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

描述(由申请人提供)：在美国，超过20%的艾滋病毒阳性者不知道他们的感染，导致医学研究所最近敦促进一步开展工作，比较艾滋病毒筛查战略的有效性。这项研究将使用随机试验来比较几种基于急诊室的艾滋病毒检测政策的变体，以确定如何提高艾滋病毒检测接受率。测试政策将使用行为经济学的原理来设计，改变选择架构，并提供小额货币激励。这将是第一项在统一的随机试验中衡量各种有希望但基本上未经测试的方法的接受率差异的研究。将测试三种默认设置：传统的选择加入(只测试那些要求测试的患者)、选择退出(除非患者拒绝，否则会定期进行测试)和主动选择测试(患者被要求说明他们是否想要接受测试)。这项研究还将首次测试小额货币奖励(1美元、5美元、10美元)对测试接受率的影响。另一项新颖的研究贡献将是检验这样一种假设，即在提出小请求或预先承诺后，对大请求(接受艾滋病毒检测)的遵从性会增加--这一“踏进门”技术以前从未在这种情况下进行过研究。析因设计将允许所有干预措施以及交互作用的直接比较。这项研究将有助于对行为经济学理论中的测试方案如何在实际扩大的环境中影响筛查计划的有效性和效率的细微经验理解(旧金山综合医院)。这将有助于实施和评估疾控中心最近关于艾滋病毒筛查的指导方针，同时还将更广泛地促进与在比较有效性研究中应用行为经济学有关的科学知识。 公共健康相关性：拟议的研究将调查如何通过应用行为经济学理论中关于选择架构和激励的最新进展来提高健康筛查计划的有效性和效率。特别是，我们测试了默认选择、小规模激励和鼓励方法在多大程度上可以提高许多临床环境(如急诊室)目前较低的艾滋病毒检测率。美国疾病控制与预防中心的指南现在已经接受了选择退出艾滋病毒筛查的使用，但为了有效地实施这种指南，更细微的理解是必不可少的。

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.