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Paladhi UR, Katz DA, Otieno G, Hughes JP, Thirumurthy H, Lagat H, Masyuko S, Sharma M, Macharia P, Bosire R, Mugambi M, Kariithi E, Farquhar C. Effectiveness of Using Additional HIV Self-Test Kits as an Incentive to Increase HIV Testing Within Assisted Partner Services. J Acquir Immune Defic Syndr 2024; 96:457-464. [PMID: 38985443 PMCID: PMC11237351 DOI: 10.1097/qai.0000000000003455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 04/11/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Incentives have shown mixed results in increasing HIV testing rates in low-resource settings. We investigated the effectiveness of offering additional self-tests (HIVSTs) as an incentive to increase testing among partners receiving assisted partner services (APS). SETTING Western Kenya. METHODS We conducted a single-crossover study nested within a cluster-randomized controlled trial. Twenty-four facilities were randomized 1:1 to (1) control: provider-delivered testing or (2) intervention: offered 1 HIVST or provider-delivered testing for 6 months (pre-implementation), then switched to offering 2 HIVSTs for 6 months (post-implementation). A difference-in-differences approach using generalized linear mixed models, accounting for facility clustering and adjusting for age, sex, and income, was used to estimate the effect of the incentive on HIV testing and first-time testing among partners in APS. RESULTS March 2021-June 2022, 1127 index clients received APS and named 8155 partners, among whom 2333 reported a prior HIV diagnosis and were excluded from analyses, resulting in 5822 remaining partners: 3646 (62.6%) and 2176 (37.4%) in the pre-implementation and post-implementation periods, respectively. Overall, 944/2176 partners (43%) were offered a second HIVST during post-preimplementation, of whom 34.3% picked up 2 kits, of whom 71.7% reported that the second kit encouraged HIV testing. Comparing partners offered 1 vs. two HIVSTs showed no difference in HIV testing (relative risk: 1.01, 95% confidence interval: 0.951 to 1.07) or HIV testing for the first time (relative risk: 1.23, 95% confidence interval: 0.671 to 2.24). CONCLUSIONS Offering a second HIVST as an incentive within APS did not significantly impact HIV testing or first-time testing, although those opting for 2 kits reported it incentivized them to test.
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Affiliation(s)
- Unmesha Roy Paladhi
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, USA
| | - David A. Katz
- Department of Global Health, University of Washington, Seattle, USA
| | | | - James P. Hughes
- Department of Biostatistics, University of Washington, Seattle, USA
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, USA
| | - Harison Lagat
- School of Nursing, University of Washington, Seattle, USA
| | - Sarah Masyuko
- Department of Global Health, University of Washington, Seattle, USA
- Ministry of Health, Nairobi, Kenya
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, USA
| | | | | | - Mary Mugambi
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | - Carey Farquhar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
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Agot K, Onyango J, Otieno G, Musingila P, Gachau S, Ochillo M, Grund J, Joseph R, Mboya E, Ohaga S, Omondi D, Odoyo-June E. Shifting reasons for older men remaining uncircumcised: Findings from a pre- and post-demand creation intervention among men aged 25-39 years in western Kenya. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003188. [PMID: 38820408 PMCID: PMC11142559 DOI: 10.1371/journal.pgph.0003188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 04/04/2024] [Indexed: 06/02/2024]
Abstract
Voluntary medical male circumcision (VMMC) reduces men's risk of acquiring Human immunodeficiency virus (HIV) through vaginal sex. However, VMMC uptake remains lowest among Kenyan men ages 25-39 years among whom the impact on reducing population-level HIV incidence was estimated to be greatest at the start of the study in 2014. We conducted a pre- and post-intervention survey as part of a cluster randomized controlled trial to determine the effect of two interventions (interpersonal communication (IPC) and dedicated service outlets (DSO), delivered individually or together) on improving VMMC uptake among men ages 25-39 years in western Kenya between 2014 and 2016. The study had three intervention arms and a control arm. In arm one, an IPC toolkit was used to address barriers to VMMC. In arm two, men were referred to DSO that were modified to address their preferences. Arm three combined the IPC and DSO. The control arm had standard of care. At baseline, uncircumcised men ranked the top three reasons for remaining uncircumcised. An IPC demand creation toolkit was used to address the identified barriers and men were referred for VMMC at study-designated facilities. At follow-up, those who remained uncircumcised were again asked to rank the top three reasons for not getting circumcised. There was inconsistency in ranking of reported barriers at pre- and post- intervention: 'time/venue not convenient' was ranked third at baseline and seventh at follow-up; 'too busy to go for circumcision' was tenth at baseline but second at follow-up, and concern about 'what I/family will eat' was ranked first at both baseline and follow-up, but the proportion reduced from 62% to 28%. Men ages 25-39 years cited a variety of logistical and psychosocial barriers to receiving VMMC. After exposure to IPC, most of these barriers shifted while some remained the same. Additional innovative interventions to address on-going and shifting barriers may help improve VMMC uptake among older men.
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Affiliation(s)
- Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Jacob Onyango
- Impact Research and Development Organization, Kisumu, Kenya
| | - George Otieno
- Center for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Paul Musingila
- Division of Global HIV and TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Susan Gachau
- Division of Global HIV and TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | | | - Jonathan Grund
- Division of Global HIV and TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Rachael Joseph
- Division of Global HIV and TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Edward Mboya
- Impact Research and Development Organization, Kisumu, Kenya
| | - Spala Ohaga
- Impact Research and Development Organization, Kisumu, Kenya
| | - Dickens Omondi
- Jaramogi Oginga Odinga University of Science and Technology, Bondo, Kenya
| | - Elijah Odoyo-June
- Division of Global HIV and TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
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Elendu C, Amaechi DC, Elendu ID, Elendu TC, Amaechi EC, Usoro EU, Chima-Ogbuiyi NL, Arrey Agbor DB, Onwuegbule CJ, Afolayan EF, Balogun BB. Global perspectives on the burden of sexually transmitted diseases: A narrative review. Medicine (Baltimore) 2024; 103:e38199. [PMID: 38758874 PMCID: PMC11098264 DOI: 10.1097/md.0000000000038199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 04/19/2024] [Indexed: 05/19/2024] Open
Abstract
Sexually transmitted diseases (STDs) pose a significant global health challenge with far-reaching social, economic, and public health implications. These infections have haunted humanity from ancient times to today, transcending geographical boundaries and cultural contexts. This article explores the multifaceted landscape of STDs, delving into their epidemiology, pathophysiology, clinical manifestations, and global response strategies. The global prevalence of STDs is staggering, with millions of new cases reported annually. Prominent among these infections is HIV/AIDS, which remains a major global health crisis, affecting over 38 million people worldwide. Additionally, bacterial STDs like chlamydia, gonorrhea, and syphilis continue to pose significant health risks, with millions of new cases reported yearly. Beyond the physical manifestations, STDs have profound social and economic implications. They can result in severe reproductive health issues, stigma, discrimination, and psychological distress, burdening healthcare systems and affecting individuals' quality of life. The global response to STDs has been multifaceted, with international organizations and governments implementing various prevention and control strategies, including sexual education programs and scaling up access to testing and treatment. However, challenges persist, including disparities in healthcare access, sociocultural factors influencing transmission, and evolving pathogens with increasing resistance to treatment. Through case studies and real-world examples, we illuminate the human stories behind the statistics, highlighting the lived experiences of individuals grappling with STDs and the complex interplay of factors shaping their journeys. Ultimately, this review calls for continued research, innovative strategies, and sustained global commitment to mitigating the burden of STDs and promoting sexual health and well-being for all.
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Kim HY, Inghels M, Mathenjwa T, Shahmanesh M, Seeley J, Matthews P, McGrath N, Adeagbo O, Gareta D, Yapa HM, Zuma T, Dobra A, Bärnighausen T, Tanser F. The impact of a conditional financial incentive on linkage to HIV care: Findings from the HITS cluster randomized clinical trial in rural South Africa. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.15.24304278. [PMID: 38562873 PMCID: PMC10984055 DOI: 10.1101/2024.03.15.24304278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Introduction HIV elimination requires innovative approaches to ensure testing and immediate treatment provision. We investigated the effectiveness of conditional financial incentives on increasing linkage to HIV care in a 2×2 factorial cluster randomized controlled trial-Home-Based Intervention to Test and Start (HITS) - in rural South Africa. Methods Of 45 communities in uMkhanyakude, KwaZulu-Natal, 16 communities were randomly assigned to the arms to receive financial incentives for home-based HIV counseling and testing (HBHCT) and linkage to care within 6 weeks (R50 [US$3] food voucher each) and 29 communities to the arms without financial incentives. We examined linkage to care (i.e., initiation or resumption of antiretroviral therapy after >3 months of care interruption) at local clinics within 6 weeks of a home visit, the eligibility period to receive the second financial incentive. Linkage to care was ascertained from individual clinical records. Intention-to-treat analysis (ITT) was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., male-targeted HIV-specific decision support app) and clustering of standard errors at the community level. Results Among 13,894 eligible men (i.e., ≥15 years and resident in the 45 communities), 20.7% received HBHCT, which resulted in 122 HIV-positive tests. Of these, 27 linked to care within 6 weeks of HBHCT. Additionally, of eligible men who did not receive HBHCT, 66 linked to care. In the ITT analysis, the proportion of linkage to care among men did not differ in the arms which received financial incentives and those without financial incentives (adjusted Risk Ratio [aRR]=0.78, 95% CI: 0.51-1.21). Among 19,884 eligible women, 29.1% received HBHCT, which resulted in 375 HIV-positive tests. Of these, 75 linked to care. Among eligible women who did not receive HBHCT, 121 linked to care within 6 weeks. Women in the financial incentive arms had a significantly higher probability of linkage to care, compared to those in the arms without financial incentives (aRR=1.50; 95% CI: 1.03-2.21). Conclusion While a small once-off financial incentive did not increase linkage to care among men during the eligibility period of 6 weeks, it significantly improved linkage to care among women over the same period. Clinical Trial Number: ClinicalTrials.gov # NCT03757104.
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Sulaiman SK, Musa MS, Tsiga-Ahmed FI, Sulaiman AK, Bako AT. A systematic review and meta-analysis of the global prevalence and determinants of COVID-19 vaccine acceptance and uptake in people living with HIV. Nat Hum Behav 2024; 8:100-114. [PMID: 37904021 PMCID: PMC10810755 DOI: 10.1038/s41562-023-01733-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 09/26/2023] [Indexed: 11/01/2023]
Abstract
People living with HIV (PLHIV) are at higher risk of poor outcomes of SARS-CoV-2 infection. Here we report the pooled prevalence of COVID-19 vaccine acceptance/uptake and determinants among this vulnerable population of PLHIV based on a systematic review and meta-analysis of studies published by 25 August 2023. Among the 54 included studies (N = 167,485 participants), 53 (N = 166,455) provided data on vaccine acceptance rate, while 27 (N = 150,926) provided uptake data. The global prevalences of COVID-19 vaccine acceptance and uptake were 67.0% and 56.6%, respectively. Acceptance and uptake rates were 86.6% and 90.1% for the European Region, 74.9% and 71.6% for the Region of the Americas, 62.3% and 78.9% for the South-East Asian Region, 64.6% and 19.3% for the Eastern Mediterranean Region, 58.0% and 35.5% for the African Region, and 57.4% and 44.0% for the Western Pacific Region. The acceptance rate increased from 65.9% in 2020 to 71.0% in 2022, and the uptake rate increased from 55.9% in 2021 to 58.1% in 2022. Men, PLHIV aged ≥40 years and those who had recently received the influenza vaccine were more likely to accept and receive the COVID-19 vaccine. Factors associated with lower uptake included Black race, other races (Latinx/Hispanic/mixed race), low education level and being unemployed. Vaccine-related factors associated with higher acceptance included belief in vaccine effectiveness, vaccine trust, perceived high susceptibility to SARS-CoV-2 infection and fear of potential COVID-19 effect in PLHIV. Sustained efforts and targeted interventions are needed to reduce regional disparities in COVID-19 vaccine uptake among PLHIV.
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Affiliation(s)
| | - Muhammad Sale Musa
- Department of Medicine, Yobe State University Teaching Hospital, Damaturu, Nigeria
| | | | - Abdulwahab Kabir Sulaiman
- Department of Medicine, Murtala Muhammad Specialist Hospital, Kano, Nigeria
- Kwanar Dawaki COVID-19 Isolation Center, Kano, Nigeria
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Martin K, Dziva Chikwari C, Dauya E, Mackworth-Young CRS, Tucker JD, Simms V, Bandason T, Ndowa F, Machiha A, Bernays S, Marks M, Kranzer K, Ferrand RA. Financial incentives to improve uptake of partner services for sexually transmitted infections in Zimbabwe antenatal care: protocol for a cluster randomised trial. Wellcome Open Res 2023; 8:263. [PMID: 37766845 PMCID: PMC10521034 DOI: 10.12688/wellcomeopenres.19199.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Sexually transmitted infections (STIs) such as chlamydia, gonorrhoea, trichomoniasis, and syphilis, are associated with adverse birth outcomes. Treatment should be accompanied by partner services to prevent re-infection and break cycles of transmission. Partner services include the processes of partner notification (PN) as well as arranging for their attendance for testing and/or treatment. However, due to a complex mix of cultural, socio-economic, and health access factors, uptake of partner services is often very low, in many settings globally. Alternative strategies to facilitate partner services are therefore needed.The aim of this study is to assess the impact of a small financial incentive on uptake of partner services for STIs as part of antenatal care (ANC) services in Zimbabwe. Methods and analysis This trial will be embedded within a prospective interventional study in Harare, aiming to evaluate integration of point-of-care diagnostics for STIs into ANC settings. One thousand pregnant women will be screened for chlamydia, gonorrhoea, trichomoniasis, and syphilis. All individuals with STIs will be offered treatment, risk reduction counselling, and client PN. Each clinic day will be randomised 1:1 to be an incentive or non-incentive day. On incentive days, participants diagnosed with a curable STI will be offered a PN slip, that when returned will entitle their partners to $3 (USD) in compensation. On non-incentive days, regular PN slips with no incentive are provided.The primary outcome measure is the proportion of individuals with at least one partner who returns for partner services based on administrative records. Secondary outcomes will include the number of days between index case diagnosis and the partner attending for partner services, uptake of PN slips by pregnant women, adverse birth outcomes in index cases, partners who receive treatment, and intervention cost. Registration Pan African Clinical Trials Registry: PACTR202302702036850 (Approval date 18 th February 2022).
