results

We found that spending was largely determined and controlled by young women themselves and that the cash transfer was predominately spent on toiletries, clothing and school supplies. In interview data, young women discussed the significant role of cash transfers for adolescent identity, specifically with regard to independence from family and status within the peer network. There were almost no negative consequences from receiving the cash transfer.

Conclusions

We established that providing adolescents access to cash was not reported to be associated with social harms or negative consequences. Rather, spending of the cash facilitated appropriate adolescent developmental behaviours. The findings are encouraging at a time in which there is global interest in addressing the structural drivers of HIV risk, such as poverty, for young women.

Trial registration

Clinicaltrials.gov NCT01233531 (1 Nov 2010). First participant enrolled 5 March 2011.

The potential impact and cost of focusing HIV prevention on young women and men: A modeling analysis in western Kenya

OBJECTIVE

We compared the impact and costs of HIV prevention strategies focusing on youth (15-24 year-old persons) versus on adults (15+ year-old persons), in a high-HIV burden context of a large generalized epidemic.

DESIGN

Compartmental age-structured mathematical model of HIV transmission in Nyanza, Kenya.

INTERVENTIONS

The interventions focused on youth were high coverage HIV testing (80% of youth), treatment at diagnosis (TasP, i.e., immediate start of antiretroviral therapy [ART]) and 10% increased condom usage for HIV-positive diagnosed youth, male circumcision for HIV-negative young men, pre-exposure prophylaxis (PrEP) for high-risk HIV-negative females (ages 20-24 years), and cash transfer for in-school HIV-negative girls (ages 15-19 years). Permutations of these were compared to adult-focused HIV testing coverage with condoms and TasP.

RESULTS

The youth-focused strategy with ART treatment at diagnosis and condom use without adding interventions for HIV-negative youth performed better than the adult-focused strategy with adult testing reaching 50-60% coverage and TasP/condoms. Over the long term, the youth-focused strategy approached the performance of 70% adult testing and TasP/condoms. When high coverage male circumcision also is added to the youth-focused strategy, the combined intervention outperformed the adult-focused strategy with 70% testing, for at least 35 years by averting 94,000 more infections, averting 5.0 million more disability-adjusted life years (DALYs), and saving US$46.0 million over this period. The addition of prevention interventions beyond circumcision to the youth-focused strategy would be more beneficial if HIV care costs are high, or when program delivery costs are relatively high for programs encompassing HIV testing coverage exceeding 70%, TasP and condoms to HIV-infected adults compared to combination prevention programs among youth.

CONCLUSION

For at least the next three decades, focusing in high burden settings on high coverage HIV testing, ART treatment upon diagnosis, condoms and male circumcision among youth may outperform adult-focused ART treatment upon diagnosis programs, unless the adult testing coverage in these programs reaches very high levels (>70% of all adults reached) at similar program costs. Our results indicate the potential importance of age-targeting for HIV prevention in the current era of 'test and start, ending AIDS' goals to ameliorate the HIV epidemic globally.

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.

Social and structural factors related to HIV risk among truck drivers passing through the Iringa region of Tanzania

Truck drivers and their assistants have been identified as groups at higher risk for HIV infection. We sought to identify and describe the social and structural factors that may contribute to HIV risk among truck drivers who visit rest stops in Iringa, Tanzania, a region characterized by high levels of migration and mobility. This analysis was part of a comprehensive strategic assessment to examine HIV risk factors in Iringa. This analysis focuses on 11 in-depth interviews with truck drivers and a transport owner. A semi-structured interview guide was developed to elicit open-ended responses and enable probing. Interviews were conducted in Swahili, transcribed, and translated into English. Data analysis followed thematic analysis procedures that included initial reading of transcripts, development of a codebook and identification of themes through in-depth reading of transcripts. Drivers described structural risk factors for HIV including work conditions, the power imbalance between male drivers and their sexual partners and minimal perceived HIV risk with certain partners (e.g., regular partners and women selling sex). Multiple and inter-related social norms associated with truck stop environments influenced HIV risk, including peer influence and expectations, presence of sex workers, ability to purchase sex throughout their travel and alcohol consumption. These distinct social norms in truck stops and other rest points facilitated behavior that many participants said they would not engage in elsewhere. HIV prevention strategies with truck drivers should address individual, social and structural barriers to HIV prevention through partnerships with the health and transportation sectors, local government and local communities. HIV prevention services should be adapted to drivers' times and places of availability, for example, condom provision where/when drivers make decisions about or have sex. A focus on positive messaging and addressing specific challenges including the continual challenge of re-choosing and reinforcing decisions to engage in safer sexual behaviors is important.

School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents

BACKGROUND

School-based sexual and reproductive health programmes are widely accepted as an approach to reducing high-risk sexual behaviour among adolescents. Many studies and systematic reviews have concentrated on measuring effects on knowledge or self-reported behaviour rather than biological outcomes, such as pregnancy or prevalence of sexually transmitted infections (STIs).

