Conditional Economic Incentives Research Articles

Results From a Pilot Study of an Automated Directly Observed Therapy Intervention Using Artificial Intelligence With Conditional Economic Incentives Among Young Adults With HIV.

Despite improvements in antiretroviral therapy (ART) availability, suboptimal adherence is common among youth with HIV (YWH) and can increase drug resistance and poor clinical outcomes. Our study examined an innovative mobile app-based intervention that used automated directly observed therapy (aDOT) using artificial intelligence, along with conditional economic incentives (CEIs) to improve ART adherence and enhance viral suppression among YWH. We conducted a pilot study of the aDOT-CEI intervention, informed by the operant framework of Key Principles in Contingency Management Implementation, to improve ART adherence among YWH (18-29) in California and Florida who had an unsuppressed HIV viral load. We recruited 28 virally unsuppressed YWH from AIDS Healthcare Foundation clinics, who used the aDOT platform for 3 months. Study outcomes included feasibility and acceptability, self-reported ART adherence, and HIV viral load. Participants reported high satisfaction with the app (91%), and 82% said that it helped them take their medication. Comfort with the security and privacy of the app was moderate (55%), and 59% indicated the incentives helped improve daily adherence. Acceptability and feasibility of the aDOT-CEI intervention were high with potential to improve viral suppression, although some a priori metrics were not met. Pilot results suggest refinements which may improve intervention outcomes, including increased incentive amounts, provision of additional information, and reassurance about app privacy and security. Additional research is recommended to test the efficacy of the aDOT-CEI intervention to improve viral suppression in a larger sample.

Rudi Kundini, Pamoja Kundini (RKPK): study protocol for a hybrid type 1 randomized effectiveness-implementation trial using data science and economic incentive strategies to strengthen the continuity of care among people living with HIV in Tanzania

BackgroundEconomic incentives can improve clinical outcomes among in-care people living with HIV (PLHIV), but evidence is limited for their effectiveness among out-of-care PLHIV or those at risk of disengagement. We propose a type 1 hybrid effectiveness-implementation study to advance global knowledge about the use of economic incentives to strengthen the continuity of HIV care and accelerate global goals for HIV epidemic control.MethodsThe Rudi Kundini, Pamoja Kundini study will evaluate two implementation models of an economic incentive strategy for supporting two groups of PLHIV in Tanzania. Phase 1 of the study consists of a two-arm, cluster randomized trial across 32 health facilities to assess the effectiveness of a home visit plus one-time economic incentive on the proportion of out-of-care PLHIV with viral load suppression (< 1000 copies/ml) 6 months after enrollment (n = 640). Phase 2 is an individual 1:1 randomized controlled trial designed to determine the effectiveness of a short-term counseling and economic incentive program offered to in-care PLHIV who are predicted through machine learning to be at risk of disengaging from care on the outcome of viral load suppression at 12 months (n = 692). The program includes up to three incentives conditional upon visit attendance coupled with adapted counselling sessions for this population of PLHIV. Consistent with a hybrid effectiveness-implementation study design, phase 3 is a mixed methods evaluation to explore barriers and facilitators to strategy implementation in phases 1 and 2. Results will be used to guide optimization and scale-up of the incentive strategies, if effective, to the larger population of Tanzanian PLHIV who struggle with continuity of HIV care.DiscussionInnovative strategies that recognize the dynamic process of lifelong retention in HIV care are urgently needed. Strategies such as conditional economic incentives are a simple and effective method for improving many health outcomes, including those on the HIV continuum. If coupled with other supportive services such as home visits (phase 1) or with tailored counselling (phase 2), economic incentives have the potential to strengthen engagement among the subpopulation of PLHIV who struggle with retention in care and could help to close the gap towards reaching global “95–95-95” goals for ending the AIDS epidemic.Trial registrationPhase 1: ClinicalTrials.gov, NCT05248100, registered 2/21/2022.Phase 2: ClinicalTrials.gov, NCT05373095, registered 5/13/2022.

Youth Ending the HIV Epidemic (YEHE): Protocol for a pilot of an automated directly observed therapy intervention with conditional economic incentives among young adults with HIV.