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Affiliation(s)
- Kevin Martin
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Chido Dziva Chikwari
- Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ethel Dauya
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Constance RS. Mackworth-Young
- Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Joseph D. Tucker
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Simms
- Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Tsitsi Bandason
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Francis Ndowa
- Skin & Genito-Urinary Medicine Clinic, Harare, Zimbabwe
| | - Anna Machiha
- AIDS and TB unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Sarah Bernays
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health, University of Sydney, Sydney, Australia
| | - Michael Marks
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Katharina Kranzer
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Rashida A. Ferrand
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
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Perkins JM, Kakuhikire B, Baguma C, Jeon S, Walker SF, Dongre R, Kyokunda V, Juliet M, Satinsky EN, Comfort AB, Siedner M, Ashaba S, Tsai AC. Perceived norms about male circumcision and personal circumcision status: a cross-sectional, population-based study in rural Uganda. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.24.23288996. [PMID: 37163008 PMCID: PMC10168507 DOI: 10.1101/2023.04.24.23288996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Introduction Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circucmsion for HIV and STI prevention. Despite male circumcision prevalence in Uganda nearly doubling from 26% in 2011 to 43% in 2016, it remained below the target level by 2020. Little is known about perceived norms of male circumcision and their association with circumcision uptake among men. Methods We conducted a cross-sectional study targeting all adult residents across eight villages in Rwampara District, southwestern Uganda in 2020-2022. We compared what men and women reported as the adult male circumcision prevalence within their village (perceived norm: >50% (most), 10% to <50% (some), <10%, (few), or do not know) to the aggregated prevalence of circumcision as reported by men aged <50 years. We used a modified multivariable Poisson regression model to estimate the association between perceived norms about male circumcision uptake and personal circumcision status among men. Results Overall, 167 (38%) men < 50 years old were circumcised (and 27% of all men were circumcised). Among all 1566 participants (91% response rate), 189 (27%) men and 177 (20%) women underestimated the male circumcision prevalence, thinking that few men in their own village had been circumcised. Additionally, 10% of men and 25% of women reported not knowing the prevalence. Men who underestimated the prevalence were less likely to be circumcised (aRR = 0.51, 95% CI 0.37 to 0.83) compared to those who thought that some village men were circumcised, adjusting for perceived personal risk of HIV, whether any same-household women thought most men were circumcised, and other sociodemographic factors. Conclusions Across eight villages, a quarter of the population underestimated the local prevalence of male circumcision. Men who underestimated circumcision uptake were less likely to be circumcised. Future research should evaluate norms-based approaches to promoting male circumcision uptake. Strategies may include disseminating messages about the increasing prevalence of adult male circumcision uptake in Uganda and providing personalized normative feedback to men who underestimated local rates about how uptake is greater than they thought.
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Affiliation(s)
- Jessica M. Perkins
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, TN, USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Sehee Jeon
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, TN, USA
| | - Sarah F. Walker
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, TN, USA
| | - Rohit Dongre
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, TN, USA
| | - Viola Kyokunda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mercy Juliet
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Emily N. Satinsky
- Department of Psychology, University of Southern California, Los Angeles, CA, USA
- Center for Global Health, Massachusetts General Hospital, Boston MA USA
| | - Alison B. Comfort
- Bixby Center for Global Reproductive Health, University of California, San Franciso, USA
| | - Mark Siedner
- Center for Global Health, Massachusetts General Hospital, Boston MA USA
- Harvard Medical School, Boston, MA, USA
- Mongan Institute, Massachusetts General Hospital, Boston MA USA
| | | | - Alexander C. Tsai
- Center for Global Health, Massachusetts General Hospital, Boston MA USA
- Harvard Medical School, Boston, MA, USA
- Mongan Institute, Massachusetts General Hospital, Boston MA USA
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Mustanski B, Saber R, Jones JP, Macapagal K, Benbow N, Li DH, Brown CH, Janulis P, Smith JD, Marsh E, Schackman BR, Linas BP, Madkins K, Swann G, Dean A, Bettin E, Savinkina A. Keep It Up! 3.0: Study protocol for a type III hybrid implementation-effectiveness cluster-randomized trial. Contemp Clin Trials 2023; 127:107134. [PMID: 36842763 PMCID: PMC10249332 DOI: 10.1016/j.cct.2023.107134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/13/2023] [Accepted: 02/21/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Despite evidence that eHealth approaches can be effective in reducing HIV risk, their implementation requirements for public health scale up are not well established, and effective strategies to bring these programs into practice are still unknown. Keep It Up! (KIU!) is an online program proven to reduce HIV risk among young men who have sex with men (YMSM) and ideal candidate to develop and evaluate novel strategies for implementing eHealth HIV prevention programs. KIU! 3.0 is a Type III Hybrid Effectiveness-Implementation cluster randomized trial designed to 1) compare two strategies for implementing KIU!: community-based organizations (CBO) versus centralized direct-to-consumer (DTC) recruitment; 2) examine the effect of strategies and determinants on variability in implementation success; and 3) develop materials for sustainment of KIU! after the trial concludes. In this article, we describe the approaches used to achieve these aims. METHODS Using county-level population estimates of YMSM, 66 counties were selected and randomized 2:1 to the CBO and DTC approaches. The RE-AIM model was used to drive outcome measurements, which were collected from CBO staff, YMSM, and technology providers. Mixed-methods research mapped onto the domains of the Consolidated Framework for Implementation Research will examine determinants and their relationship with implementation outcomes. DISCUSSION In comparing our implementation recruitment models, we are examining two strategies which have shown effectiveness in delivering health technology interventions in the past, yet little is known about their comparative advantages and disadvantages in implementation. The results of the trial will further the understanding of eHealth prevention intervention implementation.
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Affiliation(s)
- Brian Mustanski
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 446 E. Ontario Street, Floor 7, Chicago, IL 60611, United States of America.
| | - Rana Saber
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America
| | - Justin Patrick Jones
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America
| | - Kathryn Macapagal
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 446 E. Ontario Street, Floor 7, Chicago, IL 60611, United States of America
| | - Nanette Benbow
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 446 E. Ontario Street, Floor 7, Chicago, IL 60611, United States of America
| | - Dennis H Li
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 446 E. Ontario Street, Floor 7, Chicago, IL 60611, United States of America
| | - C Hendricks Brown
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 446 E. Ontario Street, Floor 7, Chicago, IL 60611, United States of America
| | - Patrick Janulis
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America
| | - Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, 295 Chipeta Way, Williams Building, Salt Lake City, UT 84108, United States of America
| | - Elizabeth Marsh
- Boston Medical Center, Section of Infectious Diseases Crosstown Building, 801 Massachusetts Avenue, Boston, MA 02118, United States of America
| | - Bruce R Schackman
- Department of Population Health Sciences, Weill Cornell Medicine, 425 East 61(st) Street, Suite 301, New York, NY 10065, United States of America
| | - Benjamin P Linas
- Boston Medical Center, Section of Infectious Diseases Crosstown Building, 801 Massachusetts Avenue, Boston, MA 02118, United States of America
| | - Krystal Madkins
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America
| | - Gregory Swann
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America
| | - Abigael Dean
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America
| | - Emily Bettin
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 625 N. Michigan Avenue, Floor 14, Chicago, IL 60611, United States of America
| | - Alexandra Savinkina
- Boston Medical Center, Section of Infectious Diseases Crosstown Building, 801 Massachusetts Avenue, Boston, MA 02118, United States of America
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Hu S, Lu Y, He X, Zhou Y, Wu D, Tucker JD, Yang B, Tang W. Effectiveness of the secondary distribution of HIV self-testing with and without monetary incentives among men who have sex with men living with HIV in China: study protocol for a randomized controlled trial. BMC Infect Dis 2023; 23:160. [PMID: 36918824 PMCID: PMC10013267 DOI: 10.1186/s12879-023-08062-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/07/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND The HIV epidemic is still expanding among men who have sex with men (MSM) in China, but HIV testing rates remain suboptimal. Network-based interventions, such as secondary distribution, have shown promise to expand HIV self-testing (HIVST) among partners of MSM living with HIV (MLWH) but have not been widely implemented. Monetary incentives could enhance the secondary distribution of HIVST in some settings. We will conduct a randomized controlled trial to examine the effectiveness of monetary incentives in expanding the secondary distribution of HIVST among MLWH in China. METHODS We will recruit 200 eligible participants at three antiretroviral therapy (ART) clinics in China. Participants are eligible if they are 18 years of age or over, assigned as male at birth, have had anal sex with men, are living with HIV, are willing to apply for the HIVST kit at ART clinics, and are willing to provide personal contact information for follow-up. Eligible participants will be randomly assigned in a 1:1 ratio to one of two groups: standard secondary distribution group and secondary distribution group with monetary incentives. Participants (defined as "index") will distribute the HIVST kits to members of their social network (defined as "alter") and will be required to complete a baseline survey and a 3-month follow-up survey. All alters will be encouraged to report their testing results by taking photos of used kits and completing an online survey. The primary study outcomes will compare the mean number of alters and newly-tested alters motivated by each index participant in each group. Secondary study outcomes will include the mean number of alters who tested positive, the cost per person tested, and the cost per HIV diagnosed for each group. DISCUSSION Few studies have evaluated interventions to enhance the implementation of secondary distribution. Our study will provide information on the effectiveness of monetary incentives in expanding HIVST secondary distribution among MLWH. The findings of this trial will contribute to implementing HIVST secondary distribution services among MLWH in China and facilitating HIV case identifications. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR2200064517; http://www.chictr.org.cn/showproj.aspx?proj=177896 . Registered on 10th October 2022.
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Affiliation(s)
- Siyue Hu
- School of Public Health, Southern Medical University, Guangzhou, China.,Dermatology Hospital of Southern Medical University, Guangzhou, China.,University of North Carolina Project - China, Guangzhou, China
| | - Ying Lu
- University of North Carolina Project - China, Guangzhou, China
| | - Xi He
- Zhuhai Xutong Voluntary Services Center, Zhuhai, China
| | - Yi Zhou
- Zhuhai Center for Diseases Control and Prevention, Zhuhai, China
| | - Dan Wu
- University of North Carolina Project - China, Guangzhou, China.,London School of Hygiene and Tropical Medicine, London, UK.,West China School of Public Health, Sichuan University, Chengdu, China
| | - Joseph D Tucker
- University of North Carolina Project - China, Guangzhou, China.,London School of Hygiene and Tropical Medicine, London, UK
| | - Bin Yang
- School of Public Health, Southern Medical University, Guangzhou, China. .,Dermatology Hospital of Southern Medical University, Guangzhou, China.
| | - Weiming Tang
- School of Public Health, Southern Medical University, Guangzhou, China. .,Dermatology Hospital of Southern Medical University, Guangzhou, China. .,University of North Carolina Project - China, Guangzhou, China.
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10
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Bulterys MA, Naughton B, Mujugira A, Mugisha J, Nakyanzi A, Naddunga F, Boyer J, Ware N, Celum C, Sharma M. Pregnant women and male partner perspectives of secondary distribution of HIV self-testing kits in Uganda: A qualitative study. PLoS One 2023; 18:e0279781. [PMID: 36787299 PMCID: PMC9928124 DOI: 10.1371/journal.pone.0279781] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 12/14/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND HIV self-testing (HIVST) is a promising strategy to increase awareness of HIV status among sub-Saharan African (SSA) men. Understanding user perspectives on HIVST secondary distribution from pregnant women attending antenatal care (ANC) to their male partners is crucial to optimizing delivery strategies. METHODS We sampled pregnant women attending ANC without their partners and purposively oversampled pregnant women living with HIV (PWHIV) to understand their unique views. We recruited male partners after obtaining contact information from women. We conducted 14 focus group discussions and 10 in-depth interviews with men and pregnant women. We assessed acceptability of HIVST secondary distribution, barriers, facilitators, and interventions to increase HIVST uptake. RESULTS Participants felt that HIVST secondary distribution was acceptable, particularly for women in stable relationships. However, many expressed concerns about accusations of mistrust, relationship dissolution, fear of discovering serodifference, and lack of counseling associated with HIVST. PWHIV reported hesitation about secondary distribution, citing fears of unintended HIV status disclosure and abandonment resulting in financial hardship for themselves and their infant. Some participants preferred that providers contact men directly to offer HIVST kits instead of distribution via women. Participants reported that community sensitization, availability of phone-based counseling, male clinic staff, extended clinic hours, and financial incentives could increase men's HIVST use and linkage to care. CONCLUSION Participants expressed high interest in using HIVST, but secondary distribution was not universally preferred. We identified potential strategies to increase HIVST acceptability, particularly among PWHIV and those in unstable partnerships which can inform strategies to optimize HIVST distribution.
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Affiliation(s)
- Michelle A. Bulterys
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Brienna Naughton
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jackson Mugisha
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Agnes Nakyanzi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Faith Naddunga
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jade Boyer
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Norma Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Monisha Sharma
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
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11
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Carries S, Mkhwanazi Z, Sigwadhi L, Moshabela M, Nyirenda M, Goudge J, Govindasamy D. An economic incentive package to support the wellbeing of caregivers of adolescents living with HIV during the COVID-19 pandemic in South Africa: a feasibility study protocol for a pilot randomised trial. Pilot Feasibility Stud 2023; 9:3. [PMID: 36624520 PMCID: PMC9827020 DOI: 10.1186/s40814-023-01237-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The mental and financial strain linked to unpaid caregiving has been amplified during the COVID-19 pandemic. In sub-Saharan Africa, carers of adolescents living with HIV (ALHIV) are critical for maintenance of optimum HIV treatment outcomes. However, the ability of caregivers to provide quality care to ALHIV is undermined by their ability to maintain their own wellbeing due to multiple factors (viz. poverty, stigma, lack of access to social support services) which have been exacerbated by the COVID-19 pandemic. Economic incentives, such as cash incentives combined with SMS reminders, have been shown to improve wellbeing. However, there is a lack of preliminary evidence on the potential of economic incentives to promote caregiver wellbeing in this setting, particularly in the context of a pandemic. This protocol outlines the design of a parallel-group pilot randomised trial comparing the feasibility and preliminary effectiveness of an economic incentive package versus a control for improving caregiver wellbeing. METHODS Caregivers of ALHIV will be recruited from public-sector HIV clinics in the south of the eThekwini municipality, KwaZulu-Natal, South Africa. Participants will be randomly assigned to one of the following groups: (i) the intervention group (n = 50) will receive three cash payments (of ZAR 350, approximately 23 USD), coupled with a positive wellbeing message over a 3-month period; (ii) the control group (n = 50) will receive a standard message encouraging linkage to health services. Participants will be interviewed at baseline and at endline (12 weeks) to collect socio-demographic, food insecurity, health status, mental health (stigma, depressive symptoms) and wellbeing data. The primary outcome measure, caregiver wellbeing, will be measured using the CarerQoL instrument. A qualitative study will be conducted alongside the main trial to understand participant views on participation in the trial and their feedback on study activities. DISCUSSION This study will provide scientific direction for the design of a larger randomised controlled trial exploring the effects of an economic incentive for improving caregiver wellbeing. The feasibility of conducting study activities and delivering the intervention remotely in the context of a pandemic will also be provided. TRIAL REGISTRATION PACTR202203585402090. Registry name: Pan African Clinical Trials Registry (PACTR); URL: https://pactr.samrc.ac.za/ ; Registration. date: 24 March 2022 (retrospectively registered); Date first participant enrolled: 03 November 2021.
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Affiliation(s)
- Stanley Carries
- grid.415021.30000 0000 9155 0024Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Zibuyisile Mkhwanazi
- grid.415021.30000 0000 9155 0024Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Lovemore Sigwadhi
- grid.11956.3a0000 0001 2214 904XBiostatistics Unit, Stellenbosch University, Stellenbosch, South Africa
| | - Mosa Moshabela
- grid.16463.360000 0001 0723 4123School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Makandwe Nyirenda
- grid.16463.360000 0001 0723 4123School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa ,grid.415021.30000 0000 9155 0024Burden of Disease Unit, South African Medical Research Council, Cape Town, South Africa
| | - Jane Goudge
- grid.11951.3d0000 0004 1937 1135Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
| | - Darshini Govindasamy
- grid.415021.30000 0000 9155 0024Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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12
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Edwards GG, Miyashita-Ochoa A, Castillo EG, Goodman-Meza D, Kalofonos I, Landovitz RJ, Leibowitz AA, Pulsipher C, El Sayed E, Shoptaw S, Shover CL, Tabajonda M, Yang YS, Harawa NT. Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine. AIDS Behav 2023; 27:10-24. [PMID: 36063243 PMCID: PMC9443641 DOI: 10.1007/s10461-022-03817-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 01/24/2023]
Abstract
Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.
