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Ostermann J, Njau B, Hobbie AM, Mtuy TB, Masnick M, Brown DS, Mühlbacher AC, Thielman NM. Divergent preferences for enhanced HIV testing options among high-risk populations in northern Tanzania: a short report. AIDS Care 2023; 35:1270-1278. [PMID: 36063533 PMCID: PMC9985668 DOI: 10.1080/09540121.2022.2119471] [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: 07/21/2021] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
To achieve the UNAIDS target of diagnosing 95% of all persons living with HIV, enhanced HIV testing services with greater attractional value need to be developed and implemented. We conducted a discrete choice experiment (DCE) to quantify preferences for enhanced HIV testing features across two high-risk populations in the Kilimanjaro Region in northern Tanzania. We designed and fielded a survey with 12 choice tasks to systematically recruited female barworkers and male mountain porters. Key enhanced features included: testing availability on every day of the week, an oral test, integration of a general health check or an examination for sexually transmitted infections (STI) with HIV testing, and provider-assisted confidential partner notification in the event of a positive HIV test result. Across 300 barworkers and 440 porters surveyed, mixed logit analyses of 17,760 choices indicated strong preferences for everyday testing availability, health checks, and STI examinations. Most participants were averse to oral testing and confidential partner notification by providers. Substantial preference heterogeneity was observed within each risk group. Enhancing HIV testing services to include options for everyday testing, general health checks, and STI examinations may increase the appeal of HIV testing offers to high-risk populations.Trial registration: ClinicalTrials.gov identifier: NCT02714140.
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Affiliation(s)
- Jan Ostermann
- Department of Health Services Policy & Management,
University of South Carolina, Columbia, SC,USA
- South Carolina Smart State Center for Healthcare Quality,
University of South Carolina, Columbia, SC, USA
- Duke Global Health Institute, Duke University, Durham, NC,
USA
- Center for Health Policy & Inequalities Research, Duke
University, Durham, NC, USA
| | - Bernard Njau
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Amy M. Hobbie
- Center for Health Policy & Inequalities Research, Duke
University, Durham, NC, USA
| | - Tara B. Mtuy
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Global Health and Development, London School
of Hygiene and Tropical Medicine, London, UK
| | | | - Derek S. Brown
- Center for Health Policy & Inequalities Research, Duke
University, Durham, NC, USA
- Brown School, Washington University in St. Louis, St.
Louis, Missouri, USA
| | - Axel C. Mühlbacher
- Center for Health Policy & Inequalities Research, Duke
University, Durham, NC, USA
- Institut Gesundheitsökonomie und Medizinmanagement,
Hochschule Neubrandenburg, Neubrandenburg, Germany
- Department of Population Health Sciences, Duke University,
Durham, NC, USA
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, NC,
USA
- Center for Health Policy & Inequalities Research, Duke
University, Durham, NC, USA
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Deane K, Wamoyi J, Mgunga S, Changalucha J. HIV testing attitudes and practices amongst 'wealthy men': qualitative evidence from Tanzania. CULTURE, HEALTH & SEXUALITY 2022; 24:1215-1229. [PMID: 34254898 DOI: 10.1080/13691058.2021.1941261] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 06/07/2021] [Indexed: 06/13/2023]
Abstract
Evidence from nationally representative surveys conducted in sub-Saharan Africa shows that significant proportions of men in the wealthiest quintile report never having tested for HIV. Despite high prevalence rates in this quintile, no research has been conducted on the HIV testing attitudes and practices of wealthier men. This article reports findings from qualitative research conducted with 23 wealthy men in Tanzania. Whilst wealthy men reported barriers to and enablers of HIV testing previously reported by the general population, concerns around loss of social status and community standing were amplified for members of this demographic. Furthermore, HIV stigma among members of this group remains high. However, enhanced access to HIV testing through private clinics, regular healthcare appointments, health insurance schemes and the means to travel to other countries enables wealthy men to avoid stigma. In settings such as the workplace, wealthy men were able to test in public in their roles as 'leaders' to encourage others to test. Future interventions to increase testing amongst men should target settings in which these leadership roles can be taken advantage of. HIV services also need integrating into the health system to remove the need for testing and treatment to be accessed at separate clinics.