Young adults have a disproportionately high rate of HIV infection, high rates of attrition at all stages of the HIV care continuum, and an elevated probability of disease progression and transmission. Tracking and monitoring objective measures of antiretroviral therapy (ART) adherence in real time is critical to bolster the accuracy of research data, support adherence, and improve clinical outcomes. However, adherence monitoring often relies on self-reported and retrospective data or requires additional effort from providers to understand individual adherence patterns. In this study, we will monitor medication-taking using a real-time objective measure of adherence that does not rely on self-report or healthcare providers for measurement. The Youth Ending the HIV Epidemic (YEHE) study will pilot a novel automated directly observed therapy-conditional economic incentive (aDOT-CEI) intervention to improve ART adherence among youth with HIV (YWH) in California and Florida who have an unsuppressed HIV viral load. The aDOT app uses facial recognition to record adherence each day, and then economic incentives are given based on a participant's confirmed adherence. We will enroll participants in a 3-month pilot study to assess the feasibility and acceptability of the aDOT-CEI intervention using predefined metrics. During and after the trial, a subsample of the pilot participants and staff/providers from participating AIDS Healthcare Foundation (AHF) clinics will participate in individual in-depth interviews to explore intervention and implementation facilitators and barriers. YEHE will provide data on the use of an aDOT-CEI intervention to improve adherence among YWH who are not virologically suppressed. The YEHE study will document the feasibility and acceptability and will explore preliminary data to inform a trial to test the efficacy of aDOT-CEI. This intervention has the potential to effectively improve ART adherence and virologic suppression among a key population experiencing health disparities. The trial registration number is NCT05789875.

Payments for ecosystem services did not crowd out pro-environmental behavior: Long-term experimental evidence from Uganda

Payments for ecosystem services (PES) are increasingly being implemented worldwide as conservation instruments that provide conditional economic incentives to landowners for a prespecified duration. However, in the psychological and economic literature, critics have raised concerns that PES can undermine the recipient's intrinsic motivation to engage in pro-environmental behavior. Such "crowding out" may reduce the effectiveness of PES and may even worsen conservation outcomes once programs are terminated. In this study, we harnessed a randomized controlled trial that provided PES to land users in Western Uganda and evaluated whether these incentives had a persistent effect on pro-environmental behavior and its underlying behavioral drivers 6 y after the last payments were made. We elicited pro-environmental behavior with an incentivized, experimental measure that consisted of a choice for respondents between more and less environmentally friendly tree seedlings. In addition to this main outcome, survey-based measures for underlying behavioral drivers captured self-efficacy beliefs, intrinsic motivation, and perceived forest benefits. Overall, we found no indications that PES led to the crowding out of pro-environmental behavior. That is, respondents from the treatment villages were as likely as respondents from the control villages to choose environmentally friendly tree seedlings. We also found no systematic differences between these two groups in their underlying behavioral drivers, and nor did we find evidence for crowding effects when focusing on self-reported tree planting behavior as an alternative outcome measure.

Interventions to increase the uptake and continuation of pre-exposure prophylaxis (PrEP) by adolescent girls and young women at high risk of HIV in low-income and middle-income countries: a scoping review

IntroductionEffective strategies to increase pre-exposure prophylaxis (PrEP) uptake and continuation among adolescent girls and young women (AGYW) who engage in sex work or transactional sex are sparsely reported. We aimed...

Impact of conditional economic incentives and motivational interviewing on health outcomes of adolescents living with HIV in Anambra State, Nigeria: A cluster-randomised trial