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Affiliation(s)
- Gabriel G Edwards
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA.
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine at UCLA, 1100 Glendon Ave., Suite 850, Los Angeles, CA, 90024, USA.
| | - Ayako Miyashita-Ochoa
- Department of Social Welfare, UCLA Luskin School of Public Affairs, Los Angeles, CA, USA
| | - Enrico G Castillo
- Center for Social Medicine and Humanities in the Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - David Goodman-Meza
- Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Ippolytos Kalofonos
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
- Greater Los Angeles Veterans Healthcare Administration, Los Angeles, CA, USA
| | - Raphael J Landovitz
- UCLA Center for Clinical AIDS Research & Education, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Arleen A Leibowitz
- Department of Social Welfare, UCLA Luskin School of Public Affairs, Los Angeles, CA, USA
| | - Craig Pulsipher
- Department of Government Affairs, APLA Health, Los Angeles, CA, USA
| | - Ed El Sayed
- Department of Pharmacology, Touro College of Medicine, New York, NY, USA
| | - Steven Shoptaw
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
- Department of Family Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Chelsea L Shover
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Michelle Tabajonda
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Yvonne S Yang
- Greater Los Angeles Veterans Healthcare Administration, Los Angeles, CA, USA
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Nina T Harawa
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
- Department of Psychiatry, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
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13
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MacDonell K, Dinaj-Koci V, Koken J, Naar S. Barriers and facilitators to scaling up Healthy Choices, a motivational interviewing intervention for youth living with HIV. BMC Health Serv Res 2022; 22:1098. [PMID: 36038882 PMCID: PMC9426253 DOI: 10.1186/s12913-022-08453-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 08/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background This study included Community Health Workers and their supervisors from HIV clinical care teams who participated in the Healthy Choices intervention program. Healthy Choices is a Motivational Interviewing-based intervention aimed at improving medication adherence and reducing alcohol use for adolescents and emerging adults ages 16—24 living with HIV. In this study, the intervention was “scaled up” for delivery by local HIV care providers in real-world clinic settings. Methods Providers (N = 21) completed semi-structured interviews (N = 29) about their experiences with intervention scale-up. Rigorous thematic analyses were conducted within discussions of barriers and facilitators of intervention implementation. Results Three dominant thematic areas emerged from the data: (1) perceptions of the Healthy Choices intervention, (2) engaging high risk YLH in in-person behavior interventions, and (3) perspectives on implementation of the intervention using local staff. Results offer insights into implementation of MI-based interventions for adolescents and emerging adults in clinic settings using local clinical staff instead of dedicated research staff. Conclusions Overall, scaled-up intervention programs for youth are challenged to maintain scientific rigor, provide rigorous training and supports, and offer an attractive and engaging program. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08453-w.
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Affiliation(s)
- Karen MacDonell
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, 1115 West Call Street, Tallahassee, FL, 32306, USA. .,Department of Health Sciences, LaGuardia Community College, CUNY, 31-10 Thomson, Avenue, E300, Long Island City, NY, 11101, USA.
| | - Veronica Dinaj-Koci
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, 1115 West Call Street, Tallahassee, FL, 32306, USA
| | - Juline Koken
- Department of Health Sciences, LaGuardia Community College, CUNY, 31-10 Thomson, Avenue, E300, Long Island City, NY, 11101, USA.,Department of Behavioral Sciences and Social Medicine, Center for Translational Behavioral Science, Florida State University, College of Medicine, 2010 Levy Ave., Bldg. B, Suite 266G, Tallahassee, FL, 32310, USA
| | - Sylvie Naar
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, 1115 West Call Street, Tallahassee, FL, 32306, USA.,Department of Behavioral Sciences and Social Medicine, Center for Translational Behavioral Science, Florida State University, College of Medicine, 2010 Levy Ave., Bldg. B, Suite 266G, Tallahassee, FL, 32310, USA
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14
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Examining the Implementation of Conditional Financial Incentives Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework to Improve HIV Outcomes among Persons Living with HIV (PLWH) in Louisiana. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159486. [PMID: 35954839 PMCID: PMC9367825 DOI: 10.3390/ijerph19159486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
Economic strengthening interventions are needed to support HIV outcomes among persons living with HIV (PLWH). The Baton Rouge Positive Pathway Study (BRPPS), a mixed method implementation science study, was conducted to assess key RE-AIM components tied to the provision of conditional financial incentives among PLWH in Baton Rouge, Louisiana. Seven hundred and eighty-one (781) PLWH enrolled at four HIV clinic sites were included in the final analyses. Participants completed an initial baseline survey, viral load test, and were contacted at 6 and 12 months (±1 month) post-enrollment for follow-up labs to monitor viral load levels. Participants received up to USD140 in conditional financial incentives. The primary analyses assessed whether participation in the BRPPS was associated with an increase in the proportion of participants who were: (a) engaged in care, (b) retained in care and (c) virally suppressed at baseline to 6 and 12 months post-baseline. We constructed a longitudinal regression model where participant-level outcomes at times t0 (baseline) and t1 (6- or 12-month follow-up) were modeled as a function of time. A secondary analysis was conducted using single-level regression to examine which baseline characteristics were associated with the outcomes of interest at 12-month follow-up. Cost analyses were also conducted with three of the participating clinics. Most participants identified as Black/African American (89%). Fewer than half of participants reported that they were unemployed or made less than USD5000 annually (43%). Over time, the proportion of participants engaged in care and retained in care significantly increased (70% to 93% and 32% to 64%, p < 0.00). However, the proportion of virally suppressed participants decreased over time (59% to 34%, p < 0.00). Implementation costs across the three sites ranged from USD17,198.05 to USD396,910.00 and were associated with between 0.37 and 1.34 HIV transmissions averted at each site. Study findings provide promising evidence to suggest that conditional financial incentives could help support engagement and retention in HIV care for a high need and at risk for falling out of HIV care population.
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15
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Kerkhoff AD, Chilukutu L, Nyangu S, Kagujje M, Mateyo K, Sanjase N, Eshun-Wilson I, Geng EH, Havlir DV, Muyoyeta M. Patient Preferences for Strategies to Improve Tuberculosis Diagnostic Services in Zambia. JAMA Netw Open 2022; 5:e2229091. [PMID: 36036933 PMCID: PMC9425150 DOI: 10.1001/jamanetworkopen.2022.29091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Delayed engagement in tuberculosis (TB) services is associated with ongoing transmission and poor clinical outcomes. OBJECTIVE To assess whether patients with TB have differential preferences for strategies to improve the public health reach of TB diagnostic services. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study was undertaken in which a discrete choice experiment (DCE) was administered between September 18, 2019, and January 17, 2020, to 401 adults (>18 years of age) with microbiologically confirmed TB in Lusaka, Zambia. The DCE had 7 attributes with 2 to 3 levels per attribute related to TB service enhancements. Latent class analysis was used to identify segments of participants with unique preferences. Multiscenario simulations were used to estimate shares of preferences for different TB service improvement strategies. MAIN OUTCOMES AND MEASURES The main outcomes were patient preference archetypes and estimated shares of preferences for different strategies to improve TB diagnostic services. Collected data were analyzed between January 3, 2022, to July 2, 2022. RESULTS Among 326 adults with TB (median [IQR] age, 34 [27-42] years; 217 [66.8%] male; 158 [48.8%] HIV positive), 3 groups with distinct preferences for TB service improvements were identified. Group 1 (192 participants [58.9%]) preferred a facility that offered same-day TB test results, shorter wait times, and financial incentives for testing. Group 2 (83 participants [25.4%]) preferred a facility that provided same-day TB results, had greater privacy, and was closer to home. Group 3 (51 participants [15.6%]) had no strong preferences for service improvements and had negative preferences for receiving telephone-based TB test results. Groups 1 and 2 were more likely to report at least a 4-week delay in seeking health care for their current TB episode compared with group 3 (29 [51.3%] in group 1, 95 [35.8%] in group 2, and 10 [19.6%] in group 3; P < .001). Strategies to improve TB diagnostic services most preferred by all participants were same-day TB test results alone (shares of preference, 69.9%) and combined with a small financial testing incentive (shares of preference, 79.3%), shortened wait times (shares of preference, 76.1%), or greater privacy (shares of preference, 75.0%). However, the most preferred service improvement strategies differed substantially by group. CONCLUSIONS AND RELEVANCE In this study, patients with TB had heterogenous preferences for TB diagnostic service improvements associated with differential health care-seeking behavior. Tailored strategies that incorporate features most valued by persons with undiagnosed TB, including same-day results, financial incentives, and greater privacy, may optimize reach by overcoming key barriers to timely TB care engagement.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco School of Medicine, San Francisco
| | | | - Sarah Nyangu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mary Kagujje
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kondwelani Mateyo
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Nsala Sanjase
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
| | - Elvin H. Geng
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco School of Medicine, San Francisco
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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16
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Gutiérrez-Velilla E, Piñeirúa-Menéndez A, Ávila-Ríos S, Caballero-Suárez NP. Clinical Follow-Up in People Living with HIV During the COVID-19 Pandemic in Mexico. AIDS Behav 2022; 26:2798-2812. [PMID: 35190942 PMCID: PMC8860257 DOI: 10.1007/s10461-022-03626-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/04/2022]
Abstract
Clinical follow-up in people living with HIV (PLWH) has individual and public health implications. The objectives of this study were to measure variables related to follow-up failures, identify self-reported reasons to maintain adequate follow-up or for having follow-up failures, and know how the pandemic influenced patients' clinical follow-up. Participants were PLWH receiving HIV-health care at a hospital-based clinic in Mexico City which became an exclusive COVID-19 health service. Participants completed a telephone semi-structured interview and online psychological questionnaires. Lower educational and socioeconomic level, longer times of transportation to the clinic, being attended by different doctors, detectable viral load, having previous dropouts, inadequate antiretroviral adherence, and less HIV knowledge were related to follow-up failures. COVID-19 had a significant negative impact, but it also had positive repercussions for patients with adequate follow-up. These results could help develop effective psychosocial programs and improve healthcare in institutions to facilitate patient retention.
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Affiliation(s)
- Ester Gutiérrez-Velilla
- Programa de Maestría y Doctorado en Ciencias Médicas, Odontológicas y de la Salud, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
- Centro de Investigación en Enfermedades Infecciosas (CIENI) del Instituto Nacional de Enfermedades Respiratorias (INER), Ciudad de México, Mexico
| | | | - Santiago Ávila-Ríos
- Centro de Investigación en Enfermedades Infecciosas (CIENI) del Instituto Nacional de Enfermedades Respiratorias (INER), Ciudad de México, Mexico
| | - Nancy Patricia Caballero-Suárez
- Centro de Investigación en Enfermedades Infecciosas (CIENI) del Instituto Nacional de Enfermedades Respiratorias (INER), Ciudad de México, Mexico.
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17
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Perceptions About Local ART Adherence Norms and Personal Adherence Behavior Among Adults Living with HIV in Rural Uganda. AIDS Behav 2022; 26:1892-1904. [PMID: 35034237 DOI: 10.1007/s10461-021-03540-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 01/08/2023]
Abstract
Although misperceived norms often drive personal health behaviors, we do not know about this phenomenon in the context of antiretroviral therapy (ART) adherence. We conducted a cross-sectional study including all persons living with HIV (PLWH) on ART across eight villages in one parish in a rural region of southwestern Uganda. We used surveys to measure personal reports of ART adherence (not missing any doses of ART in the past 7 days was considered optimal adherence whereas missing doses was considered suboptimal adherence) and perceived norms about the local ART adherence norm (whether or not each individual thought 'most other PLWH on ART in this parish' missed any doses in the past 7 days). Multivariable Poisson regression models were used to estimate the association between perceived norms and personal adherence. Among 159 PLWH on ART (95% response rate), 142 (89%) reported no missed doses. However, 119 (75%) thought most individuals in this population of PLWH on ART were sub-optimally adherent. This misperception about the local ART adherence norm was prevalent in every subgroup of PLWH. Misperceiving the local ART adherence norm to be sub-optimal adherence was associated with a reduced likelihood of optimal adherence among married PLWH (adjusted relative risk [aRR] = 0.83; 95% confidence interval [CI] 0.71-0.97). The association was similar but imprecisely estimated for all PLWH (aRR = 0.91; 95% CI 0.82-1.01). Interventions to correct misperceived ART adherence norms as a stand-alone intervention or as a complement to other adherence promotion programs may influence ART adherence behavior and perhaps reduce HIV-related stigma.
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18
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Willingness of people who inject drugs to participate in a randomised controlled trial involving financial incentives to initiate hepatitis C treatment. Drug Alcohol Depend 2022; 235:109438. [PMID: 35430521 DOI: 10.1016/j.drugalcdep.2022.109438] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/24/2022] [Accepted: 03/31/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Evidence regarding the acceptability of contingency management is limited. We investigated the willingness of people who inject drugs to participate in a randomised controlled trial (RCT) involving financial incentives to initiate HCV treatment. METHODS ETHOS Engage is an observational cohort study of people with a history of injecting drug use who either injected in the past six months or receive opioid agonist therapy (OAT) in Australia. We assessed willingness to participate in a RCT with financial incentives and factors associated with preference for entire incentive ($60) at first clinic visit versus delayed incentive with logistic regression. RESULTS 93% (593/635) of eligible participants agreed to participate in an RCT with financial incentives of which 24% were Aboriginal or Torres Strait Islander, 84% had completed secondary school, and 59% injected drugs in the prior month. Willingness to participate in an RCT increased by amount offered: unspecified (72%), $20 (75%), $60 (80%), and $100 (85%). The preferred incentive distribution method over three clinical visits was entire incentive at first clinical visit (32%). Among those with a preferred distribution method (n = 369), factors associated with entire incentive at first clinic visit were being Aboriginal or Torres Strait Islander (aOR 1.75; 95% CI 1.05-2.94), completion of secondary school (aOR 0.46; 95% CI 0.26-0.83) and mainly injected heroin in month prior (aOR 1.82; 95% CI 1.03-3.20). CONCLUSION Most participants were willing to participate in an RCT involving financial incentives to initiate treatment but differed regarding distribution. Study findings inform implementation of incentives in clinical practice.