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Affiliation(s)
- Kevin Deane
- Economics Discipline, Faculty of Arts and Social Sciences, Open University, Milton Keynes, UK
| | - Joyce Wamoyi
- Sexual and Reproductive Health Department, National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Samwel Mgunga
- Sexual and Reproductive Health Department, National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - John Changalucha
- Sexual and Reproductive Health Department, National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
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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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Mhina C, Bosworth H, Bartlett JA, Vilme H, Mosha JH, Shoo DF, Kakumbi TJ, Jacob G, Muiruri C. The impact of out-of-pocket expenditures on missed appointments at HIV care and treatment centers in Northern Tanzania. GLOBAL HEALTH JOURNAL 2021. [DOI: 10.1016/j.glohj.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kadota JL, Nabwire S, Nalugwa T, White JS, Cattamanchi A, Katamba A, Shete PB. Patient Perspectives and Willingness to Accept Incentives for Tuberculosis Diagnostic Evaluation in Uganda. Value Health Reg Issues 2021; 25:48-56. [PMID: 33773327 DOI: 10.1016/j.vhri.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 12/02/2020] [Accepted: 12/10/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES We assessed attitudes and perceptions and willingness to accept (WTA) varying incentive structures for completing tuberculosis (TB) diagnostic evaluation among patients in Uganda. METHODS We surveyed 177 adult patients undergoing TB evaluation at 10 health centers between September 2018 and March 2019. We collected household sociodemographic information and assessed attitudes and perceptions of incentives. We surveyed patients regarding their willingness to complete TB diagnostic evaluation in exchange for incentives ranging in value from 500 Ugandan shillings (USh) to 25 000USh (~$0.15-$6.75). We compared associations between WTA and patient characteristics using ordered logistic regression. RESULTS Participant willingness to return to the health center to complete TB diagnostic evaluation increased proportionally with incentive amount. The median participant accepted between 2000 and 5000 USh. Cash (52%) and transportation vouchers (34%) were the most popular incentive types. Half of respondents preferred unconditional incentives; for a multiday evaluation, 84% preferred conditioning incentive receipt upon returning to the health center. In multivariate models, we found the pairwise difference between the third and lowest income quartile (aOR = 2.38, 95% CI: 1.20-4.69; P = .01), younger age, and difficulty returning to the health center to be significantly associated with WTA higher incentive thresholds. CONCLUSIONS In Uganda, incentives such as cash transfers or transportation vouchers are an acceptable intervention for facilitating adherence to TB diagnostic evaluation. Household income is associated with preferred incentive structure and amount, especially for those at the cusp of the poverty threshold who are more likely to prefer unconditional and higher valued incentives. Targeted and context-specific socioeconomic supports for at-risk patients are needed to optimize outcomes.
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Affiliation(s)
- Jillian L Kadota
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA USA.
| | - Sarah Nabwire
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Talemwa Nalugwa
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Justin S White
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Clinical Epidemiology & Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Priya B Shete
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
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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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Adekunjo FO, Rasiah R, Dahlui M, Ng CW. Assessing the willingness to pay for HIV counselling and testing service: a contingent valuation study in Lagos State, Nigeria. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2021; 19:287-295. [PMID: 33337980 DOI: 10.2989/16085906.2020.1834417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
HIV/AIDS is a major health issue faced by the world, generally, but particularly sub-Saharan Africa. Nigeria ranked third in the world by number of people living with HIV/AIDS in 2019. Despite prominent HIV counselling and testing (HCT) intervention programmes, Nigeria faces serious challenges, such as inadequate funding and low utilisation rates. Paucity of research into such a critical topic has restricted the capacity of policy makers to address the problem adequately. Consequently, a cross-sectional study was carried out using the contingent valuation method to assess the economic quantum of payment and determining factors associated with people's willingness to pay for HCT services. Data were collected from 768 people selected by convenience sampling of three local government areas - Alimosho, Ikorodu and Surulere in Lagos State, Nigeria. Data were analysed using descriptive statistics, chi-square, Mann-Whitney, and general linear regression model analysis. Findings show that 75% of respondents were willing to pay an average fee of N1 291 ($4.22) for HCT services. Significant determinants of willingness to pay were: income; knowledge of someone living with HIV or died of AIDS; worry about HIV infection; and fear of HIV-related stigma. The findings offer vital information germane to co-payment schemes aimed at financial sustainability of HCT and HIV/AIDS programmes in Nigeria.