BackgroundAdolescents living with HIV (ALHIV) have had worse outcomes compared to adults. They face enormous difficulty in accessing HIV care services. We hypothesize that conditional economic incentives (CEI) and motivational interviewing could increase retention in care, medication adherence and ultimately viral load suppression. Therefore, we evaluated the one-year impact of conditional economic incentives and motivational interviewing on the health outcomes of ALHIV in Anambra State, Nigeria. MethodsUsing a cluster-randomised design, we examined the one-year (from December 1, 2018, to November 30, 2019), individual-level impact of an Incentive Scheme comprising conditional economic incentives and motivational interviewing on achieving undetectable viral load (primary outcome), CD4+ count, adherence to antiretroviral therapy and retention in care (secondary outcomes) by ALHIV in Anambra State, Nigeria. Twelve HIV treatment hospitals were stratified according to the type of clinic (secondary or tertiary) and randomly assigned to the intervention arm or control arm to receive the Incentive Scheme or routine care, respectively. ALHIV aged 10–19 years, initiated into HIV care for a minimum of 6 months, and who adhered poorly to medications (<100% adherence rate) were eligible for the study. Participants in the intervention arm received motivational interviewing at the study baseline and every visit. They also received US$5.6 when HIV viral load (VL) was <20 copies/mL at month 3, US$2.8 if the VL remained suppressed at months 6 and 9, and US$5.6 if the VL remained <20 copies/mL at month 12. ResultsOf the 246 trial participants, 119 were in the intervention while 127 were in the control arm. There was no difference in the baseline characteristics of the participants between the intervention and control arm except for the number of participants with undetectable viral load and the number of participants with ≥95% adherence. Although participants in the intervention arm had a 10.1% increase while those in the control arm had a 1.6% decrease in proportion with undetectable viral load (≤20 copies/ml) after 12 months, the change in the primary outcome was not statistically significant. Similarly, the differences in the secondary outcomes were not statistically significant. ConclusionThe Incentive Scheme did not improve the virologic outcome of ALHIV after 12 months. Differences in the secondary outcomes after 12 months were also not significantly different from the baseline. Trial registrationWe registered the trial retrospectively with The Pan African Clinical Trials Registry: https://pactr.samrc.ac.za/(PACTR201806003040425) on 2/2/2018.

Conditional Economic Incentives for HIV Treatment Adherence: Aligning Adolescent Developmental Hallmarks with Behavioral Economic Theory to Improve HIV Treatment Adherence.

Adolescent-tailored antiretroviral therapy (ART) adherence interventions take place within the context of unique developmental stage. Suboptimal ART adherence among adolescents living with HIV in South Africa underscores that interventions are urgently needed to improve adherence. We conducted semistructured in-depth interviews with 35 adolescents aged 10-19 years living with HIV. In addition, 14 clinicians and 35 caregivers were interviewed to provide a diverse perspective on barriers and facilitators of medication adherence for adolescents living with HIV (ALWH). Thematic coding was utilized for this analysis. Our main findings were organized by following a priori themes: (1) acceptability of conditional economic incentives (CEIs) as an adherence intervention strategy for adolescents, (2) predicted behavioral impacts, and the (3) durability of CEIs to ensure medication adherence for adolescents in the long term. Subthemes that emerged included CEIs as tool to overcome competing demands, increasing intrinsic motivation and orientation toward the future, and optimal timing of the intervention. Exposure to a CEI intervention during early adolescence (ages 10-13) may be a particularly helpful intervention as CEIs may have long-lasting effects given that habit-formation behavior is developed during early adolescence. There is little consensus on effect duration from the perspective of adolescents, clinicians, and caregivers. Future studies should continue to explore the impact of CEIs for long-term ART adherence.

Contradictory distributive principles and land tenure govern benefit-sharing of payments for ecosystem services (PES) in Chiapas, Mexico

Payments for Ecosystem Services (PES) are incentive-based instruments that provide conditional economic incentives for natural resources management. Research has shown that when economic incentives are parachuted into rural communities, participation and benefits are collectively negotiated and shared. However, we know little about how benefit-sharing evolves over time in community-based PES. To address this gap, we examine distributional justice in four communities of the state of Chiapas, Mexico, which participate in a PES programme, and we assess how local justice principles compare with the programme’s goals. Our analysis reveals patterns of both continuity and change in how communities share PES benefits, which reflect a suite of contradictory justice principles, including entitlement, merit, need, and equality. The studied communities distribute PES benefits by providing differentiated compensation to diverse groups of landholders via private cash payments, whilst also attending non-landed community members through public infrastructure investments. We show that benefit-sharing is strongly influenced by pre-existing land tenure features and associated norms, which in the study area include three different types of individual and common-property. Yet, we also show that communities continuously adjust benefit-sharing arrangements to navigate distributional challenges emerging from programme engagement. Overall, we provide novel insights on the evolution, diversity, and complexity of distributive justice in community-based PES and we advocate for a context-sensitive, nuanced, and dynamic account of justice in incentive-based conservation.

