HIV screening take-up: evaluating incentives and opt-out strategies

描述（由申请人提供）：在美国，超过20%的艾滋病毒阳性患者不知道自己感染了艾滋病毒，这导致医学研究所最近敦促进一步开展工作，比较艾滋病毒筛查策略的有效性。本研究将采用一项随机试验来比较几种基于急诊室的艾滋病毒检测政策，以确定如何提高艾滋病毒检测的接受率。测试政策的设计将使用行为经济学的原则，改变选择结构，并提供小额金钱奖励。这将是第一个在统一的随机试验中测量各种有希望但基本上未经测试的方法的吸收率差异的研究。将测试三种默认情况：传统的选择加入（只对那些要求测试的患者进行测试），选择退出（除非患者拒绝进行常规测试）和主动选择测试（患者需要说明他们是否想要进行测试）。这项研究还将首次测试小额货币激励（1美元、5美元、10美元）对考试接受率的影响。另一个新颖的研究贡献将是测试这样一个假设，即在提出一个小要求或预先承诺后，对大要求（接受艾滋病毒检测）的依从性会增加——这种“迈出第一步”的技术以前没有在这种情况下进行过研究。析因设计将允许对所有干预措施以及相互作用进行直接比较。该研究将有助于细致入微的经验理解，从行为经济学理论的测试协议如何影响在实际规模设置筛选程序的有效性和效率（旧金山总医院）。这将有助于执行和评估最近的疾病预防控制中心关于艾滋病毒筛查的指导方针，同时也更广泛地推进与将行为经济学应用于比较有效性研究有关的科学知识。

DESCRIPTION (provided by applicant): Over twenty percent of HIV-positive persons in the United States are unaware of their infection, leading the Institute of Medicine to recently urge further work to compare the effectiveness of HIV screening strategies. This study will use a randomized trial to compare several variants of emergency-room-based HIV-testing policies in order to determine how HIV test acceptance rates can be increased. The testing policies will be designed using principles from behavioral economics, varying the choice architecture and offering small monetary incentives. This will be the first study to measure differences in take-up rates across a variety of promising but largely untested approaches within a unified randomized trial. Three defaults will be tested: traditional opt-in (test only those patients who request testing), opt-out (routinely testing unless patients decline), and active-choice testing (patients are required to state whether they want to be tested). The study will also be the first to test the effect of small monetary incentives ($1, $5, $10) on test take-up. An additional novel study contribution will be to test the hypothesis that compliance with large requests (accept an HIV test) increases after making a small request or pre-commitment - this "foot in the door" technique has not been previously studied in this setting. The factorial design will permit a direct comparison of all interventions, as well as interactions. The study will contribute a nuanced empirical understanding of how testing protocols from behavioral economics theory affect the effectiveness and efficiency of screening programs in an actual scaled-up setting (San Francisco General Hospital). This will assist in implementing and assessing recent CDC guidelines on HIV screening, while also more generally advancing scientific knowledge related to applying behavioral economics in comparative effectiveness research. PUBLIC HEALTH RELEVANCE: The proposed study will investigate how the effectiveness and efficiency of health screening programs can be enhanced by applying recent advances in behavioral economics theory regarding choice architecture and incentives. In particular, we test the extent to which default choices, small incentives, and encouragement methods can increase the currently low rates of HIV testing in many clinical settings such as emergency rooms. CDC guidelines have now embraced the use of opt-out HIV screening, but more nuanced understanding is essential in order to effectively implement such guidelines.