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Qur'aniati N, Sweet L, De Bellis A, Hutton A. Construction of a conceptual model of comprehensive care for Indonesian children with human immunodeficiency virus. J Pediatr Nurs 2022; 64:e52-e60. [PMID: 35063322 DOI: 10.1016/j.pedn.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/08/2021] [Accepted: 01/08/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE To construct a conceptual model of comprehensive care for Indonesian children with Human Immunodeficiency Virus. DESIGN AND METHODS A qualitative constructivist grounded theory design. Purposive sampling was used to interview 12 children with Human Immunodeficiency Virus and 8 family members with the age of the children ranged from 9 to 18 years, and 23 health professionals, including general practitioners, paediatric specialists, nurses, midwife, and nutritionist from public health centres and provincial hospitals in East Java, Indonesia. Data was analysed using constant comparative coding methods, theoretical sensitivity, memo writing, and diagramming to facilitate the development of the substantive theory. RESULTS Exploring the perspectives of the participants has revealed the need to enhance the delivery of comprehensive care across the continuum, because HIV care and services for children was sub-optimal. Understanding children's needs and preferences forms the foundation of the development of a framework for the comprehensive care of children with HIV consisting of child-centred care and social support, delivered by integration and coordination of care through a healthcare service. CONCLUSIONS The conceptual model provides new knowledge and has the capacity to bring together optimal care across the continuum addressing the challenges of fragmentation of care for children and their families. PRACTICE IMPLICATIONS The model informs that children with HIV not only need pharmacotherapy, but also other care interventions depending on their individual needs, preferences, and age. Implementing the model may help to resolve such problems, to improve collaborative practice and enhance children's participation, thereby promoting children's health outcomes.
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Affiliation(s)
| | - Linda Sweet
- School of Nursing and Midwifery, Deakin University, Australia; Centre for Quality and Patient Safety Research, Western Health Partnership, Australia
| | - Anita De Bellis
- College of Nursing and Health Sciences, Flinders University, Australia
| | - Alison Hutton
- College of Nursing and Health Sciences, Flinders University, Australia; School of Nursing and Midwifery, College of Health Medicine and Wellbeing, The University of Newcastle, Australia
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20
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Dunlap LJ, Orme S, Zarkin GA, Holtgrave DR, Maulsby C, Rodewald AM, Holtyn AF, Silverman K. Cost and Cost-Effectiveness of Incentives for Viral Suppression in People Living with HIV. AIDS Behav 2022; 26:795-804. [PMID: 34436714 DOI: 10.1007/s10461-021-03439-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
Only 63% of people living with HIV in the United States are achieving viral suppression. Structural and social barriers limit adherence to antiretroviral therapy which furthers the HIV epidemic while increasing health care costs. This study calculated the cost and cost-effectiveness of a contingency management intervention with cash incentives. People with HIV and detectable viral loads were randomized to usual care or an incentive group. Individuals could earn up to $3650 per year if they achieved and maintained an undetectable viral load. The average 1-year intervention cost, including incentives, was $4105 per patient. The average health care costs were $27,189 per patient in usual care and $35,853 per patient in the incentive group. We estimated a cost of $28,888 per quality-adjusted life-year (QALY) gained, which is well below accepted cost-per-QALY thresholds. Contingency management with cash incentives is a cost-effective intervention for significantly increasing viral suppression.
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Affiliation(s)
- Laura J Dunlap
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, USA
| | - Stephen Orme
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, USA.
- RTI International, 701 13th Street NW, Suite 750, Washington, DC, 20005-3967, USA.
| | - Gary A Zarkin
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, USA
| | - David R Holtgrave
- School of Public Health, and Center for Collaborative HIV Research in Practice and Policy, State University of New York, Albany, NY, USA
| | - Catherine Maulsby
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andrew M Rodewald
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - August F Holtyn
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenneth Silverman
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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Reid N, Brown R, Pedersen C, Kozloff N, Sosnowski A, Stergiopoulos V. Using financial incentives to support service engagement of adults experiencing homelessness and mental illness: A qualitative analysis of key stakeholder perspectives. Health Expect 2022; 25:984-993. [PMID: 35104030 PMCID: PMC9122468 DOI: 10.1111/hex.13442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/07/2021] [Accepted: 01/12/2022] [Indexed: 12/17/2022] Open
Abstract
Introduction Homelessness and mental illness are associated with poor service engagement, health and health service use outcomes. Existing literature suggests that financial incentives may effectively support service engagement of this population, but studies investigating key stakeholder perspectives are lacking. This study aimed to elicit, using qualitative methods, nuanced service user and provider experiences by using financial incentives to support service engagement among adults experiencing homelessness and mental illness. Methods This qualitative study is part of a larger mixed‐methods pragmatic trial of financial incentives (Coordinated Access to Care for the Homeless—Financial Incentives [CATCH‐FI]) within a community‐based brief case management programme (CATCH) in Toronto, Ontario. Twenty‐two CATCH‐FI participants were purposefully recruited to participate in in‐depth, semi‐structured interviews; five CATCH service providers participated in a focus group and seven key informants in individual interviews. Data collection occurred between April 2019 and December 2020. All interviews and the focus group were audio‐recorded and transcribed. Topic guides prompted participant perspectives on and experiences of using financial incentives to support engagement, health and well‐being. Grounded theory and inductive thematic analysis guided coding and interpretation of transcripts. Triangulation and member‐checking enhanced the analytical rigour and validity of findings. Results CATCH service providers, key informants and subgroup of CATCH‐FI participants perceived financial incentives to directly facilitate service engagement. The majority of CATCH‐FI participants however highlighted that intrinsic motivation and service quality may be relatively more important facilitators of engagement. Most study participants across stakeholder groups perceived that financial incentives have direct positive influences on health and well‐being in enabling access to basic needs and simple pleasures. Conclusions Our data suggest that for some adults experiencing homelessness and mental illness, financial incentives can directly support service engagement. In addition, financial incentives may positively impact health and well‐being by easing financial stress and enabling deeper attention to individual health needs. Further research on the effectiveness and acceptability of financial incentives is needed to improve understanding and uptake of a promising intervention to support health and health service use outcomes in an underserved population. Patient or Public Contribution Study participants provided input into the study research questions, study design, interview guides and interpretation of findings.
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Affiliation(s)
- Nadine Reid
- General and Health Systems Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Health Services Research Program, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Brown
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Cheryl Pedersen
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Nicole Kozloff
- General and Health Systems Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Health Services Research Program, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Child, Youth and Emerging Adult Program, Centre of Addiction and Mental Health, Toronto, Ontario, Canada
| | - Alexandra Sosnowski
- Health Services Research Program, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Vicky Stergiopoulos
- General and Health Systems Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Health Services Research Program, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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22
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Zhou Y, Lu Y, Ni Y, Wu D, He X, Ong JJ, Tucker JD, Sylvia SY, Jing F, Li X, Huang S, Shen G, Xu C, Xiong Y, Sha Y, Cheng M, Xu J, Jiang H, Dai W, Huang L, Zou F, Wang C, Yang B, Mei W, Tang W. 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. PLoS Med 2022; 19:e1003928. [PMID: 35157727 PMCID: PMC8887971 DOI: 10.1371/journal.pmed.1003928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 03/01/2022] [Accepted: 01/21/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Digital network-based methods may enhance peer distribution of HIV self-testing (HIVST) kits, but interventions that can optimize this approach are needed. We aimed to assess whether monetary incentives and peer referral could improve a secondary distribution program for HIVST among men who have sex with men (MSM) in China. METHODS AND FINDINGS Between October 21, 2019 and September 14, 2020, a 3-arm randomized controlled, single-blinded trial was conducted online among 309 individuals (defined as index participants) who were assigned male at birth, aged 18 years or older, ever had male-to-male sex, willing to order HIVST kits online, and consented to take surveys online. We randomly assigned index participants into one of the 3 arms: (1) standard secondary distribution (control) group (n = 102); (2) secondary distribution with monetary incentives (SD-M) group (n = 103); and (3) secondary distribution with monetary incentives plus peer referral (SD-M-PR) group (n = 104). Index participants in 3 groups were encouraged to order HIVST kits online and distribute to members within their social networks. Members who received kits directly from index participants or through peer referral links from index MSM were defined as alters. Index participants in the 2 intervention groups could receive a fixed incentive ($3 USD) online for the verified test result uploaded to the digital platform by each unique alter. Index participants in the SD-M-PR group could additionally have a personalized peer referral link for alters to order kits online. Both index participants and alters needed to pay a refundable deposit ($15 USD) for ordering a kit. All index participants were assigned an online 3-month follow-up survey after ordering kits. The primary outcomes were the mean number of alters motivated by index participants in each arm and the mean number of newly tested alters motivated by index participants in each arm. These were assessed using zero-inflated negative binomial regression to determine the group differences in the mean number of alters and the mean number of newly tested alters motivated by index participants. Analyses were performed on an intention-to-treat basis. We also conducted an economic evaluation using microcosting from a health provider perspective with a 3-month time horizon. The mean number of unique tested alters motivated by index participants was 0.57 ± 0.96 (mean ± standard deviation [SD]) in the control group, compared with 0.98 ± 1.38 in the SD-M group (mean difference [MD] = 0.41),and 1.78 ± 2.05 in the SD-M-PR group (MD = 1.21). The mean number of newly tested alters motivated by index participants was 0.16 ± 0.39 (mean ± SD) in the control group, compared with 0.41 ± 0.73 in the SD-M group (MD = 0.25) and 0.57 ± 0.91 in the SD-M-PR group (MD = 0.41), respectively. Results indicated that index participants in intervention arms were more likely to motivate unique tested alters (control versus SD-M: incidence rate ratio [IRR = 2.98, 95% CI = 1.82 to 4.89, p-value < 0.001; control versus SD-M-PR: IRR = 3.26, 95% CI = 2.29 to 4.63, p-value < 0.001) and newly tested alters (control versus SD-M: IRR = 4.22, 95% CI = 1.93 to 9.23, p-value < 0.001; control versus SD-M-PR: IRR = 3.49, 95% CI = 1.92 to 6.37, p-value < 0.001) to conduct HIVST. The proportion of newly tested testers among alters was 28% in the control group, 42% in the SD-M group, and 32% in the SD-M-PR group. A total of 18 testers (3 index participants and 15 alters) tested as HIV positive, and the HIV reactive rates for alters were similar between the 3 groups. The total costs were $19,485.97 for 794 testers, including 450 index participants and 344 alter testers. Overall, the average cost per tester was $24.54, and the average cost per alter tester was $56.65. Monetary incentives alone (SD-M group) were more cost-effective than monetary incentives with peer referral (SD-M-PR group) on average in terms of alters tested and newly tested alters, despite SD-M-PR having larger effects. Compared to the control group, the cost for one more alter tester in the SD-M group was $14.90 and $16.61 in the SD-M-PR group. For newly tested alters, the cost of one more alter in the SD-M group was $24.65 and $49.07 in the SD-M-PR group. No study-related adverse events were reported during the study. Limitations include the digital network approach might neglect individuals who lack internet access. CONCLUSIONS Monetary incentives alone and the combined intervention of monetary incentives and peer referral can promote the secondary distribution of HIVST among MSM. Monetary incentives can also expand HIV testing by encouraging first-time testing through secondary distribution by MSM. This social network-based digital approach can be expanded to other public health research, especially in the era of the Coronavirus Disease 2019 (COVID-19). TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR) ChiCTR1900025433.
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Affiliation(s)
- Yi Zhou
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
- Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China
| | - Ying Lu
- Dermatology Hospital of South Medical University, Guangzhou, China
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
| | - Yuxin Ni
- Dermatology Hospital of South Medical University, Guangzhou, China
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
| | - Dan Wu
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Xi He
- Zhuhai Xutong Voluntary Services Center, Zhuhai, China
| | - Jason J. Ong
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
- Central Clinical School, Faculty of Medicine, Monash University, Melbourne, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia
| | - Joseph D. Tucker
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Sean Y. Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Fengshi Jing
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
- School of Data Science, City University of Hong Kong, Hong Kong SAR, China
| | - Xiaofeng Li
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Shanzi Huang
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Guangquan Shen
- Dermatology Hospital of South Medical University, Guangzhou, China
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
| | - Chen Xu
- Dermatology Hospital of South Medical University, Guangzhou, China
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
| | - Yuan Xiong
- Dermatology Hospital of South Medical University, Guangzhou, China
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
| | - Yongjie Sha
- Dermatology Hospital of South Medical University, Guangzhou, China
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
| | - Mengyuan Cheng
- Dermatology Hospital of South Medical University, Guangzhou, China
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
| | - Junjie Xu
- Peking University Shenzhen Hospital, Shenzhen, China
| | - Hongbo Jiang
- Guangdong Pharmaceutical University, Guangzhou, China
| | - Wencan Dai
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Liqun Huang
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Fei Zou
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Cheng Wang
- Dermatology Hospital of South Medical University, Guangzhou, China
| | - Bin Yang
- Dermatology Hospital of South Medical University, Guangzhou, China
| | - Wenhua Mei
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Weiming Tang
- Dermatology Hospital of South Medical University, Guangzhou, China
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China
- * E-mail:
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Perkins JM, Kakuhikire B, Baguma C, Jurinsky J, Rasmussen JD, Satinsky EN, Namara E, Ahereza P, Kyokunda V, Perkins HW, Hahn JA, Bangsberg DR, Tsai AC. Overestimation of alcohol consumption norms as a driver of alcohol consumption: a whole-population network study of men across eight villages in rural, southwestern Uganda. Addiction 2022; 117:68-81. [PMID: 34159646 PMCID: PMC8759576 DOI: 10.1111/add.15615] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/20/2021] [Accepted: 05/09/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Little is known about how perceived norms about alcohol consumption may influence high alcohol consumption rates in Uganda. This study estimated the accuracy of perceived norms about men's alcohol consumption and estimated the association between perceived norms and personal alcohol consumption. DESIGN Cross-sectional, whole-population, sociocentric social network study. SETTING Eight rural villages in Rwampara District, southwestern Uganda in 2016-18. PARTICIPANTS A total of 719 men aged 18 years and older (representing 91% of permanent resident men). MEASUREMENTS Self-reported frequent (≥ 4 days per week) and heavy alcohol consumption (six or more drinks on one occasion, more than three occasions of intoxication, or spending an excessive amount on alcohol). Participants also reported whether they thought most other men in their village engaged in frequent and heavy alcohol consumption (perceived norms). Using the network study design, we calculated alcohol consumption behavior within villages and social networks. Perceived norms were compared with aggregated self-reports. Multivariable Poisson regression models were used to estimate the association between perceived norms and individual behavior. FINDINGS Throughout villages, frequent and heavy alcohol consumption ranged from 7 to 37%. However, 527 (74%) participants perceived, contrary to fact, that most other men in their villages frequently consumed alcohol, and 576 (81%) perceived that most others heavily consumed alcohol. Overestimation of alcohol consumption by others was pervasive among socio-demographic subgroups and was present irrespective of the actual consumption behavior at the village level and within social networks. Men who misperceived these alcohol consumption behaviors as being common were more likely to engage in frequent [adjusted relative risk (aRR) = 3.98; 95% confidence interval (CI) = 1.69-9.34) and heavy (aRR = 4.75; 95% CI = 2.33-9.69) alcohol consumption themselves. CONCLUSIONS Most men in eight rural Ugandan villages incorrectly thought that frequent and heavy alcohol consumption were common among men in their villages. These misperceived norms had a strong positive association with individual drinking behavior.