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Affiliation(s)
| | - Rajah Rasiah
- Asia Europe Institute, University of Malaya, Kuala Lumpur, Malaysia
| | - Maznah Dahlui
- Centre of Population Health, Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Faculty of Public Health, University of Airlangga, Indonesia
| | - Chiu Wan Ng
- Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Julius Centre, University of Malaya, Kuala Lumpur, Malaysia
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Eliciting Preferences for HIV Prevention Technologies: A Systematic Review. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 14:151-174. [PMID: 33319339 PMCID: PMC7884379 DOI: 10.1007/s40271-020-00486-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 01/10/2023]
Abstract
Background Many human immunodeficiency virus (HIV) prevention technologies (pre-exposure prophylaxis, microbicides, vaccines) are available or in development. Preference elicitation methods provide insight into client preferences that may be used to optimize products and services. Given increased utilization of such methods in HIV prevention, this article identifies and reviews these methods and synthesizes their application to HIV prevention technologies. Methods In May 2020, we systematically searched peer-reviewed literature in PubMed, CINAHL, and Web of Science for studies employing quantitative preference elicitation methods to measure preferences for HIV prevention technologies among populations of any age, sex, or location. Quality assessment used an existing checklist (PREFS) and a novel adaptation of the Newcastle–Ottawa Scale (PROSPERO #CRD42018087027). Results We screened 5022 titles and abstracts, reviewed 318 full texts, and included 84 studies. Common methods employed were discrete-choice experiment (33%), conjoint analysis (25%), and willingness-to-participate/try/accept (21%). Studies were conducted in 25 countries and had a mean of 768 participants (range = 26–7176), two-thirds of them male. Common HIV prevention technologies included pre-exposure prophylaxis (23%), voluntary testing and counseling (19%), HIV self-testing (17%), vaccines (15%), and topical microbicides (9%). Most attributes focused on product design (side effects, frequency), service design (provider type, location), acceptability or willingness to accept/pay; results are summarized in these categories, by prevention type. Mean quality-adapted Newcastle–Ottawa Scale score was 4.5/8 (standard deviation = 2.1) and mean PREFS scores was 3.47/5 (standard deviation = 0.81). Conclusions This review synthesizes extant literature on quantitative measurement of preferences for HIV prevention technologies. This can enable practitioners to improve prevention products and interventions, and ultimately reduce HIV incidence.