OBJECTIVES

To evaluate the effects of school-based sexual and reproductive health programmes on sexually transmitted infections (such as HIV, herpes simplex virus, and syphilis), and pregnancy among adolescents.

SEARCH METHODS

We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for published peer-reviewed journal articles; and ClinicalTrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform for prospective trials; AIDS Educaton and Global Information System (AEGIS) and National Library of Medicine (NLM) gateway for conference presentations; and the Centers for Disease Control and Prevention (CDC), UNAIDS, the WHO and the National Health Service (NHS) centre for Reviews and Dissemination (CRD) websites from 1990 to 7 April 2016. We handsearched the reference lists of all relevant papers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), both individually randomized and cluster-randomized, that evaluated school-based programmes aimed at improving the sexual and reproductive health of adolescents.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, evaluated risk of bias, and extracted data. When appropriate, we obtained summary measures of treatment effect through a random-effects meta-analysis and we reported them using risk ratios (RR) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included eight cluster-RCTs that enrolled 55,157 participants. Five trials were conducted in sub-Saharan Africa (Malawi, South Africa, Tanzania, Zimbabwe, and Kenya), one in Latin America (Chile), and two in Europe (England and Scotland). Sexual and reproductive health educational programmesSix trials evaluated school-based educational interventions.In these trials, the educational programmes evaluated had no demonstrable effect on the prevalence of HIV (RR 1.03, 95% CI 0.80 to 1.32, three trials; 14,163 participants; low certainty evidence), or other STIs (herpes simplex virus prevalence: RR 1.04, 95% CI 0.94 to 1.15; three trials, 17,445 participants; moderate certainty evidence; syphilis prevalence: RR 0.81, 95% CI 0.47 to 1.39; one trial, 6977 participants; low certainty evidence). There was also no apparent effect on the number of young women who were pregnant at the end of the trial (RR 0.99, 95% CI 0.84 to 1.16; three trials, 8280 participants; moderate certainty evidence). Material or monetary incentive-based programmes to promote school attendanceTwo trials evaluated incentive-based programmes to promote school attendance.In these two trials, the incentives used had no demonstrable effect on HIV prevalence (RR 1.23, 95% CI 0.51 to 2.96; two trials, 3805 participants; low certainty evidence). Compared to controls, the prevalence of herpes simplex virus infection was lower in young women receiving a monthly cash incentive to stay in school (RR 0.30, 95% CI 0.11 to 0.85), but not in young people given free school uniforms (Data not pooled, two trials, 7229 participants; very low certainty evidence). One trial evaluated the effects on syphilis and the prevalence was too low to detect or exclude effects confidently (RR 0.41, 95% CI 0.05 to 3.27; one trial, 1291 participants; very low certainty evidence). However, the number of young women who were pregnant at the end of the trial was lower among those who received incentives (RR 0.76, 95% CI 0.58 to 0.99; two trials, 4200 participants; low certainty evidence). Combined educational and incentive-based programmesThe single trial that evaluated free school uniforms also included a trial arm in which participants received both uniforms and a programme of sexual and reproductive education. In this trial arm herpes simplex virus infection was reduced (RR 0.82, 95% CI 0.68 to 0.99; one trial, 5899 participants; low certainty evidence), predominantly in young women, but no effect was detected for HIV or pregnancy (low certainty evidence).

AUTHORS' CONCLUSIONS

There is a continued need to provide health services to adolescents that include contraceptive choices and condoms and that involve them in the design of services. Schools may be a good place in which to provide these services. There is little evidence that educational curriculum-based programmes alone are effective in improving sexual and reproductive health outcomes for adolescents. Incentive-based interventions that focus on keeping young people in secondary school may reduce adolescent pregnancy but further trials are needed to confirm this.

Financial incentives to improve progression through the HIV treatment cascade

PURPOSE OF REVIEW

We reviewed recent literature on conditional and unconditional financial incentives for their impact on improving movement through the HIV care cascade and HIV prevention.

RECENT FINDINGS

Concepts from behavioral economics may help improve engagement in HIV care by addressing upstream structural risk factors for HIV, such as poverty, or providing conditional rewards for immediate, measurable outcomes related to HIV care. Incentives have been shown to increase uptake of HIV testing. Yet, few studies to date focus on linkage to care: one large USA-based randomized trial failed to show an effect of incentives; and a smaller trial showed improved linkage to care among drug users, but no difference in virologic suppression. Several small USA-based studies have shown an impact of financial incentives on antiretroviral therapy adherence, but without durability beyond the incentive period. HIV prevention has the most robust evidence for decreasing HIV risk-taking behavior among adolescents and may serve as a model for research on the care cascade.

SUMMARY

Financial incentives show promise for improving engagement in HIV testing, care, and prevention. Understanding the durability, scalability, ease of implementation, and cost-effectiveness of these different approaches will be critical for maximizing the impact of incentives in curtailing the HIV epidemic.