Interventions to Improve Treatment Outcomes among Adolescents on Antiretroviral Therapy with Unsuppressed Viral Loads: A Systematic Review.

Adolescents living with HIV (ALHIV) face unique developmental challenges that increase the risk of unsuppressed viral loads. Current reviews present a need for proven interventions to improve viral suppression among ALHIV on ART, who have a history of unsuppressed viral loads. This systematic review aims to synthesize and appraise evidence of the effectiveness of interventions to improve treatment outcomes among ALHIV with unsuppressed viral loads. Six bibliographic databases were searched for published studies and gray literature from 2010 to 2021. The risk of bias and certainty of evidence was assessed using the ROBINS-I tool, CASP checklists and GRADE. A total of 28 studies were eligible for full-text screening; and only three were included in the qualitative synthesis. In addition, two studies were included from website searches. Four types of interventions to improve viral suppression were identified, namely: intensive adherence counselling; community- and facility-based peer-led differentiated service delivery (DSD); family based economic empowerment; and conditional economic incentives and motivational interviewing. We strongly recommend peer-led community-based DSD interventions, intensive adherence counselling, and family-based economic empowerment as potential interventions to improve viral suppression among ALHIV.

Preferences for Conditional Economic Incentives to Improve Pre-exposure Prophylaxis Adherence: A Discrete Choice Experiment Among Male Sex Workers in Mexico.

Pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV but requires sustained adherence. Conditional economic incentives (CEIs) can improve medication-taking behaviors, yet preferences for programs that employ CEIs to increase PrEP use among male sex workers (MSWs) have not been investigated. We conducted a discrete choice experiment in Mexico City to elicit stated preferences for a CEI-based PrEP adherence program among MSWs. Respondents expressed their preferences for different program characteristics: incentive amount; incentive format; incentive type; and adherence-verification method. We used a random utility logit model to estimate the relative importance of each attribute and estimated willingness-to-pay. MSWs preferred a higher, fixed incentive, with PrEP adherence measured via hair sampling. MSWs were willing to forego up to 21% of their potential maximum CEI amount to ensure receipt of a fixed payment. MSWs are highly willing to accept a CEI-based intervention for PrEP adherence, if offered along with fixed payments.

Cost-effectiveness and feasibility of conditional economic incentives and motivational interviewing to improve HIV health outcomes of adolescents living with HIV in Anambra State, Nigeria

BackgroundIn sub-Saharan Africa, there is increasing mortality and morbidity of adolescents due to poor linkage, retention in HIV care and adherence to antiretroviral therapy (ART). This is a result of limited adolescent-centred service delivery interventions. This cost-effectiveness and feasibility study were piggybacked on a cluster-randomized trial that assessed the impact of an adolescent-centred service delivery intervention. The service delivery intervention examined the impact of an incentive scheme consisting of conditional economic incentives and motivational interviewing on the health outcomes of adolescents living with HIV in Nigeria.MethodA cost-effectiveness analysis from the healthcare provider’s perspective was performed to assess the cost per additional patient achieving undetected viral load through the proposed intervention. The cost-effectiveness of the incentive scheme over routine care was estimated using the incremental cost-effectiveness ratio (ICER), expressed as cost/patient who achieved an undetectable viral load. We performed a univariate sensitivity analysis to examine the effect of key parameters on the ICER. An in-depth interview was conducted on the healthcare personnel in the intervention arm to explore the feasibility of implementing the service delivery intervention in HIV treatment hospitals in Nigeria.ResultThe ICER of the Incentive Scheme intervention compared to routine care was US$1419 per additional patient with undetectable viral load. Going by the cost-effectiveness threshold of US$1137 per quality-adjusted life-years suggested by Woods et al., 2016, the intervention was not cost-effective. The sensitivity test showed that the intervention will be cost-effective if the frequency of CD4 count and viral load tests are reduced from quarterly to triannually. Healthcare professionals reported that patients’ acceptance of the intervention was very high.ConclusionThe conditional economic incentives and motivational interviewing was not cost-effective, but can become cost-effective if the frequency of HIV quality of life indicator tests are performed 1–3 times per annum. Patients’ acceptance of the intervention was very high. However, healthcare professionals believed that sustaining the intervention may be difficult unless factors such as government commitment and healthcare provider diligence are duly addressed.Trial registrationThis trial is registered in the WHO International Clinical Trials Registry through the WHO International Registry Network (PACTR201806003040425).