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Ostermann J, Njau B, Hobbie A, Mtuy T, Masaki ML, Shayo A, van Zwetselaar M, Masnick M, Flaherty B, Brown DS, Mühlbacher AC, Thielman NM. Using discrete choice experiments to design interventions for heterogeneous preferences: protocol for a pragmatic randomised controlled trial of a preference-informed, heterogeneity-focused, HIV testing offer for high-risk populations. BMJ Open 2020; 10:e039313. [PMID: 33158826 PMCID: PMC7651730 DOI: 10.1136/bmjopen-2020-039313] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Approximately one million undiagnosed persons living with HIV in Southern and Eastern Africa need to test for HIV. Novel approaches are necessary to identify HIV testing options that match the heterogeneous testing preferences of high-risk populations. This pragmatic randomised controlled trial (PRCT) will evaluate the efficacy of a preference-informed, heterogeneity-focused HIV counselling and testing (HCT) offer, for improving rates of HIV testing in two high-risk populations. METHODS AND ANALYSIS The study will be conducted in Moshi, Tanzania. The PRCT will randomise 600 female barworkers and 600 male Kilimanjaro mountain porters across three study arms. All participants will receive an HIV testing offer comprised of four preference-informed testing options, including one 'common' option-comprising features that are commonly available in the area and, on average, most preferred among study participants-and three options that are specific to the study arm. Options will be identified using mixed logit and latent class analyses of data from a discrete choice experiment (DCE). Participants in Arm 1 will be offered the common option and three 'targeted' options that are predicted to be more preferred than the common option and combine features widely available in the study area. Participants in Arm 2 will be offered the common option and three 'enhanced' options, which also include HCT features that are not yet widely available in the study area. Participants in Arm 3, an active control arm, will be offered the common option and three predicted 'less preferred' options. The primary outcome will be uptake of HIV testing. ETHICS AND DISSEMINATION Ethical approval was obtained from the Duke University Health System IRB, the University of South Carolina IRB, the Ethics Review Committee at Kilimanjaro Christian Medical University College, Tanzania's National Institute for Medical Research, and the Tanzania Food & Drugs Authority (now Tanzania Medicines & Medical Devices Authority). Findings will be published in peer-reviewed journals. The use of rigorous DCE methods for the preference-based design and tailoring of interventions could lead to novel policy options and implementation science approaches. TRIAL REGISTRATION NUMBER NCT02714140.
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Affiliation(s)
- Jan Ostermann
- Department of Health Services Policy & Management, University of South Carolina, Columbia, South Carolina, USA
- South Carolina Smart State Center for Healthcare Quality, University of South Carolina, Carolina, South Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Center for Health Policy & Inequalities Research, Duke University, Durham, North Carolina, USA
| | - Bernard Njau
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Amy Hobbie
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Center for Health Policy & Inequalities Research, Duke University, Durham, North Carolina, USA
| | - Tara Mtuy
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Aisa Shayo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Max Masnick
- Selway Labs, LLC, Barrington, Rhode Island, USA
| | - Brian Flaherty
- Department of Psychology, University of Washington, Seattle, Washington, USA
| | - Derek S Brown
- Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Axel C Mühlbacher
- Center for Health Policy & Inequalities Research, Duke University, Durham, North Carolina, USA
- Institut Gesundheitsökonomie und Medizinmanagement, Hochschule Neubrandenburg, Neubrandenburg, Germany
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Center for Health Policy & Inequalities Research, Duke University, Durham, North Carolina, USA
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iSAY (incentives for South African youth): Stated preferences of young people living with HIV. Soc Sci Med 2020; 265:113333. [PMID: 32896799 DOI: 10.1016/j.socscimed.2020.113333] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 01/13/2023]
Abstract
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.
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11
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Schaffer EM, Gonzalez JM, Wheeler SB, Kwarisiima D, Chamie G, Thirumurthy H. Promoting HIV Testing by Men: A Discrete Choice Experiment to Elicit Preferences and Predict Uptake of Community-based Testing in Uganda. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:413-432. [PMID: 31981135 PMCID: PMC7255957 DOI: 10.1007/s40258-019-00549-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND OBJECTIVES HIV testing is essential to access HIV treatment and care and plays a critical role in preventing transmission. Despite this, testing coverage is low among men in sub-Saharan Africa. Community-based testing has demonstrated potential to expand male testing coverage, yet scant evidence reveals how community-based services can be designed to optimize testing uptake. We conducted a discrete choice experiment (DCE) to elicit preferences and predict uptake of community-based testing by men in Uganda. METHODS Hypothetical choices between alternative community-based testing services and the option to opt-out of testing were presented to a random, population-based sample of 203 adult male residents. The testing alternatives varied by service delivery model (community health campaign, counselor-administered home-based testing, distribution of HIV self-test kits at local pharmacies), availability of multi-disease testing, access to antiretroviral therapy (ART), and provision of a US$0.85 