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Affiliation(s)
- Jessica M. Perkins
- Peabody College of Education and Human Development, Vanderbilt University, Nashville, TN, USA,Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, TN, USA,Corresponding author: Dr. Jessica M. Perkins, , Phone: (615) 875-3289, Fax: 615-343-2661
| | | | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jordan Jurinsky
- Peabody College of Education and Human Development, Vanderbilt University, Nashville, TN, USA
| | | | - Emily N. Satinsky
- Center for Global Health, Massachusetts General Hospital, Boston MA USA
| | | | - Phionah Ahereza
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Viola Kyokunda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Judith A. Hahn
- University of California at San Francisco, San Francisco, CA, USA
| | - David R. Bangsberg
- Mbarara University of Science and Technology, Mbarara, Uganda,Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - Alexander C. Tsai
- Mbarara University of Science and Technology, Mbarara, Uganda,Center for Global Health, Massachusetts General Hospital, Boston MA USA,Harvard Medical School, Boston, MA, USA,Mongan Institute, Massachusetts General Hospital, Boston MA USA
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Iguna S, Getahun M, Lewis-Kulzer J, Odhiambo G, Adhiambo F, Montoya L, Petersen ML, Bukusi E, Odeny T, Geng E, Camlin CS. Attitudes towards and experiences with economic incentives for engagement in HIV care and treatment: Qualitative insights from a randomized trial in Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000204. [PMID: 36962322 PMCID: PMC10021832 DOI: 10.1371/journal.pgph.0000204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/19/2022] [Indexed: 11/18/2022]
Abstract
Growing literature has shown heterogenous effects of conditional cash incentives (CCIs) on HIV care retention. The field lacks insights into reasons why incentives impact various patients in different ways-differences that may be due to variations in psychological and social mechanisms of effect. A deeper understanding of patients' perceptions and experiences of CCIs for retention may help to clarify these mechanisms. We conducted a qualitative study embedded in the ADAPT-R trial (NCT#02338739), a sequential multiple assignment randomized trial (SMART) that evaluated economic incentives to support retention in HIV care among persons living with HIV (PLHIV) initiating antiretroviral therapy in Kenya. Participants who attended their scheduled clinic visits received an incentive of approximately $4 each visit. Interviews were conducted between July 2016 and June 2017 with 39 participants to explore attitudes and experiences with economic incentives conditional on care engagement. Analyses revealed that incentives helped PLHIV prioritize care-seeking by alleviating transport barriers and food insecurity: "I decided to forgo [work] and attend clinic […] the voucher relieved me". Patients who borrowed money for care-seeking reported feeling relieved from the burden of indebtedness to others: "I borrow with confidence that I will pay after my appointment." Incentives fostered their autonomy, and enabled them to support others: "I used the money to buy some clothes and Pampers for the children." Participants who were intrinsically motivated to engage in care ("my life depends on the drugs, not the incentive"), and those who mistrusted researchers, reported being less prompted by the incentive itself. For patients not already prioritizing care-seeking, incentives facilitated care engagement through alleviating transport costs, indebtedness and food insecurity, and also supported social role fulfillment. Conditional cash incentives may be an important cue to action to improve progression through the HIV treatment cascade, and contribute to better care retention.
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Affiliation(s)
- Sarah Iguna
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Jayne Lewis-Kulzer
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Gladys Odhiambo
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Fridah Adhiambo
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Lina Montoya
- Division of Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Maya L Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Elizabeth Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Thomas Odeny
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
| | - Elvin Geng
- Division of Infectious Diseases, Department of Internal Medicine, Washington University, St. Louis, Missouri, United States of America
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, California, United States of America
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25
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Bezabih AM, Gerling K, Abebe W, Abeele VV. Behavioral Theories and Motivational Features Underlying eHealth Interventions for Adolescent Antiretroviral Adherence: Systematic Review. JMIR Mhealth Uhealth 2021; 9:e25129. [PMID: 34890353 PMCID: PMC8709919 DOI: 10.2196/25129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/06/2021] [Accepted: 09/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background eHealth systems provide new opportunities for the delivery of antiretroviral therapy (ART) adherence interventions for adolescents. They may be more effective if grounded in health behavior theories and behavior change techniques (BCTs). Prior reviews have examined the effectiveness, feasibility, and acceptability of these eHealth systems. However, studies have not systematically explored the use of health behavior theories and BCTs in the design of these applications. Objective The purpose of this review was to explore whether health behavior theories and BCTs were considered to ground designs of eHealth systems supporting adolescents’ (10-24 years) ART adherence. More specifically, we examined which specific theories and BCTs were applied, and how these BCTs were implemented as design features. Additionally, we investigated the quality and effect of eHealth systems. Methods A systematic search was performed on IEEE Xplore, ACM, ScienceDirect, PubMed, Scopus, and Web of Science databases from 2000 to 2020. Theory use and BCTs were coded using the Theory Coding Scheme and the Behavior Change Technique Taxonomy version 1 (BCTTv1), respectively. Design features were identified using the lenses of motivational design for mobile health (mHealth). The number of BCTs and design features for each eHealth system and their prevalence across all systems were assessed. Results This review identified 16 eHealth systems aiming to support ART adherence among adolescents. System types include SMS text message reminders (n=6), phone call reminders (n=3), combined SMS text message and phone call reminders (n=1), electronic adherence monitoring devices (n=3), smartphone apps (n=1), smartphone serious games (n=1), gamified smartphone apps (n=1), leveraging existing social media (n=2), web-based applications (n=1), videoconferencing (n=1), and desktop applications (n=1). Nine were grounded in theory, of which 3 used theories extensively. The impact of adolescent developmental changes on ART adherence was not made explicit. A total of 42 different BCTs and 24 motivational design features were used across systems. Ten systems reported positive effects on 1 or more outcomes; however, of these ten systems, only 3 reported exclusively positive effects on all the outcomes they measured. As much as 6 out of 16 reported purely no effect in all the outcomes measured. Conclusions Basic applications (SMS text messaging and phone calls) were most frequent, although more advanced systems such as mobile apps and games are also emerging. This review indicated gaps in the use of theory and BCTs, and particularly the impact of developmental changes on ART adherence was not adequately considered. Together with adopting a developmental orientation, future eHealth systems should effectively leverage health theories and consider developing more advanced systems that open the door to using BCTs more comprehensively. Overall, the impact of eHealth systems on adolescent ART adherence and its mediators is promising, but conclusive evidence on effect still needs to be provided.
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Affiliation(s)
- Alemitu Mequanint Bezabih
- Department of Computer Science, e-Media Research Lab, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Kathrin Gerling
- Department of Computer Science, e-Media Research Lab, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Workeabeba Abebe
- Department of Pediatrics and Child Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Vero Vanden Abeele
- Department of Computer Science, e-Media Research Lab, Katholieke Universiteit Leuven, Leuven, Belgium
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Rua T, Brandão D, Nicolau V, Escoval A. The Utilisation of Payment Models Across the HIV Continuum of Care: Systematic Review of Evidence. AIDS Behav 2021; 25:4193-4208. [PMID: 34184134 PMCID: PMC8602234 DOI: 10.1007/s10461-021-03329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2021] [Indexed: 10/31/2022]
Abstract
The increasing chronicity and multimorbidities associated with people living with HIV have posed important challenges to health systems across the world. In this context, payment models hold the potential to improve care across a spectrum of clinical conditions. This study aims to systematically review the evidence of HIV performance-based payments models. Literature searches were conducted in March 2020 using multiple databases and manual searches of relevant papers. Papers were limited to any study design that considers the real-world utilisation of performance-based payment models applied to the HIV domain. A total of 23 full-text papers were included. Due to the heterogeneity of study designs, the multiple types of interventions and its implementation across distinct areas of HIV care, direct comparisons between studies were deemed unsuitable. Most evidence focused on healthcare users (83%), seeking to directly affect patients' behaviour based on principles of behavioural economics. Despite the variability between interventions, the implementation of performance-based payment models led to either a neutral or positive impact throughout the HIV care continuum. Moreover, this improvement was likely to be cost-effective or, at least, did not compromise the healthcare system's financial sustainability. However, more research is needed to assess the durability of incentives and its appropriate relative magnitude.
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Benbow ND, Mokotoff ED, Dombrowski JC, Wohl AR, Scheer S. The HIV Treat Pillar: An Update and Summary of Promising Approaches. Am J Prev Med 2021; 61:S39-S46. [PMID: 34686289 PMCID: PMC11107265 DOI: 10.1016/j.amepre.2021.05.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 01/22/2023]
Abstract
The Treat pillar of the Ending the HIV Epidemic in the U.S. plan calls for comprehensive strategies to enhance linkage to, and engagement in, HIV medical care to improve viral suppression among people with HIV and achieve the goal of 95% viral suppression by 2025. The U.S. has seen large increases in the proportion of people with HIV who have a suppressed viral load. Viral suppression has increased 41%, from 46% in 2010 to 65% in 2018. An additional increase of 46% is needed to meet the Ending the HIV Epidemic in the U.S. goal. The rate of viral suppression among those in care increased to 85% in 2018, highlighting the need to ensure sustained care for people with HIV. Greater increases in all steps along the HIV care continuum are needed for those disproportionately impacted by HIV, especially the young, sexual and racial/ethnic minorities, people experiencing homelessness, and people who inject drugs. Informed by systematic reviews and current research findings, this paper describes more recent promising practices that suggest an impact on HIV care outcomes. It highlights rapid linkage and treatment interventions; interventions that identify and re-engage people in HIV care through new collaborations among health departments, providers, and hospital systems; coordinated care and low-barrier clinic models; and telemedicine-delivered HIV care approaches. The interventions presented in this paper provide additional approaches that state and local jurisdictions can use to reach their local HIV elimination plans' goals and the ambitious Ending the HIV Epidemic in the U.S. Treat pillar targets by 2030.
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Affiliation(s)
- Nanette D Benbow
- Department of Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | | | - Julia C Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington; Public Health - Seattle & King County, Seattle, Washington
| | - Amy R Wohl
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California
| | - Susan Scheer
- HIV Epidemiology Section, San Francisco Department of Public Health, San Francisco, California
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Zhang J, Atkins DL, Wagner AD, Njuguna IN, Neary J, Omondi VO, Otieno VA, Atieno WO, Odhiambo M, Wamalwa DC, John-Stewart G, Slyker JA, Weiner BJ, Beima-Sofie K. Financial Incentives for Pediatric HIV Testing (FIT): Caregiver Insights on Incentive Mechanisms, Focus Populations, and Acceptability for Programmatic Scale Up. AIDS Behav 2021; 25:2661-2668. [PMID: 34170433 DOI: 10.1007/s10461-021-03356-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/30/2022]
Abstract
Children living with HIV experience gaps in HIV testing globally; scaling up evidence-based testing strategies is critical for preventing HIV-related mortality. Financial incentives (FI) were recently demonstrated to increase uptake of pediatric HIV testing. As part of this qualitative follow-up study to the FIT trial (NCT03049917) conducted in Kenya, 54 caregivers participated in individual interviews. Interview transcripts were analyzed to identify considerations for scaling up FI for pediatric testing. Caregivers reported that FI function by directly offsetting costs or nudging caregivers to take action sooner. Caregivers found FI to be feasible and acceptable for broader programmatic implementation, and supported use for a variety of populations. Some concerns were raised about unintended consequences of FI, including caregivers bringing ineligible children to collect incentives and fears about the impact on linkage to care and retention if caregivers become dependent on FI.
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Affiliation(s)
- Junyi Zhang
- Department of Health Services, University of Washington, Seattle, WA, 98195, USA.
| | - Dana L Atkins
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
| | - Irene N Njuguna
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
- Research and Programs, Kenyatta National Hospital, Ngong Road, Nairobi, 00202, Kenya
| | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, WA, 98104, USA
| | - Vincent O Omondi
- Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Verlinda A Otieno
- Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Winnie O Atieno
- Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Merceline Odhiambo
- Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Dalton C Wamalwa
- Department of Pediatrics, University of Nairobi, Nairobi, 00202, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
- Department of Epidemiology, University of Washington, Seattle, WA, 98104, USA
- Department of Medicine, University of Washington, Seattle, WA, 98104, USA
- Department of Pediatrics, University of Washington, Seattle, WA, 98104, USA
| | - Jennifer A Slyker
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
- Department of Epidemiology, University of Washington, Seattle, WA, 98104, USA
| | - Bryan J Weiner
- Department of Health Services, University of Washington, Seattle, WA, 98195, USA
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
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Ezenwaka U, Manzano A, Onyedinma C, Ogbozor P, Agbawodikeizu U, Etiaba E, Ensor T, Onwujekwe O, Ebenso B, Uzochukwu B, Mirzoev T. Influence of Conditional Cash Transfers on the Uptake of Maternal and Child Health Services in Nigeria: Insights From a Mixed-Methods Study. Front Public Health 2021; 9:670534. [PMID: 34307277 PMCID: PMC8297950 DOI: 10.3389/fpubh.2021.670534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Increasing access to maternal and child health (MCH) services is crucial to achieving universal health coverage (UHC) among pregnant women and children under-five (CU5). The Nigerian government between 2012 and 2015 implemented an innovative MCH programme to reduce maternal and CU5 mortality by reducing financial barriers of access to essential health services. The study explores how the implementation of a financial incentive through conditional cash transfer (CCT) influenced the uptake of MCH services in the programme. Methods: The study used a descriptive exploratory approach in Anambra state, southeast Nigeria. Data was collected through qualitative [in-depth interviews (IDIs), focus group discussions (FGDs)] and quantitative (service utilization data pre- and post-programme) methods. Twenty-six IDIs were conducted with respondents who were purposively selected to include frontline health workers (n = 13), National and State policymakers and programme managers (n = 13). A total of sixteen FGDs were conducted with service users and their family members, village health workers, and ward development committee members from four rural communities. We drew majorly upon Skinner's reinforcement theory which focuses on human behavior in our interpretation of the influence of CCT in the uptake of MCH services. Manual content analysis was used in data analysis to pull together core themes running through the entire data set. Results: The CCTs contributed to increasing facility attendance and utilization of MCH services by reducing the financial barrier to accessing healthcare among pregnant women. However, there were unintended consequences of CCT which included a reduction in birth spacing intervals, and a reduction of trust in the health system when the CCT was suddenly withdrawn by the government. Conclusion: CCT improved the utilization of MCH, but the sudden withdrawal of the CCT led to the opposite effect because people were discouraged due to lack of trust in government to keep using the MCH services. Understanding the intended and unintended outcomes of CCT will help to build sustainable structures in policy designs to mitigate sudden programme withdrawal and its subsequent effects on target beneficiaries and the health system at large.