ISAY (incentives for South African youth): Stated preferences of young people living with HIV.

High adherence to antiretroviral therapy (ART) is essential for achieving viral suppression and preventing HIV transmission. Yet adherence is suboptimal among adolescents who face unique adherence challenges. Little is known about the role of conditional economic incentives (CEIs) for increasing ART adherence in this population. During 2017-2019, we conducted a mixed-methods discrete choice experiment in Cape Town, South Africa to inform the optimal design of a CEI intervention for ART adherence among youth. In-depth interviews were conducted with n=35 adolescents (10-19 years old) living with HIV and prescribed ART, to identify attributes of a youth-centered CEI intervention for ART adherence. A discrete choice experiment was subsequently conducted with N=168 adolescents to elicit preferences for intervention components. A rank-ordered mixed logit model was used for main results; marginal willingness-to-accept (mWTA) was then estimated. Five attributes emerged from the qualitative research as important for a CEI-based intervention for youth ART adherence: (1) incentive amount, (2) incentive format, (3) incentive recipient, (4) delivery mode, and (5) program participants. Youth had a high probability of acceptance of any incentives program (88-100%), yet they did not have a strong preference of a quarterly over a monthly program. From a maximum incentive amount of R1920 (~US$115), youth were willing to forgo up to R126 per year (~US$9) if the incentive was given in cash (versus fashion vouchers); R274 (~US$19.6) if it was open to both previously adherent and non-adherent youth (instead of non-adherent only); and up to R91 (~US$6.5) to receive incentives at a clinic setting (instead of electronically). The use of incentives over the short term during the critical age- and developmental-transition, when adolescents begin to take sole responsibility for their medication-taking behaviors, holds great promise for habituating adherence into adulthood.

Group-based economic incentives to improve adherence to antiretroviral therapy among youth living with HIV: safety and preliminary efficacy from a pilot trial

ABSTRACT This study evaluated the safety and preliminary efficacy of a group-based conditional economic incentives (CEI) program for ART adherence improvement among a sample of adolescents living in Ghana. A total of 35 adolescents (mean age: 14.7 years) on ART, though still with detectable viral load, were recruited from an HIV clinic and divided into 5 balanced groups to participate in peer-led group-based CEI activities during routine clinic visits. Four assessments were conducted across four visits at baseline and 3-, 6-, and 9-month follow-up, respectively. Main outcomes were ART adherence and viral load. Linear mixed models and thematic analysis were used for data analyses. The majority (91.4%) of the participants attended all four intervention activities. Participants reported missing an average of 1.06, 0.50, 0.91, 0.55 doses of ART in the past 7 days at baseline, 3-, 6-, and 9-month assessments, respectively. Most viral loads were ≥5,000 copies/ml at both baseline (68.6%) and 6-month assessments (54.3%). The incentive was divided between individual compensation for attending clinic and completing the assessment ($5 each, $20 in total) and a group-based compensation valued at $40 that was distributed during the 9-month assessment according to average group attendance (A ≥ 90%, B ≥ 75%, C ≥ 60%, D < 60%) and group-average viral load (A = undetectable, B = 50–499, C = 500–4999, D ≥ 5,000). The mean earnings for the participants was $46.70 (77.8% of possible earning). Qualitative data suggested that the CEI helped ART adherence through gaining personal and group benefits. Participants reported no teasing, bullying, or other undesirable behaviors from group members. They liked getting money for attending clinics/group meetings and obtaining undetectable viral load. We concluded that a group-based CEI was safe and had the potential to improve ART adherence and reduce viral load among Ghanaian adolescents.

