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

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的工作来比较艾滋病毒筛查策略的有效性。这项研究将使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。测试政策将使用行为经济学的原则设计，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测量各种有希望但基本上未经测试的方法的使用率差异的研究。将测试三个默认值：传统的选择加入（仅对要求检测的患者进行检测）、选择退出（常规检测，除非患者拒绝）和主动选择检测（要求患者声明是否愿意接受检测）。这项研究也将是第一个测试小额货币激励（1美元，5美元，10美元）对考试参加率的影响的研究。另一个新的研究贡献将是测试假设，即在提出一个小的请求或预先承诺后，对大的请求（接受艾滋病毒检测）的依从性会增加-这种“踏进门”的技术以前没有在这种情况下进行过研究。析因设计将允许直接比较所有干预措施以及相互作用。这项研究将有助于从行为经济学理论的测试协议如何影响实际规模扩大的设置（旧金山弗朗西斯科）的筛查程序的有效性和效率的细致入微的实证理解。这将有助于实施和评估最近的CDC艾滋病毒筛查指南，同时也更普遍地推进与在比较有效性研究中应用行为经济学相关的科学知识。 公共卫生相关性：拟议中的研究将探讨如何有效性和效率的健康检查计划，可以通过应用行为经济学理论的最新进展，关于选择架构和激励措施。特别是，我们测试默认选择，小的激励措施和鼓励方法可以在多大程度上增加目前在许多临床环境，如急诊室艾滋病毒检测率低。疾病预防控制中心的指导方针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些指导方针，更细致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.