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Affiliation(s)
- Uchenna Ezenwaka
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu, Nsukka, Nigeria
| | - Ana Manzano
- School of Sociology and Social Policy, University of Leeds, Leeds, United Kingdom
| | - Chioma Onyedinma
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Pamela Ogbozor
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Uju Agbawodikeizu
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Enyi Etiaba
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu, Nsukka, Nigeria
| | - Tim Ensor
- Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu, Nsukka, Nigeria
| | - Bassey Ebenso
- Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Benjamin Uzochukwu
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Tolib Mirzoev
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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30
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Sibanda EL, Neuman M, Tumushime M, Mangenah C, Hatzold K, Watadzaushe C, Mutseta MN, Dirawo J, Napierala S, Ncube G, Terris-Prestholt F, Taegtmeyer M, Johnson C, Fielding KL, Weiss HA, Corbett E, Cowan FM. Community-based HIV self-testing: a cluster-randomised trial of supply-side financial incentives and time-trend analysis of linkage to antiretroviral therapy in Zimbabwe. BMJ Glob Health 2021; 6:e003866. [PMID: 34275865 PMCID: PMC8287602 DOI: 10.1136/bmjgh-2020-003866] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 02/10/2021] [Accepted: 02/18/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND HIV self-testing (HIVST) requires linkage to post-test services to maximise its benefits. We evaluated effect of supply-side incentivisation on linkage following community-based HIVST and evaluated time-trends in facility-based antiretroviral therapy (ART) initiations. METHODS From August 2016 to August 2017 community-based distributors (CBDs) in 38 rural Zimbabwean communities distributed HIVST door-to-door in 19-25 day campaigns. Communities were allocated (1:1) using constrained randomisation to either one-off US$50 remuneration per CBD (non-incentive arm), or US$50 plus US$0.20 incentive per client visiting mobile-outreach services (conditional-incentive arm). The primary outcome, assessed by population survey 6 weeks later, was self-reported uptake of any clinic service, analysed with random-effects logistic regression. Separately, non-randomised difference-in-differences in monthly ART initiations were analysed for three time periods (6 months baseline; HIVST campaign; 3 months after) at public clinics with (40 clinics) and without (124 clinics) HIVST distribution in catchment area. FINDINGS A total of 445 conditional-incentive CBDs distributed 39 205 HIVST kits (mean/CBD: 88; 95% CI: 85 to 92) and 447 non-incentive CBDs distributed 41 173 kits (mean/CBD: 93; 95% CI: 89 to 96). Survey participation was 7146/8566 (83.4%), with 3593 (50.3%) reporting self-testing including 1305 (18.3%) previously untested individuals. Use of clinic services post-HIVST was similar in conditional-incentive (1062/3698, 28.7%) and non-incentive (1075/3448, 31.2%) arms (adjusted risk ratio (aRR) 0.94, 95% CI: 0.86 to 1.03). Confirmatory testing by newly diagnosed/untreated HIVST+clients was, however, higher (conditional-incentive: 25/33, 75.8% vs non-incentive: 20/40, 50.0%: aRR: 1.59, 95% CI: 1.05 to 2.39). In total, 12 808 ART initiations occurred, with no baseline or postcampaign differences between initiation rates in HIVST versus non-HIVST clinics, but initiation rates increased from 7.31 to 9.59 initiations per month in HIVST clinics during distribution, aRR: 1.27, 95% CI 1.17 to 1.39. CONCLUSIONS Community-based HIVST campaigns achieved high testing uptake, temporally associated with increased demand for ART. Small supply-side incentives did not affect general clinic usage but may have increased confirmatory testing for newly diagnosed HIVST positive participants. TRIAL REGISTRATION NUMBER PACTR201607001701788.
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Affiliation(s)
- Euphemia Lindelwe Sibanda
- CeSHHAR Zimbabwe, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Melissa Neuman
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Karin Hatzold
- HIV and Tuberculosis, Population Services International Global, Washington, DC, USA
| | | | - Miriam N Mutseta
- Department of Sexual Reproductive Health Rights and Innovations, Population Services International Zimbabwe, Harare, Zimbabwe
| | | | - Sue Napierala
- Women's Global Health Imperative, RTI International, Berkeley, California, USA
| | - Getrude Ncube
- HIV and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen A Weiss
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Corbett
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Public Health, London, UK
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Frances M Cowan
- CeSHHAR Zimbabwe, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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31
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Kagucia EW, Ochieng B, Were J, Hayford K, Obor D, O'Brien KL, Gibson DG. Impact of mobile phone delivered reminders and unconditional incentives on measles-containing vaccine timeliness and coverage: a randomised controlled trial in western Kenya. BMJ Glob Health 2021; 6:bmjgh-2020-003357. [PMID: 33509838 PMCID: PMC7845730 DOI: 10.1136/bmjgh-2020-003357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 12/23/2020] [Accepted: 01/06/2021] [Indexed: 01/19/2023] Open
Abstract
Introduction Short message service (SMS) reminders coupled with a small monetary incentive conditioned on prompt vaccination have been shown to improve first-dose measles-containing vaccine (MCV1) uptake. We assessed whether SMS reminders and unconditional monetary incentives—more amenable to programmatic implementation—can improve MCV1 uptake in Kenya. Methods Caregivers of eligible infants aged 6–8 months were enrolled into an individually randomised controlled trial and assigned to receive either: no intervention (control), two SMS reminders (SMS) sent 3 days, and 1 day before the scheduled MCV1 date, or SMS reminders coupled with a Kenya Shilling (KES) 150 incentive (SMS +150 KES) sent 3 days before the scheduled MCV1 date. Study staff conducted a household follow-up visit at age 12 months to ascertain vaccination status. Log-binomial regression was used to estimate the relative and absolute difference in MCV1 timely coverage (by age 10 months), the primary outcome. Results Between 6 December 2016 and 31 March 2017, 179 infants were enrolled into each of the three study arms. Follow-up visits were completed between 19 April 2017 and 8 October 2017 for control (n=170), SMS (n=157) and SMS + 150 KES (n=158) children. MCV1 timely coverage was 68% among control arm infants compared with 78% in each intervention arm. This represented a non-statistically significant increase in the SMS arm (adjusted relative risk 1.13; 95% CI 0.99 to 1.30; p=0.070; adjusted risk difference 9.2%; 95% CI: −0.6 to 19.0%; p=0.066), but a statistically significant increase in the SMS + 150 KES arm (1.16; 95% CI 1.01 to 1.32; p=0.035; 10.6%; 95% CI 0.8 to 20.3%; p=0.034). Conclusion These findings suggest that the effect of SMS reminders coupled with a small unconditional monetary incentive on MCV1 uptake is comparable to that of SMS reminders alone, limiting their utility. Further studies in the absence of unexpected supply-side constraints are needed. Trial registration number NCT02904642
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Affiliation(s)
- E Wangeci Kagucia
- International Vaccine Access Center, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Benard Ochieng
- Kenya Medical Research Institute/Centers for Disease Control and Prevention Public Health and Research Collaboration, Kisumu, Kenya
| | - Joyce Were
- Kenya Medical Research Institute/Centers for Disease Control and Prevention Public Health and Research Collaboration, Kisumu, Kenya
| | - Kyla Hayford
- International Vaccine Access Center, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - David Obor
- Kenya Medical Research Institute/Centers for Disease Control and Prevention Public Health and Research Collaboration, Kisumu, Kenya
| | - Katherine L O'Brien
- International Vaccine Access Center, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dustin G Gibson
- International Vaccine Access Center, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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32
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Stecher C, Linnemayr S. Promoting antiretroviral therapy adherence habits: a synthesis of economic and psychological theories of habit formation. AIDS 2021; 35:711-716. [PMID: 33306553 PMCID: PMC9207816 DOI: 10.1097/qad.0000000000002792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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33
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Saleska JL, Turner AN, Gallo MF, Shoben A, Kawende B, Ravelomanana NLR, Thirumurthy H, Yotebieng M. Role of temporal discounting in a conditional cash transfer (CCT) intervention to improve engagement in the prevention of mother-to-child transmission (PMTCT) cascade. BMC Public Health 2021; 21:477. [PMID: 33691667 PMCID: PMC7944635 DOI: 10.1186/s12889-021-10499-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/24/2021] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Jessica Londeree Saleska
- Division of Epidemiology, Cunz Hall, The Ohio State University, College of Public Health, 1841 Neil Avenue, Columbus, OH, 43210, USA. .,The University of California Los Angeles, Global Center for Children and Families, Semel Institute for Neuroscience and Human Behavior, 10920 Wilshire Blvd, Los Angeles, CA, 90024, USA.
| | - Abigail Norris Turner
- Division of Infectious Disease, Doan Hall, The Ohio State University, College of Medicine, 410 W. 10th Avenue, Columbus, OH, 43210, USA
| | - Maria F Gallo
- Division of Epidemiology, Cunz Hall, The Ohio State University, College of Public Health, 1841 Neil Avenue, Columbus, OH, 43210, USA
| | - Abigail Shoben
- Division of Epidemiology, Cunz Hall, The Ohio State University, College of Public Health, 1841 Neil Avenue, Columbus, OH, 43210, USA
| | - Bienvenu Kawende
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Noro Lantoniaina Rosa Ravelomanana
- Division of Epidemiology, Cunz Hall, The Ohio State University, College of Public Health, 1841 Neil Avenue, Columbus, OH, 43210, USA.,The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, USA
| | - Marcel Yotebieng
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
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Krishnamoorthy Y, Rehman T, Sakthivel M. Effectiveness of Financial Incentives in Achieving UNAID Fast-Track 90-90-90 and 95-95-95 Target of HIV Care Continuum: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. AIDS Behav 2021; 25:814-825. [PMID: 32968885 DOI: 10.1007/s10461-020-03038-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2020] [Indexed: 11/26/2022]
Abstract
Financial incentives influence behavioural changes and the current review was done to assess the effectiveness of this intervention in improving HIV care continuum. We conducted systematic searches in MEDLINE, Cochrane library, ScienceDirect and Google Scholar from inception until July 2019. We carried out a meta-analysis with random-effects model quantifying inconsistency (I2) for heterogeneity and reported pooled Risk Ratios (RR) with 95% confidence intervals (CIs). A total of 22 studies with 38,119 participants were included. All the six outcomes showed better results in financial incentive arm compared to standard care with statistical significance in three outcomes-HIV testing uptake (pooled RR: 2.42; 95%CI 1.06-5.54; I2 = 100%), antiretroviral therapy (ART) adherence (pooled RR: 1.30; 95%CI 1.13-1.50; I2 = 44%), and continuity in care (pooled RR: 1.24; 95%CI 1.09-1.41; I2 = 86%). To summarize, financial incentives can be helpful in improving the uptake of HIV testing, ART adherence and continuity of care while it was better for achieving viral load suppression among studies conducted in high-income countries.
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Affiliation(s)
- Yuvaraj Krishnamoorthy
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
| | - Tanveer Rehman
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Manikandanesan Sakthivel
- State Program and Technical Manager, Cap TB project, AP/TS Unit, Solidarity and Action against The HIV Infection in India (SAATHII), Hyderabad, India
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Tanser FC, Kim HY, Mathenjwa T, Shahmanesh M, Seeley J, Matthews P, Wyke S, McGrath N, Adeagbo O, Sartorius B, Yapa HM, Zuma T, Zeitlin A, Blandford A, Dobra A, Bärnighausen T. Home-Based Intervention to Test and Start (HITS): a community-randomized controlled trial to increase HIV testing uptake among men in rural South Africa. J Int AIDS Soc 2021; 24:e25665. [PMID: 33586911 PMCID: PMC7883477 DOI: 10.1002/jia2.25665] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/30/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction The uptake of HIV testing and linkage to care remains low among men, contributing to high HIV incidence in women in South Africa. We conducted the “Home‐Based Intervention to Test and Start” (HITS) in a 2x2 factorial cluster randomized controlled trial in one of the World’s largest ongoing HIV cohorts in rural South Africa aimed at enhancing both intrinsic and extrinsic motivations for HIV testing. Methods Between February and December 2018, in the uMkhanyakude district of KwaZulu‐Natal, we randomly assigned 45 communities (clusters) (n = 13,838 residents) to one of the four arms: (i) financial incentives for home‐based HIV testing and linkage to care (R50 [$3] food voucher each); (ii) male‐targeted HIV‐specific decision support application, called EPIC‐HIV; (iii) both financial incentives and male‐targeted HIV‐specific decision support application and (iv) standard of care (SoC). EPIC‐HIV was developed to encourage and serve as an intrinsic motivator for HIV testing and linkage to care, and individually offered to men via a tablet device. Financial incentives were offered to both men and women. Here we report the effect of the interventions on uptake of home‐based HIV testing among men. Intention‐to‐treat (ITT) analysis was performed using modified Poisson regression with adjustment for clustering of standard errors at the cluster levels. Results Among all 13,838 men ≥ 15 years living in the 45 communities, the overall population coverage during a single round of home‐based HIV testing was 20.7%. The uptake of HIV testing was 27.5% (683/2481) in the financial incentives arm, 17.1% (433/2534) in the EPIC‐HIV arm, 26.8% (568/2120) in the arm receiving both interventions and 17.8% in the SoC arm. The probability of HIV testing increased substantially by 55% in the financial incentives arm (risk ratio (RR)=1.55, 95% CI: 1.31 to 1.82, p < 0.001) and 51% in the arm receiving both interventions (RR = 1.51, 95% CI: 1.21 to 1.87 p < 0.001), compared to men in the SoC arm. The probability of HIV testing did not significantly differ in the EPIC‐HIV arm (RR = 0.96, 95% CI: 0.76 to 1.20, p = 0.70). Conclusions The provision of a small financial incentive acted as a powerful extrinsic motivator substantially increasing the uptake of home‐based HIV testing among men in rural South Africa. In contrast, the counselling and testing application which was designed to encourage and serve as an intrinsic motivator to test for HIV did not increase the uptake of home‐based testing.
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Affiliation(s)
- Frank C Tanser
- Africa Health Research Institute, Durban, South Africa.,Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, United Kingdom.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Hae-Young Kim
- Africa Health Research Institute, Durban, South Africa.,Department of Population Health, New York University School of Medicine, New York, NY, USA.,KwaZulu-Natal Innovation and Sequencing Platform, KwaZulu-Natal, South Africa
| | | | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, South Africa.,Institute for Global Health, University College London, London, United Kingdom
| | - Janet Seeley
- Africa Health Research Institute, Durban, South Africa.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Sally Wyke
- University of Glasgow, Glasgow, United Kingdom
| | - Nuala McGrath
- Africa Health Research Institute, Durban, South Africa.,University of Southampton, Southampton, United Kingdom
| | - Oluwafemi Adeagbo
- Africa Health Research Institute, Durban, South Africa.,Department of Sociology, University of Johannesburg, Johannesburg, South Africa.,Department of Health Promotion, Education and Behaviour, University of South Carolina, Columbia, SC, USA
| | - Benn Sartorius
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Handurugamage Manisha Yapa
- Africa Health Research Institute, Durban, South Africa.,The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | | | - Anya Zeitlin
- Institute for Global Health, University College London, London, United Kingdom
| | - Ann Blandford
- University College London Interaction Centre, University College London, London, United Kingdom
| | | | - Till Bärnighausen
- Africa Health Research Institute, Durban, South Africa.,Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
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Fernandez MI, Harper GW, Hightow-Weidman LB, Kapogiannis BG, Mayer KH, Parsons JT, Rotheram-Borus MJ, Seña AC, Sullivan PS. Research Priorities to End the Adolescent HIV Epidemic in the United States: Viewpoint. JMIR Res Protoc 2021; 10:e22279. [PMID: 33393918 PMCID: PMC7813632 DOI: 10.2196/22279] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/30/2020] [Accepted: 09/30/2020] [Indexed: 12/14/2022] Open
Abstract
Youth represent 21% of new HIV diagnoses in the United States. Gay, bisexual, and transgender (GBT) youth, particularly those from communities of color, and youth who are homeless, incarcerated, in institutional settings, or engaging in transactional sex are most greatly impacted. Compared with adults, youth have lower levels of HIV serostatus awareness, uptake of antiretroviral therapy (ART), and adherence. Widespread availability of ART has revolutionized prevention and treatment for both youth at high risk for HIV acquisition and youth living with HIV, increasing the need to integrate behavioral interventions with biomedical strategies. The investigators of the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) completed a research prioritization process in 2019, focusing on research gaps to be addressed to effectively control HIV spread among American youth. The investigators prioritized research in the following areas: (1) innovative interventions for youth to increase screening, uptake, engagement, and retention in HIV prevention (eg, pre-exposure prophylaxis) and treatment services; (2) structural changes in health systems to facilitate routine delivery of HIV services; (3) biomedical strategies to increase ART impact, prevent HIV transmission, and cure HIV; (4) mobile technologies to reduce implementation costs and increase acceptability of HIV interventions; and (5) data-informed policies to reduce HIV-related disparities and increase support and services for GBT youth and youth living with HIV. ATN’s research priorities provide a roadmap for addressing the HIV epidemic among youth. To reach this goal, researchers, policy makers, and health care providers must work together to develop, test, and disseminate novel biobehavioral interventions for youth.