PO 7139 CONDITIONAL ECONOMIC INCENTIVES AND MOTIVATIONAL INTERVIEWING TO IMPROVE ADOLESCENTS’ RETENTION AND ADHERENCE TO ANTIRETROVIRAL THERAPY IN NIGERIA: ARA TRIAL

BackgroundAdolescent HIV patients have worse treatment outcomes compared to other age groups given their vulnerability to risk-taking behaviour. Limited evidence exists on the effectiveness of service delivery interventions to support adolescents’ retention in care and adherence to antiretroviral therapy (ART). The ARA trial tackles this challenge by evaluating the impact of conditional economic incentives coupled with motivational interviewing on adolescents’ retention in care and adherence to ART in Anambra State, Nigeria.MethodsThe study will be a cluster-randomised, controlled trial conducted in 12 HIV treatment hospitals in Anambra State, Nigeria. Six (6) hospitals each will be randomised to either intervention or control arm. A structured adherence support scheme, termed the Incentive Scheme, will be applied to the intervention hospitals while the control hospitals will receive routine HIV care. Additionally, patients in the intervention arm will receive motivational interviewing at baseline and following initiation of ART, they will receive a gift voucher of Nigerian Naira (NGN) 2000 when viral load (VL) is &lt;20 copies/mL at 12 weeks, gift voucher of NGN 1000 if the VL remains suppressed for the next 3 months, and the next 6 months, and finally gift voucher of NGN 2000 if the VL remains &lt;20 copies/mL at 1 year. All gift vouchers will be conditional not only on VL results but also on attending for motivational interviewing. The primary outcome for the trial will be the difference between groups in the proportion to HIV viral load suppression (≤20 copies/mL) by 12 months and then 24 months after withdrawal of the Incentive Scheme.ResultsThe protocol for ARA trial and planned activities is finalised. Application for approval for the trial is on-going.ConclusionThe proposed trial will provide evidence on the feasibility of applying the Incentive Scheme to improve retention and adherence to ART of adolescents living with HIV.

Conditional economic incentives and motivational interviewing to improve adolescents\u2019 retention in HIV care and adherence to antiretroviral therapy in Southeast Nigeria: study protocol for a cluster randomised trial

BackgroundAdolescent HIV patients face enormous difficulty in accessing HIV care services. Given their vulnerability to risk-taking behaviour, this group also have worse treatment outcomes compared to other age groups. Poor treatment outcomes will impact negatively on HIV/AIDS management and control particularly in sub-Saharan Africa (SSA) as more than eight out of ten of the world’s HIV-infected adolescents live in this region of the world. Limited evidence exists on the effectiveness of service delivery interventions to support adolescents’ retention on antiretroviral therapy (ART) and adherence to ART. This trial is designed to evaluate the impact of conditional economic incentive and motivational interviewing on adolescents’ retention in HIV care and adherence to ART in Anambra State, Southeast Nigeria.Methods/designThe study will be a cluster randomised controlled trial that will be conducted in selected HIV treatment hospitals in Anambra State, Nigeria. Based on sample size calculation, 12 HIV treatment hospitals from Anambra will be selected for the study. Six HIV treatment hospitals each will be randomised to either the intervention or the control arm. A structured adherence support scheme termed the ‘Incentive Scheme’ will be applied to the intervention arm while the control arm will receive routine HIV care (usual care). Additionally, patients in the intervention arm will receive motivational interviewing at baseline and following initiation of antiretroviral therapy (ART), they will receive a gift voucher of US$5.6 when HIV viral load (VL) is < 20 copies/mL at 12 weeks, a gift voucher of US$2.8 if the VL remains suppressed for the next 3 months, and the next 6 months, and finally a gift voucher of US$5.6 if the VL remains < 20 copies/mL at 1 year. All gift vouchers will be conditional not only on VL results but attending the motivational interviews. The primary outcome for the trial will be the difference between groups in the proportion with HIV VL suppression (≤ 20 copies/mL) by 12 months and then 24 months after withdrawal of incentive.DiscussionThe findings of this proposed trial will provide evidence on the feasibility of applying conditional economic incentives combined with motivational interviewing to improve retention and adherence to antiretroviral therapy of adolescents living with HIV in Nigeria and possibly in other sub-Saharan African countries.Trial registrationRegistered in the Pan African Clinical Trials Registry, ID: PACTR201806003040425. Registered on 2 February 2018.

