A pilot randomized trial of incentive strategies to promote HIV retesting in rural Uganda.

Gabriel Chamie,Moses R Kamya,Harsha Thirumurthy,Kara G Marson,Devy M Emperador,Dalsone Kwarisiima,Diane V Havlir,Alex Ndyabakira,Giuseppe Vittorio De Socio

doi:10.1371/journal.pone.0233600

Abstract

Retesting for HIV is critical to identifying newly-infected persons and reinforcing prevention efforts among at-risk adults. Incentives can increase one-time HIV testing, but their role in promoting retesting is unknown. We sought to test feasibility and acceptability of incentive strategies, including commitment contracts, to promote HIV retesting among at-risk adults in rural Uganda. At-risk HIV-negative adults were enrolled in a pilot trial assessing feasibility and acceptability of incentive strategies to promote HIV retesting three months after enrollment. Participants were randomized (1:1:3) to: 1) no incentive; 2) standard cash incentive (~US$4); and 3) commitment contract: participants could voluntarily make a low- or high-value deposit that would be returned with added interest (totaling ~US$4 including the deposit) upon retesting or lost if participants failed to retest. Contracts sought to promote retesting by leveraging loss aversion and addressing present bias via pre-commitment. Outcomes included acceptability of trial enrollment, contract feasibility (proportion of participants making deposits), and HIV retesting uptake. Of 130 HIV-negative eligible adults, 123 (95%) enrolled and were randomized: 74 (60%) to commitment contracts, 25 (20%) to standard incentives, and 24 (20%) to no incentive. Of contract participants, 69 (93%) made deposits. Overall, 93 (76%) participants retested for HIV: uptake was highest in the standard incentive group (22/25 [88%]) and lowest in high-value contract (26/36 [72%]) and no incentive (17/24 [71%]) groups. In a randomized trial of strategies to promote HIV retesting among at-risk adults in Uganda, incentive strategies, including commitment contracts, were feasible and had high acceptability. Our findings suggest use of incentives for HIV retesting merits further comparison in a larger trial. ClinicalTrials.gov identifier: NCT:02890459.

Highlights

As global efforts continue to reduce HIV incidence through combination prevention approaches, it is clear that universal HIV testing initiatives must be followed by targeted testing services that offer frequent retesting for HIV to individuals who test HIV-negative but remain at risk
93 (76%) participants retested for HIV: uptake was highest in the standard incentive group (22/25 [88%]) and lowest in highvalue contract (26/36 [72%]) and no incentive (17/24 [71%]) groups
In a randomized trial of strategies to promote HIV retesting among at-risk adults in Uganda, incentive strategies, including commitment contracts, were feasible and had high

Summary

Introduction

As global efforts continue to reduce HIV incidence through combination prevention approaches (such as pre-exposure prophylaxis, voluntary medical male circumcision, condoms, and universal HIV treatment as prevention), it is clear that universal HIV testing initiatives must be followed by targeted testing services that offer frequent retesting for HIV to individuals who test HIV-negative but remain at risk. The World Health Organization recommends HIV retesting at least annually for all sexually active adults living in high HIV burden settings, including key populations at increased risk of HIV infection, noting that more frequent testing (i.e. every 3–6 months) may be warranted based on individual risks [4, 5]. Despite guidelines recommending retesting for HIV among at-risk adults who previously tested HIV negative, published data across multiple settings in sub-Saharan Africa, including Uganda [8, 9], suggest that retesting annually (let alone more regular intervals) occurs infrequently, with most adults who access HIV testing reporting that they have not had an HIV test in the prior year [10,11,12]. Retesting for HIV is critical to identifying newly-infected persons and reinforcing prevention efforts among at-risk adults. We sought to test feasibility and acceptability of incentive strategies, including commitment contracts, to promote HIV retesting among at-risk adults in rural Uganda

Objectives

Methods

Conclusion