incentive. We estimated preferences using a random parameters logit model and explored whether preferences varied by participant characteristics through subgroup analyses. We simulated uptake when a single and when two community-based testing services are made available, using reference values of observed uptake to calibrate predictions. RESULTS The share of the adult male population predicted to test for HIV ranged from 0.15 to 0.91 when a single community-based testing service is made available and from 0.50 to 0.96 when two community-based services are provided concurrently. ART access was the strongest driver of choices (relative importance [RI] = 3.01, 95% confidence interval [CI]: 1.74-4.29), followed by the service delivery model (RI = 1.27, 95% CI 0.72-1.82) and availability of multi-disease testing (RI = 1.27, 95% CI 0.09-2.45). A US$0.85 incentive had the least yet still significant influence on choices (RI = 0.77, 95% CI 0.06-1.49). Men who perceived their risk of having HIV to be relatively elevated had higher predicted uptake of HIV self-test kits at local pharmacies, as did young adult men compared to men aged ≥ 30 years. Men who earned ≤ the daily median income had higher predicted uptake of all community-based testing services versus men who earned above the daily median income. CONCLUSION Substantial opportunity exists to optimize the delivery of HIV testing to expand uptake by men; using an innovative DCE, we deliver timely, actionable guidance for promoting community-based testing by men in Uganda. We advance the stated preference literature methodologically by describing how we constructed and evaluated a pragmatic experimental design, used interaction terms to conduct subgroup analyses, and harnessed participant-specific preference estimates to predict and calibrate testing uptake.
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Affiliation(s)
- Elisabeth M Schaffer
- Data Science to Patient Value, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Harsha Thirumurthy
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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12
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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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13
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Achieving the 90-90-90 target: incentives for HIV testing. THE LANCET. INFECTIOUS DISEASES 2018; 16:1215-1216. [PMID: 27788971 DOI: 10.1016/s1473-3099(16)30383-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 09/09/2016] [Accepted: 09/19/2016] [Indexed: 11/20/2022]
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14
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Kranzer K, Simms V, Bandason T, Dauya E, McHugh G, Munyati S, Chonzi P, Dakshina S, Mujuru H, Weiss HA, Ferrand RA. Economic incentives for HIV testing by adolescents in Zimbabwe: a randomised controlled trial. Lancet HIV 2018; 5:e79-e86. [PMID: 29170030 PMCID: PMC5809636 DOI: 10.1016/s2352-3018(17)30176-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/20/2017] [Accepted: 09/14/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND HIV testing is the important entry point for HIV care and prevention service, but uptake of HIV testing and thus coverage of antiretroviral therapy are much lower in older children and adolescents than in adults. We investigated the effect of economic incentives provided to caregivers of children aged 8-17 years on uptake of HIV testing and counselling in Harare, Zimbabwe. METHODS This randomised controlled trial was nested within a household HIV prevalence survey of children aged 8-17 years in Harare. Households with one or more survey participants whose HIV status was unknown were eligible to participate in the trial. Eligible households were randomly assigned (1:1:1) to either receive no incentive, receive a fixed US$2 incentive, or participate in a lottery for $5 or $10 if the participant presented for HIV testing and counselling at a local primary health-care centre. The survey fieldworkers who enrolled participants were not blinded to trial arm allocation, but the statistician was blinded for analysis of outcome. The primary outcome was the proportion of households in which at least one child had an HIV test within 4 weeks of enrolment. HIV test uptake in the incentivised groups was compared with uptake in the non-incentivised group using logistic regression, adjusting for community and number of children as fixed effects and research assistant as a random effect. All analyses were by intention to treat. The trial is registered with the Pan African Clinical Trials Registry, number PACTR201605001615280. FINDINGS Between Aug 4, and Dec 18, 2015, 2050 eligible households were enrolled in the prevalence survey. 649 (32%) households were assigned no incentive, 740 (34%) households were assigned a $2 incentive, and 661 (32%) households were assigned to lottery participation. Children were unavailable in 148 households in the no-incentive group, 63 households in the $2 incentive group, and 81 households in the lottery group. 1688 households had at least one child with unknown HIV status and were enrolled into the trial. 22 households had no undiagnosed child, and one household refused consent. The primary outcome of HIV testing was assessed in 472 (28%) households in the no-incentive group, 654 (39%) households in the $2 incentive group, and 562 (33%) households in the lottery group. At least one child was HIV tested in 93 (20%) households in the no-incentive group, in 316 (48%) households in the $2 incentive group (adjusted odds ratio 3·67, 95% CI 2·77-4·85; p<0·0001), and in 223 (40%) of 562 households in the lottery group (2·66, 2·00-3·55; p<0·0001). No adverse events were reported. INTERPRETATION Fixed incentives and lottery-based incentives increased the uptake of HIV testing by older children and adolescents, a key hard-to-reach population. This strategy would be sustainable in the context of vertical HIV infection as repeated testing would not be necessary until sexual debut. FUNDING Wellcome Trust.