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Affiliation(s)
- M Isabel Fernandez
- College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Lisa B Hightow-Weidman
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Bill G Kapogiannis
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health, Boston, MA, United States
| | | | | | - Arlene C Seña
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Patrick S Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
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Reid N, Nisenbaum R, Hwang SW, Durbin A, Kozloff N, Wang R, Stergiopoulos V. The Impact of Financial Incentives on Service Engagement Among Adults Experiencing Homelessness and Mental Illness: A Pragmatic Trial Protocol. Front Psychiatry 2021; 12:722485. [PMID: 34413804 PMCID: PMC8369574 DOI: 10.3389/fpsyt.2021.722485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/09/2021] [Indexed: 11/25/2022] Open
Abstract
Background: People experiencing homelessness and mental illness have poorer service engagement and health-related outcomes compared to the general population. Financial incentives have been associated with increased service engagement, but evidence of effectiveness is limited. This protocol evaluates the acceptability and impact of financial incentives on service engagement among adults experiencing homelessness and mental illness in Toronto, Canada. Methods: This study protocol uses a pragmatic field trial design and mixed methods (ClinicalTrials.gov Identifier: NCT03770221). Study participants were recruited from a brief multidisciplinary case management program for adults experiencing homelessness and mental illness following hospital discharge, and were randomly assigned to usual care or a financial incentives arm offering $20 for each week they attended meetings with a program provider. The primary outcome of effectiveness is service engagement, measured by the count of participant-provider health-care contacts over the 6-month period post-randomization. Secondary health, health service use, quality of life, and housing outcomes were measured at baseline and at 6-month follow-up. Quantitative data will be analyzed using descriptive statistics and inferential modeling including Poisson regression and generalized estimating equations. A subset of study participants and other key informants participated in interviews, and program staff in focus groups, to explore experiences with and perspectives regarding financial incentives. Qualitative data will be rigorously coded and thematically analyzed. Conclusions: Findings from this study will contribute high quality evidence to an underdeveloped literature base on the effectiveness and acceptability of financial incentives to improve service engagement and health-related outcomes among adults experiencing homelessness and mental illness.
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Affiliation(s)
- Nadine Reid
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Division of Biostatistics, Dalla Lana School of Public Health University of Toronto, Toronto, ON, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Anna Durbin
- MAP Centre for Urban Health Solutions Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Nicole Kozloff
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ri Wang
- MAP Centre for Urban Health Solutions Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,MAP Centre for Urban Health Solutions Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Abstinence-reinforcing contingency management improves HIV viral load suppression among HIV-infected people who use drugs: A randomized controlled trial. Drug Alcohol Depend 2020; 216:108230. [PMID: 32854000 PMCID: PMC7606653 DOI: 10.1016/j.drugalcdep.2020.108230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 07/07/2020] [Accepted: 08/04/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND HIV-infected people who use drugs (PWUD) have poor HIV outcomes. Few studies tested interventions to improve HIV outcomes among PWUD. Abstinence-reinforcing contingency management (CM) reduces drug use and could also improve HIV outcomes. METHODS From 2012-2017, we conducted a randomized controlled trial testing whether a 16-week abstinence-reinforcing CM intervention improved HIV viral load (VL) among HIV-infected adults using opioids or cocaine. In the CM intervention, drug-free urines led to escalating value of vouchers ($2.50-$80/voucher, $1320 total maximum). In intention-to-treat mixed-effects linear and logistic regression analyses, we examined whether the CM intervention improved log10 VL (primary outcome), abstinence and antiretroviral adherence (secondary outcomes). RESULTS Thirty-seven participants were randomized to the CM intervention and 36 to control. Median age was 49.2 years; most were male (61.6%) and non-Hispanic black (46.6%). In CM (vs. control) participants, mean reduction in log10 VL was greater (-0.16 log10 VL copies/mL per 4-week period; 95% CI: -0.29 to -0.03, p < 0.05). Over 16 weeks, CM participants had a mean reduction of 0.64 copies/mL in log10 VL greater than control participants. The CM intervention was not significantly associated with abstinence or adherence. CONCLUSIONS This is the first study to demonstrate improvements in HIV VL via an abstinence-reinforcing CM intervention. Because the CM intervention did not significantly affect abstinence or adherence, the mechanism of its effect is unclear. To end the HIV epidemic, innovative strategies must address individuals with poor HIV outcomes. Abstinence-reinforcing CM may be one potential strategy to improve HIV outcomes among a select group of PWUD.
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Gagnon M, Guta A, Upshur R, Murray SJ, Bungay V. "It gets people through the door": a qualitative case study of the use of incentives in the care of people at risk or living with HIV in British Columbia, Canada. BMC Med Ethics 2020; 21:105. [PMID: 33109165 PMCID: PMC7590593 DOI: 10.1186/s12910-020-00548-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/16/2020] [Indexed: 11/22/2022] Open
Abstract
Background There has been growing interest in the use of incentives to increase the uptake of health-related behaviours and achieve desired health outcomes at the individual and population level. However, the use of incentives remains controversial for ethical reasons. An area in which incentives have been not only proposed but used is HIV prevention, testing, treatment and care—each one representing an interconnecting step in the "HIV Cascade." Methods The main objective of this qualitative case study was to document the experiences of health care and service providers tasked with administrating incentivized HIV testing, treatment, and care in British Columbia, Canada. A second objective was to explore the ethical and professional tensions that arise from the use of incentives as well as strategies used by providers to mitigate them. We conducted interviews with 25 providers and 6 key informants, which were analyzed using applied thematic analysis. We also collected documents and took field notes. Results Our findings suggest that incentives target populations believed to pose the most risk to public health. As such, incentives are primarily used to close the gaps in the HIV Cascade by getting the "right populations" to test, start treatment, stay on treatment, and, most importantly, achieve (and sustain) viral suppression. Participants considered that incentives work because they "bring people through the door." However, they believed the effectiveness of incentives to be superficial, short-lived and one-dimensional—thus, failing to address underlying structural barriers to care and structural determinants of health. They also raised concerns about the unintended consequences of incentives and the strains they may put on the therapeutic relationship. They had developed strategies to mitigate the ensuing ethical and professional tensions and to make their work feel relational rather than transactional. Conclusions We identify an urgent need to problematize the use of incentives as a part of the "HIV Cascade" agenda and interrogate the ethics of engaging in this practice from the perspective of health care and service providers. More broadly, we question the introduction of market logic into the realm of health care—an area of life previously not subject to monetary exchanges.
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Affiliation(s)
- Marilou Gagnon
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada.
| | - Adrian Guta
- School of Social Work, University of Windsor, 167 Ferry Street, Windsor, ON, N9A 0C5, Canada
| | - Ross Upshur
- Dalla Lana Chair in Clinical Public Health, Dalla Lana School of Public Health, 678-155 College Street, Toronto, ON, M5T 3M7, Canada
| | - Stuart J Murray
- Canada Research Chair in Rhetoric and Ethics, Department of English Language and Literature, Carleton University, 1125 Colonel By Drive, Ottawa, ON, K1S 5B6, Canada
| | - Vicky Bungay
- Canada Research Chair in Gender, Equity and Community Engagement, School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T2B5, Canada
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Fahey CA, Njau PF, Katabaro E, Mfaume RS, Ulenga N, Mwenda N, Bradshaw PT, Dow WH, Padian NS, Jewell NP, McCoy SI. Financial incentives to promote retention in care and viral suppression in adults with HIV initiating antiretroviral therapy in Tanzania: a three-arm randomised controlled trial. Lancet HIV 2020; 7:e762-e771. [PMID: 32891234 DOI: 10.1016/s2352-3018(20)30230-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/25/2020] [Accepted: 07/10/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Financial incentives promote use of HIV services and might support adherence to the sustained antiretroviral therapy (ART) necessary for viral suppression, but few studies have assessed a biomarker of adherence or evaluated optimal implementation. We sought to determine whether varying sized financial incentives for clinic attendance effected viral suppression in patients starting ART in Tanzania. METHODS In a three-arm, parallel-group, randomised controlled trial at four health facilities in Shinyanga region, Tanzania, adults aged 18 years or older with HIV who had started ART within the past 30 days were randomly assigned (1:1:1) using a tablet-based application (stratified by site) to receive usual care (control group) or to receive a cash incentive for monthly clinic attendance in one of two amounts: 10 000 Tanzanian Shillings (TZS; about US$4·50) or 22 500 TZS (about $10·00). There were no formal exclusion criteria. Participants were masked to the existence of two incentive sizes. Incentives were provided for up to 6 months via mobile health technology (mHealth) that linked biometric attendance monitoring to automated mobile payments. We evaluated the primary outcome of retention in care with viral suppression (<1000 copies per mL) at 6 months using logistic regression. This trial is registered with ClinicalTrials.gov, NCT03351556. FINDINGS Between April 24 and Dec 14, 2018, 530 participants were randomly assigned to an incentive strategy (184 in the control group, 172 in the smaller incentive group, and 174 in the larger incentive group). All participants were included in the primary intention-to-treat analysis. At 6 months, approximately 134 (73%) participants in the control group remained in care and had viral suppression, compared with 143 (83%) in the smaller incentive group (risk difference [RD] 9·8, 95% CI 1·2 to 18·5) and 150 (86%) in the larger incentive group (RD 13·0, 4·5 to 21·5); we identified a positive trend between incentive size and viral suppression (p trend=0·0032), although the incentive groups did not significantly differ (RD 3·2, -4·6 to 11·0). Adverse events included seven (4%) deaths in the control group and 11 (3%) deaths in the intervention groups, none related to study participation. INTERPRETATION Small financial incentives delivered using mHealth can improve retention in care and viral suppression in adults starting HIV treatment. Although further research should investigate the durability of effects from short-term incentives, these findings strengthen the evidence for implementing financial incentives within standard HIV care. FUNDING National Institute of Mental Health at the US National Institutes of Health.
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Affiliation(s)
- Carolyn A Fahey
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA.
| | - Prosper F Njau
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania; Health for a Prosperous Nation, Dar es Salaam, Tanzania
| | | | - Rashid S Mfaume
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania
| | | | - Patrick T Bradshaw
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - William H Dow
- Department of Health Policy and Management, School of Public Health, University of California, Berkeley, CA, USA
| | - Nancy S Padian
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Nicholas P Jewell
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Sandra I McCoy
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
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Sindelar K, Maponga C, Lekoala F, Mandara E, Mohoanyane M, Sanders J, Joseph J. Beyond the facility: An evaluation of seven community-based pediatric HIV testing strategies and linkage to care outcomes in a high prevalence, resource-limited setting. PLoS One 2020; 15:e0236985. [PMID: 32877441 PMCID: PMC7467225 DOI: 10.1371/journal.pone.0236985] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 07/18/2020] [Indexed: 11/18/2022] Open
Abstract
Diverse challenges in expanding pediatric HIV testing and treatment coverage persist, making the investigation and adoption of innovative strategies urgent. Evidence is mounting for the effectiveness of community-based testing in bringing such lifesaving services to those in need, particularly in resource-limited settings. The Mobilizing HIV Identification and Treatment project piloted seven community-based testing strategies to assess their effectiveness in reaching HIV-positive children and linking them to care in two districts of Lesotho from October 2015 to March 2018. Children testing HIV-positive were enrolled into the project's mHealth system where they received e-vouchers for transportation assistance to the facility for treatment initiation and were followed-up for a minimum of three months. An average of 7,351 HIV tests were conducted per month across all strategies for all age groups, with 46% of these tests on children 0-14 years. An average of 141.65 individuals tested positive each month; 9% were children. Among the children tested 55% were over 5 years. The yield in children was low (0.38%), however facility-based yields were only slightly higher (0.72%). Seventy-five percent of children were first-time testers and 86% of those testing HIV-positive were first-time testers. Seventy-one percent of enrolled children linked to care, all but one initiated treatment, and 82% were retained in care at three months. As facility-based testing remains the core of HIV programs, this evaluation demonstrates the effectiveness of community-based strategies in finding previously untested children and those over 5 years who have limited interactions with the conventional health system. Utilizing active follow-up mechanisms, linkage rates were high suggesting accessing treatment in a facility after community testing is not a barrier. Overall, these community-based testing strategies contributed markedly to the HIV testing landscape in which they were implemented, demonstrating their potential to help close the gap of unidentified HIV-positive children and achieve universal testing coverage.
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Affiliation(s)
- Kathleen Sindelar
- Clinton Health Access Initiative, Maseru, Lesotho
- * E-mail: (KS); (JJ)
| | | | | | | | | | - Jill Sanders
- Baylor College of Medicine Children’s Foundation – Lesotho, Maseru, Lesotho
| | - Jessica Joseph
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
- * E-mail: (KS); (JJ)
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Maragh-Bass AC, Gamble T, Tolley EE. 'Either You Float or You Drown:' The Role of Social Ties and Stigma in Lived Experiences of the HIV Care Continuum in HPTN 065. AIDS Behav 2020; 24:2532-2545. [PMID: 32086602 DOI: 10.1007/s10461-020-02811-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
HPTN 065 utilized financial incentives to promote viral suppression among HIV-positive participants. Exit interviews were conducted in a sub-study of participants in Washington, DC and Bronx, NY. The present analyses explored lived experiences of social ties and stigma as individuals navigated the HIV care continuum, including gender differences in lived experiences. Using viral load data and informed by stages-of-change theory, participants were categorized into "Low-Adherers (n = 13)", "Action (n = 29)" and "Maintenance (n = 31)" stages. Secondary analyses of qualitative data were informed by grounded theory, and instances of social ties and stigma discussed by participants were quantified with descriptive statistics. Participants (N = 73) were mostly male (64%), African American (58%), with yearly income under $10,000 (52%). Low-adherers identified fewer, and sometimes more combative social ties than those in other adherence stages. Maintainers identified supportive ties as motivation for medication adherence (68%) but relied less on them for motivation than individuals in other adherence stages. Low-adherers described current experiences of stigma related to being diagnosed with HIV more than other adherence stages (23%). Individuals in Action reported stigma related to disclosing their HIV status to others (52%), while individuals in Maintenance mostly stigmatized others engaging in "risky" behaviors (32%). Findings suggest that women may perceive greater HIV stigma than men, perceive less supportive social ties, and were the majority of Low-adherers. Gender-informed approaches can facilitate community de-stigmatization of HIV, as African American women may be at greater risk of negative HIV health outcomes.