PIN58 - Youth Preferences for Conditional Economic Incentives to Improve HIV Treatment Adherence: A Discrete Choice Experiment in South Africa

PIN58 - Youth Preferences for Conditional Economic Incentives to Improve HIV Treatment Adherence: A Discrete Choice Experiment in South Africa

Punto Seguro: A Randomized Controlled Pilot Using Conditional Economic Incentives to Reduce Sexually Transmitted Infection Risks in Mexico.

Randomized controlled pilot evaluated effect of conditional economic incentives (CEIs) on number of sex partners, condom use, and incident sexually transmitted infections (STIs) among male sex workers in Mexico City. Incentives were contingent on testing free of new curable STIs and/or clinic attendance. We assessed outcomes for n=227 participants at 6 and 12months (during active phase with incentives), and then at 18months (with incentives removed). We used intention-to-treat and inverse probability weightingfor the analysis. During active phase, CEIs increased clinic visits (10-13 percentage points) and increased condom use (10-15 percentage points) for CEI groups relative to controls. The effect on condom use was not sustained once CEIs were removed. CEIs did not have an effect on number of partners or incident STIs. Conditional incentives for male sex workers can increase linkage to care and retentionand reduce some HIV/STI risks such as condomless sex, while incentives are in place.

Microfinance plus for ecosystem services: a territorial perspective on Proyecto CAMBio in Nicaragua

Drawing from discussions on the panacea problem in microfinance and natural resource management, we scrutinize a ‘green microfinance plus’ programme – Proyecto CAMBio – in a specific setting in Nicaragua, focusing in particular on its interaction with local development pathways. The programme was designed to promote biodiversity-friendly land uses through the combination of credit provision, technical assistance and conditional economic incentives. In our case study, we highlight the focus on individual producers, the implicit targeting of more established medium-sized producers, and the uncritical promotion of a particular technical model of production. The project might thereby have failed to identify and revert some negative processes of environmental degradation and did not consciously engage with the dynamics and political arenas of sustainable development. We call for a more holistic territorial perspective that is conducive to more strategic thinking about the interactive socio-technical dynamics and ensuing opportunities and constraints for different producer types and technical-commercial models. Such strategic reflection is both inevitable and political, as it impacts on the opening and closing of avenues for more or less socially inclusive and environmentally sound development pathways.

P005: Impact of conditional economic incentives to reduce risky behaviours among high-risk men who have sex with men in a three-year randomized pilot study

P005: Impact of conditional economic incentives to reduce risky behaviours among high-risk men who have sex with men in a three-year randomized pilot study

Willingness-to-accept reductions in HIV risks: conditional economic incentives in Mexico

The objective of this study was to measure willingness-to-accept (WTA) reductions in risks for HIV and other sexually transmitted infections (STI) using conditional economic incentives (CEI) among men who have sex with men (MSM), including male sex workers (MSW) in Mexico City. A survey experiment was conducted with 1,745 MSM and MSW (18-25years of age) who received incentive offers to decide first whether to accept monthly prevention talks and STI testing; and then a second set of offers to accept to stay free of STIs (verified by quarterly biological testing). The survey used random-starting-point and iterative offers. WTA was estimated with a maximum likelihood double-bounded dichotomous choice model. The average acceptance probabilities were: 73.9% for the monthly model, and 80.4% for the quarterly model. The incentive-elasticity of participation in the monthly model was 0.222, and 0.515 in the quarterly model. For a combination program with monthly prevention talks, and staying free of curable STI, the implied WTA was USD$288 per person per year, but it was lower for MSW: USD$156 per person per year. Thus, some of the populations at highest risk of HIV infection (MSM and MSW) seem well disposed to participate in a CEI program for HIV and STI prevention in Mexico. The average WTA estimate is within the range of feasible allocations for prevention in the local context. Given the potential impact, Mexico, a leader in conditional cash transfers for human development and poverty reduction, could extend that successful model to targeted HIV/STI prevention.