Results of a cluster-randomised trial of non-financial incentives to increase uptake of - PowerPoint Presentation

Results of a cluster-randomised trial of non-financial incentives to increase uptake of couples counselling and testing Dr Euphemia L Sibanda21ST International AIDS conferenceDurban, South Africa PACTR201606001630356

Collaborative study Bautista, SergioCopas, Andrew Cowan, Frances Gudukeya , StephanoHatzold, Karin Mavedzenge, Sue McCoy, Sandi Mufuka, Juliet Padian, Nancy Sibanda, Euphemia Thirumurthy, Harsha Tumushime, Mary

Importance of CHTC CHTC is associated withBetter uptake of PMTCT1,2 Improved retention 1,3 Reduction in sexual risk taking Cost effective, $16.6 per DALY averted4 Highly effective ARV interventions for discordant couples underscore importance of CHTC WHO CHTC guidelines, 2012 1 Farquhar, J Acquir Immune Defic Syndr 2004 2 Becker, AIDS Behav, 2010 3 Conkling, J Int AIDS Soc , 2010 4 John, Int J STD AIDS 2008

Sub-optimal uptake of CHTC Uptake is less than 20% in most settings6-7% in Zimbabwe rural outreachBarriers include Fear of consequences of HIV diagnosisFear of discussing CHTC Present-biased preferences

Incentives may improve CHTC uptake Provide a reason to initiate discussion on CHTCOffer an ‘immediate’ perceived benefit What incentives may work?Nature Size

1 Formative Research Qualitative study to explore nature and size of incentives 2 Cluster randomised trial Randomisation, stratified by district and proximity to clinic (n=68) No incentive Incentive Outcomes based on program data Proportion testing with a partner, per arm Prevalence of social harms 3 Telephone survey to determine % social harms among couples Study design

Focus group discussion methods 4 mixed gender FGDs held (n=34)Used vignettes to promote discussion about attitudes and views on CHTC Each ‘couple’ acted out a scene where one was convincing their partner to test togetherAll FGDs were audio recorded, transcribed verbatim and translated and coded using framework analysis

Nature and size of incentives Household items – food, bath and laundry soapEven small incentives will work The thing is, people like things that are given for free, even if a (sewing) needle were offered one would want it 49-year old married man Ah! money is a problem, we can actually cause divorces! Money causes too much talk, just giving them (non-monetary) gifts is better 45-year old married man, peasant farmer 25-year old single man, unemployed

Incentives offered Each person testing with a partner could choose one: Each valued at ~ US$1.50 750ml of cooking oil 200g petroleum jelly One bar laundry soap

The intervention Conducted in rural communities in four districts where PSI provide outreach HTC Community mobilisation prior to outreach Control arm: Standard mobilisation Intervention arm: Standard mobilisation + mention of incentives Outreach team went round communities offering HTC, with electronic data capture

Data analysis for trial Effects of incentives estimated using logistic regression Adjustment for district & proximity to clinic - fixed effectsAdjustment for community/cluster - random effects Further adjustment planned for individual factors considered a priori to be important Factors combined so as to avoid collinearity and small cells

Telephone survey Conducted among couples who tested in 8 pragmatically selected clusters (4 in each arm) Three months after testing Motivators for CHTC W hether testing was forced Whether harm ensued after CHTC

All communitiesN=68 Comparison n=34Incentives n=34 187 outreach team-days n=10,932 (58 people tested/day) Available recordsn=10,580 (96.8%) Available records n=14,099 (94.7%) 212 outreach team-daysn=14,885 (70 people tested/day) May 2015 – January 2016

Characteristics of people undergoing HTC Control (N=10,580) % Incentives (N=14,099) % Male 46 45 Age<25 33 27 Secondary/higher education 72 65 Married/cohabiting 62 80 Planning to have children 24 30 Partner/self current breastfeeding 8 12 2+ partners in the last year 6 4 No condom at last sex 78 86 Current STI 0.3 0.3 Previous HIV test 61 63 HIV+ result of current HIV test 6.5 8.8

Effect of incentives on CHTC 1062 (10.0%) tested with partner in control arm7852 (55.7%) tested with partner in incentives arm OR 12.7 (9.69 – 16.7) AOR 13.5 (10.5 – 17.4)

Effect of incentives among married/cohabiting testers 1025 (15.6%) tested with partner among those married/cohabiting in control arm 7540 (68.2%) tested with partner among those married/cohabiting in incentive arm OR 13.7 (10.6 - 17.7)

Association between CHTC and HIV Study armHIV+ Individual testers, n (%) HIV+ Couple testers, n (%)p-value (couple vs individual) Control593 (6.3)83 (7.9) 0.07 Incentives 449 (7.3%) 757 (10.0) <0.001 35 (6.7%) control arm couples had discordant results 295 ( 7.9%) intervention arm couples had discordant results p=0.25

Telephone survey 427 couple-testers completed telephone interviewResponse rate 61.3%363 (85%) were in incentives arm Motivators to CHTC – no differences between arms 396 (93%) reported desire to know each other’s status149 (41% in intervention arm) motivated by incentives 30% planning a pregnancy21% retesting at end of window period22% confirmed/suspected unfaithfulness“Other” – 3 participants (intervention arm) took the opportunity to disclose to partner

Social harms 6 & 5 participants “pressured”/were “pressured” by partner 6 and 4 from incentive arm respectivelyRelationship unrest was reported by 8 (1.9%) 6 in incentives armAll 8 were due to HIV diagnosis of one or both None said it was due to incentivesOne reported physical violence 3 separations/divorce9 (2.1%) regretted having tested with partner 5 in the incentive arm

Discussion Incentives are effective in increasing CHTCPotentially scalable given low costMain motivator for testing is desire to know joint status Incentives to increase the uptake of CHTC are associated with identification of more HIV positivesCannot rule out testing of known positives other than for disclosure purposes Ongoing cost effectiveness analysis Reported social harms related to CHTC in generalNeed to find ways of supporting couples with HIV+ diagnosis

Acknowledgements Ministry of Health & Child Care District and community leadership Study participants