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Affiliation(s)
- Katharina Kranzer
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; National and Supranational Tuberculosis Reference Laboratory, Leibniz Research Centre Borstel, Borstel, Germany.
| | - Victoria Simms
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Tsitsi Bandason
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Ethel Dauya
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Grace McHugh
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Shungu Munyati
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Suba Dakshina
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Hilda Mujuru
- Department of Paediatrics, University of Zimbabwe, Harare, Zimbabwe
| | - Helen A Weiss
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Rashida A Ferrand
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Biomedical Research and Training Institute, Harare, Zimbabwe
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15
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Jennings L, Conserve DF, Merrill J, Kajula L, Iwelunmor J, Linnemayr S, Maman S. Perceived Cost Advantages and Disadvantages of Purchasing HIV Self-Testing Kits among Urban Tanzanian Men: An Inductive Content Analysis. JOURNAL OF AIDS & CLINICAL RESEARCH 2017; 8:725. [PMID: 29051841 PMCID: PMC5645025 DOI: 10.4172/2155-6113.1000725] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Impoverished men have lower rates of facility-based HIV counseling and testing and higher unknown HIV-positive status than women. Economic theory suggests that individuals will obtain an HIV test if anticipated benefits are greater than anticipated costs. Yet, few studies have investigated the range of financial preferences of HIV self-testing (HIVST) among poor men who decline testing or do not test regularly. Twenty-three interviews were conducted to qualitatively assess perceived costs saved and costs incurred from use of HIVST kits in infrequently- or never-tested Tanzanian men. All men were shown an HIVST kit and video. They were then asked about the costs associated with provider-led HIV testing, financial benefits and concerns of HIVST and willingness to pay for HIVST. Data were transcribed, coded and analyzed using inductive content analyses. We then grouped codes into perceived cost advantages and disadvantages and tabulated the range of prices men were willing to pay for a self-test kit. Perceived cost advantages of HIVST were avoidance of spending money to test in facilities, omission of follow-up fees, affordability relative to private clinics, and increased time for earning income and other activities. Men also discussed the imbalance of the financial benefit of accessing free, public HIV testing with the resources spent for transport, purchasing meals away from home and long wait lines. Perceived cost disadvantages of HIVST were prohibitive kit costs, required prior savings to purchase kits, expenditures relating to death and preferences for free provider-performed testing. Men were also concerned about the psychological costs of inaccurate results. HIVST willingness to pay varied among men. Men's decisions to self-test for HIV takes into account expected financial gains and losses. Demand generation for HIVST among men should consider use of low fees or free HIVST, while emphasizing potential savings from reduced travel, clinical costs, or time way from work. Efforts are also needed to address anticipated emotional costs of HIVST, such as anxiety from kit errors, purchasing "death" or testing alone, which for some men was a substantial barrier.
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Affiliation(s)
- Larissa Jennings
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Social and Behavioral Interventions Program, Baltimore, USA
| | - Donaldson F Conserve
- University of South Carolina, Arnold School of Public Health, Department of Health Promotion, Education, and Behavior, Columbia, USA
| | - Jamison Merrill
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Social and Behavioral Interventions Program, Baltimore, USA
| | - Lusajo Kajula
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Juliet Iwelunmor
- University of Illinois Urbana Champaign, Department of Kinesiology and Community Health, Champaign, IL, USA
| | | | - Suzanne Maman
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
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