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Affiliation(s)
| | | | - Elizabeth E Tolley
- FHI 360, Behavioral, Epidemiological, and Clinical Sciences, Durham, NC, USA
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Integrating Financial Incentives for Viral Load Suppression into HIV Care Coordination Programs: Considerations for Development and Implementation. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2020; 26:471-480. [PMID: 32732721 DOI: 10.1097/phh.0000000000001020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Interventions that support durable viral load suppression (VLS) among people living with HIV (PLWH) who face barriers to treatment adherence are needed to maintain optimal individual health, prevent new HIV infections, and advance health equity. Efficacy trials indicate that financial incentives (FIs) are a promising strategy for promoting VLS, although less is known about their implementation in "real-world" settings. This article describes considerations for the development and implementation of FI interventions identified in existing literature, and how they informed the scale-up of a multilevel treatment adherence support program designed to increase VLS among PLWH in New York City. PROGRAM The Undetectables VLS Program comprises a social marketing campaign and a "tool kit" of evidence-based HIV treatment adherence strategies, including quarterly FIs ($100) that patients receive for achieving or maintaining an undetectable viral load (<200 copies/mL; also referred to as VLS). The intervention was developed and pilot tested by Housing Works Community Healthcare and the University of Pennsylvania from 2014 to 2016. Initial findings from the pilot evaluation showed a statistically significant positive effect on VLS. IMPLEMENTATION The New York City Department of Health and Mental Hygiene contracted with 7 agencies across New York City to scale up The Undetectables Program over a 3-year period (2016-2019) by integrating the program into existing services for PLWH. EVALUATION PLANS Quality indicators (eg, percentage of clients who received an FI each quarter; percentage of clients who were virally suppressed at 90 days postenrollment) will be used to measure program performance and impact over time. DISCUSSION Recommendations for implementing FIs for PLWH include packaging FIs with client-centered, evidence-based adherence strategies, incorporating FIs into existing service delivery systems, and obtaining organization-wide buy-in to facilitate their implementation. Implementation science research is needed to identify strategies to effectively implement and sustain evidence-based FI interventions.
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Kennedy CE, Yeh PT, Atkins K, Fonner VA, Sweat MD, O’Reilly KR, Rutherford GW, Baggaley R, Samuelson J. Economic compensation interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review and meta-analysis. PLoS One 2020; 15:e0227623. [PMID: 31940422 PMCID: PMC6961886 DOI: 10.1371/journal.pone.0227623] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 12/23/2019] [Indexed: 01/05/2023] Open
Abstract
Background Economic compensation interventions may help support higher voluntary medical male circumcision (VMMC) coverage in priority sub-Saharan African countries. To inform World Health Organization guidelines, we conducted a systematic review of economic compensation interventions to increase VMMC uptake. Methods Economic compensation interventions were defined as providing money or in-kind compensation, reimbursement for associated costs (e.g. travel, lost wages), or lottery entry. We searched five electronic databases and four scientific conferences for studies examining the impact of such interventions on VMMC uptake, HIV testing and safer-sex/risk-reduction counseling uptake within VMMC, community expectations about compensation, and potential coercion. We screened citations, extracted data, and assessed risk of bias in duplicate. We conducted random-effects meta-analysis. We also reviewed studies examining acceptability, values/preferences, costs, and feasibility. Results Of 2484 citations identified, five randomized controlled trials (RCTs) and three non-randomized controlled trials met our eligibility criteria. Studies took place in Kenya, Malawi, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. Meta-analysis of four RCTs showed significant impact of any economic compensation on VMMC uptake (relative risk: 5.23, 95% CI: 3.13 to 8.76). RCTs of food/transport vouchers and conditional cash transfers generally showed increases in VMMC uptake, but lotteries, subsidized VMMC, and receiving a gift appeared somewhat less effective. Three non-randomized trials showed mixed impact. Six additional studies suggested economic compensation interventions were generally acceptable, valued for addressing key barriers, and motivating to men. However, some participants felt they were insufficiently motivating or necessary; one study suggested they might raise community suspicions. One study from South Africa found a program cost of US$91 per additional circumcision and US$450-$1350 per HIV infection averted. Conclusions Economic compensation interventions, particularly transport/food vouchers, positively impacted VMMC uptake among adult men and were generally acceptable to potential clients. Carefully selected economic interventions may be a useful targeted strategy to enhance VMMC coverage.
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Affiliation(s)
- Caitlin E. Kennedy
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Ping Teresa Yeh
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kaitlyn Atkins
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Virginia A. Fonner
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Michael D. Sweat
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Kevin R. O’Reilly
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - George W. Rutherford
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Rachel Baggaley
- Department of HIV, World Health Organization, Geneva, Switzerland
| | - Julia Samuelson
- Department of HIV, World Health Organization, Geneva, Switzerland
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Koduah Owusu K, Adu-Gyamfi R, Ahmed Z. Strategies To Improve Linkage To HIV Care In Urban Areas Of Sub-Saharan Africa: A Systematic Review. HIV AIDS (Auckl) 2019; 11:321-332. [PMID: 31819663 PMCID: PMC6898990 DOI: 10.2147/hiv.s216093] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 09/05/2019] [Indexed: 12/17/2022] Open
Abstract
Of the 37 million people estimated to be living with HIV globally in 2017, about 24.7 million were in the sub-Saharan Africa region, which has been and remains worst affected by the epidemic. Enrolment of newly diagnosed individuals into care in the region, however, remains poor with up to 54% not being linked to care. Linkage to care is a very important step in the HIV cascade as it is the precursor to initiating antiretroviral therapy (ART), retention in care, and viral suppression. A systematic review was conducted to gather information regarding the strategies that have been documented to increase linkage to care of Persons living with HIV(PLHIV) in urban areas of sub-Saharan Africa. An electronic search was conducted on Scopus, Cochrane central, CINAHL Plus, PubMed and OpenGrey for linkage strategies implemented from 2006. A total of 189 potentially relevant citations were identified, of which 7 were eligible for inclusion. The identified strategies were categorized using themes from literature. The most common strategies included: health system interventions (i.e. comprehensive care, task shifting); patient convenience and accessibility (i.e. immediate CD4 count testing, immediate ART initiation, community HIV testing); behavior interventions and peer support (i.e. assisted partner services, care facilitation, mobile phone appointment reminders, health education) and incentives (i.e. non-cash financial incentives and transport reimbursement). Several strategies showed favorable outcomes: comprehensive care, immediate CD4 count testing, immediate ART initiation, and assisted partner services. Assisted partner services, same day home-based ART initiation, combination intervention strategies and point-of-care CD4 testing significantly improved linkage to care in urban settings of sub-Saharan African region. They can be delivered either in a health facility or in the community but should be facilitated by health workers. There is, however, the need to conduct more linkage-specific studies in the sub-region.
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Affiliation(s)
- Kwadwo Koduah Owusu
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - Raphael Adu-Gyamfi
- National AIDS/STI Control Programme, Ghana Health Service, Korle-Bu, Accra, Ghana
| | - Zamzam Ahmed
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
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Bor J, Thirumurthy H. Bridging the Efficacy-Effectiveness Gap in HIV Programs: Lessons From Economics. J Acquir Immune Defic Syndr 2019; 82 Suppl 3:S183-S191. [PMID: 31764253 PMCID: PMC7388866 DOI: 10.1097/qai.0000000000002201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University, Boston, MA
| | - Harsha Thirumurthy
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
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Batura N, Skordis J, Palmer T, Odiambo A, Copas A, Vanhuyse F, Dickin S, Eleveld A, Mwaki A, Ochieng C, Haghparast-Bidgoli H. Cost-effectiveness of conditional cash transfers to retain women in the continuum of care during pregnancy, birth and the postnatal period: protocol for an economic evaluation of the Afya trial in Kenya. BMJ Open 2019; 9:e032161. [PMID: 31699743 PMCID: PMC6858100 DOI: 10.1136/bmjopen-2019-032161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION A wealth of evidence from a range of country settings indicates that antenatal care, facility delivery and postnatal care can reduce maternal and child mortality and morbidity in high-burden settings. However, the utilisation of these services by pregnant women, particularly in low/middle-income country settings, is well below that recommended by the WHO. The Afya trial aims to assess the impact, cost-effectiveness and scalability of conditional cash transfers to promote increased utilisation of these services in rural Kenya and thus retain women in the continuum of care during pregnancy, birth and the postnatal period. This protocol describes the planned economic evaluation of the Afya trial. METHODS AND ANALYSIS The economic evaluation will be conducted from the provider perspective as a within-trial analysis to evaluate the incremental costs and health outcomes of the cash transfer programme compared with the status quo. Incremental cost-effectiveness ratios will be presented along with a cost-consequence analysis where the incremental costs and all statistically significant outcomes will be listed separately. Sensitivity analyses will be undertaken to explore uncertainty and to ensure that results are robust. A fiscal space assessment will explore the affordability of the intervention. In addition, an analysis of equity impact of the intervention will be conducted. ETHICS AND DISSEMINATION The study has received ethics approval from the Maseno University Ethics Review Committee, REF MSU/DRPI/MUERC/00294/16. The results of the economic evaluation will be disseminated in a peer-reviewed journal and presented at a relevant international conference. TRIAL REGISTRATION NUMBER NCT03021070.
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Affiliation(s)
- Neha Batura
- Institute for Global Health, University College London, London, UK
| | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Tom Palmer
- Institute for Global Health, University College London, London, UK
| | | | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | | | - Sarah Dickin
- Stockholm Environment Institute, Stockholm, Sweden
| | | | - Alex Mwaki
- Safe Water and AIDS Project, Kisumu, Kenya
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Galárraga O, Sosa-Rubí SG. Conditional economic incentives to improve HIV prevention and treatment in low-income and middle-income countries. Lancet HIV 2019; 6:e705-e714. [PMID: 31578955 PMCID: PMC7725432 DOI: 10.1016/s2352-3018(19)30233-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 06/24/2019] [Accepted: 07/01/2019] [Indexed: 10/25/2022]
Abstract
New and innovative approaches are needed to improve the prevention, diagnosis, and treatment of HIV in low-income and middle-income countries. Several trials use conditional economic incentives (CEIs) to improve HIV outcomes. Most CEI interventions use a traditional economic theory approach, although some interventions incorporate behavioural economics, which combines traditional economics with insights from psychology. Incentive interventions that are appropriately implemented can increase HIV testing rates and voluntary male circumcision, and they can improve other HIV prevention and treatment outcomes in certain settings in the short term. More research is needed to uncover theory-based mechanisms that increase the duration of incentive effects and provide strategies for susceptible individuals, which will help to address common constraints and biases that can influence health-related decisions.
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Affiliation(s)
- Omar Galárraga
- Brown University School of Public Health, Providence, RI, USA
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Banigbe B, Audet CM, Okonkwo P, Arije OO, Bassi E, Clouse K, Simmons M, Aliyu MH, Freedberg KA, Ahonkhai AA. Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria. PLoS One 2019; 14:e0221809. [PMID: 31553735 PMCID: PMC6760763 DOI: 10.1371/journal.pone.0221809] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/15/2019] [Indexed: 01/10/2023] Open
Abstract
The transition to PEPFAR 2.0 with its focus on country ownership was accompanied by substantial funding cuts. We describe the impact of this transition on HIV care in a large network of HIV clinics in Nigeria. We surveyed 30 comprehensive HIV treatment clinics to assess services supported before (October 2013-September 2014) and after (October 2014-September 2015) the PEPFAR funding policy change, the impact of these policy changes on service delivery areas, and response of clinics to the change. We compared differences in support for staffing, laboratory services, and clinical operations pre- and post-policy change using paired t-tests. We used framework analysis to assess answers to open ended questions describing responses to the policy change. Most sites (83%, n = 25) completed the survey. The majority were public (60%, n = 15) and secondary (68%, n = 17) facilities. Clinics had a median of 989 patients in care (IQR: 543-3326). All clinics continued to receive support for first and second line antiretrovirals and CD4 testing after the policy change, while no clinics received support for other routine drug monitoring labs. We found statistically significant reductions in support for viral load testing, staff employment, defaulter tracking, and prevention services (92% vs. 64%, p = 0.02; 80% vs. 20%, 100% vs. 44%, 84% vs. 16%, respectively, p<0.01 for all) after the policy change. Service delivery was hampered by interrupted laboratory services and reduced wages and staff positions leading to reduced provider morale, and compromised quality of care. Almost all sites (96%) introduced user fees to address funding shortages. Clinics in Nigeria are experiencing major challenges in providing routine HIV services as a result of PEPFAR's policy changes. Funding cutbacks have been associated with compromised quality of care, staff shortages, and reliance on fee-based care for historically free services. Sustainable HIV services funding models are urgently needed.
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Affiliation(s)
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Friends in Global Health, Maputo, Mozambique
| | | | - Olujide O. Arije
- Institute of Public Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - Kate Clouse
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Melynda Simmons
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Muktar H. Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Kenneth A. Freedberg
- Division of Infectious Disease and General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Aima A. Ahonkhai
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease and General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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50
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Zakumumpa H, Bennett S, Ssengooba F. Leveraging the lessons learned from financing HIV programs to advance the universal health coverage (UHC) agenda in the East African Community. Glob Health Res Policy 2019; 4:27. [PMID: 31535036 PMCID: PMC6743123 DOI: 10.1186/s41256-019-0118-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/26/2019] [Indexed: 02/02/2023] Open
Abstract
Background Although there is broad consensus around the need to accelerate progress towards universal health coverage (UHC) in Sub-Saharan Africa, the financing strategies for achieving it are still unclear. We sought to leverage the lessons learned in financing HIV programs over the past two decades to inform efforts to advance the universal health coverage agenda in the East African Community. Methods We conducted a literature review of studies reporting financing mechanisms for HIV programs between 2004 and 2014. This review is further underpinned by evidence from a mixed-methods study entailing a survey of 195 health facilities across Uganda supplemented with 18 semi-structured interviews with HIV service managers. Results Our data shows that there are six broad HIV financing strategies with potential for application to the universal health coverage agenda in the East African Community (EAC); i) Bi-lateral and multi-lateral funding vehicles: The establishment of HIV-specific global financing vehicles such as PEPFAR and The Global Fund heralded an era of unprecedented levels of international funding of up to $ 500 billion over the past two decades ii) Eliciting private sector contribution to HIV funding: The private sector's financial contribution to HIV services was leveraged through innovative engagement and collaborative interventions iii) Private sector-led alternative HIV financing mechanisms: The introduction of 'VIP' HIV clinics, special 'HIV insurance' schemes and the rise of private philanthropic aid were important alternatives to the traditional sources of funding iv) Commodity social marketing: Commodity social marketing campaigns led to an increase in condom use among low-income earners v) The use of vouchers: Issuing of HIV-test vouchers to the poor was an important demand-side financing approach vi) Earmark HIV taxes: Several countries in Africa have introduced 'special HIV' taxes to boost domestic HIV funding. Conclusions The lessons learned from financing HIV programs suggest that a hybrid of funding strategies are advisable in the quest to achieve UHC in EAC partner states. The contribution of the private sector is indispensable and can be enhanced through targeted interventions towards UHC goals.
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Affiliation(s)
- Henry Zakumumpa
- 1Makerere University, School of Public Health, Kampala, Uganda
| | - Sara Bennett
- 2Johns Hopkins University, Bloomberg School of Public Health, Baltimore, USA
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